Abstract
BACKGROUND:
Physical Activity in the workplace has received special attention from researchers who are looking to promote lifelong health and well-being. The workplace is being investigated as a possible place to assess and create strategies to help people to become healthier. The transtheoretical model and stages of change has been adapted as a tool to assess the stages of behavioral change towards exercising.
OBJECTIVE:
To assess the change in health behavior following a three-month exercise program based in the workplace.
METHODS:
A quasi-experimental study design was used in which 165 employees participated in the study. An intervention program of workplace exercise was applied for three months. Participants were assessed through the transtheoretical model and stages of change questionnaire before and after intervention to understand changes in their position on the behavioral change continuum.
RESULTS:
The number of employees who were physically active increased after the workplace exercise intervention (13.9% , 95% CI 9.5 to 20.1; P = 0.009). There was a significant decrease in the proportion of employees in the pre-contemplation stage (–6.1% , 95% CI 3.3 to 10.8; P = 0.045) and contemplation stage (–11.5% , 95% CI 7.5 to 17.3; P = 0.017), and a significant increase in the action stage (10.9% , 95% CI 7.0 to 16.6; P = 0.003).
CONCLUSIONS:
Engaging in workplace exercise has a significant positive effect on health behavior and willingness to become more physically active.
Introduction
There is strong evidence showing the beneficial effects of regular physical activity [1, 2]. However, the latest researches have revealed a global increase in the number of sedentary people [3, 4]. Developing countries, such as Brazil, have long working hours – 44 hours/week – and this has had a negative impact on physical activity [5–8]. The main complaint is lack of time to be physically active caused by the number of hours worked.
Recently, exercise in the workplace has been receiving special attention by professionals of health. The workplace is being investigated as a possible place to assess and create strategies to help people to become more active [9–19]. Despite all effort, there is no consensus in the literature about the following variables related to exercise: length of intervention; duration; type of exercise; and time of the day which could be most beneficial for workers. Research conducted at two workplaces with exercise intervention, one in Brazil and another in Portugal, consisting of 15 minutes of exercise during working hours, at least three times a week, have shown some benefits on muscular pain perception and in workers social environment [17, 20]. Other studies with other types of workplace exercise intervention consisting of longer follow up, frequency and intensity improved physiological parameters, work ability and subjective perception of quality of life [21, 22, 21, 22].
Exercising at workplace is rapidly growing in Brazil and its benefits have been recognized. Nonetheless, evidence for this is limited. Additionally, the short duration of the exercises challenges the recommendation of American College of Sports Medicine [2], which recommends exercise schedules of 30 minutes a day, 5 days a week. It is hypothesized that 15 minutes of workplace exercise could have a positive effect on health behavior and willingness to become more physically active.
The Transtheoretical Model and Stages of Change (TTM) emerged in the field of psychotherapy resulted from the integration of over 300 theories. The initial studies analyzed the stages model on smoking and rapidly expanded its use to substance abuse, alcohol, anxiety, eating disorders, among others [23].
The TTM has been adapted to explain attitudes towards health and fitness behaviors, to increase physical activity, healthy behavior and develop interventions based on psychological constructs (e.g. consciousness raising, environmental reevaluation, among others) [24]. Using the concept of “stages of change”, the TTM aims to provide insights in to how people change their behavior over time. The following stages are distinguished as: (1) pre-contemplation — no intention to change behavior; (2) contemplation — considering behavior changes for the next 6 months; (3) preparation — planning changes for the next month; (4) action — actively engaging in behavioral changes in the short term (that is, for less than 6 months); (5) maintenance — sustaining the behavioral change for over 6 months [23].
The effectiveness of workplace exercise interventions on lifestyle has shown improvements on health outcomes [17–22]. Nevertheless, little research has been undertaken on how long it takes for people to start changing their behavior towards physical activity. Therefore, the aim of this study is to assess the extent to which people who engage in an exercise program at work, change their behavior over time that is going. from the pre-contemplation stage through the action stage.
Methods
Characteristics of study place
A company, in the city of Londrina located in the state of Paraná in Brazil, which had never previously had an exercise program in the workplace, was chosen by convenience to participate in this study. As a law firm, the predominant job activity was performed in the sitting position while using the computer, and as such may be regarded as a typical position of office based work. The company had 300 employees. All eligible employees were invited to attend an information session in which the content of the intervention and the study design were explained. Participants who registered themselves for the information session and who agreed to participate in the study signed a Consent Form. The protocol was approved by the Ethical Committee from the Methodist University of Piracicaba (UNIMEP) under the number 14/10.
Participants
In the first part of the research, 262 employees completed the questionnaires. Through the research process, the company went through a downsizing. This resulted in an unexpected decrease of participants; with the final sample of 165 workers; 51 employees were excluded for not attending to the workplace exercise activity twice a week; 47 people stopped working for the company. All responses were concealed, in order to mask evaluator, researchers and statistician bias.
Intervention
In Brazil, there is a growing number of companies adhering to a three times a week schedule of 15 minutes of stretching exercise. There is scarcity of evidence to support this intervention, but the absence of evidence does not mean absence of effect. Thus, the intervention proposed at the cited company was comprised of 15 minutes of stretching exercises, three mornings a week for three months at the law firm during working hours. Each session was attended by 20 to 25 participants. The exercises varied to include exercising with a broomstick, a partner, tennis balls, and rubber band so that workers would feel motivated to continue exercising.
The sessions were led by an accredited physical educator. During the physical activity sessions verbal information was provided on good health behaviors based on the workers’ interests.
Health behavior change outcome
Before starting the intervention, the TTM questionnaire [21] was applied to employees. It was composed of questions about the five TTM stages and employee’s personal information. The goal was to assess the stage of behavioral change towards exercising. After three months of involvement in the activity, the questionnaire was reapplied to observe any changes in their behavioral health/physical activity.
The questionnaire included questions relating to age, gender, marital status, education. Four questions assessed the stages of changes: 1) Do you regularly practice exercise at least 5 times a week for 30 minutes during your leisure time? 2) Have you practiced exercise for over 6 months? 3) Do you have any plans to begin exercising in the next 6 months? 4) Do you have any plans to begin exercising in the next 30 days?
If the participant responded
We dichotomize the five stages of change into physically active and physically inactive. Accordingly, physically inactive were the stages pre-contemplation (1), contemplation (2) and preparation (3); and physical active stages were maintenance (5) and action (4).
Statistical analysis
Data was entered and analyzed in the software SPSS 18. Contingency tables were used to summarize dichotomous data as absolute frequencies (n), relative frequencies (% ), and a confidence interval of 95% (95% CI) was calculated by the Wilson score method. The paired proportion test estimates from a single population was used to compare the outcomes of health behavior change related to the physical activity before and after the workplace exercise intervention. The research adopted the statistical significance of p ≤ 0.05.
Results
The final sample was composed of 165 employees whose predominant job activity was performed in the sitting position at a computer. Their average age was 24.89 ± 5.32 years. The company had a significant number of female workers (64.3% ) and approximately 58% of workers had studied up to high school level. The general characteristics are presented in Table 1.
In Table 2, the stages of behavioral changes towards physical activity, prevalence of employees physically active and physically inactive not stratified and stratified by level of education before and after intervention are shown. The number of employees physically active increased considerably after the workplace exercise intervention (13.9% , 95% CI 9.5 to 20.1; P = 0.009), showing a significant decrease of employees in the pre-contemplation stage (–6.1% , 95% CI 3.3 to 10.8; P = 0.045) and contemplation stage (–11.5% , 95% CI 7.5 to 17.3; P = 0.017) of behavior change. Inversely, there was a significant increase in the action stage (10.9% , 95% CI 7.0 to 16.6; P = 0.003).
We performed a subgroup analysis by classifying participants in physically active and physically inactive, comparing its association to educational level. Thus, a significant increased number of physically active employees among those with college degrees (5.5% , 95% CI 2.9 to 10.0; P = 0.049) and favoring high school degree, but not statistically significant (11.3% , 95% CI –0.1 to 23.9; P = 0.068).
Using elementary degree as reference value for Odds ratio (OR), we observed high school degree OR 5.5 (95% CI 3.6 to 7.4); College degree OR 4.5 (95% CI 2.6 to 6.4); Graduate OR 0.5 (95% CI –1.4 to 2.4). Elementary school degree showed similar results to Graduate degrees; High school and College degrees are similar and both are different from Elementary and Graduate degrees.
Discussion
The importance of this research was based on the theory that people need to be motivated to start practicing physical activity. It is relevant to observe that sedentary behavior is growing around the world, with increasing mortality due to non-communicable diseases [27]. Additionally, one of the principles of collective health is in creating an environment to promote change. For instance, offering exercise in the workplace; informing the benefits of having a balanced diet and practicing physical activity regularly. These are examples of interventions that help people to make the right lifestyle choices [28, 29].
In this study, 18 participants moved to the action stage, which means start exercising. One possible hypothesis is the benefits generated by the 15 minutes workplace exercise intervention motivated workers to look for more exercise in their agenda as demonstrated in Table 2.
Also in Table 2, many workers moved across behavioral stages, that is, workers who were in the pre-contemplation stage moved to contemplation stage, preparation stage or even action stage for exercising in their leisure time. Thus, we may hypothesize that the intervention performed in the study was more effective among inactive employees, possibly because of changes brought by workplace exercise. The physically active employees, perhaps, did not have such changes in behavioral stages, low intensity exercise may not provide enough stimuli to motivate people thinking about exercise.
We have observed that workplace exercise could be personalized by workers depending on their stages of behavior and the interventions could be focused using strategies to reach each specific group. In other words, TTM could be used as a screening tool prior to any workplace intervention. For instance, if workers were in the maintenance stage, we would choose strategies to fortify their behavior and give rewards to keep up this behavior. Each stage of change would have its specificities, requiring professional effort to elaborate the exercise program and goals.
Future research should include randomization and a control group to compare the effectiveness of workplace exercise. In order to start our research, we had to accept the company manager request, which was to change our research design to a quasi-experimental (without control group) to avoid interpersonal problems among workers. Thus, we suggest control groups to observe other important variables, such as, the influence of season of the year on the behavior [17, 18]. Despite new studies have shown modest effect of workplace exercise, motivating behavior change at workplace could have a great positive impact in public health [14, 32].
We also would like to propose a series of questions for future research in workplace intervention. What are the factors influencing workers behavior towards physical inactivity? What are the barriers and facilitators for workplace exercise adherence? Does initial target screening help the efficacy of workplace interventions? Many of these questions will help us to understand in detail how workers behave.
Final considerations
The workplace exercise intervention broughtsignificant changes in the health behavior related to physical activity assessed by transtheoretical model of behavioral change stages. Based on the results presented above, we suggest that fifteen minutes of stretching, at least three times per week, may help some workers to change their stages of behavior. Small initiatives such as this one might have a positive impact in wellness of workers.
It is noteworthy that workers who were physically inactive seemed to have changed their behavior positively toward exercise, which shows the importance of interventions and further studies on the topic. Therefore, we recommend the reproduction of this study in other contexts, preferably, with a bigger randomized controlled population. The results of this study have to be analyzed cautiously, because it may not be true in other contexts due to personal factors according to the environment.
Conflict of interest
There are no financial or non-financial competing interests (political, personal, religious, ideological, academic, intellectual, commercial or any other) related to this manuscript.
Authors’ contributions
AJG, FC and VS participated in the conception and design, analysis and interpretation of data, drafting the article and revising it critically for important intellectual content and final approval of the version to be published.
Footnotes
Acknowledgments
VS and AJG are grateful to CAPES (Coordination for the Improvement of Higher Education Personnel) for award of the scholarship.