Effects of a multi-behavioral health promotion program at worksite on smoking patterns and quit behavior

Abstract

BACKGROUND:

Tobacco use is associated with various severe health risks. Therefore, the need to decrease smoking rates is a great public health concern. The workplace has capability as a setting through which large groups of smokers can be reached to encourage smoking cessation.

OBJECTIVE:

The aim of the present study was to evaluate effects of a multi behavioral worksite health promotion intervention. The primary outcome was the change of smoking rate. Secondary outcomes were changes in smoking attitudes and readiness to stop smoking among employees over an intervention period of 12 months.

METHOD:

112 and 110 employees were enrolled in the intervention and control arm respectively. The intervention group received a 12-month multicomponent health promotion intervention. One of the main elements of the multicomponent intervention was a smoking cessation and counseling program. During the pilot year, participants completed a self-evaluation questionnaire at baseline and again after 12 months to related outcomes and changes.

RESULTS:

Results showed that participants’ quit behavior and smoking behavior changed over time in the intervention group (IG). Readiness to quit smoking also increased in the IG compared to the comparison group (CG). Some positive intervention effects were observed for cognitive factors (e.g., changes attitudes towards smoking). Baseline willingness to change smoking behavior was significantly improved over time.

CONCLUSIONS:

This study showed initial results of a long-term multicomponent worksite health promotion program with regard to changes in smoking behavior, attitudes towards smoking and readiness to quit smoking. The evaluation suggests that a worksite health promotion program may lead to improvements in smoking behavior for a number of workers.

Keywords

abstinence cessation health promotion quit behavior smoking

1 Background

Tobacco use is the major public health risk factor in the Western world [1]. It is associated with various severe health risks, tobacco-induced illnesses (such as lung cancer) and 4.8 million deaths yearly worldwide [2]. The need to decrease smoking rates is a great public health policy issue. Health promotion interventions to support smoking and tobacco product cessation should be considered as a standard of good practice [3, 4].

The smoking prevalence among all German employees is high at approximately 20% [5]. However, there are differences among job types with rates ranging from 16% among managers to 29% among production workers [5]. Therefore, research on smoking and cessation options is especially important among the population. A workplace intervention seems to be a potential setting for offering smokers counselling programs [6]. Worksite health promotion programs have been identified as effective to improve smoking behavior for many years.

1.1 Worksite health promotion

A focus on primary prevention (e.g. improving smoking habits, physical activity and dietary behavior) is important, as group-based interventions of smoking reduction may prove to be more effective than individual interventions.

An increasing number of studies have been performed to gain more knowledge on how to prevent smoking [7]. In addition, growing attention is given to the effects of worksite health promotion programs. As mentioned by Hutchinson and Wilson (2011), the workplace has been reflected as an adequate intervention site. Reasons include: 1. the amount of time employees spend at work, 2. access to groups of population that are difficult to reach for health promotion, 3. the chance to use peer networks, employer’s support as well as incentives [8].

Fichtenberg et al. showed that smoke-free workplaces are associated with reductions in prevalence of smoking of 3.8% (95% confidence interval (CI) 2.8% to 4.7%) and 3.1 (2.4 to 3.8) fewer cigarettes smoked per day per continuing smoker. Combination of the effects of reduced prevalence and lower consumption per continuing smoker yields a mean reduction of 1.3 cigarettes per day per employee, which corresponds to a relative reduction of 29% [9].

Fishwick et al. demonstrated in their review that smoking cessation programs at work can provide useful support for workers wishing to stop smoking. However, these programs are only likely to be effective if participants have moved beyond the contemplation stage regarding smoking cessation [10].

A review by Cahill et al. found strong evidence that some worksite interventions directed towards individual smokers increase the likelihood of quitting smoking. These include individual and group counselling, and multiple interventions targeting smoking cessation [11].

Effective interventions to prevent smoking related diseases may have economic benefits besides improvement of health and quality of life [12 –15]. Accordingly, improvements in health may lead to reduced sick leaves and/or absenteeism and thus, increased productivity and less conflicts between employed smokers and non-smokers [16 –18].

1.2 Theoretical background of the intervention design

This worksite health promotion intervention was designed with regard to the modified ecological framework [19]. Based on this model, the workplace is a system in which environmental factors can be changed in a way to encourage employees to change their health behavior [20]. The model purports that there are multiple levels or factors that influence health behavior. An ecological perspective has implications to both explain health behavior and design related health promotion interventions.

As a means to explain health behavior, the ecological approach forces one to look for the cause of a health issue or problem from multiple perspectives. For example, eating behavior may be a function of personal knowledge and attitudes about food (intrapersonal). But, it could also be influenced by peer pressure (interpersonal), healthy food choices in company vending machines (institutional), an ample supply of fresh fruits and vegetables in local groceries (community) and the available of free or reduced price lunch in schools (public policy) [21].

On an individual level, the intervention was based on the Social Learning Theory, which emphasizes self-efficacy and the role of support in behavior change [22] and on the Transtheoretical Model (TM) of Health Behavior Change [23]. The process of changing dimensions of the TH includes cognitive, affective, evaluative and behavioral strategies that an employee can use to change their smoking and health behavior [24].

As Stead & Lancaster showed the chances of quitting were doubled for those who attend group behavioral programs compared with those who receive self-help material but no face-to-face behavioral support [25]. It is currently unclear whether groups are more effective than individual counselling [25].

Group behavior sessions are offered to small groups of employees, and information, advice and behavioral intervention are provided [25]. Group support allows individuals to learn behavioral techniques, and group participants provide peer support [25]. Similar to individual counseling, group therapy is normally combined with pharmacotherapy.

1.3 Study aim

The aim of the study is to evaluate the effectiveness of a multi-component worksite intervention program in promoting smoking behavior changes, including shifts in stages of readiness to change smoking behavior, related attitudes as well as other behavioral health determinants among workers over a 12-month intervention period. Moreover, associations between socio-demographic data (e.g. gender, age) and behavioral as well as cognitive outcomes are of interest.

We hyothesized that between baseline (t0) and the end of the intervention (follow-up, t2):

A significant reduction in ‘smoking behavior/consumption’ will arise.

Significant differences in secondary outcomes on changes in behavioral smoking attitudes and ‘stages of readiness to change smoking behavior’ between the intervention and the comparison group will be identified.

2 Methods

2.1 Study design

This study was an interventional study trial. Participants who gave informed consent were measured at baseline (t0) and after twelve months at follow-up (t2).

2.2 Participants and recruitment

In total 178 employees had the chance to participate in a multicomponent worksite health promotion program (intervention group). A comparison group of employees comparable to the intervention group in socio-demographic and work-related variables (e.g. gender, age, job description, location etc.) were also included. Employees of the comparison group worked in a different but comparable work place. Smokers were included in two sub-groups: taking part in the smoking cessation intervention arm or in the comparison group.

All of them were invited for voluntary participation. Recruitment for both groups was performed via email and/or direct communication to contribute to this study.

Employees participated during paid working hours; the timetable was adapted to working hours as much as possible (e.g. before working hours, around lunch time and after working hours).

Inclusion criteria were (1) working full time, (2) being able and willing to participate for the next 12 months, and (3) agreement to complete the questionnaires. Every participant gave written informed consent and participated in an introductory session in which everyone had the chance to individually ask questions. The total sample in the intervention group consisted of 112 German-speaking employees. In the comparison group 110 employees were included.

2.3 Smoking cessation intervention

Participants in the intervention group received a twelve-month health promotion intervention. The sessions took approx. 30–45 minutes each week/two weeks and were held, for example, in a separate room at the worksite in a group setting of 15–20 participants or as individual “one on one” activity related counselling session. Frequency of coaching was at least twice per month in the course of one year. In this trail we abstained from using pharmacotherapy.

Individual behavioral counseling sessions were also performed (one on one personal development service providing the knowledge, motivation, tools you need to change smoking behavior) involved tailoring recommendations, and motivational and cognitive behavioral interventions such as increasing self-efficacy, problem solving, and goal setting skills. The individual behavioral counseling also included advice regarding how to cut down to quit (i.e., gradually reducing the number of cigarettes smoked before eventually quitting).

In addition, motivational interviewing was used designed to enhance a person’s motivation to change their behavior [26]. Smokers had the chance to learn how to identify environmental and social signals which impacted their smoking and use cognitive and behavioral methods to break the link between the cue and smoking [7].

We included individual behavioral counseling that involved scheduled face-to-face appointments with a trained smoking cessation counselor.

2.4 Physical training

In addition, participants had the chance to complete physical activity training. It focused on general body strength training. The training included exercises such as back extension, shoulders and arms, particularly with regard to the occupational exposure. The exercises were conducted with repetitions until muscular exhaustion. This cycle lasted for about 30 minutes every week. Moreover, the trainers talked about the relevance of health enhancing physical activity.

2.5 Outcome assessments

Outcome assessments occur at baseline (t0), after the end of the intervention (t1) and after twelve months (t2). Participants were mailed a questionnaire 12 months after the intervention had started (follow-up).

The assessment focused on smoking and diverse behavior changes. Primary results of worksite health intervention related to smoking outcomes have been evaluated on the following types of outcome measures:

self-reported continuous abstinence defined as having smoked no cigarettes since quit day

changes in smoking behavior,

changes in smoking attitudes and stages of readiness to change smoking practices

2.6 Smoking behavior

The primary study outcome was self-reported continuous abstinence after 12 months. The Smoker Questionnaire [27] documented sociodemographic information, smoking history and smoking behavior at baseline and follow-up (see Table 1). In case the participants were still smoking at the assessment point, they were asked about the number of cigarettes smoked per day.

2.7 Smoking attitudes and stages of readiness to change smoking behavior

In addition, attitudes towards changes in smoking behavior were assessed (see Table 3). The assessment of the “readiness to change smoking behavior” stages represent ordered categories of motivational readiness to change (pre-contemplation, contemplation, preparation, action, maintenance) and was based on the recommendations of Prochaska et al. (2005). Response options for this question were categorical: ‘I do not want to change anything (pre-contemplation), “considering a change” (contemplation), “making plans to change” (preparation) and “I started doing this” (action, maintenance” [28].

2.8 Confounders

At baseline, data on potential confounders were assessed, including age, gender, marital status (defined by the following categories: married/partnership/single/divorced/widowed).

2.9 Statistical analyses

Descriptive statistics and smoking related variables were analyzed using frequency distributions and means with standard deviations.

Chi-square and t-tests determined significant differences and associations of socio-demographics, smoking behavior, attitudes towards smoking. Multiple logistic regression models were performed to determine predictors of significant smoking reduction. In addition, we performed linear mixed effect models with the outcome measures as the dependent variable, group (intervention vs. comparison group) as independent variable and time of follow-up measurements as fixed factor, while adjusting for the baseline levels of the outcome measure. A P-level of <0.05 was considered to indicate statistical significance. All statistical analyses were performed using SPSS (Version 23).

Table 1
Assessment of smoking behavior

Variable Responses

Tobacco use in last 30 days Yes/No/Don’t know

Type of tobacco use Cigarettes/Cigars/Pipe/Chewing/Other

Frequency of use Everyday/some days/not at all/don’t know (quantified for each type of tobacco by uses per day and any-use days in the last 30 days)

Intention to quit within next 30 days Yes/No/Don’t know (for each type of tobacco use)

Since registering has participant stopped use for ≥24 hours Yes/No/Don’t know

Cessation product/medication use since registering Yes/No/Don’t know If yes ⟶ type

Variable	Responses
Tobacco use in last 30 days	Yes/No/Don’t know
Type of tobacco use	Cigarettes/Cigars/Pipe/Chewing/Other
Frequency of use	Everyday/some days/not at all/don’t know (quantified for each type of tobacco by uses per day and any-use days in the last 30 days)
Intention to quit within next 30 days	Yes/No/Don’t know (for each type of tobacco use)
Since registering has participant stopped use for ≥24 hours	Yes/No/Don’t know
Cessation product/medication use since registering	Yes/No/Don’t know If yes ⟶ type

A statistical power analysis was performed and indicated that a sample size of 112 participants provides statistical power (two-tailed, alpha = 0.05) of >85%. Therefore, size of the included study groups was considered as adequate for an intervention study.

2.10 Ethics

The study was approved by the Ethics of the Medical Faculty of the Charité Universitätsmedizin Berlin. The ethical aspects were in full agreement with the Helsinki declaration. Rules and regulations of the Research Ethics Board were fulfilled.

3 Results

3.1 Socio-demographic variables

Table 2 presents the characteristics of the participants (intervention and comparison group). At baseline 112 of the participants were smokers in the intervention group (27% male/73% female); 100 smokers in the control group (21% male / 78% female).

Table 2
Comparison between intervention and comparison group at baseline

Intervention group Comparison group

Variables N M (SD) N M (SD) P

Age 112 44.4 (10.2) 110 43.1 (10.5) .35

Smoking duration (years) 111 19.7 (10.9) 110 21.1 (10.3) .33

Smoking intensity (per day) 109 21.5 (8.1) 106 22.1 (9.1) .63

Age of smoking initiation 110 16.2 (2.9) 109 15.8 (3.1) .32

Number of previous quit attempts 108 3.1 (4.5) 105 2.9 (4.3) .74

	Intervention group	Comparison group
Age	112	44.4 (10.2)	110	43.1 (10.5)	.35
Smoking duration (years)	111	19.7 (10.9)	110	21.1 (10.3)	.33
Smoking intensity (per day)	109	21.5 (8.1)	106	22.1 (9.1)	.63
Age of smoking initiation	110	16.2 (2.9)	109	15.8 (3.1)	.32
Number of previous quit attempts	108	3.1 (4.5)	105	2.9 (4.3)	.74

Most of the participants in the intervention group were in the age groups between 41 and 60 years (73.4%); only 8% were under 30, 17.3% were in the age group of 31 to 40 years. Mean age of the participants was 44 years (SD = 10.2) (see Table 2).

We found no significant differences between the intervention group and comparison group characteristics at baseline with regard to relevant socio-demographic factors (i.e. age, gender, smoking duration, daily smoking intensity, number of previous quit attempts (see Table 2).

3.2 Dropout attribution

There was a total drop-out rate (from the beginning to analyses) of 37%. Reasons why participants decided not to finish the study included illness, participants did not show up. Participants who did not provide all follow-up data did not differ in a meaningful way from those who provided data, neither on the primary outcome or any other baseline outcomes (P > 0.05).

3.3 Changes in smoking behavior

Participants’ abstinence rate after 12 months was slightly higher in the intervention group compared to the control group. However, this variance didn’t reach statistical significance (18% vs. 7%, Diff = 11%, P = 0.31).

Differences in self-reported quit rate in t2 were not significantly different within the intervention group (P = 0.58).

The average number of cigarettes smoked per day for those who relapsed was lower on average by 4.1 after 12 months respectively in the intervention group as compared to the control group. However, such differences were not statistically significant (P > 0.05).

3.4 Attitudes to changes in smoking behavior

Attitudes to changes in smoking behavior were similar in the intervention group and comparison group at baseline. As illustrated in (Table 3), few significant differences and improvements in smoking attitudes between baseline (t0) and follow-up (t2) (intervention group) were found. A significant group×time interaction for ‘want to change ... smoking less‘could be found (Table 3).

Table 3
Changes in smoking attitudes between participants in the intervention and comparison group (baseline vs. follow-up)

What do you want to change... Baseline Follow-up Baseline Follow-up P Valueª

n(%) n(%) n(%) n(%)

intervention intervention control control

group group group group

(N = 112) (N = 109) (N = 100) (N = 95)

Quit smoking <.05

... yes 22 (20) 45 (41) 27 (27) 29 (30)

... no 37 (33) 23 (21) 32 (32) 30 (31)

... undecided 53 (47) 41 (38) 41 (41) 37 (39)

Smoking less <.05

... yes 54 (48) 62 (57) 43 (43) 43 (45)

... no 24 (21) 20 (18) 30 (30) 25 (27)

... undecided 34 (31) 27 (25) 27 (27) 27 (28)

What do you want to change...	Baseline	Follow-up	Baseline	Follow-up	P Valueª
Quit smoking					<.05
... yes	22 (20)	45 (41)	27 (27)	29 (30)
... no	37 (33)	23 (21)	32 (32)	30 (31)
... undecided	53 (47)	41 (38)	41 (41)	37 (39)
Smoking less					<.05
... yes	54 (48)	62 (57)	43 (43)	43 (45)
... no	24 (21)	20 (18)	30 (30)	25 (27)
... undecided	34 (31)	27 (25)	27 (27)	27 (28)

^*Notes: M- mean; SD- standard deviation. ^aP < 0.05 is significant.

Changes in smoking attitudes (“want to quit smoking”) slightly improved in the comparison group (but not significantly). Baseline readiness to smoke less was not significantly improved over time.

3.5 Readiness to change smoking behavior

Participants of the intervention group progressed between baseline and follow-up in stages of readiness to change smoking behavior (P = 0.012; see Table 4). Significant differences were found between the intervention and comparison group (P = 0.04 for group×time interaction).

Table 4
Smoking behavior: stages of change from baseline to follow-up

Stage of Change

Pre-contemplation Contemplation Preparation Action/Maintenance P Value

n(%) n(%) n(%) n(%)

Intervention-group

Baseline (n = 112) 14 (12) 30 (26) 45 (41) 23 (21) <.05

Follow-up (n = 109) 9 (8) 14 (13) 53 (49) 33 (30)

Comparison

Baseline (n = 100) 16 (16) 25 (25) 37 (37) 22 (22) >.05

Follow-up (n = 95) 17 (18) 22 (23) 38 (39) 18 (20)

	Stage of Change
Intervention-group
Baseline (n = 112)	14 (12)	30 (26)	45 (41)	23 (21)	<.05
Follow-up (n = 109)	9 (8)	14 (13)	53 (49)	33 (30)
Comparison
Baseline (n = 100)	16 (16)	25 (25)	37 (37)	22 (22)	>.05
Follow-up (n = 95)	17 (18)	22 (23)	38 (39)	18 (20)

Notes: P < 0.05 is significant.

Changes in the proportion of the participants at each stage were evaluated and the relationship between stage changes were examined (see Table 4).

18% of the participants (intervention group) exhibited an increase in readiness to change their smoking behavior. A total of 13% of the participants, among those who were in the precontemplation/contemplation/preparation stage at the baseline switched to the action/maintenance stage after twelve months.

Only three participants among the participants, who were in the action/maintenance stage at the baseline, went back to a stage of the pre-contemplation/contemplation/preparation stage.

Readiness to make smoking behavioral changes did not improve significantly in the comparison group.

No significant gender differences were analyzed (P = 0.41): both male and female workers of the intervention group showed significant differences in readiness to change between t0 and t2 (P = 0.001).

Predictors associated with smoking as opposed to quitting at 12 months were years of smoking and number of cigarettes per day.

In detail, the higher the number of years of smoking or the number of cigarettes smoked per day, the more likely the person relapsed and/or smoked at follow-up at 12 months (RR = 1.89, 95% CI 1.18, 3.11 p = 0.007 for years of smoking).

4 Discussion

The study evaluates a twelve-month work site health promotion program. One of the main components for smokers was smoking cessation in combination with physical activity training.

The hypothesis of the current study, that a smoking cessation intervention during a behavioral program is effective, was partly corroborated by the results of this study.

At no point in the follow-up data collection did the two groups evince significantly different abstinence rates. Further, the interventions did not differentially affect participants relevant terms of smoking behavior changes.

Despite twelve months of intervention, a satisfactory adherence was obtained with a normal drop-out after twelve months. In summary, positive effects on smoking attitudes and readiness for change have been illustrated twelve months after the beginning of the intervention.

4.1 Changes in abstinence rates

We expected a significant abstinence rate increase after twelve-month worksite health promotion. However, the results showed a non-significant trend in this direction.

In this study, the smoking cessation rates in the intervention group were better than those in the control group; however this difference did not reach statistical significance. These findings are inconsistent with some other smoking cessation studies conducted elsewhere. For example, in one randomized controlled study from Switzerland, smokers were randomly assigned to intervention and control groups in order to evaluate the effectiveness of a structured smoking-cessation program. The abstinence rate was 37% at follow-up at 24 months (P > 0.05 for all). However, this study also included intensive nicotine replacement besides intensive counselling. In contrast to our study, this smoking cessation intervention at the workplace achieves high, stable, long-term abstinence rates [29].

In a comparable one year worksite smoking cessation program study performed by Glasgow et al. no significant improvements on cessation rates were analyzed. The authors concluded that more broadly focused interventions that also address worksite smoking policies, skills training, and cessation resources, or programs that target additional risk factors are needed to substantially enhance quit rates [30].

In summary, a recently published review by Cahill & Lancaster found strong evidence that some interventions directed towards individual smokers increase the likelihood of quitting smoking. These include individual and group counselling to overcome nicotine addiction, and multiple interventions targeting smoking cessation as the primary or only outcome [11]. However, the authors also declared that employees taking up these smoking cessation sessions are more likely to stop; but the absolute records of quitting are quite low. For further research, effects of comprehensive programs targeting multiple risk factors in reducing the prevalence of smoking should be implemented and evaluated [11].

In a recent Cochrane review the authors did not detect evidence that group therapy was more effective than a similar intensity of individual counselling. There is not enough evidence to evaluate whether groups are more effective, or cost-effective, than intensive individual counselling. In addition evidence of programs which included components for increasing cognitive and behavioral skills were not shown to be more effective than same-length or shorter programs without these components [31].

4.2 Readiness to change smoking behavior

Employees’ readiness to change their smoking behavior demonstrated an improvement over time. In the intervention group, the participants’ stage advanced and 30% of the participants were in the action/maintenance stage at the end of the health program. Our results indicated that a workplace health promotion program may encourage smoking changes in the participants. Likewise, other studies including behavioral components in health interventions illustrated even higher effects [32, 33].

As illustrated, participants in the intervention group did not show significant differences for some outcome variables compared to the comparison group; many-sided interpretations are reasonable. Possible explanations for this might be that the measurement of the determinants was not sufficiently sensitive to distinguish significant differences.

It is also possible that the baseline assessment triggered participants in the comparison group to change their lifestyles and this may have affected results. For example, participants in the comparison group also improved on outcome variables (e.g. readiness to change) similar to the intervention group.

In addition, the timing of the assessments could be a limitation explaining the absence of significant effects. Previous studies evaluating the effectiveness of worksite health programs found short-term effects straight after the final session of the intervention reasonable to assume that the effects of our intervention wore off before the follow-up measurement [34].

4.3 Physical activity during smoking cessation

In addition, as proved in this study, several studies also implemented and verified the supportive effect of physical activity during smoking cessation to reduce tobacco-related cravings [35], negative affect, and withdrawal symptoms [36] and is believed to be a potentially useful strategy for supporting tobacco abstinence [37, 38]. Therefore we would recommend to include physical activity training elements in further smoking cessation interventions.

5 Strength and limitations

This study examines the effectiveness of a one year worksite intervention targeting changes in smoking behavior and related attitudes as well as readiness to change in a quasi-experimental comparison group study design. An important strength of this study is the length of the intervention with twelve months. A further strength is that the intervention was designed for this target worker population.

Even with these study strengths, our investigation does have some limitations. First, this study was not randomized; the group was self-selected which may limit the generalizability of results on program effectiveness. This evaluation study is further limited by the nature of the data, which were self-reported.

However, with having twelve months between baseline and follow-up, the self-report bias may have been minimized since participating workers can be assumed of not being able to remember the questions and responses of the baseline questionnaire.

6 Conclusion

We demonstrated initial results of a one year multicomponent worksite health promotion program with regard to changes in smoking behavior, motivation and attitudes. The evaluation suggests that a worksite health promotion program may lead to preliminary improvements in smoking behaviors for a number of workers. An investigation of long-term effects of this multicomponent intervention is strongly recommended.

The results clearly illustrate the difficulty faced by tobacco smokers to quit smoking for a prolonged time despite structured smoking cessations and health promotion. This should not undermine the role of long-term smoking interventions and what could be achieved in reducing the smoking rate. In contrast, more efforts should be exerted to strengthen health promotion programs and to increase the abstinence rate. In sum, these findings from the twelve-months pilot study suggest that a worksite health promotion program may support smokers in changing their motivation to quit smoking and their attitudes even not using pharmacotherapy.

Conflict of interest

None to report.

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	Intervention group		Comparison group
Variables	N	M (SD)	N	M (SD)	P
Age	112	44.4 (10.2)	110	43.1 (10.5)	.35
Smoking duration (years)	111	19.7 (10.9)	110	21.1 (10.3)	.33
Smoking intensity (per day)	109	21.5 (8.1)	106	22.1 (9.1)	.63
Age of smoking initiation	110	16.2 (2.9)	109	15.8 (3.1)	.32
Number of previous quit attempts	108	3.1 (4.5)	105	2.9 (4.3)	.74

	Stage of Change
	Pre-contemplation	Contemplation	Preparation	Action/Maintenance	P Value
	n(%)	n(%)	n(%)	n(%)
Intervention-group
Baseline (n = 112)	14 (12)	30 (26)	45 (41)	23 (21)	<.05
Follow-up (n = 109)	9 (8)	14 (13)	53 (49)	33 (30)
Comparison
Baseline (n = 100)	16 (16)	25 (25)	37 (37)	22 (22)	>.05
Follow-up (n = 95)	17 (18)	22 (23)	38 (39)	18 (20)