Workplace Physical Activity Interventions: A Systematic Review

Literature Review: Workplace Physical Activity Interventions

Workplace Physical Activity Interventions:A Systematic ReviewQuyen G. To, MPH; Ted T. L. Chen, PhD; Costan G. Magnussen, PhD; Kien G. To, MPH

Abstract

Objective.To assess the effectiveness of workplace interventions in improving physical activity.Data Source. EBSCO research database (and all subdatabases).Study Inclusion and Exclusion Criteria. Articles were published from 2000 to 2010 in English, had

appropriate designs, and measured employees’ physical activity, energy consumption, and/or body massindex (BMI) as primary outcomes. Articles that did not meet the inclusion criteria were excluded.

Data Extraction. Data extracted included study design, study population, duration, interventionactivities, outcomes, and results.

Data Synthesis. Data were synthesized into one table. Results of each relevant outcome including pvalues were combined.

Results. Twelve (60%) of 20 selected interventions reported an improvement in physical activity level,steps, or BMI, and there was one slowed step reduction in the intervention group. Among these, 10 wereless than 6 months in duration; 9 used pedometers; 6 applied Internet-based approaches; and 5 includedactivities targeting social and environmental levels. Seven of 8 interventions with pre-posttest and quasi-experimental controlled design showed improvement on at least one outcome. However, 7 of 12 randomizedcontrolled trials (RCTs) did not prove effective in any outcome.

Conclusion. Interventions that had less rigorous research designs, used pedometers, applied Internet-based approaches, and included activities at social and environmental levels were more likely to reportbeing effective than those without these characteristics. (Am J Health Promot 2013;27[6]:e113–e123.)

Key Words: Physical Activity, Review, Workplace, Worksite, Intervention, Exercise, HealthPromotion, Effectiveness. Manuscript format: literature review; Setting: workplace; Healthfocus: fitness/physical activity, weight control; Strategy: education, skill building/behaviorchange; Target population age: adults; Target population circumstances: all education levels,all income levels, all locations, all races/ethnicities

OBJECTIVE

Physical activity is an importantlifestyle factor that contributes to im-proved health and prevention ofchronic conditions such as obesity,osteoporosis, diabetes, cardiovasculardiseases, stroke, and cancer.1,2 Howev-er, Americans—as are most industrial-ized populations—are not sufficientlyactive. In 2005, 23.7% of Americanadults reported no leisure-time physi-cal activity.3 In addition, more than athird do not meet minimum physicalactivity levels as recommended by thePhysical Activity Guidelines for Ameri-cans 20084 (at least 150 min/wk ofmoderate intensity, or 75 min/wk ofvigorous intensity physical activity, oran equivalent combination of moder-ate and vigorous intensity physicalactivity). The importance of physicalactivity promotion was emphasized byHealthy People 2020,5 which identified15 objectives for physical activity.

The workplace is considered to bean important and ideal setting forhealth promotion interventions.6–10 Inaddition to the potential to access alarge proportion of employed popula-tions,11 the workplace has a captive andrelatively stable population and pro-vides a setting where multilevel inter-ventions—intrapersonal, interperson-al, organizational, and environ-mental—can be facilitated.8–10,12

Moreover, individuals can spend morethan a third of their waking hours atwork, so the potential for exposure toworkplace intervention activities isconsiderable. Despite these favorablecharacteristics for intervention, theeffectiveness of current workplacephysical activity interventions is un-clear.13,14 Therefore, this review aimsto answer the question concerning

Quyen G. To, MPH, is with the Department of Health Promotion, Education, andBehavior, University of South Carolina, Columbia, South Carolina, and CommunityHealth Sciences, Tulane School of Public Health and Tropical Medicine, New Orleans,Louisiana. Ted T. L Chen, PhD, is with Community Health Sciences, Tulane School ofPublic Health and Tropical Medicine, New Orleans, Louisiana. Costan G. Magnussen,PhD, is with the Research Centre of Applied and Preventive Cardiovascular Medicine,University of Turku, Turku, Finland, and the Menzies Research Institute Tasmania,University of Tasmania, Hobart, Australia. Kien G. To, MPH, is with the Faculty of PublicHealth, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam, and the Schoolof Public Health, Curtin University, Perth, Australia.

Send reprint requests to Quyen G. To, MPH, Tulane School of Public Health and TropicalMedicine, New Orleans, LA 70112; [email protected].

This manuscript was submitted April 24, 2012; revisions were requested July 3 and November 9, 2012; the manuscript wasaccepted for publication November 20, 2012.

Copyright � 2013 by American Journal of Health Promotion, Inc.0890-1171/13/$5.00 þ 0DOI: 10.4278/ajhp.120425-LIT-222

American Journal of Health Promotion July/August 2013, Vol. 27, No. 6 e113

For individual use only.Duplication or distribution prohibited by law.

whether or not workplace interven-tions are effective in promoting andincreasing physical activity.

METHODS

Data SourcesA literature search for studies was

conducted using all subdatabases(MEDLINE, Academic Search Com-plete, CINAHL, ERIC, PsycINFO, etc.)integrated in the EBSCO researchdatabase to reduce the chance ofmissing any important articles. Thesearch terms included the following:‘‘physical activity,’’ ‘‘exercise,’’ ‘‘work-site,’’ ‘‘workplace,’’ ‘‘intervention,’’ and‘‘program,’’ which created eight com-binations representing ‘‘physical activ-ity OR exercise’’ AND ‘‘workplace ORworksite’’ AND ‘‘intervention OR pro-gram.’’ A filter was set to select onlypeer-review articles that were published

within a 10-year period from 2000 to2010. Because the technique andmethod of designing interventions maychange over time in concert withtechnology development, the authorshoped that by limiting the articles tothis time frame, the interventionswould be more homogeneous. Therewere 319 articles found.

Inclusion and Exclusion CriteriaThe process of selecting articles for

review began by reading abstractsagainst the inclusion criteria: (1) arti-cles selected should be in English; (2)their design should be a randomizedcontrolled trial (RCT), controlledquasi-experiment, or single pre-post-test; (3) the interventions should beconducted in workplaces with employ-ees as participants; and (4) theseinterventions should measure primaryoutcomes of physical activity, energyconsumption, or body mass index

(BMI). After eliminating duplicates(37 articles), reviews (18 articles), andthose that did not meet the inclusioncriteria (such as irrelevant topics,participants not employees, setting notthe workplace, articles editorial orreport style, unclear or ineligible de-signs), 20 articles were eligible andincluded for review. The Figure illus-trates the flow of how studies wereselected for reviewing.

Quality Assessment of StudiesTwo independent evaluators as-

sessed the quality of studies based onthe criteria that were developed by 33international experts using the Delphitechnique.15 This list includes eightquestions: (1a) Was a method ofrandomization performed? (1b) Wasthe treatment allocation concealed?(2) Were the groups similar at baselineregarding the most important prog-nostic indicators? (3) Were the eligi-bility criteria specified? (4) Was theoutcome assessor blinded? (5) Was thecare provider blinded? (6) Was thepatient blinded? (7) Were point esti-mates and measures of variability pre-sented for the primary outcomemeasures? (8) Did the analysis includean intention-to-treat analysis? However,in consideration of the nature ofcommunity-based interventions, thefifth and sixth criteria were excludedfrom the list. For the remaining crite-ria, the evaluators assigned yes ¼ 1point, no ¼ 0 points, don’t know ¼ 0points or N/A. Therefore, the maxi-mum score was 7. The percentage ofinterobserver agreement was calculat-ed to assess the concurrence betweenthe two evaluators. Disagreements werediscussed between both evaluators, andif they could not be resolved, the firstauthor made the final decision. Kappastatistics are also reported.

Data Extraction and Data SynthesisThe information extracted included

study design, study population, dura-tion of interventions, intervention ac-tivities, outcomes, and results ofinterventions. Study designs weregrouped into three types: pretest andposttest without control group, RCT,and quasi-experimental study withcontrol group. The sample size, type ofworkplace, and country of each inter-vention were also extracted. Interven-tion activities were summarized and

Figure

Literature Search Diagram

e114 American Journal of Health Promotion July/August 2013, Vol. 27, No. 6


synthesized. Outcomes of interest in-cluded physical activity, BMI, energyconsumption, and those relating tothese outcomes. Only results of theseoutcomes were extracted and synthe-sized. Statistically significant differencewith p , .05, p , .001, and p , .0001are indicated as (þ), (þþ), and (þþþ),respectively, whereas (�) indicates lackof statistical evidence of effectiveness.If there was a positive change but the pvalue was not reported, or if there was amarginal change, (þ/�) is displayed.

RESULTS

Study DesignAmong 20 interventions, there were

three single pretest and posttest stud-ies,16–18 five quasi-experimental con-trolled studies,19–23 and 12 RCTs.24–35

The duration of interventions rangedfrom 6 weeks to 2 years, with one studyconducting follow-up measures for 6years.33 Nine interventions were con-ducted in the UnitedStates16,20,21,23,26,31–33,35; two each in

Belgium,19,34 Canada,17,29 and theNetherlands25,30; and one each inAustralia,18 Denmark,28 and Switzer-land.22 Two interventions were multi-national, including one in the UK,Australia, and Spain24 and one in theUnited States and Canada,27 Althoughmost of the interventions focused onlyon physical activity, six also targetednutrition.20,26,31–33,35

Quality Assessment of StudyMethodology

Interobserver agreement was 93.4%.Kappa was 0.86, indicating an ‘‘almostperfect’’ agreement.36 Table 1 displaysthe overall quality of studies resultingfrom the independent assessment.Most studies received scores of 3points,21,24,27,29,31,33,35 while six studiesreceived scores of 2 points16,19,22,23 and1 point.17,18 The other six studiesreceived scores of 4 points25,26,28,32 and5 points.30,34

Sample Size and CharacteristicsTable 2 summarizes the reviewed

studies. The total population of all 20

studies was 9865, ranging from 35 to1442 participants. Participants wereemployees from various organizations.Six studies recruited employees fromsocial and government-related agen-cies16,17,19,22,25,28; five from academicsettings or medical centers18,20,24,26,32;two from manufacturing plants21,35;one from a financial service firm,23

Home Depot offices,27 bus garages,31

and fire departments.33 Two studiesrecruited participants from multipleorganizations, which included a re-gional health authority, a postsecond-ary institution, and a municipalgovernment29 for one study, and com-mercial settings and local governmentinstitutes for the other.34 One study didnot provide information about theorganization.30

There was only one study that didnot report any characteristics of thesample.27 One study35 had 45% ofparticipants being 40 years old or older(mean age was not reported). Meanage of participants was 31 in oneintervention,30 and 38 or above in theothers. Although one study37 did not

Table 1Quality Assessment of Studies

1a. Was a

Method of

Randomization

Performed?

1b. Was the

Treatment

Allocation

Concealed?

2. Were the

Groups Similar

at Baseline?

3. Were the

Eligibility

Criteria

Specified?

4. Was the

Outcome

Assessor

Blinded?

5. Was the

Care Provider or

Interventionist

Blinded?

6. Was the

Patient or

Participant

Blinded?

7. Were the

Point Estimate

and Measures

of Validity

Presented for

the Primary

Outcome

Measures?

8. Did the

Analysis

Include an

Intention-

to-Treat

Analysis?

Total

Score

(maximum

of 7)

1. Faghri et al. (2008)16 0 0 N/A 1 0 N/A N/A 1 0 2

2. Chan et al. (2004)17 0 0 N/A 0 0 N/A N/A 1 0 1

3. Shaw et al. (2007)18 0 0 N/A 0 0 N/A N/A 1 0 1

4. De Cocker et al. (2009)19 0 0 0 1 0 N/A N/A 1 0 2

5. Touger-Decker et al. (2010)20 0 0 1 1 0 N/A N/A 1 0 3

6. Yap et al. (2008)21 0 0 1 1 0 N/A N/A 1 0 3

7. Titze et al. (2001)22 0 0 1 0 0 N/A N/A 1 0 2

8. Gemson et al. (2008)23 0 0 1 1 0 N/A N/A 0 0 2

9. Gilson et al. (2009)24 1 0 1 0 0 N/A N/A 1 0 3

10. Proper et al. (2003)25 1 0 0 1 1 N/A N/A 1 0 4

11. Sternfeld et al. (2009)26 1 0 0 1 0 N/A N/A 1 1 4

12. Dishman et al. (2009)27 1 0 0 1 0 N/A N/A 1 0 3

13. Pedersen et al. (2009)28 1 0 0 1 1 N/A N/A 1 0 4

14. Plotnikoff et al. (2007)29 1 1 0 0 0 N/A N/A 1 0 3

15. Slootmaker et al. (2009)30 1 0 1 1 0 N/A N/A 1 1 5

16. French et al. (2010)31 1 0 0 1 0 N/A N/A 1 0 3

17. Siegel et al. (2010)32 1 0 1 1 0 N/A N/A 1 0 4

18. MacKinnon et al. (2010)33 1 0 1 0 0 N/A N/A 1 0 3

19. Spittaels et al. (2007)34 1 0 1 1 0 N/A N/A 1 1 5

20. Campbell et al. (2002)35 1 0 0 1 0 N/A N/A 1 0 3



Table 2Summary of Studies Examining Workplace Physical Activity Interventions†

Study Study Design

Study Population

(No.)

Duration of

Intervention Intervention Activities

Main

Outcomes

Physical Activity

Measure Results*

1. Faghri

et al. (2008)16

Pre-posttest 206 participants (two

state agencies in the

United States)

10 wk � Pedometers delivered

� Walking teams

� Weekly motivational e-mails

� Information, instructions and monthly

newsletter posted on the Web site

� Online maps with colored routes

and associated distances.

No. of steps Pedometers þPhysical activity Questionnaires þBMI �

2. Chan et al.

(2004)17

Pre-posttest 177 participants (five

governmental-funded

agencies in Canada)


� Weekly meetings for 30–60 min

in the first 4 wk to be trained on

setting and achieving individual

goal of steps per day

No. of steps Pedometers þBMI þ

3. Shaw et al.

(2007)18

Pre- posttest 23 participants at

Caulfield General

Medical Centre

(CGMC) in Melbourne

3 mo � Delivered pedometer to participants

who were required to record the number

of steps taken each day and return the

log book to win a motivational prize

No. of steps Pedometers þþPhysical activity Questionnaires

adapted from

Active Australia

Survey

þ

4. De Cocker

et al. (2009)19

Quasi-experimental

controlled study

298 participants (a

social services

company in Belgium)


� Goal setting

� E-mails with messages and instructions

� Informative and reminding e-mails

� Flyers, posters on strategic places

� Staircase promotion, walking circuit

� Worksite step competition

� New Year’s wishes and feedback

on the competition

Physical activity IPAQ �No. of steps Pedometers �BMI �

5. Touger-Decker

et al. (2010)20

Quasi-experimental

controlled study

137 participants (an

academic health

science center in the

United States)

12 wk, but also

follow-up at

week 26

� In-person group: weekly group

sessions with registered dietitian

� Internet-based group: weekly session content

and materials received online; forums for

discussing with RD and other IB groups

� Pedometers were delivered but not measured

Physical activity IPAQ þ/�Body weight þþþ

6. Yap et al.

(2009)21

Quasi-experimental

controlled study

73 participants (two

manufacturing

factories in the

United States)

6 wk � Control group: weekly untailored e-mail

messages on general health without

physical activity information or Web

site access

� Intervention group: weekly e-mail

messages tailored to individual

stages of change, Web site access

� Accelerometers were delivered

No. of steps Accelerometers þ

7. Titze et al.

(2001)22

Quasi-experimental

study

598 participants

(Department of Inner

Affairs of Swiss

government, six

intervention offices,

two control offices)

4 mo � Written information about physical activity

recommendations, health benefits, ways to

increase physical activity, and stretching

exercises at the photocopier

� Information about sport facilities nearby

� ‘‘Action days’’ to encourage the use of stairs,

cycling, or walking to work

� Walks, bird watching, fitness lesson with experts

at lunch breaks

� ‘‘Gymnastic breaks’’ in the morning, fitness tests,

and hiking days

� Physical activity counseling was provided

Physical activity Modified PAFQ þ



Table 2, Continued

Study Study Design

Study Population

(No.)

Duration of


Main

Outcomes

Physical Activity

Measure Results*

8. Gemson et al.

(2008)23

Quasi-experimental

study

553 participants from

seven sites of a

multinational, financial

services firm in the

United States

12 mo � Control group: hypertension screening program,

wallet-sized health information cards, educational

brochure

� Intervention group: received the same as control

group plus pedometer, poster placed at screening

station, wallet-sized health information card with

extra information, three brief messages

Vigorous physical

activity

Questionnaires þ/�

Use of pedometers

(%)

þ/�

BMI þ

9. Gilson et al.

(2009)24

RCT 214 participants

(universities in UK,

Australia, Spain)

10 wk � Control group: weekly e-mails to remind of

maintaining normal activities

� Intervention group 1: asked to walk more using a

route during work breaks and weekly e-mails;

maps with step counts and time (10 min–45 min)

provided

� Intervention group 2: asked to walk more during

the work tasks and weekly e-mails

� Pedometer diaries were used to record the steps

and extra activities or unusual work days

No. of steps: group 1 Pedometers þþNo. of steps: group 2 þTime of sitting �

10. Proper et al.

(2003)25

RCT 299 participants (three

municipal services in

the Netherlands)

9 mo � Control group: written information on lifestyle

factors

� Intervention group: seven individual counseling

sessions of 20 min each using the PACE

materials; and written information on lifestyle

factors

BMI �Physical activity PAR þ

11. Sternfeld et al.

(2009)26

RCT 787 participants

(administrative offices

of a health care

organization in the

United States)

16 wk with a

follow-up at 8

mo after

intervention

period

� Based on the selected behavioral paths,

participants from each group accordingly received

e-mail messages individually tailored, Web site

support, educational materials, tracking and

simulation tools to support participant reach the

weekly goals

Walking þþSedentary behavior þPhysical activity PAQ þþ

12. Dishman et al.

(2009)27

RCT 1442 participants (16

worksites of the Home

Depot in the United

States and Canada)

12 wk � Control group: monthly educational messages

� Intervention group: handbooks with instructions

on pedometers as well as information and tools to

assist participants set and achieve individual

goals; teams established and results among

teams, sites compared biweekly; incentives given

to both individuals, teams and sites achieving the

goals

� Pedometers delivered

� Organizational actions: senior management

endorsement, joint employee-management

steering committees, group and organizational

goals and incentives, environmental prompts

Physical activity IPAQ þNo. of steps Pedometers þ/�

13. Pedersen et al.

(2009)28

RCT 549 participants (nine

offices of a public

administration

authority in Denmark)

1 yr � Specific resistance training group: three weekly

20-min sessions to strengthen the muscles

� All-round physical exercise group: steppers

placed at different points, 8-min CD-based

exercise program, an introductory sessions 1–4

times per month, two campaigns to encourage

participants increase their physical activity

� Reference intervention group: group

establishment to improve the knowledge on

health and working conditions

Physical activity IPAQ �



Table 2, Continued

Study Study Design

Study Population

(No.)

Duration of


Main

Outcomes

Physical Activity

Measure Results*

14. Plotnikoff et al.

(2007)29

RCT 887 participants (a

regional health

authority, a

postsecondary

institution, a municipal

government in

Alberta, Canada)

1 yr � Control group: no activity

� Intervention group 1: stage matched booklets

� Intervention group 2: Canada’s Physical Activity

Guide and handbook

Physical activity GLTEQ �

15. Sloothmaker

et al. (2009)30

RCT 102 participants (eight

worksites around

Amsterdam,

Netherlands)

3 mo, with a

follow-up at 8

mo after

intervention

period

� Intervention group: PAM software and the Web-

based tailored physical activity advice (PAM

COACH)

� Control group: a single brochure with information

about health benefits of physical activity and

physical activity recommendations.

Physical activity AQuAA �BMI �

16. French et al.

(2010)31

RCT 1123 participants in four

bus garages (two

urban and two

suburban) in

Minneapolis, United

States

18 mo � Forming garage advisory groups

� Improve fitness facilities

� Scales placed in restrooms and fitness rooms

� Self-weighing team competition with incentives

� Team walking competitions, fitness classes (yoga,

tai chi)

� Route H garage expo: demonstrating various

physical activities

� New driver weight gain prevention peer-mentoring

program

Physical activity GLTEQ �BMI �

17. Siegel et al.

(2010)32

RCT 413 participants in eight

intervention schools

and eight control

schools in California,

United States

2 yr � Although an example of physical activity

intervention was walking clubs, other activities

were not described

Physical activity IPAQ �BMI þ

18. MacKinnon

et al. (2010)33

RCT 599 firefighters from five

fire departments in

Northern Oregon and

Southern Washington,

United States

2 yr, with follow-

ups each year

until year 6

� Team-centered curriculum group: team leader

used a scripted manual to facilitate a series of

eleven 45-minute sessions with other participants

using corresponding workbooks

� Motivational interviewing group: 1-h meetings with

counselors and additional in-person or phone

contacts

� Control group: some information on test results

and explanation

BMI þ/�Physical activity Questionnaires �

19. Spittaels et al.

(2007)34

RCT 526 participants in four

commercial settings

and two local

government institutes

in Northern Belgium

6 mo � Group 1: received computer-tailored physical

activity advice supplemented with five stage of

change–targeted reminder e-mails

� Group 2: received tailored physical activity advice

without e-mails

� Group 3: received standard advice

Physical activity IPAQ �BMI �

20. Campbell et al.

(2002)35

RCT 859 women (nine

worksites of textile or

light manufacturing

industry in the United

States)

6 mo and follow-

up at month 18

� Intervention group: two individualized computer-

tailored magazines and a natural helper program

to train women in the workplace to diffuse

information and provide support for healthy

behavior changes

� Delayed intervention group: one individually

tailored magazine at the sixth month without a

natural helper program

Physical activity Questionnaires �BMI �

† BMI indicates body mass index; PAQ, Physical Activity Questionnaire; RD, Registered Dietician; IB, Internet Based; PAFQ, Physical ActivityFrequency Questionnaire; RCT, randomized controlled trial; PACE, Patient-centered Assessment and Counseling for Exercise and Nutrition; PAR,Physical Activity Recall; GLTEQ, Godin Leisure Time Exercise Questionnaire; PAM, personal activity monitor; AQuAA, Questionnaire for Adults andAdolescents.

* (þþþ) p , 0.0001; (þþ) p , 0.001; (þ) p , 0.05; (þ/�) marginal change or p value was not reported; (�) not significant.



report the proportion of male andfemale participants, many had femalesin the majority.16–18,20,24,26,28–30,32 Onestudy recruited only females.35 Also,one study recruited only overweightand obese participants,20 and onerecruited only those with hyperten-sion.23 In the remaining studies, mostparticipants were overweight at the timeof taking part in the interventions, withaverage BMIs (.25)16,17,23–25,28,30–33,35

or 60% overweight and obese.26

Response Rate and Proportion ofParticipation

The total number of employ-ees was also reported in 14 stud-ies,16,19,21–23,25–28,30,31,33–35 rangingfrom 152 to 15,853 people. Table 3shows response rates and the propor-tion of participation among the stud-ies. Response rates, computed bydividing the number of participantswith complete follow-up data by thenumber of enrolled participantswith complete baseline data, rangedfrom 25% to 96%. Most studieshad response rates of 60% orabove.18,20–22,24–27,30–35 The proportionof participation, calculated by dividingthe number of enrolled participants atbaseline by the total number of em-ployees, ranged from 3% to 78%. Theresponse rates for four studies20,30,33,35

at the second follow-up were above69%.

InterventionsAlthough seven interventions in-

cluded activities targeting at social andenvironmental levels,16,19,22,24,27,28,31

most of the other interventions onlytarget at the interpersonal or intraper-sonal level.17,18,20,21,23,25,26,29,30,33–35

One intervention did not specify itsactivities.32 The intervention activitiesat social and environmental levels com-prised maps with routes and distanc-es16,24; staircase promotion and walkingcircuit19; ‘‘action days’’ and ‘‘gymnasticbreaks’’ in the morning22; organiza-tional actions such as joint employeemanagement steering committees, se-nior management endorsement, andenvironmental prompts27; stepperplacement at different points and aphysical activity campaign28; fitness fa-cility improvement; scales placed inrestrooms and fitness rooms; and afitness expo to demonstrate variousphysical activities.31 The interpersonal

and intrapersonal intervention activi-ties included delivering pedometers,16–

21,23,24,27 regularly providing necessaryinformation and educational materialsto participants delivered through on-line tools16,19–21,24,26,30,34,35 or printmaterials,19,22,23,27,29 establishing phys-ical activity teams for competi-tions,16,19,27,31,33 holding regularmeetings or consultations,17,20,22,25,33

and offering fitness classes.22,28,31

Theoretical models were used in only12 interventions,16,19,21–23,25,26,29,32–35

of which the transtheoretical model ofhealth behavior change38 was usedseparately in six interven-tions;16,21,22,25,26,29 social cognitive the-ory39 in three interventions,19,32,33 andthe framework of five E’s (evidence,engage, educate, environment, andevaluate) in one intervention.23 Theother two interventions34,35 appliedsimultaneously two theories, the trans-theoretical model of health behaviorchange and theory of planned behav-ior40 and the transtheoretical model ofhealth behavior change and socialcognitive theory. In addition, strategies

of goal setting19,26,27 and incentiveoffering18,19,27,31 were used.

Outcome MeasuresSeventeen of 20 interventions used

questionnaires to measure physical ac-tivity levels.16,18–20,22,23,25–35 All but threequestionnaires16,23,35 were standardized.The International Physical ActivityQuestionnaire (IPAQ)41,42 was used bysix interventions19,20,27,28,32,34; GodinLeisure Time Exercise Questionnaire(GLTEQ)43 by two interventions29,31;Physical Activity Questionnaire (PAQ)44

by Sternfeld et al. (2009)26; PhysicalActivity Recall (PAR) questionnaire45–47

by Proper et al. (2003)25; PhysicalActivity Frequency Questionnaire(PAFQ)48 by Titze et al. (2001)22; ActivityQuestionnaire for Adults and Adoles-cents (AQuAA)49 by Slootmaker et al.(2009)30; The Active Australian Surveyquestionnaires by Shaw et al. (2007)18,50;and a questionnaire with calculatedreliability was used by McKinnon et al.(2010).33 Moreover, pedometers wereused in seven interventions to count thenumber of steps.16–19,21,24,27 One study

Table 3Response Rates and Proportions of Participation*

Study Total Employees Baseline PP (%) RR1 (%) RR2 (%)

1. Faghri et al. (2008)16 1100 206 18.7 56 N/A

2. Chan et al. (2004)17 X† 177 X 59.8 N/A

3. Shaw et al. (2007)18 X 35 X 66 N/A

4. De Cocker et al. (2009)19 555 298 53.7 49.3 N/A

5. Touger-Decker et al. (2010)20 X 137 X 82.5 69.3

6. Yap et al. (2008)21 618 73 11.8 93.1 N/A

7. Titze et al. (2001)22 796 598 75 63 N/A

8. Gemson et al. (2008)23 15,853 553 3 25 N/A

9. Gilson et al. (2009)24 X 214 X 84 N/A

10. Proper et al. (2003)25 600 299 49.8 69.6 N/A

11. Sternfeld et al. (2009)26 8000 787 9.8 69.7 N/A

12. Dishman et al. (2009)27 4472 1442 32.2 66.9 N/A

13. Pedersen et al. (2009)28 2163 549 25.4 58 N/A

14. Plotnikoff et al. (2007)29 X 887 X 57.2 N/A

15. Slootmaker et al. (2009)30 152 102 67 96 78

16. French et al. (2010)31 1440‡ 1123 78 74 N/A

17. Siegel et al. (2010)32 X 413 X 82 N/A

18. MacKinnon et al. (2010)33§ 766 599 78 81 71

19. Spittaels et al. (2007)34 8000 526 7 72 N/A

20. Campbell et al. (2002)35 1176* 859 73 76.8 75.6

* PP, indicates proportion of participation; RR1, response rate at the first follow-up; RR2, responserate at the second follow-up.

† X indicates data were not reported.‡ The number is inferred based on the number of participants at baseline and PP.§ RRs for follow-up phases without intervention were not included here.



measured percentage of pedometer useinstead of steps.23 There were fourinterventions using both pedometersand questionnaires to measure physicalactivity.16,18,19,27 Changes in BMI weremeasured in 11 interven-tions.16,17,19,23,25,30–35 Another studymeasured changes in body weight andcircumference as primary outcomes andphysical activity as the secondary out-come.20

Effects of InterventionsFive interventions reported signifi-

cant effectiveness on all outcomes ofinterest,17,18,21,22,26 whereas seven oth-ers showed the effectiveness on at leastone outcome.16,20,23–25,27,32 Eight in-terventions did not find any signifi-cant improvement in anyoutcome.19,28–31,33–35 Concerningstudy design, seven of eight interven-tions with pre-posttest16–18 and quasi-experimental controlled20–23 designshowed significant improvements in atleast one outcome. Although theother intervention showed a reductionin physical activity,19 the interventiongroup reduced significantly less com-pared with the control group. On thecontrary, 7 of 12 RCTs were notshown to be effective for any out-come.28–31,33–35

Among 11 interventions with theduration of less than 6 months, 9interventions showed positive changeson at least one outcome16–18,20–22,24,26,27

(one showed a reduction in physicalactivity to be significantly less among theintervention group compared with thecontrol group19). All seven interven-tions that used pedometers to mea-sure steps were found to increasesteps16–18,21,24,27 or slow step reduc-tion19 in the intervention group. Inaddition, six of seven interventionsusing online tools showed positivechanges.16,19–21,24,26 All five interven-tions with activities targeting socialand environmental levels16,19,22,24,27

were effective in increasing physicalactivity levels.

On the other hand, among nineinterventions with durations of 6months or longer, three interventionsshowed positive changes on only oneoutcome.23,25,32 The others showed nosignificant change. No interventionlonger than 6 months used pedome-ters to measure steps, but two used

online tools,34,35 and two includedactivities targeting social and environ-mental levels.28,31

Outcome indicators varied acrossthe interventions. These indicatorswere percentage change in step counts,in physical activity level, in weight, andin pedometer use; average change inBMI, in step counts, in time spent onphysical activity, in energy expenditure;and odds of changing from not meet-ing the guideline to meeting it. Amongeffective interventions, ranges of thechanges for four common indicators(i.e., change in step counts, in energyexpenditure, in BMI, and in metabolicequivalent of task minutes [MET-min-utes] per week) were (1) 126 to 3451steps/d; (2) 176.18 to 370 kcal/d; (3)�0.04 to �1.0 BMI unit (kg/m2); and(4) 205.8 to 887.25 MET-min/wk.

DISCUSSIONThis review aimed to assess the

effectiveness of workplace interven-tions to promote and increase physicalactivity among employees. In general,12 (60%)16–18,20–27,32 interventionswere effective on at least one outcomeand 1 intervention19 slowed step re-duction. Interventions with a morerigorous research design (i.e., RCT)were more likely to have a longerduration and were less likely to beeffective. Ten of 13 effective interven-tions (77%) were less than 6 months induration. Whether or not this is due tothe long duration of the interventions,more accurate reflection of the effec-tiveness of the workplace interventionsby virtue of higher internal validity,characteristics of the samples or set-tings in which these interventions wereconducted, instruments or difficultiesin implementation as a result of thecomplexity of intervention activities, orother reasons is unable to be deter-mined. One explanation might be dueto a temporary novelty or excitementabout the intervention activities or aninitial belief that the intervention canhelp participants to reach the recom-mended physical activity, especiallywhen many of the participants in thesestudies were overweight or obese,might fail to control their weight, andhave a strong desire to lose weight. Itmay be that the longer the interven-tions were, the more difficult it was tokeep participants’ enthusiasm and,

thus, prevent a return to their accus-tomed habits. However, this may be justspeculation as a firm conclusion aboutthe relative effectiveness of the inter-ventions could not be reached becausethe discrepancy in time points amongstudies when follow-up measurementswere conducted confounded and lim-ited the comparability of results. Thisconfounding issue and the absence ofrelevant literature needs to be ad-dressed to allow the effectiveness ofshort-term versus long-term interven-tions to be determined.

Other common characteristicsamong the effective interventions thatmay give readers cues to establish theirown hypotheses include (1) 9 of 13effective interventions (69%) used pe-dometers,16–21,23,24,27 although stepswere measured in only 7 interven-tions.16–19,21,24,27 Despite the effective-ness of pedometers found in somestudies,51,52 only 2 RCTs24,27 out of 12used pedometers; both were shown tobe effective. (2) Six16,19–21,24,26 of 13effective interventions (46%) appliedInternet-based approaches, which werefound to be useful in some studies.53–55

With these approaches, participants areable to decide when to receive infor-mation and can access the informationat will, provided they have an Internetconnection. They can also easily man-age the provided online materials.Additionally, there may be more priva-cy, and messages can be individuallytailored to participants. (3)Five16,19,22,24,27 of 13 effective interven-tions (38%) included activities target-ing social and environmental levels.Although workplaces were seen to havethe potential to create multilevel influ-ences,12 only two RCTs24,27 that in-cluded the activities at social andenvironmental levels were effective.The other two RCTs28,31 that includedthe activities at social and environmen-tal levels were not effective. Targeting atsocial and environmental levels may benecessary, but not sufficient. To elicitan effective intervention, a combina-tion of many different factors, such asdesign, implementation, and measure-ment, may be needed.

In addition, the review revealed thatsustainability was not adequately con-sidered in many interventions. As oftenseen, after a program ends, its effectscould not be maintained. In our



opinion, one way to sustain an inter-vention may be to pay employees fordoing physical activity. The employerscan pay employees in terms of workingtime in which employees have to workif they do not want to do physicalactivity. The utility of this method maybe an interesting topic for futureresearch. However, to be able toconvince the employers about thebenefits of permanently providing in-centives to employees, more researchshould be done to test the hypothesisthat as physical activity level increases,productivity increases, whereas healthinsurance and other health-relatedcosts decline. Achieving these resultscould considerably contribute to thesustainability of the program becauselong-term commitments from employ-ers could be reached and motivation ofemployees to participate in physicalactivity maintained.

Methodological IssuesAs indicated in the quality assess-

ment (Table 1), many studies receiveda score of 3 or less (maximum is 7).Two criteria that most studies did notmeet were the concealment of treat-ment allocation and the blinding ofthe outcome assessor. While it may beimpossible under many circumstancesfor community-based or workplace-based interventions to fulfill thesecriteria, as mentioned in the PreferredReporting Items for Systematic Reviewsand Meta-Analysis (PRISMA) state-ment,56 this may cause risks of bias andthus need to be considered wheninterpreting the findings.

In addition, some other methodo-logical issues need to be considered.First, there was insufficient informa-tion to evaluate sample representative-ness. Some studies did not describe orprovide detailed information on therecruitment procedure. Others did notprovide information on total popula-tions. By looking at the characteristicsof samples, most participants werefemale, aged .38, and were over-weight. These characteristics may onlyrepresent a group of people who aremore likely to have intent to change.

Second, limited information aboutbusiness activities by season was provid-ed, and information regarding weatherduring the intervention periods was alsolacking. The interventions that oc-

curred when employees were in peakseasons might be less effective andparticipatory than those occurring inless busier seasons. Moreover, the effec-tiveness of the interventions may not beseen if the baseline phase was conduct-ed in summer and follow-up in winter.

Third, many interventions usedquestionnaires (despite being validat-ed) to measure physical activity level.This may potentially cause recall orreporting bias. Fourth, there was littleinformation on whether employerswere involved in the intervention, andwhat the level of their involvement was.The involvement of employers as acomponent of intervention may en-hance participation by helping em-ployees overcome one of the mostcited barriers for nonparticipation, alack of time,57 by increasing employ-ees’ awareness of current programs viainternal communication networks, orby adopting policies motivating em-ployees to participate. These data, ifprovided, could assist in the evaluationof effective interventions.

Finally, many studies did not report pvalues or perform the necessary posthoc statistical analyses, such as analysisto compare those lost to follow-up andthose that remained and an intention-to-treat analysis. Moreover, informationabout whether or not a process evalu-ation was conducted was rarely provid-ed. The lack of such informationincreases the difficulty in making firmconclusions about the effectiveness ofthese interventions.

LimitationsThis review has several limitations.

First, although every effort was made insearching and screening all availablearticles, some interventions may havebeen missed during the searchingprocess. Second, populations werequite heterogeneous, some in NorthAmerica, some in Europe and Austral-ia. Characteristics of workplace andtype of work also differed. Third,different questionnaires used in mea-suring physical activity level also af-fected the strength of the conclusion.Fourth, the effectiveness of interven-tions was qualitatively assessed, and nometa-analysis was done due to thevariety of statistical procedures andoutcome indicators (e.g., percentageof changes in physical activity, odds,

and regression coefficients). Finally, wewere unable to synthesize other mean-ingful outcomes (e.g., blood pressureor lipid level) as only a few studiesprovided information on these mea-sures. Future research may considerthese outcomes.

CONCLUSION

Interventions that (1) had less rig-orous research designs (i.e., singlepretest and posttest or quasi-experi-mental controlled), (2) used pedome-

SO WHAT? Implications for Health

Promotion Practioners and

ResearchersWhat is already known on this topic?

Evidence on the effectiveness ofworkplace physical activity interven-tions has been mixed. A meta-analy-sis published in 1998 found that theinterventions had little or no effecton physical activity improvement.Another review published in 2003,however, supported workplace physi-cal activity interventions.What does this article add?

This article complements previousreviews by reviewing and discussingthe effectiveness of more recentinterventions. It shows commoncharacteristics contributing to theeffectiveness of interventions andprovides implications for practice inthe future.What are the implications for healthpromotion practice or research?

Future interventions should bedesigned to attract both genders andinvolve employers in a long-termcommitment to the program. More-over, interventions should focusmore on the social and environmen-tal level. Combining Internet-basedapproaches to tailor and delivermessages to participants and pe-dometer usage may increase effec-tiveness. Details on characteristics ofgroups, recruitment procedures,employer involvement, seasons whenintervention occurred, proper statis-tic analyses, and process evaluationshould be reported for the effective-ness to be precisely evaluated. Finally,it is necessary that investigators con-duct interventions with the samedata collection points (despite dif-ferent durations) to control fordifferent measurement intervals.



ters, (3) applied Internet-based ap-proaches, and (4) included activities atsocial and environmental levels weremore likely to report being effectivethan those without these characteris-tics.

Acknowledgment

We thank the reviewers for their valuable comments, whichstrengthened the article. All authors declared any conflict ofinterest. No funding was provided.

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Workplace Physical Activity Interventions: A Systematic Review