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Stairway to Health
Evaluation report for BC Ministry of Health Stairway to Health Initiative April 1, 2004 and April 30, 2005
Table of Contents
Executive Summary…………………………………………………………………3
Chapter 1: Introduction……………………………………………………………..6
Chapter 2: Programs and Support for Behaviour Change………………………7
Chapter 3: Policy and Environmental Changes…………………………………23
Chapter 4: Health Information…………………………………………………….26
Chapter 5: Project Management and Implementation………………………….33
Chapter 6: Conclusions and Recommendations………………….....................38
References………………………………………………………………………….40
Appendix A: Work Breakdown Structure and GANTT Chart……………………41
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Executive Summary The Stairway to Health Initiative is a comprehensive workplace wellness initiative being implemented at the BC Ministry of Health. The vision for the initiative is “a healthy, satisfied and productive workforce”. The goal is to enhance the health and well-being of employees of the Ministry of Health by providing credible information, resources that enable them to take charge of their own health, and a work environment that makes the healthy choice the easy choice. Within the broader initiative the Ministry of Health was also participating in the pilot of a new Health Canada resource that encourages workplaces to implement stairway-based strategies to encourage physical activity. This report provides an overview of the project, activities and evaluation results from the first year of implementation.
OVERVIEW:
Stairway to Health was designed based upon current evidence in the field of health promotion. It is a comprehensive multi-risk factor strategy that includes the provision of information and education, behaviour change interventions, environmental and policy supports to enable healthy behaviours and capacity-building within the organization. Activities were organized and delivered based upon these key components and addressed physical activity, healthy eating, tobacco cessation and stress management.
Information and Education: activities included development of a health information webpage for employees, HealthBytes®, newsletter inserts, lunch room information, lunch hour presentations and health and wellness fairs, events and celebrations.
Behaviour Change: activities included point-of-choice posters to encourage stair use, team events like the Mt Everest and CN Tower Challenge, a 10,000 Steps pedometer challenge and library lending program, a fruit and vegetable challenge, healthy food choices at events and a tobacco cessation program called QuitNow.
Policy and environmental changes: activities included stairway beautification, music in the stairwells, permanent stair signage and differential pricing of healthy options in the vending machines.
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Organizational Capacity: activities included development of a wellness webpage for staff and formation of a cross-branch wellness Committee.
Stairway to Health was initiated and developed in a supportive organizational and provincial context. The initiative was championed by the Population Health and Wellness Division and supported fully by Ministry of Health Executive. The initiative was planned and implemented by staff from the Healthy Living and Chronic Disease Prevention Branch. Planning was supported by the Ministry of Health Project Management Office. The Population Health and Wellness Division had already led the way by taking an innovative and cost-effective approach to enhancing their physical space to promote health. Interest in the approach, within and outside of the organization, was high. In addition, international, national and provincial attention (both public and scientific) was on physical activity, healthy eating and obesity and the current government had publicly committed to making British Columbia the healthiest jurisdiction to host the Olympics.
RESULTS
It Works! The Ministry of Health environment was significantly different after Stairway to Health. The healthy choices were easier!
Physical changes in the stairwell combined with activities that prompt employees to use the stairs appear to be an effective component of an overall health and wellness strategy for the workplace.
o Stairwell use increased steadily over the year and increased significantly over baseline during the team challenges and stairwell events.
Vending machine choices were improved, priced to encourage purchase
and labeled to prompt employees to choose the healthy option. Healthy food options were provided at Ministry sponsored events.
Physical changes in one worksite area serve as a catalyst for other employees to take ownership and change their own environment.
Stairway to Health activities raised awareness of lifestyle choices and helped to motivate some employees to either initiate or maintain healthy lifestyle changes.
o Approximately 20% of staff participated in the events. o Pedometers helped to motivate people to take up or maintain their
activity levels o The Hearts@Work screening identified 23 cases where employees
should follow-up with their Doctor and lower their chronic disease risk.
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Stairway to Health helped to create a feeling of connection to others in the workplace
Participant satisfaction was universally high across the events and activities.
How To Make It Work!
Executive buy-in for the project was evident and essential to its success.
Internal champions make it happen!
Resources for coordination, implementation and project management are necessary
Evaluation of worksite health promotion initiatives remains challenging but
necessary.
SUMMARY AND RECOMMENDATIONS
Individual lifestyle choices are only one of many determinants of health but it was evident that the initiative also contributed to a positive worksite environment, empowered employees and created a connection with others. These are important determinants of health.
The importance of reaching the ‘at risk’ versus ‘singing to the choir’ has been emphasized in the health promotion literature. To have an impact on health outcomes at the worksite strategies need to enable healthy lifestyles for all. The clear emphasis on environmental and policy approaches within Stairway to Health represents an attempt to overcome the past criticisms of worksite health promotion efforts that focused entirely on individual choice without consideration for the context in which individuals make their lifestyle choices.
Based upon the feedback and the results of the first year of implementation, Stairway to Health positively contributed to health at the Ministry of Health. Recommendations for the future include: sustaining the organizational capacity that supports implementation (e.g. Cross-Ministry committee), sustaining and improving the successful activities, building in employee incentives, extending the activities to additional employee health issues, continuing to include strategies that target the physical and policy environment and finding ways to share the experiences with other worksites in British Columbia.
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Chapter
1 Introduction The Stairway to Health Initiative is a comprehensive workplace wellness initiative being implemented at the BC Ministry of Health. The vision for the workplace wellness initiative is:
“a healthy, satisfied and productive workforce”
The goal is:
to enhance the health and well-being of employees of the Ministry of Health by providing credible information, resources that enable them to take charge of their own health, and a work environment that makes the healthy choice the easy choice.
Within the broader initiative the Ministry of Health was also participating in the pilot of a new resource. The purpose of the Health Canada Stairway to Health Pilot Project is twofold: 1) To implement and evaluate the impact of a set of evidence-based stairway-
based interventions in the Ministry of Health.
2) To describe program implementation (barriers, facilitators, costs) to allow for program modifications (course correction) and dissemination to other workplaces.
Planned Activities
Stairway to Health was designed based upon current evidence in the field of health promotion. It was a comprehensive multi-risk factor strategy that included the provision of information and education, behaviour change interventions, environmental and policy supports to enable healthy behaviour and capacity-building within the organization. Activities were organized and delivered based upon these key components and addressed physical activity, healthy eating, tobacco cessation and stress management.
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Chapter
2 Programs and Support for Behaviour Change Stairway to Health
A major focus of the Stairway to Health Initiative was the Stairway to Health Stairwell Intervention Package. The initiative was based upon a landmark initiative implemented at the Centres for Disease Control and Prevention Atlanta and included:
Components
1) Stairwell Beautification
Painting
Artwork
Whiteboards (for staff communication)
2) Point-of-Choice Posters and permanent signage
3) Stairclimbing Challenges and Competitions
CN Tower Climb
Mount Everest
4) Events
Artwork Judging Competition
5) Music in the Stairwells Stairwells were beautified in June 2004 and following that posters, music, challenges and events were introduced at various times over the year to encourage people to choose the active alternative and use the stairs instead of the elevator. Permanent signage was also added at the entrance to the stairwell.
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Impact Indicators
Infrared counters were positioned to monitor each entry into the stairwell at the Main and 2nd floors. A single case baseline design (ABACADAEAD) with visual inspection was used to examine the impact of the interventions on stair use. Figure 1 illustrates the average stair use on the Main floor across the conditions. Figure 1 also shows that there was an increasing trend in stair use across the intervention. After the CN Tower challenge for example stair use remained elevated.1
When specific follow-up analyses were conducted using newly established baselines each time, there were significant increases during both poster campaigns (one with temporary point of choice prompts and one with temporary point of choice prompts plus stair stepper signs), and during the CN Tower Challenge (see Tables 1 and 2). When each intervention condition was compared to the September baseline there was a significant increase in stair use found during both poster campaigns, and both the CN and Mount Everest Challenge (See Table 3). The introduction of Music in December coincided with large drops in staff presence due to Christmas vacations and therefore the lack of change may be attributed to this. During the second music time period there was a significant drop in stair use that conflicts with previous research findings (Kerr et al., 2004). This drop may be because 200 staff members were relocated to other buildings during that measurement period or conversely music in the stairwells might enhance the atmosphere but not provide the ‘prompt’ for entry into the stairwells. It was evident from the process evaluation that the stairwell environment was improved.
“The Stairway to Health improvements made the trips up and down the flights much more enjoyable and scenic than plain stairwells-enjoyed seeing the comments on the white boards, and used the white boards to help tally the flights”.
1 Note: The single case baseline design was chosen because the ‘subject’ acts as its own control. This design is efficacious in ‘real world’ situations where resources are constrained (finding and monitoring a control sight doubles the cost in person time and $$$). However, to make strong statements about the efficacy of the intervention this design depends upon the measured behaviour returning to baseline between each condition. This is a limitation of the design and affects our ability to make definitive statements of effectiveness.
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Figure 1. Mean Stair Use Main Floor
y = 0.5409x + 613.39R2 = 0.1292
0
100
200
300
400
500
600
700
800
900
1000
1 7 13 19 25 31 37 43 49 55 61 67 73 79 85 91 97 103
109
115
121
127
133
139
145
151
157
163
Time Period
Stair M MeansLinear (Stair M Means)
Baseline Posters Baseline
CN
Tow
erC
halle
nge
Bas
elin
e
Music Baseline Stairstepper signs
Baseline Music Mt Everest
* ** ** *
* = p<.05, ** = p<.001
Table 1. Means and standard deviations for intervention and baseline conditions
Condition Mean Std. Deviation Baseline 1 Sep 3 2004-Sep 30 2004 557.6842 63.72689
Posters Oct 4 2004-Oct 29 2004 598.2632 58.46731
Baseline 2 Nov 1 2004-Nov 22 2004 639.7500 81.56133
CN Tower Climb Challenge Nov 23 2004-Nov 26 2004
941.2500 44.37248
Baseline 3 Nov 29 2004-Dec 8 2004 722.0000 66.36641
Music Dec 9 2004-Dec 31 2004 682.5556 134.39132
Baseline 4 Jan 4 2005-Jan 31 2005 689.7778 88.15331
Stair Stepper Signs & Posters Feb 1 2005-Feb 28-2005
734.0556 63.20319
Baseline 5 Mar 1 2005-Apr 5 2005 686.8462 135.24043
Music Apr 6 2005-Apr 22 2005 587.5385 80.01626
Baseline 5 Mar 1 2005-Apr 5 2005 620.0000 118.74553
Music and Mt. Everest Climb Challenge Apr 25 2005-Apr 29 2005
689.2000 98.42611
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Table 2. Comparison between Intervention Conditions and reestablished baselines.
Baseline to Condition Comparison t df Sig. (2-tailed)
Baseline 1 Sep 3 2004-Sep 30 2004 - Posters Oct 4 2004-Oct 29 2004 -2.135 18 .047
Baseline 2 Nov 1 2004-Nov 22 2004 – CN Tower Climb Challenge Nov 23 2004-Nov 26 2004
-6.593 3 .007
Baseline 3 Nov 29 2004-Dec 8 2004 - Music Dec 9 2004-Dec 31 2004 .803 8 .445
Baseline 4 Jan 4 2005-Jan 31 2005 - Stair Stepper Signs & Posters Feb 1 2005-Feb 28-2005
-2.641 17 .017
Baseline 5 Mar 1 2005-Apr 5 2005 - Music Apr 6 2005-Apr 22 2005 2.185 12 .049
Baseline 5 Mar 1 2005-Apr 5 2005 - Music and Mt. Everest Climb Challenge Apr 25 2005-Apr 29 2005 -.952 4 .395
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Table 3. Comparison between Baseline 1 and all other intervention conditions
Baseline 1 with Intervention Condition Comparison t df Sig. (2-tailed)
Baseline 1 Sep 3 2004-Sep 30 2004 – Posters Oct 4 2004-Oct 29 2004 -2.135 18 .047
Baseline 1 Sep 3 2004-Sep 30 2004 – CN Tower Climb Challenge Nov 23 2004-Nov 26 2004 -12.290 3 .001
Baseline 1 Sep 3 2004-Sep 30 2004 – Music Dec 9 2004-Dec 31 2004
.236 14 .817
Baseline 1 Sep 3 2004-Sep 30 2004 - Stair Stepper Signs & Posters Feb 1 2005-Feb 28-2005
-7.778 18 .000
Baseline 1 Sep 3 2004-Sep 30 2004 - Music Apr 6 2005-Apr 22 2005
-1.046 12 .316
Baseline 1 Sep 3 2004-Sep 30 2004 - Music and Mt. Everest Climb challenge Apr 25 2005-Apr 29 2005 -3.873 4 .018
In addition to raw floor data of stair use infrared sensors were placed on two of four elevators on the main floor to try to remove the impact of variations in building use from the analysis. When the analyses were conducted using proportion of stair to elevator use the significant changes in proportional use were during the CN Tower challenge only. However, when all intervention conditions were compared to the September Baseline the significant differences found in the raw data were mirrored. It is unclear whether the proportional use data was limited by the unaccounted for variability in the use of only two elevator banks.
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Process Indicators
Participation in the events
240 (22%) staff participated in the CN Tower Climb Challenge
142 (16%) staff participated in the Mt. Everest Climb Challenge
50 (5%) staff voted on Artwork displayed in the Stairwells
Who participated in the evaluation?
Evaluations were completed for the events to obtain staff feedback and describe who participated. It was evident that those individuals who were willing to complete an evaluation were ‘highly active’ and champions of the initiative.
Approximately 10% of the event participants completed the CN Tower Climb and Mt. Everest Challenge evaluations. The majority of these respondents were from the 4th Floor (where Population Health and Wellness the Division that sponsored the initiative resides). One third of the respondents in the Artwork Judging Competition were also from the 4th floor. The majority of respondents to all evaluations climbed on average 14 flights a day. Approximately 75% of respondents were female which closely matches the profile of the Ministry of Health staff.
Participant Satisfaction The evaluations showed that there was a very positive response to the events. Positive outcomes of the challenge of the CN Tower and Mt. Everest Challenges reported by staff fell into 4 major themes and are illustrated in Table 4: 1. Interaction/bonding with co-workers, 2. Health aspects, 3. Challenge/Goal-setting, and, 4. Enjoyment.
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Table 4. Samples of staff comments related to each major theme
Theme Example comments Interaction/bonding with co-workers
“Provided something fun to talk about with co-workers”. “A feeling of a “team” atmosphere, building a closer bond with fellow employees”. “Bonding and laughing with co-workers as teammates and as opposition…We organized two teams in our department and challenged each other”. “People began interacting more”.
Health Aspects “Encouraged people to keep taking the stairs instead of the elevator”. “People used their coffee breaks to walk the stairs, so it got people up from their desks more often”. “I now use the stairs on a daily basis, and I hope to continue and not get lazy and stop”. “Felt good at work, incorporating exercise into the day”. “I just quit smoking, so it was a great challenge and a distraction”. “Improved my cardio”.
Challenge/Goal-setting “Met someone who decided to go from the Main floor to the 7th floor every time she wanted to use the bathroom—that’s energetic!”. “It was a personal challenge”. “Nice to see people using the stairwell and setting and achieving their goals for the number of stairs they aimed to climb”.
Enjoyment “These events are fun…they create an escape from daily routines”. “It was lots of fun… and ” “We had a blast” “What a great positive motivator for us when we are surrounded by hard times”.
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Negative outcomes of the challenge
Most participants indicated that there were no negative outcomes but the following were some of the comments that were provided:
“Some people on my floor (e.g., new people) didn’t participate because they weren’t invited to join a team, and didn’t initiate one. Maybe we need to have someone on each floor help to get people organized or encourage them to form a team”
“Found some of the totals hard to believe”.
“Found it hard to find time during the day to climb the stairs”.
“Some people took the event too seriously”.
“Stairwells became more/too crowded”.
“Sore legs and it was hard to breathe”.
Future Directions
The following suggestions for improvement were made by participants:
“Have a volunteer on each floor to help get teams formed and spread the word prior to the event”.
“Pick a new peak to climb, or do a cross country route (i.e., here to Newfoundland”). “Post the categories for prizes in advance”. “Play energetic music in the stairwells”. “More incentives to increase participation”. “Keep repeating the challenge, but using different buildings/mountains and adding new incentives/prizes”.
“Have a challenge by age group”. “Fans in the stairwell”
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Additional comments illustrated that the participants felt positive about the Challenge.
“The committee did a great job in organizing the challenge. Hats off to them” “I look forward to the next event. Great idea!” “Thanks for organizing the event”.
10,000 Steps Challenge
The goal of the 10,000 Steps Challenge, was to increase participants’ awareness of his/her baseline activity level, and to encourage an increase in the amount of walking he/she performs through evidence-based goal setting and monitoring. Participants were provided with a pedometer on loan/or for purchase. During orientation, employees were provided with verbal and written instruction on how to use the pedometer, logging information (distance walked per day) and setting weekly goals. Participants were given progression programs to assist them in improving their walking distance safely and appropriately. Who participated in the evaluation?
173 Ministry of Health staff participated in the pedometer challenge (19% of the staff)
25% (approx.) purchased or borrowed pedometers during the promotion.
25% of the people who actually participated in the event completed an evaluation
70% of the people who responded were between 40 and 60 years of age.
73% of the respondents were women 1/3 of the people who completed the evaluation were from the 4th floor
(Population Health and Wellness is on the 4th floor and they spearheaded the initiative)
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95% of the respondents already met the Centers for Disease Control and Prevention and Health Canada guideline of “30 minutes of moderate physical activity almost every day of the week”
Over half of the people who took part in the evaluation used the stairs very often with the average number of flights climbed per day at 14.63.
Impact Indicators
Self-reported measures of physical activity behaviour did not show change
Self-reported physical activity levels were not significantly different from pre to post 10,000 steps challenge (strenuous, moderate or light). However, these results are confounded by the low response rate (24%) and the finding that only 2 out of the 41 individuals responding didn’t meet the guideline of 30 minutes of moderate activity almost every day at baseline. 10,000 steps is the equivalent of a person’s regular daily movement (5-6,000 steps - unless they are in meetings all day) plus about 30 extra minutes of exercise a day. The individuals who completed the survey were already achieving 10,000 steps per day and thus it would be more difficult to detect changes unless they set a more aggressive goal. In addition, the pre challenge measure was retrospective and there is the possibility that memory bias influenced the ability to ‘see’ a change if it was there.
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Pedometers motivated people Despite the lack of difference found on the physical activity instrument half of the participants reported that the pedometer encouraged them to become more active and another quarter reported that it helped them maintain their activity. Figure 2. Encouragement to be active through pedometer use
51.20%
26.80% 22.00%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
BECOME MOREACTIVE
MAINTAINCURRENT ACTIVITY
LEVEL
NO CHANGE INACTIVITY LEVEL
ENCOURAGEMENT TO BE ACTIVE THROUGH PEDOMETER USE
Series1
Figure 3. Percentage of people still using the pedometer
STILL USING PEDOMETER
7%
49%
44% ALL THE TIMESOMETIMESNOT AT ALL
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Process Indicators
rted social benefits for Ministry employees that participated.
Many reported that pedometers were easy to use
use 39.0% reported that they needed help at first but then found the pedometer
Positive outcomes of the 10,000 Step Challenge
ith friends. . s a family, and getting kids to enjoy being active too
omes of the 10,000 Step Challenge
en coworkers.
Ideas for the future
gested, and include the following:
irs from the basement to
n the Corporate Games or commute
There were many repo10,000 Steps participants were very satisfied with the initiative. 39/41 people reported that they would recommend pedometers to their friends for helping to increase activity levels. 90.2% of the individuals who completed the evaluation reported that they would participate in another worksite challenge
58.5% reported that the pedometer was easy to
easy to use
Key Themes: 1. Getting out w2. Assisting with weight loss3. Encouraged getting out a4. Meeting other people when they were out walking, and then starting walking with those people too. 5. Created camaraderie on/between floors, and provided a positive work environment.
Negative outc 1. The challenge created too much competition betwe2. Important figureheads were not seen to participate. 3. The challenge didn’t last long enough.
Five ideas were sug
1. Challenge in time to see who can walk the 7 flights of stathe 7th floor the fastest without running. 2. Creating a walking club(s). 3. Encouraging the Ministry to take part ichallenges. 4. Bringing in more speakers to give lectures on other aspects of health. 5. Offer personal assessments from a dietician or a nutritionist.
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Fruit and Vegetable Challenge
130 employees participated in the Fruit and Vegetable Challenge Although there was no formal evaluation of behaviour change the evaluation indicated that participants became more aware of what they were eating and some indicated that they made changes. There was a positive response to the Fruit and Vegetable Challenge. Who participated in the Fruit and Vegetable Challenge evaluation? 19 people (7%) participated in the evaluation. As with other evaluations the majority of participants in the evaluation were from the 4th floor. However, it was evident that this challenge drew a slightly different population because the average flights of stairs climbed in a normal week by these respondents were 10 (compared to an average of 14 in the stair-climbing challenge evaluation participants). Positive outcomes of the Fruit and Vegetable Challenge
The following suggestions/comments were made by participants:
“Our area discovered new vegetables to eat ie: for the color white – daikon radish. Noticed how little I pay attention to all the colors of fruits and vegetables that are available”
“Made me more aware of what I was eating and how much (veggies and fruit that is). I thought I ate a fair amount but when I started totaling everything it didn’t seem to add up as much as I thought. Either that or I was understanding what I had. I appreciated the card with the serving sizes but I must admit I was getting a bit obsessive about counting”.
“Raised awareness of importance of a healthy diet”.
“Was done in a fun way…encouraged team spirit”.
“I started to be more conscious about what I eat”.
“The challenge started the day after I quit smoking, so I accumulated a lot of points”.
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Negative outcomes of the Fruit and Vegetable Challenge
Most respondents indicated that there were no negative outcomes from the Fruit and Vegetable Challenge. The one comment is provided below.
“I think there were great discrepancies in counting – some tended to undercount and other overcount. Maybe there is a need for more explicit education about counting with examples e.g., Would one medium-sized banana be 1 point or 2 or 3?”
Future Recommendations:
The following suggestions/comments were made by participants:
“It always works best from the top down for motivation and participation – get the managers and supervisors more involved in each department to encourage staff participation”.
“Seemed like the goal was to see who could consume the most fruit/veggies per day – not sure if this was the desired outcome (is eating 26 pounds of broccoli a day really a good thing?). Maybe the emphasis should have been on achieving a healthy range of volume and balance, not total consumption”.
“More prizes for winners, and more “door prize” type goodies for participants to help motivate people to participate. The “door prizes” don’t have to be large – e.g., heart stickers, mugs”.
“Make the point system a little fairer. I don’t smoke and never have but I have been working out a long time and it would have been nice to get a few points for that. Maybe an extra point for a vegetable or a fruit that you have never eaten or cooked before”.
“Perhaps daily things in the entrance? Apples each day to grab on your way up?”.
Any other comments?
Here is a list of additional comments made by participants:
“Can we get the music back in the stairwells?”.
“I think these challenges are fun and a great way to encourage staff to improve health-related behaviors”.
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“I think everything handled exceptionally well. Loved the cards to recipe info and the diagram. Also the e mails with updates, helpful info, and recipes very fun and informative”.
“The recipes were great. It is nice to get recipes for a vegetable you have never cooked”.
“It was a fun event, however, the smoking reduction was the only reason I got so many points. I didn’t have a high consumption of fruit and veggies, but I definitely have increased my consumption since the challenge”.
Quit Now
QuitNow by phone: 1-877-455-2233 Quitnow by phone is a confidential tobacco cessation helpline available free-of-charge to residents of British Columbia. The service is available 24/7 with translation services in 130 languages. Call toll free at 1 877 455-2233 to speak to a friendly, professional quit specialist who will help guide you through the quitting process.
o For friends and family of smokers Quitnow by phone can offer tips on supporting smokers in their attempts to quit.
o If callers are not yet ready, Quitnow by phone will provide information designed to support a future attempt at change.
o For recent quitters Quitnow by phone will be there with support when they need it most.
Quitnow.ca: www.quitnow.caQuitnow.ca is an Internet-based quit smoking service that is available 24/7, free-of-charge to all British Columbia residents. It combines effective methods for quitting smoking with a powerful individualized program. The site offers online peer support, email reminders and tips and expert advice on quitting strategies. Employees were more aware of tools and resources available to help them quit smoking and a number of employees reported that the Stairway to Health challenges motivated and assisted them in their efforts to quit smoking.
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Chapter
3
Policy and Environmental Changes “making the healthy choices the easy choices”
Organizational policy and the ‘built’ environment predispose, enable and reinforce health behaviours. Policy and physical space also directly impact on physical health, eg. appropriate ventilation, natural light and the regulation of smoking in confined spaces. The Stairway to Health Initiative aimed to change the environment to enable and reinforce healthy behaviour but was developed within in a broader context of organizational and provincial context of health and wellness.
Context for Action: The BC Ministry of Health had many supports in place prior the Stairway to Health including change room facilities with showers, access to employee fitness, an active Occupational Health and Safety Committee and locked bike storage. There was also a Division responsible for Population Health and Wellness.
Prior to implementation of the Stairway to Health Initiative The Population Health and Wellness Division modeled the creation of health promoting physical space during a recent office move. Significant modifications in the physical space and lay-out of their branch were enhanced to improve the psychological and physical health of staff members. The changes, designed by employees using evidence from the literature, included enhancing the exposure to natural light, facilitating air circulation, reducing sound transmission, providing the ability to modify the climate independent of other floors within the building and creating a welcoming physical and social atmosphere with plants, colour, lighting and comfortable spaces for meeting and social gathering. All of these modifications were made within the existing budget for the move and when the opportunity has presented itself other Divisions have followed suit. For the full report on this initiative please see Population Health and Wellness.
There was also a supportive Provincial context for action with ActNow BC being implemented by the Government. ActNow BC focuses on promoting physical activity, healthy eating, reducing tobacco use and obesity as well as promoting healthy choices during pregnancy. ActNow BC includes health prevention initiatives like Action Schools! BC, BC’s Tobacco Strategy and the School Fruit and Vegetable Snack Program Pilot. ActNow BC is about supporting British Columbians to make small choices that can result in big improvements to their
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quality of life. Key decision-makers at the Ministry of Health envisioned the Ministry as a model for an ActNow Workplace.
To make the healthy choices the easy choices the Stairway to Health Initiative did the following:
Recreated a Committee (Stairway to Health) that addresses workplace health
Provided differential pricing on ‘healthier options’ in the vending machines
Enhanced healthy choices and point of choice labeling in the cafeteria
Beautified the Stairwells
Hung permanent signage to direct individuals to the Stairs
Provided “lending pedometers” for staff who couldn’t afford to purchase a pedometer
Expanded the bicycle storage facilities to include another 16 spaces for a total of 80
Food provided at events were healthy choices (high nutrient value)
Impact Indicators
Two measures were designed to determine if the Stairway to Health Initiative had a significant impact on the environment at the Ministry of Health. The first was a question on the Ministry of Health Organizational Employee Satisfaction survey that asked employees to indicate whether the work environment enabled healthy lifestyle choices. The baseline for this survey was collected in March 2004, however, a follow-up survey has not yet been administered. The second measure of organizational change was the score on a validated worksite audit tool called Heart Check (Golaszewski & Fisher, 2002). This tool, completed by employees, scores a worksite on a variety of known indicators of worksite health. The Heart Check instrument was completed by the Physical Activity Manager in consultation with management and members of the Stairway to Health Committee in March 2004 and March 2005. Scores on each component area and total worksite score are displayed in Table 5. The worksite improved from achieving 21% of the ideal score in 2004 to 51% of the ideal worksite score in 2005.
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Table 5. Heart Check Score comparisons from March 2004 to March 2005 Component / Subject
Indicator examples
2004 Raw Score
2005 Raw score
Total available
points Smoking Non-smoking
policy, support for cessation, Information available
5 15 22
Nutrition Policies for the provision of healthy food, Vending machines with healthy options, Incentives for healthy food choices, labeling
1 19 32
Physical Activity Fitness facilities on site, qualified fitness staff, fitness testing, worksite teams
14 23 50
Stress Counselling, workshops, EFAP
12 16 31
Screening Risk Assessment
0 17 28
Administrative supports for health promotion planning
Health promotion committee, HP staff, high level support from management, Training available
2 13 45
Organizational policy foundations (e.g. flex time,
Flexible schedule, Grievance procedures in place, vacation time allowance, disability coverage, care of dependents
14 14 18
Total 48 115 226
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Chapter
4 Health Information A key component of the Stairway to Health Initiative was the provision of health information to increase the knowledge and awareness of healthy living among the staff. The activities planned within this component were: Dr. Martin Collis: Walking the Talk – a motivational kick-off talk for Stairway to Health that emphasized ‘walking’ and ‘wellness’. Canada’s Healthy Workplace Launch with the “Kindness Crew” and Lecture Series
Living Stress Free
Healthy Eating
Getting Active and Sticking with it
Work- Life Balance
Ergonomics/Healthy Workplace Environments (What Can You Do in Your Office?)
Lunch Room Health Information
Canada’s Food Guide to Healthy Eating and Canada’s Physical Activity Guide to Healthy Active Living
The Healthy Heart Kit
World No Tobacco Day Information
Display information in common areas specific to Tobacco Cessation, Tobacco Free Sports and other related programs, initiatives and resources
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Website & Newsletter
• Physical Activity page
• Healthy Eating page
• Tobacco page
• Stress page
• Health eNews (the official employee newsletter)
Health Bytes – a 12 week electronic intervention available to all staff that provided information and tips for lifestyle behaviour change. An e-mail teaser was used to invite staff to click and read more about the lifestyle topic of the week. Hearts@Work – a lifestyle risk factor screening and education fair sponsored by the Healthy Heart Society and implemented by staff volunteers. Staff could complete a Stanford Heart Health On-line Risk Assessment, have on-site analysis of cholesterol, blood glucose and blood pressure levels plus information and advice from nurses, physical activity, nutrition, tobacco cessation and stress management experts. Health Bytes, Hearts at work and the Canada’s Healthy Workplace Week had evaluation components.
Health Bytes
An independent evaluation of Health Bytes was carried out by Strategic Initiatives Inc. and more detailed results can be obtained from Strategic Initiatives Inc..
To evaluate Health Bytes an electronic survey was sent out to the 986 employees who had continued to receive Health Bytes teasers. Response rate for the survey was 15%.
The conclusions from the report indicated that:
The Health Bytes pilot was evaluated highly by MOH staff
81% said the information was useful
73% of respondents felt that it was likely that they would make positive changes in their lifestyle
Around 45% of the staff would click through from the email teaser in search of more information, many of whom went on to search for more information from the suite of BC HealthGuide resources (Online, Nurse Line and the Handbook)
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Hearts @ Work
250 staff attended and completed the 6 risk factor stations.
51 participants shared their physical measures with the MOH staff for the evaluation.
In general, participants in the screening reported healthy lifestyles
45 years was the average age
25 was the average BMI
123/78 was the average blood pressure
4.8 mmol/L was the average cholesterol
7 fruit and vegetables/day was the average consumption
79% didn’t smoke
22 people reported an average of 4 bouts (range 1-10) of light physical activity/week with the average session being 34 minutes
29 indicated that they participated in moderate physical activity each week with the average number of sessions being 4 (range 1 -7)
16 participated in vigorous physical activity 3 x per week (range 1-6) for an average of 51 minutes.
The Benefits of Screening Of the participants who volunteered their measures the Hearts@Work screening identified and recommended follow-up and re-assessment with personal physicians to:
5 individuals who had greater than 6.2 mmol/L total cholesterol (at risk)
8 individuals between 5.2 and 6.2 mmol/L (need to modify lifestyle)
10 individuals with blood pressure scores over the healthy range (<140 systolic or < 90 mm/Hg diastolic)
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Feedback
3% (8) of participants completed evaluation forms
5/8 intended to make lifestyle changes
7/8 said they would recommend Hearts@Work to a friend
The major issue highlighted by the evaluations was the waiting. The Cholesterol test took about 5 minutes / person and 6 hours was not adequate for dealing with the number of attendees. Participants recommended having more staff at this station.
Canada’s Healthy Workplace Week
As a site in the pilot of the Stairway to Health Initiative across Canada the Ministry of Health participated in the Canada’s Healthy Workplace Week. A number of activities were scheduled during this week to raise awareness and provide education for Ministry staff that were interested in making changes. The week was kicked off with a fun and exciting event with the “Kindness Crew” who uniquely showed employees the benefits of giving and receiving acts of kindness in the workplace. Workshop topics during the week were:
Healthy Eating Physical Activity Stress Ergonomics Work/Life Balance
130 employees participated in the lecture series during Healthy Workplace Week. 19% completed evaluations. One third of the individuals who completed surveys were males and two-thirds females (n = 21, four did not complete this question). It was apparent that email was the primary communication method that reached these participants and that there was a high level of satisfaction with the workshop (see Table 6).
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Table 6. Results of the workshop evaluations* Lecture Component Mean Rating Range of Ratings
Topic: Interest 3.4 3-4 Length 3.2 2-4 Met expectations 3.4 3-4
Presenter: Organized and clear 3.6 3-4 Enthusiastic 3.7 3-4 Knowledgeable 3.7 2-4 Interacted and responded well to questions
3.8 3.-4
Overall: Information and Facilities 3.0 1-4 Quality of the Lecture 3.4 2-4 * 1 = Poor, 2= Fair, 3= Good, 4 = Excellent
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Website, Health eNewsletter, email notification and posters
The Health eNewsletter, Ministry of Health rebuilding site and the wellness page were used to communicate about initiatives as well as provide health information for staff. It was evident that when the websites were first announced that they received hits but this activity tailed off over time. The Health eNewsletter which is mailed to the employee by email and they have to click to enter appears to be the more effective method of communicating information most likely because it is not passive. In 2005: The newsletters received 1889 hits from Ministry of Health employees while the rebuilding site had 59 hits. In 2004 The newsletters received 2500 hits from MOH employees, the general rebuilding site received 785 hits and the wellness pages 190 hits. Emailing to the Ministry of Health Distribution list was one of the most commonly used forms of notifying the employees about initiatives. Approximately four emails were sent out per activity and posters were put up on all floors in highly visible areas. 600 copies of Canada’s Food Guide to Healthy Eating and 500 copies of Canada’s Physical Activity Guide for Healthy Active Living for Adults were distributed over the time course of the project.
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Chapter
5
Project Management and Implementation Initial planning of the Stairway to Health Initiative was carried out by the Population Health and Wellness Division. A Gantt chart (Appendix A) and work breakdown structure (Appendix A) were created to communicate the vision of, and guide the project. The Physical Activity Manager invited stakeholders from within the organization to participate on the Stairway to Health Committee and the plan was modified and implemented with the help of the Committee, staff from Population Health and Wellness and a co-op work term position that managed specific activities.
All of the initiatives identified in the plan were successfully implemented over the year.
A focus group with the Stairway to Health Committee highlighted a number successes, challenges, barriers and facilitators that will help to inform the ongoing initiative as well as provide advise for other worksites.
1. What went well? What facilitated implementation?
Nothing went external so didn’t have to worry about Public Affairs Bureau
issues Executive support to initiate Existing expertise within the Ministry for planning and implementation The change management initiative at the Human Resources level Size of the Ministry of Health Central Focus on the Stairs Resources were available in the Ministry Keeping all of the data for evaluation The use of Co-op students to support implementation Communication around the events
- the reports from the Leadership area, the Health eNewsletter - in-house posters were very professional - CN Tower Posters were great
2. What didn’t go well?
Hard to bring in ‘help/volunteers’ for Hearts@Work
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Visibility of the Executive Buy-in through participation so that employees were encouraged to take the time to participate
Structural changes – Facility modification needs more advance time Complaints when the music left Financial constraints to do things (resources were limited)
3. What recommendations would enhance the Stairway to Health’s chances of success in other worksites?
An established annual budget for coordination Executive approval Central focus on the stairs Develop a small, medium and large worksite kit for sharing Need guidelines for negotiating with vending machine companies
Other Indicators of Impact Short-term disability A related samples t-test was used to determine if the average short-term disability per FTE was significantly lower during the Stairway to Health Intervention. There was no significant difference in short-term disability per FTE during Stairway to Health (see Figure 4).
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Figure 4. Ministry of Health STIIP Hours Per FTE Between the Pay Periods Ending 2003/04/05 and 2005/03/19
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Diffusion / Sharing with Others The Stairway to Health Initiative provided opportunities to discuss worksite wellness approaches across Canada and served as a resource for other Ministries and worksites. The Ministry staff involved with implementing Stairway to Health were asked to share their experiences and tools. Key contacts and discussion topics included following:
Key dissemination contacts Request/Issue Ministry of Sustainable Resources 10,000 Steps templates and
information Ministry of Water, Land and Air Protection 10,000 steps and pedometers MCAWS Stairwell beautification Ministry of Forestry Co-sharing information about
initiatives Public Service Agency Overall initiative and a presentation
on Stairway to Health pilot for all Ministry Human Resource Strategic Initiative Directors
Delta Hotels Mt. Everest Challenge templates and information
Alberta Health and Wellness Info sharing about initiatives (Alberta Healthy U at Work)
Ontario Government Stairway posters/signage University of Toronto Centre for Health Promotion-
discuss/sharing of survey tools Ministry of Skills Development and Labour General information BC Nurseline 10,000 steps templates and
information Evaluation Issues Measuring the impact of the intervention on health behaviours, outcomes, absenteeism and short-term disability was problematic due to the context and resource constraints. Significant organizational restructuring and rationalization had occurred immediately prior to and during the intervention. These activities could have a powerful influence on short-term disability and absenteeism. The evaluation was also implemented internally (by Ministry of Health staff) and was constrained by the ‘real world’ concerns of overburdening the employee with evaluation, providing guarantees of anonymity and confidentiality and having the time prior to intervention to implement a baseline health survey with a representative sample of employees. To truly evaluate the initiative there would need to be significant resources, an external evaluator, a comparison worksite and willing support for evaluation among employees and management.
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The purpose of the evaluation was therefore to, within the constraints of the ‘real world’, provide evidence of the impact and feasibility of implementing Stairway to Health. The best evidence of impact comes from the infrared counters on the stairs but the results drawn from post-event evaluations and the focus groups can also be considered as a lower level of evidence.
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Chapter
6
Conclusions
IT WORKS! The Ministry of Health environment was significantly different after Stairway to Health. The healthy choices were made easier!
Physical changes in the stairwell combined with activities that prompt employees to use the stairs appear to be an effective component of an overall health and wellness strategy for the workplace.
Vending machine choices were improved, priced to encourage purchase and labeled to prompt employees to choose the healthy option and healthy food was provided at Ministry of Health sponsored events.
Physical changes in one worksite area serve as a catalyst for other employees to take ownership and change their own environment.
Stairway to Health activities raised awareness of lifestyle choices and helped to motivate some employees to either initiate or maintain healthy lifestyle changes.
Stairway to Health helped to create a feeling of connection to others in the workplace
Participants satisfaction was universally high across events and activities. Participants provided helpful advice for moving forward.
How to make it work!
Executive buy-in for the project was evident and essential to its success.
Ministry approval and resources are not provided unless there is executive buy-in. These resources were one of the critical factors in the success of Stairway to Health. In addition, the Deputy Minister and several of the Assistant Deputy Minister’s and Directors sponsored events, encouraged staff and participated themselves. It was evident from the feedback that, it is not only important for executives to support an initiative through organizational means, but to be seen participating themselves.
Internal champions made it happen!
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The Ministry of Health was unique in that there were several employees in the Population Health and Wellness Division with the knowledge and expertise and passion to plan and implement the initiative. The use of internal resources facilitated the implementation of a number of activities including the evaluation and reduced the costs to the organization.
Resources for coordination, implementation and project management are necessary
The planning committee agreed that resources for coordination and implementation for key facilitators of the Stairway to Health Initiative. Feedback from participant evaluations highlight the importance of incentives and physical resources such as posters, all of which have costs attached to them. The project charter, timeline and work-break-down structure made communication about the initiative easier and the support from the Project Management Office facilitated this.
Evaluation of worksite health promotion initiatives remains challenging
There was an obvious respondent bias in the evaluation that limits the conclusions that can be drawn about the efficacy of the initiative. The ‘healthy and motivated‘ completed evaluations. The importance of reaching the ‘at risk’ versus ‘singing to the choir’ has been emphasized in the health promotion literature. To have an impact on health outcomes at the worksite we need strategies that attract and enable healthy lifestyles for all. Although many more employees participated in the activities than completed evaluations the extent to which the initiative attracted a broad variety of employees, including the more at-risk remains unknown.
Summary Individual lifestyle choices are only one of many determinants of health in the workplace but it was evident that despite a narrower focus on healthy lifestyles, the initiative also contributed to a positive worksite environment, empowered employees and created a connection with others. These are important determinants of worksite health.
The importance of reaching the ‘at risk’ versus ‘singing to the choir’ has been emphasized in the health promotion literature. To have an impact on health outcomes at the worksite strategies need to enable healthy lifestyles for all. The clear emphasis on environmental and policy approaches within Stairway to Health represents an attempt to overcome the past criticisms of worksite health promotion efforts that focused entirely on individual choice without consideration for the context in which individuals make their lifestyle choices.
Based upon the feedback and the results of the first year of implementation Stairway to Health positively contributed to health at the Ministry of Health. Recommendations for the future include: sustaining the Cross-Ministry committee, sustaining and improving the successful activities, building in employee incentives, extending the activities to additional employee health issues, continuing to include strategies that target the physical and policy environment and finding ways to share the experiences with other worksites.
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References
Kerr, N.A., Yore, M.M., Ham, S.A., & Dietz, W.H. (2004). Increasing Stair Use in a Worksite Through Environmental Changes. American Journal of Health Promotion, 18 (4): 312–315. Golaszewski, T. & Fisher, B. (2002). Heart Check: The Development and Evolution of
an Organizational Heart Health Assessment. American Journal of Health Promotion, 17 (2): 132-153.
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APPENDIX A
Work Breakdown Structure and GANTT Chart
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