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Physical fitness programming for health promotion at the worksite
PREVENTIVE
MEDICINE
Physical
12, 632-643
Fitness
RUSSELL *Department
of Physical
Education
(1983)
Programming for Health the Worksite’ R.
PATE*
and Columbia,
AND
fSchoo1 South
STEVEN of Public Carolina
Promotion
at
N. BLAmt
Health, 29208
University
of South
Carolina,
Exercise enthusiasts and health professionals have recommended that physical fitness programs be implemented in the occupational setting. Such programs are promoted on the basis of expected benefits to both the employee and employer. The potential for benefit to the employee seems substantial, since a sizable body of knowledge links regular exercise to improved functional capacity and reduced risk for development of certain chronic diseases. The available literature provides some direct evidence that exercise programs can improve the health status of employee groups. Specifically, programs may generate improvements in cardiorespiratory fitness and cardiovascular health and promote long-term adherence to exercise. The physiological goals can be attained with programs that provide 20-30 min of moderately intense “aerobic” activity 3 or more days per week. Several factors are known to affect adherence of employees to company-sponsored fitness programs. Of particular importance are program leadership, motivational schema, program activities, convenience of participation, and social support. It is recommended that, where feasible, supervisors of employee fitness programs (a) secure professioflal leadership, (b) provide on-site or other facilities that maximize convenience, (c) allow participation across the widest possible time span, (d) provide programs offering a wide range of activities, (e) attend carefully to evaluation, recognition, and other motivational concerns, and (f) incorporate a comprehensive health promotion perspective.
INTRODUCTION
In recent years, regular physical exercise has gained wide acceptanceas one component of a healthful lifestyle. Becauseof the importance of health in job performance, many exercise authorities and health professionalshave recommendedthat physical fitnessprogramsbe offered in the occupationalsetting. Such programs have benefits for both the employee and the employer. Although the development of the worksite physical fitness program is a recent phenomenonin the United States, the researchconducted to date doesprovide someinformation on the effects of such programs on the health and job performance of workers. Also, over the past decadea considerablevolume of researchhasbeen conducted on the factors that contribute to the successfulimplementationof physical fitness programs. This paper will (a) summarizethe researchthat provides the rationale for fitness programsin the occupational setting, (b) identify the characteristicsof adult fitness programs that contribute to the attainment of physiological and behavioral objectives, and (c) describethe key componentsof worksite fitness programs. ’ From a paper presented at the University of Connecticut Fitness, May 12-13, 1983, Farmington, Conn. 632 0091-7435/83
$3.00
Copyright 0 1983 by Academic Press, Inc. All rights of reproduction in any form reserved.
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PROGRAMMING
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There is widespread agreement that regular exercise constitutes a good health habit; however, there is disagreement and misunderstanding regarding the specific benefits of exercise. The elucidation of biological mechanisms underlying the contribution of exercise to health is incomplete. We do not now have, nor are we likely to have, definitive evidence based on randomized clinical trials in large groups to demonstrate that regular exercise lengthens life. We are left, therefore, with circumstantial and indirect evidence on the relationship between health and exercise. In this section we will review the literature on exercise from the perspectives of epidemiology, clinical practice, and controlled experiments. Epidemiologic evidence. In 1965, a sample of 6,928 noninstitutionalized adults in Alameda County (Oakland), California, were surveyed to determine their current health practices and health status (13). They were resurveyed in 1974 and, since that time, have been under continuous surveillance with respect to mortality. Physical health at baseline was associated with seven beneficial habits, of which one was regular physical exercise (4). Mortality was lower over a 9.5year follow-up period in individuals reporting more beneficial health practices at baseline (14). The authors attempted to weigh precisely each of the seven practices in terms of their impact on mortality. While this proved to be impossible, they did conclude that the habits seemed to be equally important. Exercise was thus judged to be as important as not smoking, as using alcohol moderately or not at all, as getting 7-8 hr of sleep, as maintaining proper weight, as eating breakfast, and as not eating between meals. Regular exercise has also been associated with a reduced risk of coronary heart disease (CHD). Morris and colleagues have been following executive-level British civil servants for several years. They recently published data incorporating 1,138 clinical events of CHD in 17,944 male civil servants who were followed for 8.5 years (32). At baseline, these men were classified as vigorous exercisers (VE) or nonvigorous exercisers (NVE) based on extensive physical activity diaries. VE was defined as activity requiring an energy expenditure of 7.5 kcal/min or more, and is equivalent to fast walking. The rate of first coronary events was more than twice as high in NVE men than in VE men; the finding was highly significant statistically. Multivariate and stratified analyses, taking into account age and other potentially confounding variables, failed to change the basic finding. Regular physical activity was also associated with lower mortality in a study of 16,936 Harvard alumni (117,680 man-years of follow-up) (36). Activity was assessed by questionnaire, and mortality surveillance was conducted by the Harvard alumni office (1% lost to follow-up). Men who participated in strenuous sports (at least 2,000 kcal/week) had only about one-half the risk of fatal heart attack compared to their more sedentary peers. This significant difference also persisted after statistical adjustment for possible confounding variables. Paffenbarger et al. (35) followed 6,351 San Francisco longshoremen for 22 years to determine the association between job classification and CHD mortality. Energy expenditure measurements allowed for a relatively accurate assessment of
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job-related physical activity. Men in jobs requiring high levels of exertion had fewer fatal heart attacks than did men in jobs requiring moderate or light activity. The risk ratio of 1.8 for the total CHD comparison increased to 2.9 when the endpoint was sudden death. Early criticism of this study, based on possible premorbid job shifts, has been discounted by an elegant reanalysis which accounted for job changes (12). Most epidemiologic studies on exercise and CHD show a possible protective effect for an active lifestyle (8). Explanations of this association are still somewhat obscure. Haskell (24) has reviewed clinical and experimental studies that invoke the myocardial supply-demand ratio to explain the relationships. Clinical evidence. Physical activity and physical fitness are associated with various measures of improved health in clinical observations. Cooper et al. (15) reported that men with higher levels of physical fitness (as measured by maximal treadmill exercise test performance) were at lower risk for CHD. Fitter men had lower serum cholesterol, triglycerides, glucose, and uric acid; they also had lower blood pressures and less body fat. Gibbons and his colleagues recently reported similar results for women patients at the Cooper Clinic (22). Changes in physical fitness are also associated with beneficial changes in some CHD risk factors. Blair et al. (11) found that increased treadmill time was significantly related to improvements in high-density lipoprotein cholesterol (HDL), total cholesterol/HDL ratio, and serum uric acid levels in 753 Cooper Clinic men. Physical activity may be associated with the more global aspects of health. In a cross-sectional study, we examined the association between physical activity and several health indicators (7). Men and women employed in an insurance company headquarters were given a physical examination and completed an extensive psychosocial questionnaire. Employees reporting more leisure-time physical activity who were also classified as having an internal health locus of control (as distinguished from external) reported fewer medical complaints and had fewer positive findings on physical examination. Individuals reporting more physical activity who also perceived high levels of social support reported greater satisfaction with life. Experimental evidence. There is overwhelming evidence that regular exercise increases physical-work capacity (PWC) (1). Well-controlled experimental studies have documented the degree of exercise (intensity, frequency, and duration) necessary for changing physical fitness. We now have enough data on specific exercise programs to make accurate predictions of changes in various physiological variables. The association between a high PWC and health is still tenuous. The rationale for the hypothesis is that individuals with a high PWC find it easier to perform all submaximal exercise (25). This means that the tasks of daily living are less stressful, and the individual is probably not as tired at the end of the day. Experimental studies suggest that regular exercise has a positive impact on CHD risk factors, particularly on plasma lipoproteins (48). Studies with animal models support the hypothesis of a direct effect of exercise on the atherosclerotic process. For example, Kramsch et al. (28) found that sedentary monkeys had lower HDL levels than those who received exercise. Furthermore, the exercised
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monkeys had less angiographic evidence of CHD, fewer pathognomonic ECG changes, and less sudden death. Experimental studies on exercise support the claims of beneficial effects on weight control, psychological status, adult onset diabetes, and certain orthopedic problems (25). Benefits of Fitness Programs at the Worksite There is widespread belief that occupational physical fitness programs provide tangible benefits to employers and employees (29). Many of these claims, however, are not well documented (25). If the relationship between exercise and health is valid, as discussed in the preceding section, employee fitness programs should improve health. The assumption is that worksite programs can effectively change workers’ exercise habits and physical fitness. It is clear that employees who participate in exercise classes at the worksite improve their physical fitness (16, 38). Whether or not changes in physical fitness in a population of workers (i.e., an entire company) can be produced is less clear. We have conducted two studies, not yet published, that suggest that companywide fitness changes can occur. The Johnson & Johnson LIVE for LIFE Program found that treated employees in four companies made significantly greater gains in exercise participation and physical fitness than did control employees in four other companies (9). The company-wide changes were approximately half what one would expect in a controlled laboratory study. In a second study with school employees, Blair et al. (10) found that teachers in the three schools that comprised the treatment group improved their exercise participation and physical fitness compared with teachers in a control school. Thus, it seems reasonable to conclude that carefully designed exercise programs can produce real changes in exercise and physical fitness in populations of employees. If employees as a group improve their exercise participation, and if this results in improved health status, perhaps the company would benefit as well. It has been suggested that worksite fitness programs will reduce absenteeism and health care costs, improve employee attitude and job satisfaction, and generally increase productivity (5). Data supporting these claims are sparse. We evaluated the association between leisure time physical activity and several measures of job performance in insurance company employees in a cross-sectional design (6) and found no evidence of better job performance in exercisers. Other studies are more supportive of employer benefits resulting from fitness programs. There is some evidence of reduced absenteeism by participants in an exercise program (5). Shephard and his colleagues (43) report less absenteeism and less turnover in insurance company employees who participated in a fitness program. In a later publication, the same investigators reported a reduction in health care costs by exercise program participants (44). The total savings averaged $85 per employee per year. All studies on exercise participation and employee productivity (“bottom line” factors) have design or measurement flaws. A more complete review of studies on productivity and exercise is available (21). It seems reasonable to assume that regular physical activity provides some health benefits. Furthermore, recent studies suggest that the worksite is a feasible location for physical fitness programs, and that company-wide changes in exercise
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and fitness can be produced. That exercise programs and physical fitness have an impact on worker satisfaction, absenteeism, productivity, turnover, and medical claims is much less clear. The available studies provide some support for the hypothesis that exercise programs can effect the “bottom line,” but the evidence is weak. Much more research and more tightly controlled studies are needed (21, 25). CHARACTERISTICS
OF SUCCESSFUL
ADULT
FITNESS
PROGRAMS
Fitness programs for adults should strive to attain two fundamental goals. First, programs should provide a dose of exercise which is sufficient to stimulate desired physiological adaptations. Second, fitness programs should attempt to alter exercise habits permanently and positively-that is, participants should exhibit longterm adherence to structured or individually implemented exercise regimens. Regardless of physical setting, fitness programs that attain these goals share certain common characteristics. Attainment
of Physiological
Goals
Over the past 20 years, a considerable volume of research has been directed toward quantifying the physiological effects of various exercise programs. This research has shown that the physiological adaptations to exercise are highly specific to the type of exercise stress imposed (31, 37). For example, the adaptations to high-resistance, low-repetition exercise (e.g., weight training) are very different from those elicited by low-resistance, high-repetition exercise (e.g., jogging). Also, it has demonstrated that desired physiological adaptations result only if certain minimal levels of exercise are prescribed (47). The threshold level varies with the initial fitness status of the subject (17). Effective fitness programs should provide exercise regimens that meet certain general criteria and also allow for individualization. The principal physiological goals of fitness programs should be improvement of cardiorespiratory fitness and promotion of cardiovascular health. Substantial evidence indicates that these fitness goals can be attained with exercise programs that increase the sedentary adult’s energy expenditure by approximately 1,000 kcal per week (2). These “extra” calories must be expended at a rate that is at least half the participant’s maximum rate of aerobic energy expenditure (maximal oxygen uptake, VOZmax). Table 1 lists the specific criteria met by effective cardiorespiratory fitness programs (39). There is some evidence indicating that reduction of cardiorespiratory disease risk may require more activity than is needed to achieve fitness. Paffenbarger et al. (36) have reported that the threshold for reduction of CHD risk occurs at the leisure-time energy expenditure of approximately 2,000 kcal per week. For improvement or maintenance of cardiorespiratory fitness, the mode of exercise must be “aerobic” in nature. That is, the activity should increase the rate of aerobic metabolism and should maintain this increase for an extended period of time. Primary aerobic activities such as walking, jogging, swimming, and cycling have studied extensively and clearly can bring about significant . been . improvements m V02,,. Other activities such as basketball, racquetball, hand-
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FITNESS
Mode: Large muscle, rhythmic activity (e.g., walking, jogging, swimming, cycling or “aerobic” sports) Frequency: 3 to 7 exercise sessions per week Duration: 20 to 60 min per session Intensity: 50 to 75% of V02 max 60 to 85% of maximal heart rate
ball, rope skipping, and aerobic dance would seem to qualify as appropriate aerobic activities. The cardiorespiratory fitness benefits of these activities are not yet documented. These primary aerobic activities should be employed at least 3 days per week for a minimum of 20-30 min per session. As previously indicated, the intensity of activity should be sufficient to elevate the rate of aerobic metabolism to 50% of maximum (note-at an exercise intensity of 50% cOZmax, heart rate is approximately 60% of maximum). Aerobic sports activities, since they tend to be discontinuous, may require more frequent or longer durations of participation to generate benefits comparable to those provided by the primary aerobic activities. To summarize, adult fitness programs that seek to improve cardiorespiratory fitness and promote cardiovascular health should provide participants with 2030 min of moderately intense aerobic activity 3 days per week. To promote neuromuscular fitness, aerobic activities should be complemented by appropriate stretching and high-resistance exercises. A discussion of neuromuscular fitness is beyond the scope of this paper; however, several references on the topic are included (18, 20, 23, 34, 41). Attainment of Behavioral Goals Current knowledge allows us to be quite specific and confident in making recommendations with regard to the physiological aspects of fitness programming. Regrettably, much less is known about the psychosocial factors that influence the physical activity behavior of adults. Participation in a physical fitness program is optional (i.e., not demanded by the employer) for the vast majority of adults. Thus, it is clear that the physiological benefits of exercise accrue only to those persons who freely choose to exercise in an appropriate manner. Although the psychosocial factors (3) that affect exercise behavior are not fully understood, these variables are most likely major contributors to the success of structured employee fitness programs. Recent experience with implementation of fitness programs for defined groups indicates that only 20% of the target population will enroll in a program (42), and within 6 months, approximately 50% of the enrollees will have dropped out (19). Such data, discouraging though they may be, are consistent with success rates reported for other health-behavior-change programs (19). The process of behavior change has generally been conceptualized as involving two distinct steps: initi-
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ation of the behavior and adherence to the newly adopted behavior. According to this model, employee fitness programs should strive to accomplish two prime behavioral objectives. First, potential participants must be motivated to begin a fitness program. Second, participants should become long-term participants in either a professionally supervised or personally implemented exercise regimen. Recruitment. Available research provides some guidance in designing recruitment strategies for adult fitness programs. Previous reports have developed a profile of the person who is most likely to enter an exercise program. In addition, a few successful recruitment techniques have been identified. Volunteers for exercise programs tend to be of higher socioeconomic status (28). This finding may reflect the better educational level of this group. The availability of more leisure time and a more flexible work schedule in this group, however, may facilitate entry into health promotion programs. The suggestion is that special inducements, such as wage incentives and “company-time” programming, may be needed to attract large numbers of hourly-wage employees into fitness programs. Moreover, exercise program volunteers are less likely than nonvolunteers to be at risk for CHD (42, 49). Thus, the persons who are in greatest need of a fitness program may be the least likely to enroll. Heinzelmann and Bagley (26) have reported that health attitudes and beliefs influence participation in an exercise program. They report that volunteers are more likely than nonvolunteers to acknowledge personal vulnerability to disease (particularly heart disease), to perceive the health benefits of exercise, and to express feelings of control over health status. Shephard and co-workers (42), in an extensive study of recruitment for an employee fitness program, observed generally low correlations between health beliefs and health practices. Shephard et al. did find, however, that volunteers for exercise programs believed more strongly than nonvolunteers that exercise prevents heart attacks. These reports suggest that a small number of very specific beliefs regarding the health benefits of exercise may influence entry into fitness programs. Many persons enter fitness programs for reasons unrelated to health (27, 42). Opportunities for recreation, socialization, fitness enhancement for sports participation, and improvement in appearance attract some participants. Concerns regarding appearance and socialization appear to be particularly important for women, while many male participants are attracted by the self-discipline aspect of fitness programs (42). Since adults initiate exercise programs for many different reasons, a multifocal approach to program recruitment is recommended (25, 27, 42). Advertisements and oral presentations should emphasize not only the health benefits of exercise but also the anticipated social and cosmetic aspects of fitness programs. One approach to recruitment that has proven useful is holding discussions with small groups of employees (27); this approach has been more effective than giving lectures to large groups. Adherence. Long-term adherence to a fitness program is influenced by several factors unrelated to program initiation. Published reports have identified certain personal traits that supposedly predispose persons to drop out of exercise programs. Dishman (19) has reported that adherence to exercise is inversely related
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to percentage body fat and directly related to self-motivation. Thus, obese persons and those whose psychological profiles indicate low self-motivation are at high risk for dropping out. Data collected in the cardiac rehabilitation setting suggest that smokers, blue-collar workers, and those who are sedentary in their leisure time are least likely to adhere to an exercise program (33). Also, social support from “significant others” may be a key factor in adherence. One study found that 80% of those men whose wives had a positive attitude toward the program exhibited a good adherence rate; only 40% of men whose wives’ attitudes were neutral or negative showed good adherence (26). Numerous factors related to program organization and leadership can affect participant adherence. Wanzel (46) studied drop-outs from an employee fitness program and found the following to be the most common reasons for withdrawal: facility too far from workplace (43%), exercise program required excessive rearrangement of participants’ schedules (40%), facility too crowded at usual exercise time (14%), and medical reasons or injury (18%). Similar findings have been reported by other authors (5). Camaraderie and social interaction are important promoters of adherence (27). Participants who like the exercise leader, who enjoy the company of fellow participants, and who are attracted to the “play” aspects of the program are likely to continue. COMPONENTS
OF EMPLOYEE
FITNESS
PROGRAMS
The information presented in the preceding sections provides a basis for the design of employee fitness programs. Available research findings and practical experience suggest that successful occupationally-based physical fitness programs incorporate the following components. Philosophy
A fitness program should reflect a strong commitment by the employer to the promotion of employee health and well-being. Many successful fitness programs are administratively linked to the company medical department and, consequently, receive the professional credibility accorded to the medical profession. At present, there is a strong trend toward development of comprehensive employee health promotion programs in which fitness activities are complemented by nutrition education, smoking cessation, and stress management interventions. We consider this trend to be salutary. Regardless of the administrative pattern or the scope of the program, exercise programming should seek to develop the healthrelated components of fitness (i.e., cardiorespiratory endurance, body composition, and neuromuscular fitness, especially of the lower back). Leadership
Competent leadership may be the most important ingredient in an employee fitness program. Program directors and exercise leaders should have rigorous academic preparation in physical education, health education, and/or exercise physiology. Many colleges and universities now offer specialized undergraduate and graduate degree programs in the field of adult physical fitness. Leaders should
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be capable of measuring and interpreting individual fitness characteristics, prescribing safe and effective exercise programs, and motivating participants to join and adhere to an exercise program. The American College of Sports Medicine administers an extensive certification program for leaders of preventive and rehabilitative exercise programs. This organization has published a complete list of competency requirements which should be met by exercise leaders and technicians (2). Promotion Promotional activities should be designed in accordance with principles discussed previously in this article. Recruitment techniques should be diverse and should address the various reasons for joining an exercise program (e.g., health enhancement, fitness, cosmetic effects, socialization). If feasible, program leaders should actively involve prospective participants in small group discussions that focus on the goals and benefits of the fitness program. Endorsements and personal support by corporate leaders may be helpful in promoting recruitment. A special effort may be required to recruit those employees who are most in need of regular exercise (e.g., those who are sedentary, obese, and/or at risk for cardiovascular disease). In approaching such employees, we suggest that small group or one-on-one meetings be conducted. These sessions should (a) educate the employee regarding the various benefits of exercise, (b) emphasize the relationship between exercise habits and risk of chronic disease, (c) assist the employee in selecting an approach to exercise that overcomes perceived difficulties, and (d) use cognitive-behavioral strategies to alter the employee’s perception of him/herself as an exerciser (30). Approaches such as these have been used successfully in the Johnson & Johnson LIVE for LIFE Program (9). In that project, changes in exercise participation and physical fitness were consistent across educational levels, SES strata, and job classification (9). Although men and younger individuals were somewhat more likely to change, women and individuals in older age categories also improved. The study suggests that, with a well-designed program, improvements can be expected for all categories of employees. Evaluation Employee fitness programs should incorporate appropriate procedures for fitness and health status evaluation in beginning exercisers. Screening techniques should be employed to identify those persons for whom exercise is contraindicated or who should exercise only in a medically supervised setting (40). Since documented improvement is a ‘strong motivator of continued participation in an exercise program, exercisers should have the opportunity to complete fitness tests at regular intervals. Some occupationally based fitness programs provide on-site, medically supervised stress-testing services. Although this may be the ideal arrangement, on-site testing is not an essential program component, since such services normally are available through community-based providers. Submaximal exercise tests can be used in the nonmedical setting to monitor progress in a fitness program. These tests are easy to administer, require little time, and are safe.
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The program, as a whole, should be subjected to regular evaluation. Careful records of employee participation and fitness change should be maintained. Feedback should be solicited from participants for the purposes of modifying and upgrading program services. Independent evaluation should be provided to company management at regular intervals. Facilities A wide range of exercise facilities have been utilized successfully in various employee fitness programs. Perhaps, the ideal is an on-site facility equipped to provide several kinds of exercise training. For many smaller companies, this approach may be financially unrealistic. Useful alternatives include (a) provision of on-site changing and shower facilities to enable employees to exercise out-ofdoors or to use active modes of transportation to and from work (e.g., jogging, cycling); (b) reservation of any existing large room for exercise classes conducted before or after work; (c) contracting with a community recreation department, nonprofit agency, or commercial vendor for use of nearby, off-site exercise facilities. Program
Formats
To succeed, employee fitness programs must be attractive, effective, and convenient. Programs should offer the widest possible range of exercise modalities and should offer services at times that are optimally convenient. Employers can effectively encourage participation by allowing exercise to be performed on company time or by implementing “flex-time” scheduling techniques. Recognition
and Support
Long-term adherence to exercise should be promoted through the use of appropriate award systems and by construction of social support networks. Recognition should be provided principally for attainment of participation goals (e.g., an average of 3 exercise sessions per week for 10 consecutive weeks). Awards can be inexpensive, but they should be presented in a visible setting and/or publicized through internal publications. Spouses and other family members should be as actively involved in the program as possible. The support of “significant others” may provide the key to long-term adherence to a healthful lifestyle. REFERENCES 1. American College of Sports Medicine. Position statement on the recommended quantity and quality of exercise for developing and maintaining fitness in healthy adults. Med. Sci. Sports Exercise 10, VII-X (1978). 2. American College of Sports Medicine. “Guidelines for Graded Exercise Testing and Exercise Prescription,” 2nd ed. Lea & Febiger, Philadelphia, 1980. 3. Becker, M. H., and Maiman, L. A. Socio-behavioral determinants of compliance with health and medical care recommendations. Med. Cure 13, lo-24 (1975). 4. Belloc, N. B., and Breslow, L. Relationship of health status and health practices. Prev. Med. 1, 409-421 (1972). 5. Bjurstrom, L. A., and Alexiou, N. G. A program of heart disease prevention for public employees. J. Occup. Med. 20, 521-531 (1978).
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6. Blair, S. N., Blair, A., Howe, H. G., Pate, R., Rosenberg, M., and Parker, G. M. Leisure time physical activity and job performance. Res. Quart. Exercise Sport 51, 718-723 (1980). 7. Blair, S. N., Pate, R. R., Blair, A., Howe, H. G., Rosenberg, M., and Parker, G. M. Leisure time physical activity as an intervening variable in research. Hen/t/t Education 11, S-11 (1980). 8. Blair, S. N. Exercise and coronary heart disease. B.&v. Med. Update 4, 12-15 (1982). 9. Blair, S. N. The effect of the Live for Life program on employee exercise patterns and physical fitness. Presented to the Society for Behavioral Medicine, Baltimore, March 3, 1983. 10. Blair, S. N., Collingwood, T. R., Reynolds, R., Smith, M., Hagan, R. D., and Sterling, C. L. Health promotion for educators: Impact on health behaviors, satisfaction, and general wellbeing. Am. J. Pub. Health, in press. 11. Blair, S. N., Cooper, K. H., Gibbons, L. W., Gettman, L. R., Lewis, S. and Goodyear, N., Changes in coronary heart disease risk factors associated with increased treadmill time in 753 men. Amer. J. Epidemiol., in press. 12. Brand, R. J., Paffenbarger, R. S., Sholtz, R. I., and Kampert, J. B. Work activity and fatal heart attack studied by multiple logistic risk analysis. Amer. J. Epidemio. 110, 52-62 (1979). 13. Breslow, L. A quantitative approach to the World Health Organization definition of health: Physical, mental and social well-being. Inc. J. Epidemio. 1, 347-355 (1972). 14. Breslow, L., and Enstrom, J. E. Persistence of health habits and their relationship to mortality. Prev. Med. 9, 469-483 (1980). 15. Cooper, K. H., Pollock, M. L., Martin, R. I?, White, S. R., Linnerud, A. C., and Jackson, A. Physical fitness levels vs. selected coronary risk factors. JAMA 236, 166-169 (1976). 16. Cox, M., Shephard, R. J., and Corey, P. Influence of an employee fitness programme upon fitness, productivity and absenteeism. Ergonomics 24, 795-806 (1981). 17. DeVries, H. A. Exercise intensity threshold for improvement of cardiovascular-respiratory function in older men. Geriatrics 26, 94-101 (1971). 18. DeVries, H. A. “Physiology of Exercise for Physical Education and Athletics,” 3rd ed., p. 461. W. C. Brown, Dubuque, Iowa, 1980. 19. Dishman, R. K. Prediction of adherence to habitual physical activity, in “Exercise in Health and Disease” (F. J. Nagle and H. J. Montoye, Eds.), p. 259. C. C. Thomas, Springfield, Ill., 1981. 20. Falls, H. B., Baylor, A. M., and Dishman, R. K. “Essentials of Fitness.” Saunders, Philadelphia, 1980. 21. Fielding, J. E. Effectiveness of employee health improvement programs. J. Occup. Med. 24, 907-916 (1982). 22. Gibbons, L. W., Blair, S. N., Copper, K. H., and Smith, M. Association between coronary heart disease risk factors and physical fitness. Circulation 67, 977-983 (1983). 23. Goldberg, A., Etlinger, J., Goldspink, D., and Jablecki, C. Mechanism of work-induced hypertrophy of skeletal muscle. Med. Sci. Sports 7, 185-198 (1975). 24. Haskell, W. L. Mechanisms by which physical activity may enhance the clinical status of cardiac patients, in “Heart Disease and Rehabilitation” (M. L. Pollock and D. H. Schmidt, Eds.). Houghton Mifflin, Boston, 1979. 25. Haskell, W. L., and Blair, S. N. The physical activity component of health promotion in occupational settings. Public Health Rep. 95, 109-118 (1980). 26. Heinzelmann, F., and Bagley, R. Response to physical activity programs and their effects on health behavior. Public Health Rep. 85, 905-911 (1970). 27. Heinzelmann, F. Social and psychological factors that influence the effectiveness of exercise programs, in “Exercise Testing and Exercise Training in Coronary Heart Disease” (J. P. Naughton and H. K. Hellerstein, Eds.), p. 275. Academic Press, New York, 1973. 28. Kramsch, D. M., Aspen, A. J., Abramowitz, B. M., Kreimnedahl, T., and Hood, W. B. Reduction of coronary atherosclerosis by moderate conditioning exercise in monkeys on an atherogenic diet. Nenl Engl. J. Med. 305, 1483-1488 (1981). 29. Martin, J. Corporate health: A result of employee fitness. Physician Sportsmed. 6, 135-137 (1978). 30. Martin, J. E., and Dubbert, P. M. Exercise and health: The adherence problem. Behav. Med. Update 4, 16-24 (1982). 31. McCafferty, W. B., and Horvath, S. M. Specificity of exercise and specificity of training: A subcellular review. Res. Quart. 48, 358-371 (1977).
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32. Morris, J. M., Pollad, R., Eve&t, M. G., and Chave, S. P. W. Vigorous exercise in leisure-time: Protection against coronary heart disease. Lancer 2, 1207-1210 (1980). 33. Oldridge, N. B. Compliance with exercise programs, in “Heart Disease and Rehabilitation” (M. L. Pollock and D. H. Schmidt, Eds.), p. 619. Houghton Mifflin, Boston, 1979. 34. O’Shea, J. P. “Scientific Principles and Methods of Strength Fitness,” 2nd ed. Addison-Wesley, Reading, Mass., 1976. 35. Paffenbarger, R. S., and Hale, W. E. Work activity and coronary heart mortality. New Engl. J. Med. 292, 545-550 (1975). 36. Paffenbarger, R. S., Wing, A. L., and Hyde, R. T. Physical activity as an index of heart attack risk in college alumni. Amer. J. Epidemiol. 108, 161-175 (1978). 37. Pate, R. R., Hughes, R. D., Chandler, J. V., and Ratliffe, J. L. Effects of arm training on retention of training effects derived from leg training. Med. Sci. Sports 10, 71-74 (1978). 38. Pauly, J. T., Palmer, J. A., Wright, C. C., and Pfeiffer, G. J. The effect of a 1Cweek employee fitness program on selected physiological and psychological parameters. J. Occup. Med. 24, 457-463 (1982). 39. Pollock, M. L. How much exercise is enough? Physician Sportsmed. 6, 50-60 (1978). 40. Pollock, M. L., Wilmore, J. G., and Fox, S. M. “Health and Fitness through Physical Activity.” Wiley, New York, 1978. 41. Sharkey, B. J. “Physiology of Fitness.” Human Kinetics Publishers, Champaign, Ill., 1979. 42. Shephard, R. J., Morgan, P., Finncane, R., and Schimmelfing. Factors influencing recruitment to an occupational fitness program. J. &cup. Med. 22, 389-398 (1980). 43. Shephard, R. J., Cox, M., and Corey, P. Fitness program participation: Its effect on worker performance. J. &cup. Med. 23, 359-363 (1981). 44. Shephard, R. J., Corey, P., Renzland, P., and Cox, M. The influence of an employee fitness and lifestyle modification program upon medical care costs. Canad. J. Public Health 73, 259-263 (1982). 45. Wallston, B. S., and Wallston, K. A. Locus of control and health: A review of the literature. Health Educ. Monogr. 5, 107-l 17 (1978). 46. Wanzel, R. S. Factors related to withdrawal from an employee fitness program. Presented to the American Alliance for Health, Physical Education, and Recreation Convention, Seattle, 1977. 47. Wenger, H. A., and MacNab, R. B. J. Endurance training: The effects of intensity, total work, duration and initial fitness. J. Sports Med. Phys. Fitness 15, 199-211 (1975). 48. Wood, P. D., Haskell, W. L., Blair, S. N., Williams, P. T., Krauss, R. M., Lindgren, F. T., Albers, J. J., Ho, P., and Farquhar, J. W. Increased exercise level and plasma lipoprotein concentrations: A one-year randomized, controlled study in sedentary, middle-aged men. Metabolism 32, 31-39 (1983). 49. Yarvote, P. M., McDonagh, T. J., Goldman, M. E., and Zuckerman, J. Organization and evaluation of a physical fitness program in industry. .I. &cup. Med. 16, 589-598 (1974).
MEDICINE
Physical
12, 632-643
Fitness
RUSSELL *Department
of Physical
Education
(1983)
Programming for Health the Worksite’ R.
PATE*
and Columbia,
AND
fSchoo1 South
STEVEN of Public Carolina
Promotion
at
N. BLAmt
Health, 29208
University
of South
Carolina,
Exercise enthusiasts and health professionals have recommended that physical fitness programs be implemented in the occupational setting. Such programs are promoted on the basis of expected benefits to both the employee and employer. The potential for benefit to the employee seems substantial, since a sizable body of knowledge links regular exercise to improved functional capacity and reduced risk for development of certain chronic diseases. The available literature provides some direct evidence that exercise programs can improve the health status of employee groups. Specifically, programs may generate improvements in cardiorespiratory fitness and cardiovascular health and promote long-term adherence to exercise. The physiological goals can be attained with programs that provide 20-30 min of moderately intense “aerobic” activity 3 or more days per week. Several factors are known to affect adherence of employees to company-sponsored fitness programs. Of particular importance are program leadership, motivational schema, program activities, convenience of participation, and social support. It is recommended that, where feasible, supervisors of employee fitness programs (a) secure professioflal leadership, (b) provide on-site or other facilities that maximize convenience, (c) allow participation across the widest possible time span, (d) provide programs offering a wide range of activities, (e) attend carefully to evaluation, recognition, and other motivational concerns, and (f) incorporate a comprehensive health promotion perspective.
INTRODUCTION
In recent years, regular physical exercise has gained wide acceptanceas one component of a healthful lifestyle. Becauseof the importance of health in job performance, many exercise authorities and health professionalshave recommendedthat physical fitnessprogramsbe offered in the occupationalsetting. Such programs have benefits for both the employee and the employer. Although the development of the worksite physical fitness program is a recent phenomenonin the United States, the researchconducted to date doesprovide someinformation on the effects of such programs on the health and job performance of workers. Also, over the past decadea considerablevolume of researchhasbeen conducted on the factors that contribute to the successfulimplementationof physical fitness programs. This paper will (a) summarizethe researchthat provides the rationale for fitness programsin the occupational setting, (b) identify the characteristicsof adult fitness programs that contribute to the attainment of physiological and behavioral objectives, and (c) describethe key componentsof worksite fitness programs. ’ From a paper presented at the University of Connecticut Fitness, May 12-13, 1983, Farmington, Conn. 632 0091-7435/83
$3.00
Copyright 0 1983 by Academic Press, Inc. All rights of reproduction in any form reserved.
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PROGRAMMING
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There is widespread agreement that regular exercise constitutes a good health habit; however, there is disagreement and misunderstanding regarding the specific benefits of exercise. The elucidation of biological mechanisms underlying the contribution of exercise to health is incomplete. We do not now have, nor are we likely to have, definitive evidence based on randomized clinical trials in large groups to demonstrate that regular exercise lengthens life. We are left, therefore, with circumstantial and indirect evidence on the relationship between health and exercise. In this section we will review the literature on exercise from the perspectives of epidemiology, clinical practice, and controlled experiments. Epidemiologic evidence. In 1965, a sample of 6,928 noninstitutionalized adults in Alameda County (Oakland), California, were surveyed to determine their current health practices and health status (13). They were resurveyed in 1974 and, since that time, have been under continuous surveillance with respect to mortality. Physical health at baseline was associated with seven beneficial habits, of which one was regular physical exercise (4). Mortality was lower over a 9.5year follow-up period in individuals reporting more beneficial health practices at baseline (14). The authors attempted to weigh precisely each of the seven practices in terms of their impact on mortality. While this proved to be impossible, they did conclude that the habits seemed to be equally important. Exercise was thus judged to be as important as not smoking, as using alcohol moderately or not at all, as getting 7-8 hr of sleep, as maintaining proper weight, as eating breakfast, and as not eating between meals. Regular exercise has also been associated with a reduced risk of coronary heart disease (CHD). Morris and colleagues have been following executive-level British civil servants for several years. They recently published data incorporating 1,138 clinical events of CHD in 17,944 male civil servants who were followed for 8.5 years (32). At baseline, these men were classified as vigorous exercisers (VE) or nonvigorous exercisers (NVE) based on extensive physical activity diaries. VE was defined as activity requiring an energy expenditure of 7.5 kcal/min or more, and is equivalent to fast walking. The rate of first coronary events was more than twice as high in NVE men than in VE men; the finding was highly significant statistically. Multivariate and stratified analyses, taking into account age and other potentially confounding variables, failed to change the basic finding. Regular physical activity was also associated with lower mortality in a study of 16,936 Harvard alumni (117,680 man-years of follow-up) (36). Activity was assessed by questionnaire, and mortality surveillance was conducted by the Harvard alumni office (1% lost to follow-up). Men who participated in strenuous sports (at least 2,000 kcal/week) had only about one-half the risk of fatal heart attack compared to their more sedentary peers. This significant difference also persisted after statistical adjustment for possible confounding variables. Paffenbarger et al. (35) followed 6,351 San Francisco longshoremen for 22 years to determine the association between job classification and CHD mortality. Energy expenditure measurements allowed for a relatively accurate assessment of
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job-related physical activity. Men in jobs requiring high levels of exertion had fewer fatal heart attacks than did men in jobs requiring moderate or light activity. The risk ratio of 1.8 for the total CHD comparison increased to 2.9 when the endpoint was sudden death. Early criticism of this study, based on possible premorbid job shifts, has been discounted by an elegant reanalysis which accounted for job changes (12). Most epidemiologic studies on exercise and CHD show a possible protective effect for an active lifestyle (8). Explanations of this association are still somewhat obscure. Haskell (24) has reviewed clinical and experimental studies that invoke the myocardial supply-demand ratio to explain the relationships. Clinical evidence. Physical activity and physical fitness are associated with various measures of improved health in clinical observations. Cooper et al. (15) reported that men with higher levels of physical fitness (as measured by maximal treadmill exercise test performance) were at lower risk for CHD. Fitter men had lower serum cholesterol, triglycerides, glucose, and uric acid; they also had lower blood pressures and less body fat. Gibbons and his colleagues recently reported similar results for women patients at the Cooper Clinic (22). Changes in physical fitness are also associated with beneficial changes in some CHD risk factors. Blair et al. (11) found that increased treadmill time was significantly related to improvements in high-density lipoprotein cholesterol (HDL), total cholesterol/HDL ratio, and serum uric acid levels in 753 Cooper Clinic men. Physical activity may be associated with the more global aspects of health. In a cross-sectional study, we examined the association between physical activity and several health indicators (7). Men and women employed in an insurance company headquarters were given a physical examination and completed an extensive psychosocial questionnaire. Employees reporting more leisure-time physical activity who were also classified as having an internal health locus of control (as distinguished from external) reported fewer medical complaints and had fewer positive findings on physical examination. Individuals reporting more physical activity who also perceived high levels of social support reported greater satisfaction with life. Experimental evidence. There is overwhelming evidence that regular exercise increases physical-work capacity (PWC) (1). Well-controlled experimental studies have documented the degree of exercise (intensity, frequency, and duration) necessary for changing physical fitness. We now have enough data on specific exercise programs to make accurate predictions of changes in various physiological variables. The association between a high PWC and health is still tenuous. The rationale for the hypothesis is that individuals with a high PWC find it easier to perform all submaximal exercise (25). This means that the tasks of daily living are less stressful, and the individual is probably not as tired at the end of the day. Experimental studies suggest that regular exercise has a positive impact on CHD risk factors, particularly on plasma lipoproteins (48). Studies with animal models support the hypothesis of a direct effect of exercise on the atherosclerotic process. For example, Kramsch et al. (28) found that sedentary monkeys had lower HDL levels than those who received exercise. Furthermore, the exercised
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monkeys had less angiographic evidence of CHD, fewer pathognomonic ECG changes, and less sudden death. Experimental studies on exercise support the claims of beneficial effects on weight control, psychological status, adult onset diabetes, and certain orthopedic problems (25). Benefits of Fitness Programs at the Worksite There is widespread belief that occupational physical fitness programs provide tangible benefits to employers and employees (29). Many of these claims, however, are not well documented (25). If the relationship between exercise and health is valid, as discussed in the preceding section, employee fitness programs should improve health. The assumption is that worksite programs can effectively change workers’ exercise habits and physical fitness. It is clear that employees who participate in exercise classes at the worksite improve their physical fitness (16, 38). Whether or not changes in physical fitness in a population of workers (i.e., an entire company) can be produced is less clear. We have conducted two studies, not yet published, that suggest that companywide fitness changes can occur. The Johnson & Johnson LIVE for LIFE Program found that treated employees in four companies made significantly greater gains in exercise participation and physical fitness than did control employees in four other companies (9). The company-wide changes were approximately half what one would expect in a controlled laboratory study. In a second study with school employees, Blair et al. (10) found that teachers in the three schools that comprised the treatment group improved their exercise participation and physical fitness compared with teachers in a control school. Thus, it seems reasonable to conclude that carefully designed exercise programs can produce real changes in exercise and physical fitness in populations of employees. If employees as a group improve their exercise participation, and if this results in improved health status, perhaps the company would benefit as well. It has been suggested that worksite fitness programs will reduce absenteeism and health care costs, improve employee attitude and job satisfaction, and generally increase productivity (5). Data supporting these claims are sparse. We evaluated the association between leisure time physical activity and several measures of job performance in insurance company employees in a cross-sectional design (6) and found no evidence of better job performance in exercisers. Other studies are more supportive of employer benefits resulting from fitness programs. There is some evidence of reduced absenteeism by participants in an exercise program (5). Shephard and his colleagues (43) report less absenteeism and less turnover in insurance company employees who participated in a fitness program. In a later publication, the same investigators reported a reduction in health care costs by exercise program participants (44). The total savings averaged $85 per employee per year. All studies on exercise participation and employee productivity (“bottom line” factors) have design or measurement flaws. A more complete review of studies on productivity and exercise is available (21). It seems reasonable to assume that regular physical activity provides some health benefits. Furthermore, recent studies suggest that the worksite is a feasible location for physical fitness programs, and that company-wide changes in exercise
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and fitness can be produced. That exercise programs and physical fitness have an impact on worker satisfaction, absenteeism, productivity, turnover, and medical claims is much less clear. The available studies provide some support for the hypothesis that exercise programs can effect the “bottom line,” but the evidence is weak. Much more research and more tightly controlled studies are needed (21, 25). CHARACTERISTICS
OF SUCCESSFUL
ADULT
FITNESS
PROGRAMS
Fitness programs for adults should strive to attain two fundamental goals. First, programs should provide a dose of exercise which is sufficient to stimulate desired physiological adaptations. Second, fitness programs should attempt to alter exercise habits permanently and positively-that is, participants should exhibit longterm adherence to structured or individually implemented exercise regimens. Regardless of physical setting, fitness programs that attain these goals share certain common characteristics. Attainment
of Physiological
Goals
Over the past 20 years, a considerable volume of research has been directed toward quantifying the physiological effects of various exercise programs. This research has shown that the physiological adaptations to exercise are highly specific to the type of exercise stress imposed (31, 37). For example, the adaptations to high-resistance, low-repetition exercise (e.g., weight training) are very different from those elicited by low-resistance, high-repetition exercise (e.g., jogging). Also, it has demonstrated that desired physiological adaptations result only if certain minimal levels of exercise are prescribed (47). The threshold level varies with the initial fitness status of the subject (17). Effective fitness programs should provide exercise regimens that meet certain general criteria and also allow for individualization. The principal physiological goals of fitness programs should be improvement of cardiorespiratory fitness and promotion of cardiovascular health. Substantial evidence indicates that these fitness goals can be attained with exercise programs that increase the sedentary adult’s energy expenditure by approximately 1,000 kcal per week (2). These “extra” calories must be expended at a rate that is at least half the participant’s maximum rate of aerobic energy expenditure (maximal oxygen uptake, VOZmax). Table 1 lists the specific criteria met by effective cardiorespiratory fitness programs (39). There is some evidence indicating that reduction of cardiorespiratory disease risk may require more activity than is needed to achieve fitness. Paffenbarger et al. (36) have reported that the threshold for reduction of CHD risk occurs at the leisure-time energy expenditure of approximately 2,000 kcal per week. For improvement or maintenance of cardiorespiratory fitness, the mode of exercise must be “aerobic” in nature. That is, the activity should increase the rate of aerobic metabolism and should maintain this increase for an extended period of time. Primary aerobic activities such as walking, jogging, swimming, and cycling have studied extensively and clearly can bring about significant . been . improvements m V02,,. Other activities such as basketball, racquetball, hand-
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TO ENHANCE
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FITNESS
Mode: Large muscle, rhythmic activity (e.g., walking, jogging, swimming, cycling or “aerobic” sports) Frequency: 3 to 7 exercise sessions per week Duration: 20 to 60 min per session Intensity: 50 to 75% of V02 max 60 to 85% of maximal heart rate
ball, rope skipping, and aerobic dance would seem to qualify as appropriate aerobic activities. The cardiorespiratory fitness benefits of these activities are not yet documented. These primary aerobic activities should be employed at least 3 days per week for a minimum of 20-30 min per session. As previously indicated, the intensity of activity should be sufficient to elevate the rate of aerobic metabolism to 50% of maximum (note-at an exercise intensity of 50% cOZmax, heart rate is approximately 60% of maximum). Aerobic sports activities, since they tend to be discontinuous, may require more frequent or longer durations of participation to generate benefits comparable to those provided by the primary aerobic activities. To summarize, adult fitness programs that seek to improve cardiorespiratory fitness and promote cardiovascular health should provide participants with 2030 min of moderately intense aerobic activity 3 days per week. To promote neuromuscular fitness, aerobic activities should be complemented by appropriate stretching and high-resistance exercises. A discussion of neuromuscular fitness is beyond the scope of this paper; however, several references on the topic are included (18, 20, 23, 34, 41). Attainment of Behavioral Goals Current knowledge allows us to be quite specific and confident in making recommendations with regard to the physiological aspects of fitness programming. Regrettably, much less is known about the psychosocial factors that influence the physical activity behavior of adults. Participation in a physical fitness program is optional (i.e., not demanded by the employer) for the vast majority of adults. Thus, it is clear that the physiological benefits of exercise accrue only to those persons who freely choose to exercise in an appropriate manner. Although the psychosocial factors (3) that affect exercise behavior are not fully understood, these variables are most likely major contributors to the success of structured employee fitness programs. Recent experience with implementation of fitness programs for defined groups indicates that only 20% of the target population will enroll in a program (42), and within 6 months, approximately 50% of the enrollees will have dropped out (19). Such data, discouraging though they may be, are consistent with success rates reported for other health-behavior-change programs (19). The process of behavior change has generally been conceptualized as involving two distinct steps: initi-
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ation of the behavior and adherence to the newly adopted behavior. According to this model, employee fitness programs should strive to accomplish two prime behavioral objectives. First, potential participants must be motivated to begin a fitness program. Second, participants should become long-term participants in either a professionally supervised or personally implemented exercise regimen. Recruitment. Available research provides some guidance in designing recruitment strategies for adult fitness programs. Previous reports have developed a profile of the person who is most likely to enter an exercise program. In addition, a few successful recruitment techniques have been identified. Volunteers for exercise programs tend to be of higher socioeconomic status (28). This finding may reflect the better educational level of this group. The availability of more leisure time and a more flexible work schedule in this group, however, may facilitate entry into health promotion programs. The suggestion is that special inducements, such as wage incentives and “company-time” programming, may be needed to attract large numbers of hourly-wage employees into fitness programs. Moreover, exercise program volunteers are less likely than nonvolunteers to be at risk for CHD (42, 49). Thus, the persons who are in greatest need of a fitness program may be the least likely to enroll. Heinzelmann and Bagley (26) have reported that health attitudes and beliefs influence participation in an exercise program. They report that volunteers are more likely than nonvolunteers to acknowledge personal vulnerability to disease (particularly heart disease), to perceive the health benefits of exercise, and to express feelings of control over health status. Shephard and co-workers (42), in an extensive study of recruitment for an employee fitness program, observed generally low correlations between health beliefs and health practices. Shephard et al. did find, however, that volunteers for exercise programs believed more strongly than nonvolunteers that exercise prevents heart attacks. These reports suggest that a small number of very specific beliefs regarding the health benefits of exercise may influence entry into fitness programs. Many persons enter fitness programs for reasons unrelated to health (27, 42). Opportunities for recreation, socialization, fitness enhancement for sports participation, and improvement in appearance attract some participants. Concerns regarding appearance and socialization appear to be particularly important for women, while many male participants are attracted by the self-discipline aspect of fitness programs (42). Since adults initiate exercise programs for many different reasons, a multifocal approach to program recruitment is recommended (25, 27, 42). Advertisements and oral presentations should emphasize not only the health benefits of exercise but also the anticipated social and cosmetic aspects of fitness programs. One approach to recruitment that has proven useful is holding discussions with small groups of employees (27); this approach has been more effective than giving lectures to large groups. Adherence. Long-term adherence to a fitness program is influenced by several factors unrelated to program initiation. Published reports have identified certain personal traits that supposedly predispose persons to drop out of exercise programs. Dishman (19) has reported that adherence to exercise is inversely related
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to percentage body fat and directly related to self-motivation. Thus, obese persons and those whose psychological profiles indicate low self-motivation are at high risk for dropping out. Data collected in the cardiac rehabilitation setting suggest that smokers, blue-collar workers, and those who are sedentary in their leisure time are least likely to adhere to an exercise program (33). Also, social support from “significant others” may be a key factor in adherence. One study found that 80% of those men whose wives had a positive attitude toward the program exhibited a good adherence rate; only 40% of men whose wives’ attitudes were neutral or negative showed good adherence (26). Numerous factors related to program organization and leadership can affect participant adherence. Wanzel (46) studied drop-outs from an employee fitness program and found the following to be the most common reasons for withdrawal: facility too far from workplace (43%), exercise program required excessive rearrangement of participants’ schedules (40%), facility too crowded at usual exercise time (14%), and medical reasons or injury (18%). Similar findings have been reported by other authors (5). Camaraderie and social interaction are important promoters of adherence (27). Participants who like the exercise leader, who enjoy the company of fellow participants, and who are attracted to the “play” aspects of the program are likely to continue. COMPONENTS
OF EMPLOYEE
FITNESS
PROGRAMS
The information presented in the preceding sections provides a basis for the design of employee fitness programs. Available research findings and practical experience suggest that successful occupationally-based physical fitness programs incorporate the following components. Philosophy
A fitness program should reflect a strong commitment by the employer to the promotion of employee health and well-being. Many successful fitness programs are administratively linked to the company medical department and, consequently, receive the professional credibility accorded to the medical profession. At present, there is a strong trend toward development of comprehensive employee health promotion programs in which fitness activities are complemented by nutrition education, smoking cessation, and stress management interventions. We consider this trend to be salutary. Regardless of the administrative pattern or the scope of the program, exercise programming should seek to develop the healthrelated components of fitness (i.e., cardiorespiratory endurance, body composition, and neuromuscular fitness, especially of the lower back). Leadership
Competent leadership may be the most important ingredient in an employee fitness program. Program directors and exercise leaders should have rigorous academic preparation in physical education, health education, and/or exercise physiology. Many colleges and universities now offer specialized undergraduate and graduate degree programs in the field of adult physical fitness. Leaders should
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be capable of measuring and interpreting individual fitness characteristics, prescribing safe and effective exercise programs, and motivating participants to join and adhere to an exercise program. The American College of Sports Medicine administers an extensive certification program for leaders of preventive and rehabilitative exercise programs. This organization has published a complete list of competency requirements which should be met by exercise leaders and technicians (2). Promotion Promotional activities should be designed in accordance with principles discussed previously in this article. Recruitment techniques should be diverse and should address the various reasons for joining an exercise program (e.g., health enhancement, fitness, cosmetic effects, socialization). If feasible, program leaders should actively involve prospective participants in small group discussions that focus on the goals and benefits of the fitness program. Endorsements and personal support by corporate leaders may be helpful in promoting recruitment. A special effort may be required to recruit those employees who are most in need of regular exercise (e.g., those who are sedentary, obese, and/or at risk for cardiovascular disease). In approaching such employees, we suggest that small group or one-on-one meetings be conducted. These sessions should (a) educate the employee regarding the various benefits of exercise, (b) emphasize the relationship between exercise habits and risk of chronic disease, (c) assist the employee in selecting an approach to exercise that overcomes perceived difficulties, and (d) use cognitive-behavioral strategies to alter the employee’s perception of him/herself as an exerciser (30). Approaches such as these have been used successfully in the Johnson & Johnson LIVE for LIFE Program (9). In that project, changes in exercise participation and physical fitness were consistent across educational levels, SES strata, and job classification (9). Although men and younger individuals were somewhat more likely to change, women and individuals in older age categories also improved. The study suggests that, with a well-designed program, improvements can be expected for all categories of employees. Evaluation Employee fitness programs should incorporate appropriate procedures for fitness and health status evaluation in beginning exercisers. Screening techniques should be employed to identify those persons for whom exercise is contraindicated or who should exercise only in a medically supervised setting (40). Since documented improvement is a ‘strong motivator of continued participation in an exercise program, exercisers should have the opportunity to complete fitness tests at regular intervals. Some occupationally based fitness programs provide on-site, medically supervised stress-testing services. Although this may be the ideal arrangement, on-site testing is not an essential program component, since such services normally are available through community-based providers. Submaximal exercise tests can be used in the nonmedical setting to monitor progress in a fitness program. These tests are easy to administer, require little time, and are safe.
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The program, as a whole, should be subjected to regular evaluation. Careful records of employee participation and fitness change should be maintained. Feedback should be solicited from participants for the purposes of modifying and upgrading program services. Independent evaluation should be provided to company management at regular intervals. Facilities A wide range of exercise facilities have been utilized successfully in various employee fitness programs. Perhaps, the ideal is an on-site facility equipped to provide several kinds of exercise training. For many smaller companies, this approach may be financially unrealistic. Useful alternatives include (a) provision of on-site changing and shower facilities to enable employees to exercise out-ofdoors or to use active modes of transportation to and from work (e.g., jogging, cycling); (b) reservation of any existing large room for exercise classes conducted before or after work; (c) contracting with a community recreation department, nonprofit agency, or commercial vendor for use of nearby, off-site exercise facilities. Program
Formats
To succeed, employee fitness programs must be attractive, effective, and convenient. Programs should offer the widest possible range of exercise modalities and should offer services at times that are optimally convenient. Employers can effectively encourage participation by allowing exercise to be performed on company time or by implementing “flex-time” scheduling techniques. Recognition
and Support
Long-term adherence to exercise should be promoted through the use of appropriate award systems and by construction of social support networks. Recognition should be provided principally for attainment of participation goals (e.g., an average of 3 exercise sessions per week for 10 consecutive weeks). Awards can be inexpensive, but they should be presented in a visible setting and/or publicized through internal publications. Spouses and other family members should be as actively involved in the program as possible. The support of “significant others” may provide the key to long-term adherence to a healthful lifestyle. REFERENCES 1. American College of Sports Medicine. Position statement on the recommended quantity and quality of exercise for developing and maintaining fitness in healthy adults. Med. Sci. Sports Exercise 10, VII-X (1978). 2. American College of Sports Medicine. “Guidelines for Graded Exercise Testing and Exercise Prescription,” 2nd ed. Lea & Febiger, Philadelphia, 1980. 3. Becker, M. H., and Maiman, L. A. Socio-behavioral determinants of compliance with health and medical care recommendations. Med. Cure 13, lo-24 (1975). 4. Belloc, N. B., and Breslow, L. Relationship of health status and health practices. Prev. Med. 1, 409-421 (1972). 5. Bjurstrom, L. A., and Alexiou, N. G. A program of heart disease prevention for public employees. J. Occup. Med. 20, 521-531 (1978).
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