Evaluation of research strategies applied to Workplace Health Promotion

Introduction: Workplace Health Promotion (WHP) is conceptualized as a set of strategies and interventions to help people change their lifestyles and the environment where they develop their activities seeking to reach an optimum state of health. Objective: To present the results of a critical literature review about the more used research strategies and themes studied related to health promotion at workplace. Methods: We conducted a bibliographical research on the American Journal of Health Promotion. This journal was chosen because it contained important studies about WHP. We only included observational and interventional studies published from 2005 to 2009. Results: Thirty-two articles were included in this research. The observational studies were the most cited design than interventions studies. The measurement procedures most used were questionnaire (n= 14; 44%) and telephone survey (n=6; 19%). The two themes more recurrent in the analyzed control (n=5;15.5%). Dental health (n=1;3%) and the stress management (n=1;3%) were the two themes less present among the articles analyzed. Final considerations: WHP was exploited in various ways and the studies analyzed presented different types of evaluation. These data can support the planning and the actions with intersectoral and multidisciplinary approaches when implementing strategies to WHP.


IntroductIon
According the Ottawa charter, Health Promotion (HP) is the process of enabling people to improve and increase the control of their health, therefore, HP is not just responsibility of health sector [1].In the same direction the Luxembourg Declaration (1997) refers Workplace Health Promotion (WHP) as "the combined efforts of employers, employees and society to improve the health and wellbeing of people at work".This can be achieved through a combination of: 1) improving the work organization and environment; 2) promoting active participation; 3) encouraging personal development" [2].
The concept of WHP has been intensely discussed both in public or private organizations and there is a consensus that the success of globalization can only be achieved if the institutions offers manpower healthy, skilled and motivated [3].The literature reveals that several types of programs based on the philosophy of WHP are offered in workplaces such as programs that encourage physical activity, tobacco control, stress management, control of hypertension and weight, in addition programs aimed at preventing accidents and sexually transmitted diseases, topics related to nutrition, promoting and maintaining mental health and even activities involving detection / prevention of cancer in the work population [4].
Observing the bibliographical production on WHP is possible to notice a diversity of understandings and definitions on this subject, resulting in a variability of contexts and strategies used for achieve that.Therefore, there is a need to know the themes and the methodological designs utilized in this field of knowledge in order to help researches in the development of new studies.The aim of this article was to present the results of a literature review about the more used research strategies and themes studied related to health promotion in workplace.

methods
This research was conducted in the The American Journal of Health Promotion databases.We chose this database because it contained articles which approaches targeted both to practitioners of WHP as for scientists interested in knowing the latest results and trends in the practice of health promotion and research related to this subject.The bibliographical research was limited from articles published from 2005 to 2009.We made our search using the key words: Health Promotion, Workplace, and Occupational Health.The inclusion criteria comprised only observational and interventional studies published in the journal and in the period cited above.The findings were analyzed according author, year, subject approaches/ objectives, design, measurement procedures and conclusions cited in all articles included.The design of the studies was classified according to methodological criteria of Hulley et al. [5] and descriptive statistics was used to analyse the data.
Table 1 presents the findings related to the design of studies, data collection instruments used and the main findings of the studies that were part of this research.The observational studies accounted for 80% of the findings, followed by 20% of intervention studies.With respect to measurement procedures used for data collection in observational and interventional studies, it was found that most of the studies used questionnaires (n = 14; 44%) and telephone survey (n=6; 19%).Company's annual physical checkups "This study suggests the relationships of smoking as well as age and sex to dental care costs in an employer setting".

2
Lynch [7] Financial Analysis (to examine the relationship between health risks and medical care expenditures).
Medical expenditure data available in the fiscal year "Such information provides a solid foundation for health promotion efforts in Japan and direction for subsequent investigations of health risks and medical expenditures".

3
Nishimura [8] Financial Analysis (to examine the differences in medical care costs among individuals who carried the diagnosis of selected lifestyle diseases (diabetes mellitus, hypertension, and hyperlipidemia); individuals whose levels of risks (blood glucose, blood pressure, and total cholesterol) satisfied the diagnosis guidelines yet who did not carry the diagnoses; individuals who had these risks but whose risk levels were not high enough to satisfy the diagnosis guidelines and individuals without the risks).

Medical claims and health checkups
"In a Japanese employee population, the diagnosis status of diabetes mellitus, hyperlipidemia and hypertension was found to be associated with higher medical care costs while risk levels for the diseases were not in a 1-year time period".

4
Daly [9] Applied Research Brief: Behavior Change (to explore the potential effectiveness of a proactive telephone-based intervention in increasing workplace adoption of health promotion initiatives).

Telephone interview at baseline and again 4 years later
"The findings of this study suggest that a proactive telephone-based intervention has the potential to be effective in increasing the prevalence of health promotion initiatives across a range of health topics in a large population of workplaces".

5
Barbeau [10] Culture Change (Qualitative and quantitative research to understand the meaning and function of union membership in workers' lives and applied this information to health promotion intervention design).
Qualitative and Quantitative instruments developed by authors "The findings provide a compelling rationale for considering unions as a channel for health promotion interventions".

6
Plotnikoff [11] Behavior Change (to evaluate a 12-week workplace e-mail intervention designed to promote physical activity and nutrition behavior).
Electronic health messages intervention (e-mails) and control groups "E-mail is a promising mode of delivery for promoting physical activity and nutrition in the workplace".

7
Thompson [12] Culture Change (to identify factors related to formation, participation, and characteristics of employee advisory boards in blue-collar worksites).

dIscussIon
The merit of this research is related to analysis and systematization of papers which published details of studies conducted in workplace.About the analysis of the types of approaches and programs implemented in this review, we found that most studies used informative strategies aimed to educate workers in topics related to behavioral aspects of health maintenance.Tones & Tilford [38] refers that this type of strategy represents the preventive model of health education that seeks to bring individuals to the standards of living well established by the biomedical sciences.In other words, health education allows people gain knowledge about health, but not awareness to ensure the best psychosocial conditions in this context.
According to this line of thought, we note that the articles analyzed showed more targeted approaches to health prevention.That is, although the actions developed have been called as "health promotions actions", they showed a strong preventive component, which reduces the concept of Health Promotion (HP).This conceptual distinction is important, because prevention is an idea associated with Occupational Health (OH), and OH is dedicated to "all aspects of health and safety in the workplace and has a strong focus on primary prevention of hazards" [39].
Hence, OH is limited OH is limited to the health sector, that relates to the notion of risk and control, while the Health Promotion encompasses broader actions that go beyond the biomedical dimensions of health, since elaborates actions aiming" to enabling people to improve the control and power increase of their health" [1].Therefore, the intersectoral actions may be a good way to develop WHP.
By the analysis of 32 articles we found that Health Promotion (HP) has been developed in the workplace in several ways, using different resources, with no protocol or standardization of procedures.Corroborating our findings, a study of Aldana [40] related the existence of more than 500 evaluation studies of programs with varying quality and methodology, a large number of GONÇALO CS, MIALHE FL.

EVALUATION OF RESEARCH STRATEGIES APPLIED TO WORKPLACE HEALTH PROMOTION
results on secondary descriptions of programs, a variety of articles reviewing multiple studies and summarize the growth in the number of scientific studies and evaluation of programs implemented in the workplace (workplace settings).
Thus, we recognize the difficulties to plan and evaluate actions directed to WHP due to their complexity but we think there is a strong necessity of develop strategies in this context mainly because WHO considers WHP as a priority for health promotion in the XXI century.

fInAl consIderAtIons
We found that WHP was exploited in various ways and the reviewed studies presented different methodological designs.We suggest that future papers present more detailed explanations about cognitive, psychosocial, environmental and organizational barriers involved in the planning and execution of WHP actions in order to enable the enhancement of interventions published by others researchers.