Health Promotion International, Vol. 21 No. 4
doi:10.1093/heapro/dal031
Advance access publication 8 September 2006
Ó The Author (2006). Published by Oxford University Press. All rights reserved.
For Permissions, please email: [email protected]
The results of a worksite health promotion programme
in Kuala Lumpur, Malaysia
FOONGMING MOY1, ATIYA A. B. SALLAM1 and MEELIAN WONG2
1
Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala
Lumpur, Malaysia and 2Department of Community, Occupational and Family Medicine,
Faculty of Medicine, National University of Singapore, Singapore
SUMMARY
The worksite is one of the key channels for the delivery
of interventions to reduce chronic diseases among adult
populations. It provides easy and regular access to a
relatively stable population and it encourages sustained
peer support. This paper reports a 2-year follow-up of the
impact of a worksite health promotion programme on
serum cholesterol and dietary changes among employees
in a city in Malaysia. A quasi-experimental study was
conducted among Malay-Muslim male security guards,
with those working in a public university in Kuala Lumpur
comprising the intervention group, and those working
in the teaching hospital of the same university as the
comparison group. They were comparable in sociodemographic characteristics. The intervention group
received intensive individual and group counselling on
diet, physical activity and quitting smoking. The comparison group was given minimal education on the same
lifestyle changes through mail and group counselling.
The intervention group showed a statistically significant
reduction in their mean total cholesterol levels as compared with the comparison group, with an intervention
effect of –0.38 (95% CI = –0.63, –0.14) mmol/l. The
intervention group also reported a reduction in the
amount of cigarettes smoked. The worksite was shown
to be an effective channel for health promotion. The
adoption of the new lifestyle behaviours should be
supported and sustained through modification of work
policies.
Key words: health promotion; total cholesterol; worksite
INTRODUCTION
Malaysia is developing rapidly from an agricultural to a developed state. The nation’s health
status has improved significantly with its infant
mortality rate decreasing from 19.7 in 1981 to
5.9 per 1000 live births in 2004, while the life
expectancy of males and females were 70.4
and 76.2 years in the same year (Statistics
Department, 2004). However, these changes
were coupled with changes from physically active
to sedentary lifestyle. The diets also changed
from high fibre and low fat to high fat and low
fibre which contributed to the high-energy
content (Tee, 2002). Consequently, the disease
pattern had changed from a predominance of
communicable to non-communicable diseases.
For the year 2002, heart diseases and diseases
of pulmonary circulation and cerebrovascular
diseases were the second and fourth leading
causes of death, respectively, in Malaysia
(Ministry of Health, 2002).
In the year 2004, 40% of the total population
of 25.58 million population in Malaysia was
employed (Statistics Department, 2004). With a
high proportion of adults in employment and
chronic illnesses resulting in a considerable
economic burden, the workplace has been
recognized as an important target for health
promotion (Kristensen, 2000). It provides easy
301
302
F Moy et al.
and regular access to a large captive group and it
encourages sustained peer support and positive
peer influence (Harris and Fries, 2002).
Recent research had shown that effective
worksite health promotion programmes were
those that offered multiple risk-factor interventions combined with group participation and
individualized risk reduction counselling to highrisk employees (Pelletier, 2001). These programmes were found to produce positive clinical
(Pelletier, 2001) and cost (Aldana, 2001) outcomes such as increases in health awareness, risk
reduction, disease prevention and a reduced
demand for health services.
A pilot survey on a group of security guards at
a public university in Kuala Lumpur (Moy and
Atiya, 2003) found them to be at increased risk
for morbidity and mortality, with 60% of them
being overweight/obese and with higher prevalence of hypertension, diabetes mellitus than
the Malaysian general population (National
Health Morbidity Survey II, 1997). Hence, a
health promotion programme was implemented
for this target group at the worksite in 2003 with
the aim of reducing their risks of chronic
diseases. This paper reports the long-term impact
of the programme on the employees’ lifestyle
practices and their cholesterol levels.
METHODS
A pre-test–post-test quasi-experimental study
design was used in which a comparison group
similar to the intervention group in sociodemographic characteristics was selected.
Although randomized controlled trial is the
best method for intervention studies, randomization of individuals at the same worksite may
not be appropriate since the staff worked closely
with each other, leading to contamination or spill
over effect of the intervention. According to the
health promotion experts (World Health Organization, 1998; Green and Tones, 1999; Rimer
et al., 2001), the non-randomized experimental
design with a comparable group, with pre- and
post-intervention data for each group, reporting
on all outcomes targeted at individuals in the
study were considered to provide the strongest
evidence for a causal relationship between the
intervention and any change in outcome
measures.
In this study, the intervention group consisted
of security guards recruited from a public
university in Kuala Lumpur, while the comparison group of security guards was selected from
another security unit of another worksite—the
teaching hospital of the same university. All
security guards of both units were invited to
participate. As the majority of the staff (>95%)
were Malay males, the females and other ethnic
groups were excluded in the data analysis.
Ethical clearance was obtained from the Ethical
Committee of the university. Participation was
voluntary and informed consent was given by all
the participants.
Data collection
Pre-tested self-administered questionnaires
were used to gather information on sociodemographic characteristics, medical history
and self-reported lifestyle behaviours (dietary
practices, physical activity and smoking). Indepth interviews and focus group discussions
were conducted to better understand some of
the behaviours or perceptions of the respondents
after the survey. Anthropometric measurements
(weight, height, waist and hip circumference),
blood pressure and biochemical measurements
(fasting blood glucose and full lipid profiles)
were taken at baseline and at 6-month intervals
for 2 years. All measurements were taken at the
worksite and blood specimens were analysed in
the Clinical Diagnostic Laboratory of the same
hospital. The detailed methodology is described
elsewhere (Moy and Atiya, 2004). The main
outcome measure was the total cholesterol level
while all the other measurements [body mass
index (BMI), fasting blood glucose, LDL- and
HDL-cholesterol and triglycerides] were secondary outcome measures.
Data analysis
The data were entered and analysed in SPSS
for Windows version 11.0. Level of significance
was pre-set at 0.05. Statistical methods such
as repeated measures analysis of variance
(ANOVA) were used to evaluate changes in
outcome measures such as total cholesterol
levels over time; with grouping (intervention or
comparison) as the between groups factor and
follow-up interval as the repeated measures
factor. The Hyunh–Feldt correction was used to
correct for the violation of the assumption of
sphericity (compound symmetry). To assess
whether there was a difference in the outcome
Ms 1762: worksite health promotion programme
measures over the study period, student’s t-test
was used to compare the baseline and the final
readings. Categorical data were analysed using
the x2-test. 95% confidence intervals (CI) were
reported where appropriate.
303
both management units’ approval so that the
security guards would not be taken away from
their duties for too long. This was also an
approach used to encourage participation.
RESULTS
The intervention programme
The intervention group received one-to-one
counselling (at least twice yearly) and group
teaching (3–4 times per year) based on the
feedback of health check results. The topics
covered included nutrition, physical activity and
other risk factors associated with cardiovascular
diseases, with a focus on the dietary aspects of
reducing cholesterol levels and weight management for the high-risk group. The dietary advice
was based on the National Cholesterol Education Programme (NCEP) Step I diet (National
Cholesterol Education Programme, 1993) and
the American Heart Association Guide for
improving cardiovascular health at the community level (Pearson et al., 2003). For those in the
normal or low-risk category, they were encouraged to maintain their healthy diet and physical
activity. Group counselling was also given on
topics such as quitting smoking, ways to increase
physical activity and stress management. Specially designed pamphlets were distributed to
the intervention participants. Self-monitoring
booklets were given to the participants to
monitor their anthropometric and biomedical
measurements. Motivation and encouragement
were given to participants based on their results.
Quiz programmes were conducted to increase
awareness of the intervention participants and
incentives in the forms of small gifts were given
to the winners.
The investigators also worked with management to provide a supportive environment at
the worksite; and to modify some of the work
practices and social norms of the employees.
Microwave oven and water cooler were placed in
the work office. A weighing scale was also placed
in the office for their staff to monitor their weight.
The comparison group was given minimal
heath education through feedback of health
check results through mails, distribution of
standard brochures and group sessions held
only once yearly. These activities were provided
for the comparison group as it would be
unethical to withhold information.
All the activities were conducted at the main
office at the worksite during working hours with
Response rate
There were 127 and 112 staff in the intervention
and comparison groups, respectively. Only
Malay males were included in the study since
there were very few Indians and females (<5%).
The number of eligible participants was 111 and
99 for the intervention and comparison groups,
respectively. Of these, 102 (91.9%) staff from
the intervention and 84 (84.8%) staff from the
comparison groups participated in the baseline
health check.
The groups were followed up for 2 years. Five
measurements were taken and the response rates
were 82.4, 82.4, 78.4 and 75.5% for the intervention group and 89.3, 81.0, 85.7 and 86.9% for
the comparison group, using the number of
participants at baseline as the denominator.
Socio-demographic and baseline
characteristics
The respondents from both groups were mostly
married and with secondary education. However, the intervention group was significantly
younger (mean age of 43.9 ± 7.8 years) and
had longer years of service (17.8 ± 10.5 years)
(P < 0.05).
The baseline anthropometric and biochemical
measurements of the intervention and comparison groups were comparable except for the
total cholesterol and the triglyceride levels,
which were significantly higher (P < 0.05) in
the intervention group.
When the participants were further divided
into groups of normal weight/overweight and
normal cholesterol/hypercholesterolemia, only
34.0 and 33.3% of the intervention and comparison groups had normal BMI (<25 kg/m2);
whereas 28.4 and 44.8% of them, respectively,
had normal total cholesterol levels (<5.2 mmol/l).
Table 1 shows that there was no difference in
the marital status, education level and the mean
age of the respondents and non-respondents
(P > 0.05) at follow-up at 2 years. The BMI of
the respondents were slightly lower than the
non-respondents; whereas the total cholesterol
F Moy et al.
The respondents and non-respondents in
the intervention group did not differ in physical
activity; however, more non-respondents from
the comparison group reported having engaged
in exercise. There was no difference in the
prevalence of smoking among the respondents
and non-respondents in both the intervention
and comparison groups.
levels of the respondents were higher than
the non-respondents in both groups; but the
differences were not statistically significant
(P > 0.05).
Table 1: Characteristics of respondents and
non-respondents at 2 years
Characteristics
Intervention Comparison
group (SD) group (SD)
Respondents (n)
77
73
Socio-demographic characteristics
Married (%)
88.3
94.5
Secondary education (%) 85.7
83.6
Mean age in years
45.6 (7.2)
48.0
Lifestyle behaviours
Adequate exercise* (%)
45.0
33.3
Smoking currently (%)
41.7
35.6
Anthropometry and
biochemical measurement
26.3 (3.8)
26.2
Mean BMI (kg/m2)
Total cholesterol (mmol/l) 5.9 (1.2)
5.5
Non-respondents (n)
25
11
Socio-demographic characteristics
Married (%)
84.0
90.1
Secondary education (%) 88.0
81.8
Mean age in years
44.9 (9.4)
48.4
Lifestyle behaviours
Adequate
45.5
50.0
exercise* (%)
Smoking currently (%)
40.0
36.4
Anthropometry and biochemical measurement
2
26.4 (4.9)
26.9
Mean BMI (kg/m )
Total cholesterol (mmol/l) 5.8 (0.7)
5.1
Outcome measures
Figure 1 shows the total cholesterol measurements over time by group. The intervention
group showed significant improvement (F = 3.16,
P = 0.018) in the total cholesterol level with a
reduction of 0.21 mmol/l (95% CI = –0.36, –0.06)
in the total cholesterol level (3.6%) over the
past 2 years from March 2003 to March 2005
(Table 2). The comparison group showed fluctuating levels till the 18th month, after which a
statistically significant increase in the cholesterol
level was observed (F = 2.65, P = 0.04). There
was an increase of 0.17 mmol/l (95% CI = –0.03,
0.38) between the final and baseline measurements in the comparison group. The intervention
effect or between group difference was –0.38
mmol/l (95% CI = –0.63, –0.14) (Table 2).
When the participants were stratified
into categories of normal level of cholesterol
(<5.2
mmol/l)
and
hypercholesterolemia
(5.2 mmol/l), it was found that participants
with normal cholesterol from the intervention
group had a maintained lower mean cholesterol
(4.7)
(3.2)
(1.1)
(5.8)
(1.7)
(1.1)
Total cholesterol (mmol/l)
*Exercising for at least 20 min per session and three
times a week.
5.9
0.20
5.8
0.15
5.7
0.10
5.6
0.05
5.5
0.00
5.4
-0.05
5.3
-0.10
5.2
-0.15
5.1
-0.20
5.0
mean difference (mmol/l)
304
-0.25
0
6
12
18
24
Follow up (months)
intervention (total chol)
comparison (total chol)
intervention (difference)
comparison (difference)
Fig. 1: Mean values and mean difference in cholesterol level (mmol/l) of intervention and comparison
groups over 24 months of follow up.
Ms 1762: worksite health promotion programme
305
Table 2: Mean total cholesterol levels and mean difference (mmol/l) of participants by categories
Cholesterol levels
Intervention group
Comparison group
Difference
(between groups)
All participants (n)
102
Baseline (mean ± SD)
5.83 ± 1.13
At 2 years (mean ± SD)
5.62 ± 1.04
Mean difference (95% CI)
–0.21 (–0.36; –0.06)
Participants with total cholesterol <5.2 mmol/l
n
24
Baseline (mean ± SD)
4.49 ± 0.56
At 2 years (mean ± SD)
4.49 ± 0.85
Mean difference (95% CI)
0.00 (0.37; –0.37)
Participants with total cholesterol 5.2 mmol/l
n
78
Baseline (mean ± SD)
6.24 ± 0.92
At 2 years (mean ± SD)
5.97 ± 0.83
Mean difference (95% CI)
–0.27 (–0.43; –0.12)
84
5.44 ± 1.10
5.61 ± 1.16
0.17 (–0.03; 0.38)
–0.38 (–0.63; –0.14)
32
4.36 ± 0.73
4.98 ± 1.16
0.62 (0.29; 0.95)
–0.62 (–1.10; –0.13)
52
6.10 ± 0.70
6.00 ± 0.99
–0.10 (–0.34; 0.14)
–0.17 (–0.44; 0.10)
Table 3: Mean LDL-cholesterol and mean difference (mmol/l) of participants by categories
Intervention group
All participants (n)
Baseline (mean ± SD)
At 2 years (mean ± SD)
Mean difference (95% CI)
Participants with LDL cholesterol <4.53
n
Baseline (mean ± SD)
At 2 years (mean ± SD)
Mean difference (95% CI)
Participants with total cholesterol 4.53
n
Baseline (mean ± SD)
At 2 years (mean ± SD)
Mean difference (95% CI)
102
3.61 ± 1.00
3.77 ± 0.78
0.16 (0.00; 0.32)
mmol/l
85
3.31 ± 0.74
3.60 ± 0.70
0.29 (0.14; 0.44)
mmol/l
17
5.11 ± 0.75
4.62 ± 0.58
–0.49 (–0.99; 0.02)
level at 4.49 mmol/l throughout the 2-year follow
up, whereas the comparison group showed an
increase in cholesterol level from 4.36 ± 0.73 to
4.98 ± 1.16 mmol/l. The difference between
groups was significant with –0.62 mmol/l (95%
CI = –1.10, –0.13). Hypercholesterolemic participants from both the intervention and comparison
groups showed an improvement in their total
cholesterol levels; however, the reduction was
much greater (–0.27 mmol/l or 4%) in the
intervention group compared to the comparison
groups (–0.10 mmol/l or 1.6%). The difference
observed between groups (intervention effect)
was –0.17 mmol/l (95% CI = –0.44, 0.10)
(Table 2).
LDL-cholesterol for the intervention and comparison groups was 3.61 ± 1.00 and 3.42 ±
0.97 mmol/l, respectively. Table 3 showed that
Comparison group
Difference
(between groups)
84
3.42 ± 0.97
3.80 ± 0.96
0.38 (0.19; 0.56)
–0.21 (–0.46; 0.03)
76
3.24 ± 0.80
3.68 ± 0.89
0.44 (0.24; 0.64)
–0.15 (–0.39; 0.10)
8
5.18 ± 0.68
4.96 ± 0.88
–0.23 (–0.86; 0.40)
–0.26 (–1.08; 0.56)
overall there was an increase in the mean LDLcholesterol for both groups where this was
mostly contributed by those in the lower LDLcholesterol (<4.53 mmo/l) group; participants
with high levels (4.53 mmol/l) demonstrated
reduced levels with a larger reduction in the
intervention group; however, the difference
between groups was not significant (–0.26, 95%
CI = –1.08, 0.56).
Table 4 shows the changes in all health risk
measures during the 2 year follow-up. Other than
total cholesterol and LDL-cholesterol, measures
such as systolic and diastolic blood pressure also
improved in both groups although the difference
was not statistically significant (P > 0.05)
(Table 4). The HDL-cholesterol was reduced
significantly in both groups (P < 0.05). However,
the reduction was larger in the intervention
306
F Moy et al.
Table 4: Changes during 2-year follow-up for all health risk measures by group
Health risk measures
Intervention group (n = 102)
24 month
(b)
BMI (kg/m2)
Systolic BP (mm Hg)
Diastolic BP (mm Hg)
Total Cholesterol (mmol/l)
HDL (mmol/l)
LDL (mmol/l)
Triglycerides (mmol/l)
Fasting blood glucose (mmol/l)
26.43
132.6
81.0
5.62
0.96
3.77
2.29
6.15
±
±
±
±
±
±
±
±
3.28
15.1
10.8
1.04
0.17
0.78
1.14
1.48
Baseline
(a)
26.42
133.0
82.2
5.83
1.17
3.61
2.24
5.69
±
±
±
±
±
±
±
±
4.01
16.1
11.1
1.13
0.25
1.00
1.30
1.34
Comparison group (n = 84)
Difference
(b – a)
0.01
–0.39
–1.13
–0.21
–0.21
0.16
0.05
0.46
±
±
±
±
±
±
±
±
2.30
14.28
9.64
0.75*
0.21*
0.81
1.10
1.36
24 month
(b)
26.40
132.8
82.7
5.61
1.03
3.80
2.03
5.92
±
±
±
±
±
±
±
±
2.75
17.4
10.8
1.16
0.20
0.96
1.19
1.17
Baseline
(a)
26.30
136.3
84.0
5.44
1.15
3.42
1.89
5.68
±
±
±
±
±
±
±
±
3.01
18.1
11.8
1.10
0.24
0.97
1.01
1.20
Difference
(b – a)
0.06
–3.43
–1.28
0.17
–0.12
0.38
0.14
0.25
±
±
±
±
±
±
±
±
1.23
16.80
9.78
0.93
0.16*
0.87
0.89
1.21
*Statistical difference (P < 0.05) between follow up at 24 months and baseline measurements.
50
45
40
35
30
% 25
20
15
10
5
0
baseline
24-month
baseline
intervention
24-month
comparison
adequate exercise
smoking
Fig. 2: Self-reported lifestyle behaviours of participants.
group following the reduction of total cholesterol
level between follow up and baseline. There was
no significant difference in the levels of triglycerides and fasting blood sugar in both groups
over the 24-month study period. The BMI of the
intervention group remained quite similar over
the 24-month follow up; while there was a small
increase in the comparison group (Table 4).
Self-reported prevalence of smoking and
physical activities did not show much improvement throughout the 24-month follow up period
(Figure 2). However, the reported mean amount
of cigarettes smoked per day was reduced
from 16.0 ± 7.6 to 13.8 ± 7.8 cigarettes in the
intervention group (P > 0.05) whereas the comparison group showed no change with an average
of 17 cigarettes per day through out the study
period.
Lifestyle modification which involved dietary
modification such as reducing food intake
(calorie), reducing fat intake, increasing vegetables and fruits in the diet as well as increasing
physical exercise or physical activities were also
surveyed. The following figure (Figure 3) showed
that more participants from the intervention group reported to have increased exercise,
reduced total food intake and fat intake;
whereas, more participants from the comparison
group reported to have increased vegetable and
fruit consumption as well as reduced sugar in
their diets. However, these differences were not
statistically significant (P > 0.05).
DISCUSSION
Participants from the intervention group showed
a statistically significant reduction in their total
cholesterol levels from 5.83 to 5.62 mmol/l,
whereas the comparison group showed an
Ms 1762: worksite health promotion programme
307
100
90
80
70
60
%
50
40
30
20
10
0
incr exercise increase veg
increase
fruits
intervention
reduce fat
intake
reduce food reduce sugar
intake
comparison
Fig. 3: Self-reported lifestyle behaviours by participants who managed to reduce their cholesterol levels.
increase of 5.44 to 5.61 mmol/l at 2-year followup. These improvements among the participants
in the intervention group were gradual followed
by a more marked decline after the 6-month
follow-up. This trend could be explained by the
fact that it took time to effect behaviour change.
Participants had to be convinced of the benefits
of the recommended diet and internalize the
new behaviours before changes could take place.
This pattern is consistent with another study that
showed similar results (Jairath et al., 2002).
There was a dip in the cholesterol level in the
comparison group at the 18th month: possible
reasons could be due to the effect of group
counselling conducted after the 12th month
measurement. The participants were given the
results of their laboratory tests, together with a
brief interpretation of the results and advice on
methods to reduce cholesterol levels.
Participants with high cholesterol from both
groups reported a decrease in their cholesterol
levels with the intervention group demonstrating
a larger reduction. As for the participants with
normal cholesterol levels, the intervention group
managed to maintain their cholesterol levels with
no change after 2 years, whereas the comparison
group showed an increase of 0.62 mmol/l in their
cholesterol levels. The different results observed
among both groups could be due to the health
information and skills taught to the intervention
group. Participants from the intervention group
were taught more intensive and specific methods
to reduce cholesterol intake through diet modification. Participants from the comparison group
might be aware of the risks of hypercholesterolemia but they did not have adequate skills
to modify their diet. However, health checks
with feedback succeeded in increasing their
awareness and this could have motivated them
to control their cholesterol levels by themselves.
This finding has also been identified as possible
explanations for the non significant intervention effect in other trials (Pine et al., 1997;
Ammerman, 2003).
The magnitude of the reduction of total
cholesterol achieved in this study (overall reduction of 6.5%) was less than those achieved in
clinical setting which was in the range of 7–15 %
(Clarke et al., 1997; Delahanty et al., 2001). Tang
et al. (Tang et al., 1998) in their systematic review
of dietary intervention trials to lower blood total
cholesterol in free-living participants of at least
6 months reported a reduction of 5.3%. A review
of worksite based nutrition and cholesterol
control reported cholesterol reductions in the
range of 5–9% (Harris and Fries, 2002). The
above results should be interpreted cautiously.
Since these studies were conducted among
Caucasians in the United States and the European countries holding a variety of occupations
from white collar to blue collar workers, whereas
our participants were Malay security guards.
The HDL-cholesterol which is protective
against cardiovascular diseases was reduced
308
F Moy et al.
significantly in both groups, with a larger
reduction among the intervention group. The
reduction of HDL-cholesterol among the intervention group was most probably due to the
effect of reduction of total cholesterol through
diet modification but without a large increase in
physical activity or exercise. This was confirmed
by comparing their self-reported physical activity
at baseline and follow up. Similar results were
also shown in other studies that used only dietary
intervention (Geil et al., 1995; Aldana et al.,
2002). Improvement in ratios of total serum
cholesterol to HDL-cholesterol was observed in
studies combining dietary and physical fitness
intervention (Angotti and Levine, 1994; Lalonde
et al., 2002). From the in-depth interviews, it was
found that the participants were aware of the
benefits of exercise but barriers such as working
shifts or overtime deterred them from exercising.
Many of them worked overtime because their
income was insufficient to provide for their
families. Some of them worked two shifts a day
(morning and afternoon) and they were too tired
to exercise after that.
There was no improvement in the outcome
measure on BMI. From the in-depth interviews,
the participants perceived that overweight/
obesity was a sign of prosperity and they did
not think it would increase their risk for diseases,
as they felt fine. To them, ‘healthy’ meant being
able to work to earn a living and function
normally in their daily lives. There was also a
misconception that losing weight reflected illhealth and this was the common perception
among their family members and peers. On the
other hand, they felt it was more important to
control their cholesterol levels since this could
help to attain their personal goal of avoiding
heart attacks and strokes. Therefore, more
efforts need to be taken to change this misconception.
The prevalence of smoking did not change
much from the baseline; however, there was a
small reduction in the number of cigarettes
smoked among the intervention group. Those
who did not quit smoking gave reasons such as
boredom during night shift and influence of
peers. The above findings showed that the
participants did not seem to have the wholesome
wellness concept that emphasizes optimal health.
Slightly more participants from the intervention group reported reduced fat and total food
intake, and this could be attributed to more
advice and exposure to methods of reducing
cholesterol given through individual and group
counselling. On the other hand, more participants from the comparison group reported an
increase in vegetable and fruits intake as well as
reduced sugar intake. However, these positive
changes in self-reported behaviour among the
comparison group were not accompanied by a
reduction in BMI or cholesterol. In fact, the
cholesterol levels and BMI increased at follow
up. The reduction of sugar intake and increase in
vegetables and fruits would not be effective
enough to reduce cholesterol level and BMI
without reduction in total calorie and fat intakes
in one’s diet (National Cholesterol Education
Programme, 2002).
This study has some limitations. The response
rates of the comparison group were better than
the intervention group probably because the low
intensity of the programme attracted better
response. This was also a finding reported
by Emmons et al. (1999). The respondents from
the comparison group were also significantly
older than the intervention group due to different recruitment policies. The management of the
intervention group recruited younger staff
whereas the management from the comparison
group was more likely to recruit ex-uniform
(police and army) staff.
Another limitation of this study was the
relatively small sample size of each group;
however, the analysis of repeated measures
generally reduce the error term and enhance the
power of the analysis, resulting in the need for
fewer participants (Munro, 2001). This sample
was of only Malay males who worked as security
guards; therefore, it is not possible to generalize
for the other occupation groups of other ethnicities (e.g. Chinese and Indians) in Malaysia.
In this study, it was necessary to offer a
minimal intervention to the control (comparison) worksite because it would be unethical to
withhold information that is probable to have at
least minimal effectiveness. As a result, the comparison group showed an improvement too,
hence making it difficult to achieve an intervention effect. In addition, the improvement in
the comparison group could be due to the
Hawthorne effect.
Despite the limitations mentioned, the
strength of this study was that it is one of the
few worksite health promotion programmes that
was conducted among Malay-Muslims over a
relatively long follow-up period of 24 months.
This long period offers a better understanding of
Ms 1762: worksite health promotion programme
behavioural change among the participants. It is
hoped that the behaviour change over time
among the participants would spread to their
peers at the workplace through diffusion, thus
impacting healthier lifestyle behaviours among
the workers.
A meta-analysis by Law et al. (1994) showed
that a 10% reduction in plasma cholesterol was
followed by a 25% reduction in incidence of
coronary artery disease after 5 years. Fager and
Wiklund (Fager and Wiklund, 1997) predicted
that a fall of 1% in total blood cholesterol would
decrease the incidence of coronary events by
2%. The European guidelines on cardiovascular
disease prevention in clinical practice (Third
Joint Task Force of European and other
Societies on Cardiovascular Disease Prevention
in Clinical Practice, 2003) reports that although
plasma cholesterol did not differentiate well
between individuals destined and not destined
to develop coronary artery disease, it is a
powerful predictor of coronary artery disease at
the population level. Therefore, the changes
observed in this study have the potential for
substantial benefits in preventing cardiovascular
disease if they can be sustained.
In this study, there was not much improvement
in self-reported exercise or physical activity. In
order to encourage exercise among the participants, structured exercise programmes should
be implemented within the working hours.
Working overtime should also be reduced
through increasing more staff and revising their
salary scheme. This will enable the participants
to have more time to rest and exercise. Referral
to quit smoking clinics for the smokers may
probably be more effective than the current programme. As for the wrong perception on their
body image, some kind of reward system should
be considered for weight management besides
using health education to correct their perceptions. Behavioural change targeting lifestyle
modification with the ultimate goals of reducing
health risks could be achieved with sustained
intervention. Participation from all levels of the
organization including the management and the
employees should be encouraged.
CONCLUSIONS
Our study demonstrated a moderate improvement in cardiovascular risk reduction following
309
individualized and group dietary counselling.
To achieve a greater impact of worksite health
promotion, future strategies should aim at providing a more conducive environment to facilitate individual behaviour change. Management
should support individualized interventions by
implementing or modifying some work policies
that promote and sustain healthy lifestyle
behaviours.
ACKNOWLEDGEMENTS
We would like to thank the research funding
agencies (Vote F and China Medical Board) of
the University of Malaya for this project. Our
sincere gratitude also goes to the University of
Malaya and the University Malaya Medical
Centre for granting permission for the conduct
of the study. Not forgetting the participants from
the University of Malaya and the University
Malaya Medical Centre in the study. Mr Chong
Fah Mook and the staff of Department of Social
and Preventive Medicine who assisted in the
study were acknowledged.
Address for correspondence:
Foongming Moy
Department of Social and Preventive Medicine
Faculty of Medicine University of Malaya
50603 Kuala Lumpur
Malaysia
E-mail: [email protected]
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