A program manual to assist with implementation of a volunteer health and wellness program

Based on the success of a community health and wellness program, Wellness in the City, delivered in Dallas County by trained volunteers, Texas Cooperative Extension (TCE) decided to pilot the program in 16 counties in North and East Texas. Before implementing the program, TCE wanted the Dallas County program to be reviewed and revised as needed to meet the diverse community needs in the pilot counties. TCE also asked for an implementation manual to be developed for the county agents to utilize. ^ To achieve these objectives, I first reviewed literature on other volunteer-implemented health interventions in the U.S. to see how they were planned, disseminated, implemented, and evaluated. Next, I reviewed the Wellness in the City program and materials. I applied all the information I gathered up to that point to the program development committee meetings (committee included seven TCE county agents, a TCE regional program director, and me). The program structure and training materials were revised based on our research and program implementation experience. These changes were made to ensure adequate training for the volunteers and to create a program that is applicable in the communities it will be piloted in. ^ With the program structure and training presentations developed, next I focused on compiling the implementation manual, which includes program details and volunteer recruitment, training, and management materials. The goal was to create a manual with everything the county agents will need to implement the program, so they can focus their efforts on putting the manual to use and recruiting and managing the volunteers. The final step was developing a program evaluation form for the agents to complete. It includes questions to assess the agents' thoughts about the training content, the feasibility of implementing the program using the manual, and the challenges of the program. ^

Lessons for emerging state Children's Health Insurance Premium Assistance programs: Case study of the Massachusetts Masshealth Family Assistance Program (MHFAP)

Providing health insurance coverage for vulnerable populations such as low-income high-risk children with limited access to health care is a challenge for many states. Over the past decade, higher private insurance premiums and unpredictable labor markets have increased the number of uninsured and underinsured children nationwide. Due to recent economic downfalls, many states such as Texas, have expressed interest in using premium assistance programs to increase enrollment of low income children and families in private coverage through employer sponsored health insurance. Massachusetts has been especially successful in reducing the number of uninsured children through the implementation of MassHealth Family Assistance Program (MHFAP), an employer based premium assistance program. The purpose of this study is to identify key implementation factors of a fully established premium assistance program which may provide lessons and facilitate implementation of emerging premium assistance programs. ^ The case study of the fully established MassHealth Family Assistance Program (MHFAP) has illustrated the ability of states to expand their Medicaid and SCHIP programs in order to provide affordable health coverage to uninsured and underinsured low income children and their families. As demonstrated by MHFAP, the success of a premium assistance program depends on four key factors: (1) determination of participant and employer eligibility; (2) determination of employer benefits meeting benchmark equivalency (Medicaid or State Children's Health Insurance Program); (3) the use of appropriate marketing and outreach strategies; and (4) establishment of adequate monitoring and reporting techniques. Successful implementation strategies, revealed by the case study of the Massachusetts MassHealth Family Assistance Program, may be used by emerging premium assistance programs, such as Texas Children's Health Insurance Premium Assistance Program (CHIP-PA) toward establishment of an effective, efficient, and equitable employer sponsored health program.^

A path analysis of an after-school health and exercise program for elementary school children in El Paso, Texas

As schools are pressured to perform on academics and standardized examinations, schools are reluctant to dedicate increased time to physical activity. After-school exercise and health programs may provide an opportunity to engage in more physical activity without taking time away from coursework during the day. The current study is a secondary data analysis of data from a randomized trial of a 10-week after-school program (six schools, n = 903) that implemented an exercise component based on the CATCH physical activity component and health modules based on the culturally-tailored Bienestar health education program. Outcome variables included BMI and aerobic capacity, health knowledge and healthy food intentions as assessed through path analysis techniques. Both the baseline model (χ2 (df = 8) = 16.90, p = .031; RMSEA = .035 (90% CI of .010–.058), NNFI = 0.983 and the CFI = 0.995) and the model incorporating intervention participation proved to be a good fit to the data (χ2 (df = 10) = 11.59, p = .314. RMSEA = .013 (90% CI of .010–.039); NNFI = 0.996 and CFI = 0.999). Experimental group participation was not predictive of changes in health knowledge, intentions to eat healthy foods or changes in Body Mass Index, but it was associated with increased aerobic capacity, β = .067, p < .05. School characteristics including SES and Language proficiency proved to be significantly associated with changes in knowledge and physical indicators. Further effects of school level variables on intervention outcomes are recommended so that tailored interventions can be developed aimed at the specific characteristics of each participating school. ^

Evaluation of a wellness program at a large private sector petrochemical company in Texas

The study purpose was to analyze the effects Integrated Health Solutions (IHS), an employee wellness program that has been implemented for one year on the corporate campus of a major private sector petrochemical company in Houston, TX, has on employee health. ^ Chronic diseases are the leading causes of morbidity and mortality in the United States and are the most preventable of all health problems. The costs of chronic diseases in the working-age adult population include not only health problems and a decrease in quality of life, but also an increase the cost of health care and costs to businesses and employers, both directly and indirectly. These emerging costs to employers as well as the fact that adults now spend the majority of waking hours at the office have increased the interest in worksite health promotion programs that address many of the behavioral factors that lead to chronic conditions. Therefore, implementing and evaluating programs that are aimed at promoting health and decreasing the prevalence of chronic diseases at worksites is very important. ^ Data came from existing data that were collected by IHS staff during employee biometric screenings at the company in 2010 and 2011. Data from employees who participated in screenings in both 2010 and 2011 were grouped into a cohort by IHS staff. ^ One-tailed t-tests were conducted to determine if there were significant improvements in the biometric measures of body fat percentage, BMI, waist circumference, systolic and diastolic blood pressures, total, HDL, and LDL cholesterol levels, triglycerides, blood glucose levels, and cardiac risk ratios. Sensitivity analysis was conducted to determine if there were differences in program outcomes when stratified by age, gender, job type, and time between screenings. ^ Mean differences for the variables from 2010 to 2011 were small and not always in the desired direction for health improvement indicators. Through conducting t-tests, it was found that there were significant improvements in HDL, cardiac risk ratio, and glucose levels. There were significant increases in cholesterol, LDL, and diastolic blood pressures. For the IHS program, it appears that gender, job type, and time between screenings were possible modifiers of program effectiveness. When program outcome measures were stratified by these factors, results suggest that corporate employees had better outcomes than field employees, males had better outcomes overall than females, and more positive program effects were seen for employees with less time between their two screenings. ^ Recommendations for the program based on the results include ensuring validity of instruments and initial and periodic training of measurement procedures and equipment handling, using normative data or benchmarks to decrease chances for biased estimates of program effectiveness, measuring behaviors as well as biometric and physiologic statuses and changes, and collecting level of engagement data.^

Consumer Health Information for Asians (CHIA): a collaborative project.

According to the 2000 United States Census, the Asian population in Houston, Texas, has increased more than 67% in the last ten years. To supplement an already active consumer health information program, the staff of the Houston Academy of Medicine-Texas Medical Center Library worked with community partners to bring health information to predominantly Asian neighborhoods. Brochures on health topics of concern to the Asian community were translated and placed in eight informational kiosks in Asian centers such as temples and an Asian grocery store. A press conference and a ribbon cutting ceremony were held to debut the kiosks and to introduce the Consumer Health Information for Asians (CHIA) program. Project goals for the future include digitizing the translated brochures, mounting them on the Houston HealthWays Website, and developing touch-screen kiosks. The CHIA group is investigating adding health resources in other Asian languages, as well as Spanish. Funding for this project has come from outside sources rather than from the regular library budget.

Nutrition knowledge and attitudes of physician assistants in Texas

Physician Assistants (PAs) are increasingly assuming more responsibilities as "front-line" health providers due to emphasis on primary care and cost-containment in the rapidly changing health care environment. Nutrition plays an important role in health promotion and disease prevention. Primary care providers, including PAs, have enormous potential as nutrition counselors and advocates. There have been no studies to date that address the PAs' adequacy of nutrition education or their attitudes toward the value of nutrition. Therefore, it was the purpose of the study to determine the nutrition knowledge and attitudes of PAs in Texas.^ All certified physician assistants in Texas were eligible for the study. A mailed survey was sent to 1,482 PAs in Texas with a response rate of 54.2%. The sample utilized for data analysis was 764 PAs.^ The study compared the nutrition knowledge mean scores for PAs who graduated from a PA program greater than 11 years ago with those who graduated less than 11 years ago. The study also examined Texas PAs' attitudes about their nutrition education training, the value of nutrition counseling, and their perceived ability to provide such nutrition counseling. Demographic and practice information was collected from the PAs. Demographically, PAs in Texas were found to be comparable to the national population of PAs surveyed in 1996.^ The overall mean level of nutrition knowledge was 70% correct. The mean level of nutrition knowledge was significantly related to the type of PA program that the PA graduated from (i.e., Certificate only or Master's degree level). No significant relationships were found between the mean nutrition knowledge score and age, year of graduation, length of practice, or the type of nutrition education provided in PA program.^ The majority of the PAs surveyed felt that diet and nutrition has an important role in disease prevention and felt that PA programs should place a greater emphasis on nutrition education. Many PAs surveyed were not satisfied with the amount of nutrition education they had received in their PA education programs and were not confident in their ability to provide nutrition counseling to patients.^ Suggestions are offered for improvement in PA nutrition education in the areas of both nutrition knowledge and patient counseling skills. In addition, this study recommends developing and strengthening partnerships between PAs and nutrition organizations. ^

Social capital and adolescent health risk behavior in El Salvador

An emerging body of research suggests that the social capital available in one's social environment, as defined by supportive and caring interpersonal relationships, may provide a protective effect against a number of youth risk behaviors. In exploring the potential protective effect of social capital at school and at home on adolescent health and social risk behavior, a comprehensive youth risk behavior study was carried out in El Salvador during the summer of 1999 with a sample of 984 secondary school students attending 16 public rural and urban schools. The following dissertation, entitled Social Capital and Adolescent Health Risk Behavior in El Salvador, presents three papers centered on the topics of social capital and risk behavior. ^ Paper #1. Dangers in the Adolescent River of Life: A Descriptive Study of Youth Risk Behavior among Urban and Rural presents prevalence estimates of four principal youth risk behavior domains—aggression, depression, substance use, and sexual behaviors among students primarily between the ages of 13 and 17 who attend public schools in El Salvador. The prevalence and distribution of risk behaviors is examined by gender, geographic school location, age, and subjective economic status. ^ Paper #2. Social Capital and Adolescent Health Risk Behavior among Secondary School Students in El Salvador explores the relationship between social resources (social capital) within the school context and several youth risk behaviors. Results indicated that students who perceived higher social cohesion at school and higher parental social support were significantly less likely to report fighting, having been threatened or hurt with a weapon, suicidal ideation, and sexual intercourse than students with lower perceived social cohesion at school and parental social support after adjusting for several socio-demographic variables. ^ Lastly, paper #3. School Health Environment and Social Capital : Moving beyond the individual to the broader social developmental context provides a theoretical and empirical basis for moving beyond the predominant individual-focus and physical health concerns of school health promotion to the larger social context of schools and social health of students. This paper explores the concept of social capital and relevant adolescent development theories in relation to the influence of social context on adolescent health and behavior. ^

Determining acquisition and cessation antecedents to adolescent cigarette smoking for development of intervention strategies

Our national focus and emphasis on the promotion of healthy behavior choices regarding tobacco and other drugs continues to target adolescents. Multiple studies have shown that adolescence is the optimum period for the prevention of substance use initiation as life-long patterns of health behaviors are established during this critical developmental stage. Tobacco use is associated with an increase in morbid and mortal health conditions of which prevalence increases throughout the lifespan. Attention to the antecedents of preventable health conditions aims to modify the risks and identify health promotion factors. Modifying antecedent factors for tobacco initiation in youth and identifying protective factors for successful smoking cessation has major public health implications across the lifespan. Of foremost interest are those risk factors and resultant behaviors that predict a youth's probability of initiating cigarette use and their cessation of cigarette use. Specifically, this dissertation supports previous results identifying intervention variables on the initiation/cessation continuum model especially with the established predictors of smoking (decisional balance and susceptibility) and with more recently identified predictors of smoking (nicotine dependence and withdrawal symptoms) in current and former smokers in a sample of high school students in Austin and Houston, Texas. These results offer insight for the development of appropriate intervention program strategies for our youth. ^

Access to health care among children in the U.S.: Use of health inequalities measures to evaluate progress in reduction of disparities from 1997 to 2005

Much of the literature on disparities in access to health care among children has focused on measuring absolute and relative differences experienced by race/ethnic groups and, to a lesser extent, socioeconomic groups. However, it is not clear from existing literature how disparities in access to care may have changed over time for children, especially following implementation of the State Children’s Health Insurance Program (SCHIP). The primary objective of this research was to determine if there has been a decrease in disparities in access to care for children across two socioeconomic groups and race/ethnicity groups after SCHIP implementation. Methods commonly used to measure ‘health inequalities’ were used to measure disparities in access to care including population-attributable risk (PAR) and the relative index of inequality (RII). Using these measures there is evidence of a substantial decrease in socioeconomic disparities in health insurance coverage and to a lesser extent in having a usual source of care since the SCHIP program began. There is also evidence of a considerable decrease in non-Hispanic Black disparities in access to care. However, there appears to be a slight increase in disparities in access to care among Hispanic compared to non-Hispanic White children. While there were great improvements in disparities in access to care with the introduction of the SCHIP program, continuing progress in disparities may depend on continuation of the SCHIP program or similar targeted health policy programs. ^

Health education intervention to reduce risk of infectious disease transmission among community health workers and their clients

Indigent and congregate-living populations have high susceptibilities for disease and pose a higher risk for disease transmission to family, friends and to persons providing services to these populations. The adoption of basic infection control, personal hygiene, safe food handling and simple engineering practices will reduce the risk of infectious disease transmission to, from and among indigent and congregate-living populations. ^ The provision of social services, health promotion activities and other support services to indigent and congregate-living populations is an important aspect of many public health-related governmental, community-based and other medical care provider agencies. ^ In the interest of protecting the health of indigent and congregate-living populations, of personnel from organizations providing services to these populations and of the general community, an educational intervention is warranted to prevent the spread of blood-borne, air-borne, food-borne and close contact-borne infectious diseases. ^ An educational presentation was provided to staff from a community-based organization specializing in providing housing, health education, foodstuffs and meals and support services to disabled, low-income, homeless and HIV-infected individuals. The educational presentation delivered general best practices and standard guidelines. A pre and post test were administered to determine and measure knowledge pertinent to controlling the spread of infectious diseases between and among homeless shelter-living clients and between clients and the organization's staff. ^ Comparing pre-test and post-test results revealed areas of knowledge currently held by staff and other areas that staff would benefit from additional educational seminars and training. ^

Malaria prevention in Kenyan women of childbearing age

The objective of this program is to reduce malaria incidence in Kenya. Malaria poses a large public health challenge in Kenya, and although public health efforts have traditionally been focused on treatment of infected patients, due to increased drug resistance and lack of drug-adherence, prevention strategies are needed. This program targets Kenyan women, the likely caretakers in the home, and promotes malaria prevention behaviors through health education. ^ A planning group will be assembled and a needs assessment will be performed, verifying risk factors and conditions associated with malaria, as well as personal and external determinants. Behavioral and environmental outcomes will be determined, and performance objectives for each outcome will be established. Matrices of change objectives will be created, and detailed methods and strategies will be linked to each change objective. Program elements include media, education, and incentives. All materials used in this program will be subjected to pre-test to ensure cultural relevance and fidelity. Matrices of change objectives will be created for program adopters and implementers, as well as correlating methods and strategies associated with each change objective. Performance objectives will also be compiled for program maintainers. A program evaluation plan will follow "Pre-Post Comparison Group" design. Outcome evaluation and process evaluation will be conducted. The sample population will be screened based on age and gender so as to maintain comparability to the target population. Measurements will be taken before the program to establish baseline, directly following the program to determine short-term effects, and three months after the program is completed to determine long-term effects. ^ One limitation of this program is selection bias, due to the nature of quasi-experimental studies. Thorough screening prior to sample selection will minimize selection bias and ensure group homogeneity. Another limitation is attrition, and this will be minimized where possible through the use of incentives. In cases where loss to follow-up is not avoidable, such as death or natural disasters, the attrition effect will be estimated using structural equation modeling after reviewing the sample size, differential attrition and total attrition. ^ This intervention is based heavily on health promotion theories, but it is important to remember that in the field, the program plan will likely include only the necessary practical strategies. The target population, Kenyan women of childbearing age, will be significant in decreasing the malaria disease burden in Kenya.^

Improving the health and well-being of women at risk for neural tube defect recurrence

There is growing interest in providing women with internatal care, a package of healthcare and ancillary services that can improve their health during the period after the termination of one pregnancy but before the conception of the next pregnancy. Women who have had a pregnancy affected by a neural tube defect can especially benefit from internatal care because they are at increased risk for recurrence and improvements to their health during the inter-pregnancy period can prevent future negative birth outcomes. The dissertation provides three papers that inform the content of internatal care for women at risk for recurrence by examining descriptive epidemiology to develop an accurate risk profile of the population, assessing whether women at risk for recurrence would benefit from a psychosocial intervention, and determining how to improve health promotion efforts targeting folic acid use.^ Paper one identifies information relevant for developing risk profiles and conducting risk assessments. A number of investigations have found that the risk for neural tube defects differs between non-Hispanic Whites and Hispanics. To understand the risk difference, the descriptive epidemiology of spina bifida and anencephaly was examined for Hispanics and non-Hispanic Whites based on data from the Texas Birth Defects Registry for the years 1999 through 2004. Crude and adjusted birth prevalence ratios and corresponding 95% confidence intervals were calculated between descriptive epidemiologic characteristics and anencephaly and spina bifida for non-Hispanic Whites and for Hispanics. In both race/ethnic groups, anencephaly expressed an inverse relationship with maternal age and a positive linear relationship with parity. Both relationships were stronger in non-Hispanic Whites. Female infants had a higher risk for anencephaly in non-Hispanic Whites. Lower maternal education was associated with increased risk for spina bifida in Hispanics.^ Paper two assesses the need for a psychosocial intervention. For mothers who have children with spina bifida, the transition to motherhood can be stressful. This qualitative study explored the process of becoming a mother to a child with spina bifida focusing particularly on stress and coping in the immediate postnatal environment. Semi-structured interviews were conducted with six mothers who have children with spina bifida. Mothers were asked about their initial emotional and problem-based coping efforts, the quality and kind of support provided by health providers, and the characteristics of their meaning-based coping efforts; questions matched Transactional Model of Stress and Coping (TMSC) constructs. Analysis of the responses revealed a number of modifiable stress and coping transactions, the most salient being: health providers are in a position to address beliefs about self-causality and prevent mothers from experiencing the repercussions that stem from maintaining these beliefs. ^ Paper three identifies considerations when creating health promotion materials targeting folic acid use. A brochure was designed using concepts from the Precaution Adoption Process Model (PAPM). Three focus groups comprising 26 mothers of children with spina bifida evaluated the brochure. One focus group was conducted in Spanish-only, the other two focus groups were conducted in English and Spanish combined. Qualitative analysis of coded transcripts revealed that a brochure is a helpful adjunct. Questions about folic acid support the inclusion of an insert with basic information. There may be a need to develop different educational material for Hispanics so the importance of folic acid is provided in a situational context. Some participants blamed themselves for their pregnancy outcome which may affect their receptivity to messages in the brochure. The women's desire for photographs that affect their perception of threat and their identification with the second role model indicate they belong to PAPM Stage 2 and 3. Participants preferred colorful envelopes, high quality paper, intimidating photographs, simple words, conversational style sentences, and positive messages.^ These papers develop the content of risk assessment, psychosocial intervention, and health promotion components of internatal care as they apply to women at risk for recurrence. The findings provided evidence for considering parity and maternal age when assessing nutritional risk. The two dissimilarities between the two race/ethnic groups, infant sex and maternal education lent support to creating separate risk profiles. Interviews with mothers of children with spina bifida revealed the existence of unmet needs-suggesting that a psychosocial intervention provided as part of internatal care can strengthen and support women's well-being. Segmenting the audience according to race/ethnicity and PAPM stage can improve the relevance of print materials promoting folic acid use.^

Household risk factors and the health and nutritional status of children in rural Honduras

During this cross-sectional study, both quantitative and qualitative research methods were used to elucidate the role that household environment and sanitation play in the nutritional status of children in a rural Honduran community. Anthropometric measurements were taken as measures of nutritional status among children under five years of age, while interviews regarding the household environment were conducted with their primary caregivers. Community participatory activities were conducted with primary caregivers, and results from water quality testing were analyzed for E. coli contamination. Anthropometric results were compared using the 1977 NCHS Growth Charts and the 2006 WHO Child Growth Standard to examine the implications of using the new WHO standard. The references showed generally good or excellent agreement between z-score categories, except among height-for-age classifications for males 24-35.9 months and weight-for-age classifications for males older than 24 months. Comparing the proportion of stunted, underweight, and wasted children, using the WHO standard generally resulted in higher proportions of stunting, lower underweight proportions, and higher overweight proportions. Logistic regression was used to determine which household and sanitation factors most influenced the growth of children. Results suggest only having water from a spring, stream, or other type of surface water as the primary source of drinking water is a significant risk factor for stunting. A protective association was seen between the household wealth index and stunting. Through participatory activities, the community provided insight on health issues important for improving child health. These activities yielded findings to be harnessed as a powerful resource to unify efforts for change. The qualitative findings were triangulated with the quantitative interview and water testing results to provide intervention recommendations for the community and its primary health care clinic. Recommendations include educating the community on best water consumption practices and encouraging the completion of at least some primary education for primary caregivers to improve child health. It is recommended that a community health worker program be developed to support and implement community interventions to improve water use and household sanitation behaviors and to encourage the involvement of the community in targeting and guiding successful interventions. ^

Marketing physical activity and healthy eating: A literature review of recent social marketing campaigns and development of a social marketing plan for the CATCH program

Background. This culminating experience project was inspired by an independent study conducted at The University of Texas School of Public Health with Dr. Andrew Springer, DrPH, who works on the evaluation of the Coordinated Approach to Child Health (CATCH) program in Travis County, Texas. It was indicated that a social marketing plan could enhance current efforts for the CATCH program. The aims of the project were to (1) review and synthesize literature on social marketing, with a specific focus on diet, physical activity, and obesity prevention; and (2) apply the gained knowledge toward a practical solution – a social marketing plan for the CATCH program.^ Methods. The literature review aimed to answer the following questions: (1) What audiences (ethnic and age groups), settings, health behaviors, and behavioral science theories have been used in social marketing campaigns? (2) What features of social marketing were used (e.g. formative research, segmentation, and the marketing mix - including promotional strategies and communication channels)? (3) What were the outcomes of the social marketing campaigns? The search aimed to identify studies that met the following inclusion criteria: (a) The study explicitly stated that social marketing was used; (b) The intervention promoted physical activity and/or healthy eating; (c) The population was children, adolescents, young adults, and/or parents; (d) Results of the intervention were available in the published literature The literature review includes studies from the past five years (2004 to 2009). After reviewing the social marketing literature, the insight and knowledge gained was applied to develop a social marketing plan for the CATCH program. The plan was guided by Hands-on Social Marketing, A Step-by-Step Guide and the Center for Disease Control and Prevention's Social Marketing web course.^

Systematic review of worksite-based behavior change programs that target metabolic syndrome risk factors

Approximately one-third of US adults have metabolic syndrome, the clustering of cardiovascular risk factors that include hypertension, abdominal adiposity, elevated fasting glucose, low high-density lipoprotein (HDL)-cholesterol and elevated triglyceride levels. While the definition of metabolic syndrome continues to be much debated among leading health research organizations, the fact is that individuals with metabolic syndrome have an increased risk of developing cardiovascular disease and/or type 2 diabetes. A recent report by the Henry J. Kaiser Family Foundation found that the US spent $2.2 trillion (16.2% of the Gross Domestic Product) on healthcare in 2007 and cited that among other factors, chronic diseases, including type 2 diabetes and cardiovascular disease, are large contributors to this growing national expenditure. Bearing a substantial portion of this cost are employers, the leading providers of health insurance. In lieu of this, many employers have begun implementing health promotion efforts to counteract these rising costs. However, evidence-based practices, uniform guidelines and policy do not exist for this setting in regard to the prevention of metabolic syndrome risk factors as defined by the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III). Therefore, the aim of this review was to determine the effects of worksite-based behavior change programs on reducing the risk factors for metabolic syndrome in adults. Using relevant search terms, OVID MEDLINE was used to search the peer-reviewed literature published since 1998, resulting in 23 articles meeting the inclusion criteria for the review. The American Dietetic Association's Evidence Analysis Process was used to abstract data from selected articles, assess the quality of each study, compile the evidence, develop a summarized conclusion, and assign a grade based upon the strength of supporting evidence. The results revealed that participating in a worksite-based behavior change program may be associated in one or more improved metabolic syndrome risk factors. Programs that delivered a higher dose (>22 hours), in a shorter duration (<2 years) using two or more behavior-change strategies were associated with more metabolic risk factors being positively impacted. A Conclusion Grade of III was obtained for the evidence, indicating that studies were of weak design or results were inconclusive due to inadequate sample sizes, bias and lack of generalizability. These results provide some support for the continued use of worksite-based health promotion and further research is needed to determine if multi-strategy, intense behavior change programs targeting multiple risk factors are able to sustain health improvements in the long-term.^