Examination Of The Difference

Examination of the difference in smoking in young workers from 2005 to 2010 showed that there was a significant decrease in prevalence in white-collar workers, but the prevalence was relatively stable in blue-collar workers (Asfar et al., 2016). This emphasizes the gap in health education, with the one group’s decrease reflecting influence from tobacco control efforts, and the other’s plateau highlighting the need for further interventions in the blue-collar industry.

A systematic review of the associations between ischaemic heart disease and work conditions, found those with low decision latitude (with the greatest association in blue-collar workers), and job strain to have increased risk (Theorell et al., 2016). A further study, looking at Korean blue-collar workers in particular, found they did not practice health-promoting behaviour regularly, thereby increasing risks associated with cardiovascular disease (Hwang, Hong, Rankin, 2015). Importantly, however, was the finding that social support in the workplace was a significant predictor of health behaviour.

Obesity, well-known for its association with various negative health outcomes and increasing prevalence among blue-collar workers (Gu et al., 2014), has also been associated with the duration of sick leave and productivity loss in the workplace (Robroek, Van Den Berg, Plat, Burdof, 2010). This study also highlights how negative health outcomes result from inter-related factors. In this case, smoking, insufficient physical activity, and insufficient fruit and vegetable intake were also associated, highlighting the importance of targeted lifestyle interventions.

A review of the relationship with being overweight in the work-place, found obesity to be a predictor of long-term sick leave (Van Duijvenbode, Hoozemans, Van Poppel, Proper, 2009) and in an earlier review, Schmier, Jones, and Halpern (2006) found workplace injuries to be higher among overweight and obese employees. A higher body mass was also found to be positively associated with health care costs. Finally, the study by Gupta et al (2016), investigated the effect of temporal sitting patterns among blue-collar workers and the association with obesity. They found that long, uninterrupted bouts during work days were associated with increased BMI, but there was little association with sitting duration during leisure time.

Further research into the effects of temporal sitting patterns within blue-collar workers found moderate periods to be positively associated with intense neck-shoulder pain (Hallman et al., 2016). Again, this was found during the work day, with no association found between temporal sitting patterns and pain during leisure time. Results also showed brief bursts to have the opposite effect, with a negative association to pain intensity. Pain, described in terms of musculoskeletal disorders, was shown to account for half the working days lost amongst a group of blue-collar industrial workers (Morken et al., 2003). However, high social support was shown to have a preventative effect on short-term sickness-leave.

It is clear that Blue-collar workers, as a demographic, require integrated lifestyle interventions to improve their health outcomes and reduce the risks of injury and life-threatening diseases. This paper will continue by reviewing the recent literature on behavioural lifestyle interventions for blue-collar workers.

Review of the Literature

Smoking Cessation

Original work by Strickland et al. (2015), involved collecting information from focus groups with 144 unionized blue-collar, current smokers. They found that 65% wanted to quit smoking within the next 6 months, and only 15% had heard of the highly advertised, union-sponsored cessation programs. Following this, they developed a study to test the effectiveness and relevance of 12 targeted messages, to increase the use of union-based cessation programs. The messages were tested on 41 current smokers and those that emphasized family or work were responded to most favourably. Overall, it was the connection between their work and health that was appealing; concern that their health could influence their ability to work and provide for their family. Despite the small sample size, the study provides a relevant insight into an effective way to reach this demographic. However, further research should be done in this area as the sample was over-represented by young workers and only those in the carpentering industry.

Another study went further by implementing an Antitobacco messaging campaign at one worksite of blue-collar workers, with a second used as a control (Stewart, Formica, Adachi-Mejia, Wang, Gerrard, 2016). 222 and 243 participants, respectively, completed the follow-up survey after the intervention. Those who experienced the intervention had increased their knowledge of the dangers of smoking and second-hand smoke. Follow-up of the intervention group showed that non-smokers decreased exposure to second-hand smoke, and among smokers, there was an increase in family rules regarding exposure to second-hand smoke. While these results are promising and represent a low-cost option to increasing the knowledge of the negative health effects of smoking, there was no difference in motivation or interest to quit.

These studies are a good basis for further research into the effectiveness of advertising campaigns, while also highlighting the gap in health education of smokers. Yet, as these early studies suggest, a low-cost, simple campaign has a positive impact on blue-collar workers, even if just to spread awareness and increase health knowledge (Stewart, Formica, Adachi-Mejia, Wang, Gerrard, 2016).

Physical Activity

An early, influential study, carried out in the Netherlands, emphasized the positive effect of face-to-face counselling in the workplace by its ability to increase physical activity in blue-collar workers (Proper, Hildebrandt, Van Der Beek, Twisk, Van Mechelen, 2003). More recently, research has examined this further and looks into ways health and fitness can be implemented into the lives of the blue-collar demographic more readily.

Using a resistance training intervention, Zavanela et al. (2012), examined the outcome with health and fitness benefits. The target group involved male bus drivers, with 48 participants allocated to the intervention. The same amount was allocated to the control group, which involved continuing their normal activity. The intervention group completed a 24-week training program, which took place at an on-site gymnasium, and the training stimulus level was increased with progression of the program. Significant between-group differences were demonstrated, with significant improvements shown only in the intervention group. This group had a reduction in blood pressure and pain incidence, as well as improvements in flexibility and muscle. A decrease in worker absence was also recorded from the intervention group, maintained at follow-up. This study provides conclusive evidence to the benefits of exercise and is important in establishing how dramatic the effects can be when aimed at a blue-collar demographic. Given the guidance this study provides, further research should be focused on how to motivate and educate blue-collar men, to ensure they will complete the exercise even without supervision.

The participation action research approach, carried out in Australia, enabled blue-collar construction workers to actively structure, and be involved in, their own intervention program (Lingard Turner, 2015). In the preliminary stage, healthy eating, smoking cessation and physical activity were all identified as being necessary intervention targets through surveys and assessments. Using this information, a ‘healthy option’ was implemented in the on-site café, as well as on-site stretching and yoga sessions, and further relevant interventions. While the study set-up was encouraging, the results, however, were disappointing. Minimal improvements were noted, such as healthier eating of fruits and vegetables, but even this was not maintained at follow-up. Despite this, the design of the study was beneficial in collecting feedback from the workers involved. Participants from the study highlighted that the particular work environment they were subject to, was preventing them from developing healthier behaviours. This further demonstrates the importance of interventions in the blue-collar workplace, as it is clear that this plays a role in their particularly negative health outcomes. Further information from the study shows that the workers are concerned about their health behaviour, as well as understanding its importance.

While there is some research focused on improving physical activity in the workplace, and therefore improving health promotion of blue-collar workers, it is clear that a lot more needs to be done. It is important to be aware of the restrictions these workplaces impose between the workers reaching their health-promotion goals, and ways to work around this. Investing resources for on-site exercise stimuli, as shown by Zavanela et al. (2012), may be a beneficial place to start.

Health Promotion Targeted at Cardiovascular Disease

Carried out in Japan, a study that used an intervention-based health promotion plan (Shimizu, Horiguchi, Kato, Nagata, 2004) and another, using a multicomponent health promotion plan (Muto Yamauchi, 2001), both demonstrated that work-place interventions could be effective in reducing risks associated with cardiovascular disease. The risks that were targeted include BMI, blood pressure and cholesterol, all of which decreased significantly in both of the studies.

More recent work has built on these results, necessary as the prevalence of cardiovascular disease is evidently higher in blue-collar workers. A study which took place in Korea used a health promotion plan with the goal of decreasing metabolic syndrome (Hwang, Kim, Won, Hong, 2014). Metabolic syndrome involves a group of symptoms which factor highly in the risk of cardiovascular disease. Included in the study, were 104 blue-collar workers with at least two symptoms of metabolic disorder. The intervention involved health lectures and group discussion which took place every week, for six weeks, with telephone counselling provided. The focus of the intervention were the risks associated with cardiovascular disease, as well as other health problems, such as alcohol, diet and physical activity. The intervention had a positive effect by significantly decreasing metabolic factors. These included weight, waist circumference and cholesterol levels. While these improvements are beneficial, the intervention was not successful in decreasing blood pressure and lipid level – both biological risks of metabolic syndrome. However, given the effects that were seen after only six weeks of lectures, it is possible that a longer-term follow-up period, or extended lecture sessions, may have decreased the biological risks over time.

Another study looked at the effects of aerobic exercise in a blue-collar workplace intervention (Korshøj, Ravn, Holtermann, Hansen, Krustrup, 2016). Biomarkers of cardiovascular disease, including high-sensitive C-reactive protein (hsCRP) and the ratio of HDL to LDL cholesterol levels, were tested. The randomised controlled trial involved 57 cleaners receiving two lectures on healthy living during the four months, and 57 cleaners receiving the intervention. The intervention involved being assigned to 30 minutes of supervised aerobic exercise, taking place twice a week for all four months of the study. Recordings of the biomarkers were taken both at baseline, and at the end of the four months, showing significant between-group differences. The intervention group, compared to the controlled lecture group, had decreased hsCRP and level of LDL cholesterol. Both of these decreases were considered clinically significant in reducing the risk of cardiovascular disease.

The evidence from these studies suggest that the workplace is effective for interventions towards reducing the risk of cardiovascular disease, however, focus should be directed towards the most effective interventions, which again, appear to weigh heavily on those that increase physical activity. Further research and interventions should focus on how to encourage employees to participate in regular physical activity.

Weight Loss

Obesity, as a risk-factor for many health problems, including cardiovascular disease, is another health factor that has been targeted with interventions in the workplace. In the study by Morgan et al. (2012), a weight loss program intervention was implemented with male shift-workers. Weight, quality of life, and other outcomes were assessed from the intervention. 110 overweight or obese workers were recruited to the study and involved in the

3-month workplace plan. The plan consisted of a face-to-face information session where they were told to submit their daily diet and physical activity through online diaries, were provided with a pedometer (step-counter) for self-monitoring, and a motivational monetary reward was in place for the group with the highest average weight loss. Sixty-five of the recruited workers were randomised to a 14-week wait-list control group. Results of the study were promising, with the weight loss intervention group showing clinically important decreases in weight, and an increase in this group’s health-related quality of life. With a simple-to-implement design, this study provides a low-cost way of encouraging overweight and obese workers to become more health-focused and promoting, simply by providing support, information, and motivational rewards.

Another randomized controlled trial investigated the effects of a 6-month workplace intervention on body weight, BMI, and other health-related, lifestyle outcomes (Viester, Evert, Verhagen, Bongers, Van Der Beek, 2017). The blue-collar construction workers were randomised to the intervention, accounting for 162, or the control group of 152 participants. The intervention program involved personalised health coaching, relevant information, and the tools to increase physical activity and improve lifestyle behaviour. The program took place at the worksite, during the workday, ranging from 2-4 sessions over a 6-month period. Two follow-up periods took place, with the first one taken at 6 months, and showing promising results. At this time, a significant intervention effect was seen, with a decrease in BMI, body weight, and an increase in the proportion of physical activity meeting recommended guidelines. However, while these effects were somewhat maintained at the second follow-up period, 12 months from baseline, they were no longer statistically significant. Despite this, there were important lifestyle changes immediately after the 6-month intervention had taken place, particularly an increase in vigorous exercise and a decrease in consuming sugar-sweetened beverages. This indicates the possibility of prolonged effects for the duration that the intervention is carried out. Further research should look at the duration of effects of this low-cost intervention when extended beyond 6 months.

Finally, an earlier study on this topic, Lassen et al. (2010) took a different approach to targeting weight-loss, by focusing instead on the worksite canteen as an intervention target. This was a large-scale study, involving five worksites in the intervention and three as a minimum-intervention control. From the worksites included in the study, 102 workers were recorded for outcome measures. The intervention involved encouraging the participating canteens to initiate nutrition-related activities, these involved a free fruit programme, healthy lunchtime clubs, and curtailing soda and candy sales. No difference was recorded for any of the nutrients from baseline to endpoint in the control group canteens, however, there was a significant decrease in fat content, of the canteens at the intervention worksites. The outcome of the study showed moderate improvements, with a decrease in consummation of energy from fat, and an increase in dietary fibre and fruit. However, considering that this study took place over eight worksites in total, a sample of 102 participants is relatively small. Despite this, it provides a potentially very simple solution for decreasing the risks associated with excess body weight. Also, by educating and motivating the kitchen staff, the intervention does not necessarily require an increased budget. Further research should investigate these positive outcomes on a larger-scale canteen intervention.

The studies described provide guidance towards an effective intervention plan that can easily be implemented into the work environment. Given that blue-collar workers are spending the majority of their day at the worksite, it is important to provide an environment which better caters to a healthier lifestyle. As demonstrated, this could be implemented by changing the food available in the on-site canteen (Lassen et al., 2010), and by encouraging health promotion through physical activity (Viester, Evert, Verhagen, Bongers, Van Der Beek, 2017) and education (Morgan et al. 2012).

Chronic Pain

While pain intervention research is still in the early days, there is no denying its importance. Evidence of chronic pain in blue-collar workers has been shown in various types of occupations, such as manual labour in the metal industry (Morken et al., 2003), and those that involve prolonged periods of sitting (Hallman et al., 2016). This review will finish by examining two recent randomized trials, comparing the effectiveness of pain-targeted interventions.

In a study by Marchand et al. (2014), 413 workers with neck or back pain, and on sick-leave, were randomised to a work-focused rehabilitation or a control intervention. Both groups were subject to multidisciplinary interventions at neck and back clinics, with a focus emphasizing that their occupational work would not cause damage or pain to their neck or back. The clinic intervention lasted five to six days. The intervention group experienced an additional focus on the return to work process and on reducing the fear avoidance beliefs of work, they also had individual appointments with caseworkers. Overall, no difference was found between the two groups. However, the fear avoidance beliefs across the groups had decreased at the 4-month follow-up. This decrease was associated with return to work and reduced disability after one year. While the intervention group was no more effective than the control group, this study provides useful information on the effects of a less intense rehabilitation period, as it gives the same outcome that a more intense session was able to provide. Therefore, simply providing a rehabilitation service may be effective enough for decreasing pain and helping employees who are suffering, return to work, and therefore being cost-effective to implement.

Another study assessed the effectiveness of counselling low-back pain patients, with 20% as blue-collar workers, who expressed concern over continuing their current job (Jensen et al., 2011). The control group was assigned to usual care, whereas the intervention involved an initial counselling session with an occupational physician, a workplace visit if necessary, a 6-week status interview, focusing predominantly on adherence and compliance with the plan, and a 3-month follow-up with the occupational physician. Improvements of the trial were demonstrated in the intervention group only. This group experienced a reduction in pain, of clinical significance, and an increase in physical function. The benefits shown from the intervention were due to the counselling sessions that provided advice and guidance on meeting worksite barriers and encouraging physical activity. A limitation of the study was the participants and assessors being non-blind to the treatment. For this reason, it is important that further research is done in this area to prevent biased results. However, it provides an important insight into the effect that two short counselling sessions could potentially have on reducing disability and increasing function in blue-collar pain patients.

Despite the lack of research on pain interventions, it is important to be aware of what is currently available, and to allow future research to develop from this in a relevant, and often over-looked, field. Conclusion

Having discussed and reviewed the relevant, recent literature on the topic of lifestyle behaviour interventions in blue-collar males, it is undoubtable that more research is required. There has been an abundance of research in the past, identifying the specific health risks that arise in, and are potentially caused by, the workplace. There have also been interventions carried out in the workplace, with more directed on occupations in general, but still with some focused on blue-collar workers. However, after review of the more recent literature, it is clear that very little research has attempted, on a large-scale, to improve these health risks. This review concludes that there is a solid basis for conducting research into improving the blue-collar workplace, and that this demographic should be of highest priority to focus on. From the research that has been conducted, interventions aimed at increasing and motivating physical activity, as well as counselling or social support for mental health, at the workplace, would be the most beneficial in decreasing lifestyle health risks in these workers.