Effectiveness Of Workplace Interventions Research Articles

Workplace physical activity interventions and moderate-to-vigorous intensity physical activity levels among working-age women: a systematic review protocol.

BackgroundThe rapid pace of modern life requires working-age women to juggle occupational, family and social demands. This modern lifestyle has been shown to have a detrimental effect on health, often associated with increased smoking and alcohol consumption, depression and cardiovascular disease risk factors. Despite the proven benefits of regular moderate-to-vigorous intensity physical activity (MVPA), few are meeting the current physical activity (PA) recommendations of 150 min of MVPA/week. It is important that appropriate and effective behavioural interventions targeting PA are developed and identified to improve the MVPA levels of working-age women. As these women spend a substantial proportion of their waking hours at work, workplaces may be an opportune, efficient and relatively controlled setting to implement programmes and strategies to target PA in an effort to improve MVPA levels and impact cardiometabolic health. The purposes of this systematic review are to compare the effectiveness of individual-level workplace interventions for increasing MVPA levels in working-age women in high-income/developed countries and examine the effectiveness of these interventions for improving the known beneficial health sequelae of MVPA.Methods/DesignEight electronic databases will be searched to identify all prospective cohort and experimental studies that examine the impact of individual-level workplace interventions for increasing MVPA levels among working-age (mean age 18–65 years) women from high-income/developed countries. Grey literature including theses, dissertations and government reports will also be included. Study quality will be assessed using a modified Downs and Black checklist, and risk of bias will be assessed within and across all included studies using the Cochrane’s risk of bias tool and Grades of Recommendation, Assessment, Development and Evaluation approach. Meta-analyses will be conducted where possible among studies with sufficient homogeneity.DiscussionThis review will determine the effectiveness of individual-level workplace interventions for increasing MVPA levels in working-age women in high-income/developed countries, and form a current, rigorous and reliable research base for policy makers and stakeholders to support the development and implementation of effective workplace interventions that increase MVPA levels in this population.Systematic review registrationPROSPERO CRD42014009704

Weighing up the evidence: a systematic review of the effectiveness of workplace interventions to tackle socio-economic inequalities in obesity.

Addressing socio-economic inequalities in obesity is a public health priority and the workplace is seen as a potential health promotion site. However, there is a lack of evidence on what works. This article systematically reviews studies of the effects of workplace interventions on socio-economic inequalities in obesity. Following PRISMA guidelines, we searched for published or unpublished experimental and observational evaluation studies. Nine electronic databases were searched as well as websites and bibliographies. Included studies were data extracted, quality assessed and narratively synthesized. Eighteen studies were included of which 14 examined behavioural interventions and 4 mixed or environmental ones. While most studies (n = 12) found no effects on inequalities in obesity--and a minority found increases (n = 3), there was also some evidence of potentially effective workplace interventions (n = 3) especially in terms of physical activity interventions targeted at lower occupational groups. There is experimental evidence that workplace delivered physical activity interventions have the potential to reduce inequalities in obesity by targeting lower occupational groups. However, overall, the evidence base is small, largely from the USA, and of a low quality. More high-quality, experimental study designs are required.

Participatory workplace interventions can reduce sedentary time for office workers--a randomised controlled trial.

BackgroundOccupational sedentary behaviour is an important contributor to overall sedentary risk. There is limited evidence for effective workplace interventions to reduce occupational sedentary time and increase light activity during work hours. The purpose of the study was to determine if participatory workplace interventions could reduce total sedentary time, sustained sedentary time (bouts >30 minutes), increase the frequency of breaks in sedentary time and promote light intensity activity and moderate/vigorous activity (MVPA) during work hours.MethodsA randomised controlled trial (ANZCTR number: ACTN12612000743864) was conducted using clerical, call centre and data processing workers (n = 62, aged 25–59 years) in 3 large government organisations in Perth, Australia. Three groups developed interventions with a participatory approach: ‘Active office’ (n = 19), ‘Active Workstation’ and promotion of incidental office activity; ‘Traditional physical activity’ (n = 14), pedometer challenge to increase activity between productive work time and ‘Office ergonomics’ (n = 29), computer workstation design and breaking up computer tasks. Accelerometer (ActiGraph GT3X, 7 days) determined sedentary time, sustained sedentary time, breaks in sedentary time, light intensity activity and MVPA on work days and during work hours were measured before and following a 12 week intervention period.ResultsFor all participants there was a significant reduction in sedentary time on work days (−1.6%, p = 0.006) and during work hours (−1.7%, p = 0.014) and a significant increase in number of breaks/sedentary hour on work days (0.64, p = 0.005) and during work hours (0.72, p = 0.015); there was a concurrent significant increase in light activity during work hours (1.5%, p = 0.012) and MVPA on work days (0.6%, p = 0.012).ConclusionsThis study explored novel ways to modify work practices to reduce occupational sedentary behaviour. Participatory workplace interventions can reduce sedentary time, increase the frequency of breaks and improve light activity and MVPA of office workers by using a variety of interventions.Trial RegistrationAustralian New Zealand Clinical Trials Registry ACTN12612000743864.

Implementation of the Participatory Approach to increase supervisors’ self-efficacy in supporting employees at risk for sick leave; design of a randomised controlled trial

BackgroundThe burden of sick leave for society and organisations underlines the urgent need to prevent sick leave. An effective workplace intervention for organisations to shorten sick leave episodes is the Participatory Approach (PA). In this study, we hypothesize that implementation of the PA for supervisors within organisations may prevent sick leave as well. However, implementation of the PA within an organisation is difficult, and barriers at different levels (employee, supervisor and organisational) exist. Therefore, the primary aim of this study is to evaluate the effectiveness of a multifaceted implementation strategy of the PA.MethodsIn a cluster randomised controlled trial (RCT) a multifaceted implementation of the PA will be compared with a minimal implementation strategy of the PA. Participating organisations are a university medical centre, a university and a steel factory. Randomisation will take place at department level. Intervention departments will receive a multifaceted implementation strategy of the PA, which incorporates a working group, supervisor training, and supervisor coaching. Control departments will receive the minimal implementation strategy of the PA, consisting of written information only. The primary outcome measure is self-efficacy of supervisors in joint problem solving to improve work functioning of employees with health complaints and to prevent sick leave. A secondary outcome measure at supervisor level is self-efficacy in communicating with employees about situations of reduced work functioning or being at risk for sick leave. Secondary outcome measures at employee level are attitude, self-efficacy, and social influence, with regard to addressing situations of reduced work functioning or being at risk for sick leave, as well as work functioning, psychological well being, and sick leave. Measurements will take place at baseline, and after six and twelve months follow-up. A process evaluation will be performed as well.DiscussionThis study will be relevant for all organisations with employees at risk for sick leave in health care, education, and industry. Study results will give an insight into the effectiveness of the multifaceted implementation strategy of the PA for supervisors to improve work functioning of employees with health complaints, and to prevent sick leave.Trial registrationNTR3733

A review of guidelines for collaboration in substance misuse management

Substance misuse among the working population results in increasing economic costs. General practitioners (GPs) and occupational physicians (OPs) can play a central role in detecting and managing substance misuse in the working population. Their collaboration could be critical in coordinating care, in facilitating rehabilitation and in reducing sickness absence. To search guidelines for evidence on collaboration between GPs and OPs in substance misuse detection and management in the working population. International guidelines regarding collaborative care for alcohol, illicit drug, hypnotic and tranquillizer misuse were identified by a systematic search in the Guidelines International Network and US National Guidelines Clearinghouse databases. In total, 20 guidelines were considered of sufficient methodological quality, based on the criteria of the Appraisal of Guidelines for Research and Education II instrument. Only two guidelines reported on the OP's role in screening and intervention for alcohol misuse. There is a lack of guidance on the OP's role and on collaboration between GPs and OPs in this field. Further study is required on their respective roles in substance misuse management, the effectiveness of workplace interventions and the benefits of collaboration.

Design of the DISCovery project: tailored work-oriented interventions to improve employee health, well-being, and performance-related outcomes in hospital care

BackgroundIt is well-known that health care workers in today’s general hospitals have to deal with high levels of job demands, which could have negative effects on their health, well-being, and job performance. A way to reduce job-related stress reactions and to optimize positive work-related outcomes is to raise the level of specific job resources and opportunities to recover from work. However, the question remains how to translate the optimization of the balance between job demands, job resources, and recovery opportunities into effective workplace interventions. The aim of the DISCovery project is to develop and implement tailored work-oriented interventions to improve health, well-being, and performance of health care personnel.Methods/DesignA quasi-experimental field study with a non-equivalent control group pretest-posttest design will be conducted in a top general hospital. Four existing organizational departments will provide both an intervention and a comparison group. Two types of research methods are used: (1) a longitudinal web-based survey study, and (2) a longitudinal daily diary study. After base-line measures of both methods, existing and yet to be developed interventions will be implemented within the experimental groups. Follow-up measurements will be taken one and two years after the base-line measures to analyze short-term and long-term effects of the interventions. Additionally, a process evaluation and a cost-effectiveness analysis will be carried out.DiscussionThe DISCovery project fulfills a strong need for theory-driven and scientifically well-performed research on job stress and performance interventions. It will provide insight into (1) how a balance between job demands, job resources, and recovery from work can be optimized, (2) the short-term and long-term effects of tailored work-oriented effects, and (3) indicators for successful or unsuccessful implementation of interventions.

Relationships Among Employees’ Working Conditions, Mental Health, and Intention to Leave in Nursing Homes

Employee turnover is a large and expensive problem in the long-term care environment. Stated intention to leave is a reliable indicator of likely turnover, but actual predictors, especially for nursing assistants, have been incompletely investigated. This quantitative study identifies the relationships among employees' working conditions, mental health, and intention to leave. Self-administered questionnaires were collected with 1,589 employees in 18 for-profit nursing homes. A working condition index for the number of beneficial job features was constructed. Poisson regression modeling found that employees who reported four positive features were 77% less likely to state strong intention to leave (PR = 0.23, p < .001). The strength of relationship between working conditions and intention to leave was slightly mediated by employee mental health. Effective workplace intervention programs must address work organization features to reduce employee intention to leave. Healthy workplaces should build better interpersonal relationships, show respect for employee work, and involve employees in decision-making processes.

Implementation of physical coordination training and cognitive behavioural training interventions at cleaning workplaces – secondary analyses of a randomised controlled trial

This study evaluates the implementation of physical coordination training (PCT) and cognitive behavioural training (CBTr) interventions in a randomised controlled trial at nine cleaners’ workplaces. Female cleaners (n = 294) were randomised into a PCT, a CBTr or a reference (REF) group. Both 12-week interventions were performed in groups guided by an instructor. Records were kept on intervention dose (adherence) unanticipated events at the work place (context) and quality of intervention delivery (fidelity). Participant adherence was 37% in the PCT and 49% in the CBTr interventions. Optimal implementation was reached by only 6% in PCT and 42% in the CBTr. Analysis of the barriers to successful implementation indicated that the intervention process is sensitive to unanticipated events. In order to succeed in improving the health of high-risk populations such as cleaners and to correctly interpret intervention effects, more research on implementation is needed. Trial registration: ISRCTN96241850. Practitioner Summary: Both physical coordination training and cognitive behavioural training are potential effective workplace interventions among low educated job groups with high physical work demands. However, thorough consideration should be given to feasibility in the design of interventions. The optimal intervention should be tailored to closely match the implementation context and be robust and flexible to minimise susceptibility to changes in work organisation.

Commentary on Van Bogaert P Commentary on Kowalski C, Ommen O, Driller E, Ernstmann N, Wirtz M, Koehler T &amp; Pfaff H (2010) Burnout in nurses – the relationship between social capital in hospitals and emotional exhaustion. Journal of Clinical Nursing 19, 1654–1663. Journal of Clinical Nursing20, 913–914

High rates of burnout are a persistent problem in the nursing profession as well as in the helping professions generally. As yet, there have been few attempts to systematically reduce its prevalence by means of systematically implemented (organisational) interventions in (quasi-) experimental designs – even though a large amount of research on burnout and its associated factors exists. Van Bogaert, in his commentary (Van Bogaert 2011) on our paper (Kowalski et al. 2010), stressed the relevance of the nursing unit teams as the multidisciplinary core of a clinical microsystem. This, in the context of searching for effective strategies against burnout within the nursing profession, provides a promising framework and leverage for prevention. From our perspective it is important, as Van Bogaert (2011) did, to emphasise the existence of different levels to encounter and reduce the challenge of burnout in nurses in particular and in the helping professions in general. In contemporary discussions – both in mainstream media and some scholar-led discourses – the focus for reducing the prevalence of burnout is still the effective treatment of individual patients/employees that are already sick, i.e. a curative point of view. Existing research, however, persistently shows associations between the prevalence of burnout and organisational/workplace/group conditions, pointed out by Shanafelt (2009) using the example of physicians. We argue, in line with Van Bogaert (2011), for a more active involvement of health care workers encouraged by nurse and hospital leaders to achieve effective organisational and workplace interventions. These interventions are intended to prevent the development of burnout. We would like to add a third aspect that should help reduce the persistent problem of high turnover rates in the nursing profession: effective return to work, i.e. a rehabilitative perspective. Although research is still needed that investigates the mediating factors between burnout and permanently leaving nursing, sick leave follow-up meetings have proved to be effective in assisting formerly sick employees and might also be effective in helping nurses return to work after suffering from burnout. To implement the findings from existing research, we suggest tackling the burnout challenge by intervening at three stages in the course of the disease: first, to prevent its occurrence, particularly taking into account the workplace environment, the organisational culture within the hospital, and the nursing unit teams; second, to cure those suffering from burnout by paying attention to both individual and workplace causes and by strengthening personal and workplace resources; third, to effectively facilitate the return to work of those affected by burnout within a climate of encouraging co-workers and superiors. Those who have successfully returned to work might serve as facilitators/role models to prevent stigmatisation. The workplace environment and factors associated with it are central to interventions at all three stages. Assessing the workplace environment and its associated factors either within a framework of an organizational culture, climate or systems theory approach is of great importance. Equally, using the existing research as groundwork to realise interventions that fight burnout for the good of nurses, patients, and the health care system, is a vital issue in this area. The authors did not receive any support in the form of grants, equipment or anything else. None.

Effectiveness of workplace interventions in Europe promoting healthy eating: a systematic review

The worksite is a promising setting for health promotion. This review summarizes the evidence of effect of intervention studies in European countries promoting a healthy diet solely and in combination with increasing physical activity at the workplace. A systematic review of published literature was carried out. Inclusion criteria were: studies conducted in European countries; papers published from 1 January 1990 to 1 October 2010; worksite-based interventions promoting a healthy diet solely or in combination with physical activity; primary prevention; measurement of anthropometrical or behavioural change and adults (≥18 years old). Levels of evidence for intervention effectiveness on behavioural determinants, nutrition and physical activity behaviours and body composition and the quality of the included interventions were assessed. Seventeen studies solely focusing on promotion of a healthy diet were identified. Eight were educational, one used worksite environmental change strategies, and eight used a combination of both (multi-component). None of the interventions were rated as 'strong'; seven met the criteria for 'moderate' quality. The reviewed studies show moderately evidence for effects on diet. Thirteen studies focusing both on nutrition and physical activity (nine educational and four multi-component studies) were identified. Ten were rated as having 'weak' and three as having 'moderate' methodological quality, providing inconclusive evidence for effects. Limited to moderate evidence was found for positive effects of nutrition interventions implemented at the workplace. Effects of workplace health promotion interventions may be improved if stronger adherence to established quality criteria for such interventions is realized.

Absenteeism following a workplace intervention for older food industry workers

The effects of workplace interventions on sickness absence are poorly understood, in particular in ageing workers. To analyse the effects of a senior programme on sickness absence among blue-collar food industry workers of a food company in Finland. We followed up 129 employees aged 55 years or older, who participated in a senior programme (intervention group), and 229 employees of the same age from the same company who did not participate (control group). Total sickness absence days and spells of 1-3, 4-7, 8-21 and >21 days were recorded for the members of the intervention group from the year before joining the programme and for the control group starting at age 54 years. Both groups were followed for up to 6 years. The median number of sickness absence days per person-year increased significantly from baseline in both groups during the follow-up. Compared with the control group, the intervention group had increased risk for 1-3 days spells [rate ratio 1.34 (1.21-1.48)] and 4-7 days spells [rate ratio 1.23 (1.07-1.41)], but the risk for >21 days spells was decreased [rate ratio 0.68 (0.53-0.88)] after participation in the senior programme. A programme to enhance individual work well-being in ageing workers may increase short-term but reduce long-term sickness absence.

The effect of workplace intervention on pain and sickness absence caused by upper-extremity musculoskeletal disorders

The aim of this study was to assess the effect of an ergonomic intervention on pain and sickness absence caused by upper-extremity musculoskeletal disorders. In this randomized controlled study, subjects aged 18-60 years (N=177) seeking medical advice due to upper-extremity symptoms were included if their symptoms, or the exacerbation of symptoms, had started <30 days prior to the medical consultation and immediate sick leave was not required. Workplace ergonomic improvements were made in the intervention group. Data on symptoms and sickness absences were gathered during one-year follow-up. Pain intensity, pain interference with work, leisure time, or sleep did not differ between the intervention and control group during the one-year follow-up. During the first three months of follow-up, the percentage of employees with sickness absence due to upper-extremity or other musculoskeletal disorders did not differ between the intervention (N=89) and control (N=84) group, but the total number of sickness absence days in the intervention group was about half of that in the control group (mean 6.2 versus 9.8 days for upper-extremity disorder and 6.0 versus 11.5 days for upper-extremity and other musculoskeletal disorders combined). During 4-12 months of follow-up, the percentage of employees with sickness absence due to upper-extremity disorder (10.1% versus 16.7%, P=0.20) or upper-extremity and other musculoskeletal disorders combined (20.2% versus 32.1%, P=0.07) was lower in the intervention than the control group. Our findings suggest that an early ergonomic intervention reduces sickness absence due to upper-extremity or other musculoskeletal disorders.

Patterns of Workplace Supervisor Support Desired by Abused Women

The purpose of this study was to understand differences in patterns of supervisor support desired by female victims of intimate partner violence (IPV) and to examine whether the pattern of support desired at work is reflective of a woman's stage of change in the abusive relationship, IPV-related work interference, and IPV-related job reprimands or job loss. We conducted interviews in Spanish or English with adult women working in low-income jobs who had been physically or sexually abused by an intimate partner/ ex-partner in the past year ( N = 133). Cluster analysis revealed three distinct clusters that form a hierarchy of type of support wanted: those who desired limited support; those who desired confidential, time-off, and emotional support; and those who desired support in wide variety of ways from their supervisor. The clusters appeared to reflect stages of behavior change in an abusive relationship. Specifically, the limited-support cluster may represent an early precontemplation stage, with women reporting the least interference with work. The support-in-every-way cluster may represent later stages of change, in which women are breaking away from the abusive partner and report the greatest interference with work. Women in the confidential-, time-off-, and emotional-support cluster are in a transition stage in which they are considering change and are exploring options in their abusive relationship. Understanding the hierarchy of the type of support desired, and its relationship to stages of change in the abusive relationship and work interference, may provide a strong foundation for developing appropriate and effective workplace interventions to guide supervisors in providing support to women experiencing IPV.

Design of the DIRECT-project: interventions to increase job resources and recovery opportunities to improve job-related health, well-being, and performance outcomes in nursing homes

BackgroundBecause of high demands at work, nurses are at high risk for occupational burnout and physical complaints. The presence of job resources (such as job autonomy or social support) and recovery opportunities could counteract the adverse effect of high job demands. However, it is still unclear how job resources and recovery opportunities can be translated into effective workplace interventions aiming to improve employee health, well-being, and performance-related outcomes. The aim of the current research project is developing and implementing interventions to optimize job resources and recovery opportunities, which may lead to improved health, well-being and performance of nurses.Methods/designThe DIRECT-project (DIsc Risk Evaluating Controlled Trial) is a longitudinal, quasi-experimental field study. Nursing home staff of 4 intervention wards and 4 comparison wards will be involved. Based on the results of a base-line survey, interventions will be implemented to optimize job resources and recovery opportunities. After 12 and 24 month the effect of the interventions will be investigated with follow-up surveys. Additionally, a process evaluation will be conducted to map factors that either stimulated or hindered successful implementation as well as the effectiveness of the interventions.DiscussionThe DIRECT-project fulfils a strong need for intervention research in the field of work, stress, performance, and health. The results could reveal (1) how interventions can be tailored to optimize job resources and recovery opportunities, in order to counteract job demands, and (2) what the effects of these interventions will be on health, well-being, and performance of nursing staff.

A workplace intervention for sick-listed employees with distress: results of a randomised controlled trial

ObjectivesTo evaluate the effectiveness of a participatory workplace intervention compared with usual care for sick-listed employees with distress, with regard to return to work (RTW) within the 12-month follow-up.MethodsEmployees with...

Tai Chi workplace program for improving musculoskeletal fitness among female computer users

Workplace computer use has increased dramatically in recent years and has been linked to musculoskeletal disorders, a leading cause of work disability and productivity losses in industrialized nations. Tai Chi is a simple, convenient workplace intervention that may promote musculoskeletal health without special equipment or showering, yet no study has investigated Tai Chi as a workplace physical exercise for health promotion. To examine the effects of a workplace Tai Chi (TC) intervention on musculoskeletal fitness and psychological well-being among female university employees who are computer users. The exercise program consisted of two 50 minute TC classes per week for 12 consecutive weeks during the months of May-August 2007. Fifty-two participants were enrolled in a class conducted on campus by a professional TC practitioner during the lunch hour. Socio-demographic characteristics, including information on age, marital status, ethnicity, job category and perceived overall health were collected from all participants. Fitness testing conducted by qualified personnel was assessed pre- and post-program. The tests included resting heart rate, resting blood pressure, anthropometric measures, musculoskeletal fitness and back fitness. Psychological well-being was assessed by the Perceived Stress Scale pre- and post-program. There were significant positive results in several areas including resting heart rate, waist circumference and hand grip strength. Results showed that the TC program was effective in improving musculoskeletal fitness and psychological well-being. Significant improvements in physiological and psychological measures were observed, even at the large class sizes tested here, suggesting that TC has considerable potential as an economic, effective and convenient workplace intervention.

The private sector and HIV/AIDS in Africa: taking stock of 6 years of applied research

Until recently, little was known about the costs of the HIV/AIDS epidemic to businesses in Africa or about business responses to the epidemic. This paper synthesizes the results of a set of studies conducted between 1999 and 2006. Data for the studies included were drawn from human resource, financial, and medical records of 16 large companies and from 7 surveys of small, medium-sized, and large companies in South Africa, Uganda, Kenya, Zambia, Ethiopia, and Rwanda. Estimated workforce HIV prevalence ranged from 5 to 37%. The average cost per employee lost to AIDS varied from 0.5 to 5.6 times the average annual compensation of the employee affected. Labor cost increases were estimated at 0.6-10.8% but exceeded 3% at only two of 14 companies. Antiretroviral treatment at a cost of US$360/patient per year was found to have positive financial returns for most but not all companies. Managers of small and medium-sized enterprises (SME) reported low AIDS-related employee attrition, little concern about the impacts of AIDS, and relatively little interest in taking action. AIDS was estimated to increase the average operating costs of SME by less than 1%. For most companies, AIDS is causing a moderate increase in labor costs, with costs determined mainly by HIV prevalence, employee skill level, and employment policies. Treatment of HIV-positive employees is a good investment for many large companies. Small companies have less capacity to respond to workforce illness and little concern about it. Research on the effectiveness of workplace interventions is needed.

An overview of HIV/AIDS workplace policies and programmes in southern Africa

Workplace programmes refer to a range of company-based interventions including the institution of an HIV/AIDS policy, voluntary counselling and testing (VCT), and antiretroviral therapy (ART) provision. To review the existing information on workplace policies and programmes in southern Africa, and ascertain the common accomplishments in and challenges to implementation and efficacy. Given the paucity of peer-reviewed academic publications, information for this review was also drawn from working papers, symposia proceedings, and case studies. A convenience sample of 17 key informants was identified, and semi-structured interviews were conducted. Workplace policies and programmes of varying sophistication are proliferating in large companies and selected sectors. Accomplishments include the institution of a legal apparatus that safeguards against discriminatory practices, the high prevalence of HIV education programmes, the growing provision of VCT, and the development of supply-chain initiatives that may enable smaller companies to develop HIV programmes. Challenges include poor recognition and monitoring of legal violations by management and unions, lack of monitoring and evaluation (M&E) methodologies for workplace HIV prevention programmes, persistent stigma in the workplace resulting in poor uptake of HIV testing, and low enrollment into workplace ART programmes. The existing literature indicates a wide variation in workplace policies and programmes currently in place in southern Africa. The effectiveness of workplace interventions at the firm level, including prevention and treatment programmes is difficult to assess with currently available data. Further research on workplace programmes that addresses operational challenges to implementation and develops M&E strategies is urgently needed.

Improving antimicrobial prescribing through knowledge and skills

Sir, In their recent qualitative study of factors influencing antimicrobial prescribing by non-consultant hospital doctors De Souza et al. found that undergraduate education, hospital guidelines and concerns about emerging resistance were minor influences on prescribing practice. Prescribing was more influenced by instruction passed down through a hierarchical system and subsequently on personal experience. This will lead to poor adherence to local guidelines and inevitably poor prescribing. Poor prescribing by new UK graduates, often due to a lack of an integrated scientific and clinical knowledge base, and the lack of practical prescribing instruction for undergraduates are wellrecognized problems. Clinician education has been found to be the most effective workplace intervention on improving antibiotic selection in a recent systematic review. One apparent barrier to appropriate antimicrobial prescribing is the lack of awareness among senior and training grade clinicians of the local and national resources available to support decision making, including local hospital protocols. Prescribing guidelines appear to be ineffective unless accompanied by educational or financial incentives. Whilst in NHS hospitals it is unlikely that we will be able to meaningfully financially reward individuals or even clinical groups it would seem that optimizing prescribing through improving knowledge and clinical skills may be a more pragmatic approach. At Ninewells Hospital and Medical School in Dundee a concerted and multi-disciplinary effort has been made over recent years to promote and improve prudent antimicrobial prescribing through greater engagement in the undergraduate medical school curriculum and continuing postgraduate educational meetings. Pro-active promotion of local good practice guidance through a variety of educational activities is one such example. Audits of knowledge and behaviour regarding sepsis and antimicrobial therapy among training-grade doctors showed promising improvements between 1999 and 2003 as a result of these initiatives. However, these evaluations and those of others have highlighted the need for clinically focussed and sustainable national learning tools that address the technical and non-technical knowledge and skills of the antimicrobial prescriber. An outcomes based web-based program (Appropriate Antimicrobial Prescribing for Tomorrows Doctors: APT) for teaching and reflective learning of antimicrobial prescribing has recently been developed by infection specialists and medical educationalists and has been adopted by medical schools throughout the UK. The primary resource for the APT project is an interactive website (http://www.dundee.ac.uk/ facmedden/APT/index.htm) with access to clinical worked examples, prescribing exercises, self-assessment tools and a reflective learning logbook. Although the emphasis is on prudent prescribing of antibiotic therapy the principles learned through APT can be applied to all areas of prescribing. In our medical school this forms an integral part of clinical infection teaching in the fourth year that also includes recognition, diagnosis and management of common infections, infection control and health protection aspects of infection. This teaching is delivered by infectious disease physicians, microbiologists, infection control nurses, pharmacists and public health clinicians. Evaluation of this program through student and staff feedback has revealed very positive results and we are presently evaluating student knowledge through a series of short exams at the beginning and end of each attachment, and at the end of the year. In line with national Scottish Recommendations for improving antimicrobial prescribing practice in Scotland the APT work has been further adapted for providing mandatory online e-based training and assessment for foundation doctors in Scotland through the Doctors Online Training System (DOTS) developed by NHS Education Scotland (NES) (https://www. nhsdots.org/nhsdots/dotsx/login.asp). This site is password protected and linked to the NES Healthcare Acquired Infection portal (http://www.nes.scot.nhs.uk/hai/). At any given time there are more than 1600 foundation doctors in Scotland who will have to undertake this mandatory exercise and show evidence of satisfactory completion of this module. This program, through clinical vignettes, revises, evaluates and then reinforces the principles and practices taught at undergraduate level for foundation doctors. An extension and probable further adaptation of this program is proposed for more senior training and non-training grade doctors and ultimately non-medical prescribers. Any persons outside Scotland interested in this work should please contact dilip.nathwani@nhs.net. Ongoing evaluation of this program will inform its further development and impact.

Secondary prevention of work-related upper extremity disorders: recommendations from the annapolis conference

Efforts to improve the secondary prevention of work-related upper extremity (WRUE) symptoms continue to present a challenge. As with many occupational musculoskeletal pain disorders no single, direct cause-effect relationship exists among specific exposures, pathologic processes, and symptoms. The field has yet to create truly effective and efficient interventions for these problems that are based on current epidemiological and clinical knowledge. A working conference was held in Annapolis, Maryland on September 23rd and 24th, 2005 with leaders in research and application related to upper extremity disorders to address this challenge. The intent of the meeting was to review "state of the art" evidence in epidemiology and intervention research in order to develop suggestions regarding next steps in intervention research and application. On day 2 a number of stakeholders were present to discuss what they perceived as the missing pieces in both epidemiological research and applied intervention research in order to generate more effective workplace interventions. The papers in this series of the Journal of Occupational Rehabilitation indicate that scientifically sound progress has been made over the past decade in identifying ergonomic, workplace psychosocial, and individual factors in both the etiology and exacerbation of these symptoms/disorders. However, there is a gap between this knowledge and the development and practical implementation of comprehensive interventions for these problems. The conference also highlighted the paucity of economic analyses of the impact of these disorders as well as the economic study of the impact of intervention. Approaches for such evaluations were presented and are included in this special section of the journal. This series of papers and the summary of the invited group's discussions provided in this paper clearly emphasize the need for innovative ways to think about these problems and specific research topics that can help translate this knowledge into effective secondary prevention efforts.