Briefly, the original Gear Up for Health was a telephone-delivered health promotion program focused on tobacco use cessation and weight management among motor freight workers, comprised of truck drivers and/or dock workers from 8 terminal sites in the eastern United States.⁷ Workers were invited to participate in the intervention composed of 5 telephone counseling calls using principles of motivational interviewing, a tailored feedback report, and targeted written materials. Out of 542 workers who completed the baseline survey, 227 agreed to participate and completed at least 1 telephone counseling call; non-participants included all other respondents to the baseline survey (e.g., those who received no intervention; those who provided a mailing address only and thus received written materials but no counseling calls). Guided by the Social Contextual Model,⁸ this program utilized qualitative formative research to identify elements of the workers’ social context, for example, supervisory support, and then incorporate these factors into the design of the calls and written materials. Workers self-reported tobacco use on surveys at baseline and 10 months later, a timeline which was comprised of a 4 month intervention plus a 6 month post-intervention period. Participants were more likely to have reported quitting tobacco compared to non-participants: 23.8% vs. 9.1% (site adjusted OR=3.13, 95% CI: 1.22–7.98%, p=0.02).⁷ There were no significant effects on weight management.⁷

The original Gear up for Health program was offered to Teamsters members in close collaboration with both union and management. When that study was completed, we began to discuss ways in which to disseminate this formerly worksite-based approach more broadly. The development of Gear Up for Health-HWF was guided by our conceptual model, presented in Figure 1, which outlines the steps needed in intervention adaptation and dissemination.⁹ Together with the evaluation approach described by Glasgow and colleagues, RE-AIM,¹⁰ our conceptual model provides the basis for collecting contextually-relevant information regarding the fit of the intervention within a particular organization (e.g., reach, implementation, acceptability) and effectiveness (e.g., tobacco use cessation).

Through discussions with our partners in the Safety and Health Department of the International Brotherhood of Teamsters, we learned that dissemination of programs like this for their members would most likely be provided through union-affiliated health and welfare funds. Our partners identified and assisted us with building a collaboration with a large New England HWF, which has contracts with 10 local Teamsters chapters providing health care coverage to members and their families. We worked closely with the HWF to determine best strategies for promoting this program among their membership, based on approaches they had used in the past. As part of the ‘Assessment Phase’ of adapting this intervention for dissemination through the HWF, we systematically reviewed the literature on dissemination and other similar tested interventions, and identified the essential elements (i.e., core components) of the program, and those that might be potentially modifiable.^9,11 Table 1 shows selected examples of core and modifiable elements and the associated design element in Gear Up for Health-HWF. Since we did not find significant differences for weight in the original Gear Up for Health,⁷ we decided to remove weight management as a main targeted behavioral outcome.

As displayed in the conceptual model, intervention activities were coordinated through the HWF in the ‘Preparation Phase’. Through in-person and phone meetings, the research team presented our original and adapted Gear Up for Health materials and recruitment ideas to the HWF administrators for their review and feedback. Based on their experience with contacting their membership, to recruit participants, we posted a message on their website newsletter, mailed colored postcards with our logo, and attended several union meetings to promote the program and provided an information sheet to hand out at meetings that we did not attend. Data Collection. Over approximately 9 months, individuals contacted the study team, were assessed for eligibility (self-reported tobacco use in past 7 days and a HWF covered member), completed a baseline survey either online or over the phone in which a research staff member read the online survey to them, and were enrolled in the Gear Up for Health-HWF program. Respondents were asked to indicate their age; their highest level of education completed; having Hispanic ethnicity and choosing all that apply from race categories; and their current money situation. We also assessed number of quit attempts (“How many serious quit attempts lasting at least 1 day have you made in the last 10 months?”); confidence to quit¹² (“How confident are you that you can quit using all forms of tobacco?”) and readiness to quit¹² (“Are you seriously thinking about quitting using all tobacco products in the next 6 months?” and “Are you seriously thinking about quitting all tobacco products in the next month?”). Responses to these questions formed three categories: preparation (thinking about quitting within the next 30 days), contemplation (thinking about quitting within the next 6 months), and pre-contemplation (no indication of intent within the next 30 days or 6 months). We assessed 7 groups of common union-based job categories; mean number of hours worked per week over past 4 weeks; their usual work schedule¹³; and sleep adequacy¹⁴ (“How often during the past 4 weeks did you get enough sleep and feel rested upon waking up?”).

Six months after their final counseling call, participants were contacted by mailed letter and a follow up telephone call 1 week later to remind them to complete the survey on-line. If the survey was not completed, then participants were encouraged to complete the survey over the phone during the reminder phone call. Health educators used a computer-based system to track their call schedules, number of call attempts, and call outcomes (e.g., participant not home, etc.)

Intervention Description. Participants were mailed a binder that included a personalized introductory letter, a 4-page tailored feedback report, and 16 targeted tip sheets; and up to 4 coaching calls using motivational interviewing from 1 of 2 health educators were made. The tip sheets were subdivided into 4 topic areas: (1) Quitting tobacco (e.g., local resources); (2) Your workplace (e.g., sleep and shift work); (3) Family and friends (e.g., social support); and (4) Managing your weight (e.g., physical activity). The counseling calls included an introduction; information about confidentiality; learning about the participant’s life and perceived health; assessing current tobacco use and past quit attempts; gathering participant’s self-rated pros, cons, importance, confidence, and readiness to change; discussing NRT and other quitting techniques and plans; and setting goals. The intervention was conducted over 16 weeks.

Analysis Plan. Descriptive statistics of baseline and follow-up survey and process tracking system variables included frequencies and proportions of categorical measures and means and standard deviations of continuous measures. We used the Chi-square test of homogeneity to assess if completion of the final survey and quit status was associated with participant characteristics and if acceptability measures were associated with quit status. We followed an intent-to-treat approach in calculating the quit rate, whereby participants who did not complete the final survey were assumed to be non-quitters.

Of the approximately 7,000 unionized workers and dependents covered by the HWF, 68 (1%) individuals contacted us with an interest in participating. All 68 individuals completed the baseline survey, were eligible, and enrolled in the program; 5 subsequently dropped out citing not wanting the counseling (n=3), not providing contact information (n=1), and illness (n=1). The majority completed the baseline survey online (69%). The most frequently cited recruitment method was receiving a mailed study postcard (68%), followed by the newsletter (28%). Most individuals were HWF members (n=52); 15 were spouses of members and 1 was a dependent of a member. Participant characteristics are presented in Table 2. Among these 68 participants, 49 (72%) completed the final survey. The majority completed the final survey online (78%). Comparing those who completed the baseline survey only vs. both the baseline and follow-up survey, there were no statistically significant differences according to gender, age, education level, or baseline level of self-efficacy to quit tobacco. However, those in preparation stage of change at baseline more often completed surveys at both time points compared to those in precontemplation or contemplation (77% vs. 28%, p=0.01).

All participants received the materials binder; 58 (85%) received NRT; and 47 (69%) completed all 4 coaching calls, 16 (24%) completed 1–3 calls, and 5 (7%) completed no calls.

Among respondents to the final survey (n=49), 21 self-reported not using tobacco in the past 7 days. Assuming that non-respondents continued to use tobacco, our results indicate a 7-day quit rate of 30.9% (95% CI: 19.6–42.1%). Among those who reported quitting (n=21), using a scale of 1 (not at all confident) to 10 (very confident), 48% (n=10) rated their confidence to remain quit between 6–9 and 52% (n=11) gave a rating of 10. Among those who did not quit (n=28), using the same scale, 25% (n=7) rated their confidence to quit between 1–5 and 71% (n=20) gave a rating of 6–10 (one participant did not answer). Also among those who did not quit (n=28), 78% (n=22) were in preparation to quit and 18% (n=5) were in precontemplation or contemplation (one participant did not answer). Of the socio-demographic measures in Table 2, only age differed statistically significantly between those who quit and those who did not; such that quitters were older compared to non-quitters (54.6 vs. 45.5 years, p<0.001). Of the organizational factors, job category differed significantly between those who quit and those who did not (skill/craft/machine operators: 36% quit; manual laborers: 10% quit; all other job types: 43% quit; p=0.04). Number of hours worked per week also differed significantly, such that quitters worked more hours compared to non-quitters (45.8 vs. 36.3 hours/week, p=0.02).

Perceived acceptability of Gear Up for Health-HWF is presented in Table 3. Of the factors listed in Table 3, only the perceived number of phone calls from the health counselor was significantly different between quitters and non-quitters, such that more quitters found the number of calls to be ‘just right’ compared to non-quitters (86% vs. 48%, p<0.01).

Although there are notable strengths to this study including the inclusion of multiple measures of contextually relevant information (e.g., reach, implementation), use of evidenced-based behavioral change techniques (e.g., motivational interviewing based coaching, tailored materials), there are also weaknesses. Tobacco use cessation was self-reported and biochemical verification was not obtained. Biochemical verification of quitting may reduce trust among participants in workplace settings in which testing for other drugs can already be common.⁷ While biochemical verification provides added precision, its value may be off-set in studies in which data collection occurs primarily through telephone and Internet channels,²¹ as is the case in our study of participants spread over multiple worksites in different states. Our sample size is also small, which limits the generalizability of our data. We also did not include a control group, which limits our ability to isolate the specific effects of our program. However, we believe our research design is in line with current calls for designs beyond the traditional randomized trial³ and contributes to the understanding of low-cost, feasible recruitment and evaluation methods. We also provide only short-term follow-up of a one-time tobacco use cessation program, thus our results can not directly speak to long-term implications for tobacco control.

Adapted from an evidenced-based worksite program, Gear Up for Health-HWF was a tobacco use cessation program resulting from a union-management collaboration and disseminated to workers and their dependents through an overarching HWF. Given the caveats of self-reported tobacco use and a small sample size with no control group, we found relatively high levels of implementation, effectiveness, and acceptability which were similar to the results obtained from the original Gear Up for Health. Even though a low level of reach was obtained, implementing a telephone counseling program with tailored/targeted materials may still have value to a HWF wishing to deliver a tobacco use cessation program to their members, particularly if the costs are distributed over many members and the program is in line with their organizational mission. Future work in this area should examine moderators (e.g., organizational readiness) of adoption of health programs in HWFs and other organizations that could serve the large adult working population in general, and the higher-risk blue-collar population, in particular.