# Presentation: 717522

## Sequential emails for workplace health promotion

**Funded by:**
**Health e Technologies Initiative, **
***The Robert Wood Johnson Foundation***

## Research Team

- Interdisciplinary collaborators
- Patricia D. Franklin, MD MBA MPH
- University of Massachusetts Medical School
- Michael Roizen, MD
- Cleveland Clinic
- Paula Rosenbaum, PhD
- SUNY Upstate Medical University
- Michael Carey, PhD
- Syracuse University
- Robert Ploutz-Snyder, PhD
- SUNY Upstate Medical University

## Business Collaborators

- RealAge, Inc.
- Excellus BlueCross/Blue Shield of CNY
- 19 Worksites in Central NY

## Health-e-Employees:

- Will a sequential email worksite health promotion program:
_**Reach**_ a significant proportion of employees?
_**Improve**__ _health behaviors?
- Fruit and vegetable intake
- Physical activity
_**Reduce**__ __**costs**_ of lost productivity and illness?

## Today

- Will a sequential email worksite health promotion program _**reach**_ a significant proportion of employees?
- % enroll; % attrition
- % emails opened
- Participant profile

## Worksite Health Promotion

- Pelletier (1999) and Aldana (2001) reviewed 11 and 72 studies, respectively, and found consistent evidence that worksite health promotion programs were associated with reductions in health risks and costs.
- Labor intensive; little evidence on sustained effects.

## Internet and email

- Internet spans geography
- Sustains relationships
- Links information and people
- Available 24/7
- Easily customized
- (Wellman, 2001)
- 41% employers are “likely” to use web-based health utilization management
- (Deloite& Touche, 2001)

## Background

- 75- 84% of adults report diets that include less than the recommended daily intake of fruits, vegetables, and vitamins
- 55% adults report overweight (BMI 25-30); prevalence is increasing

## Background

- 25 % of Americans report no regular activity (President’s Council on Physical Fitness)
- Moderate levels of physical activity decreased in the past decade
- 23% to 15% in 2004
- 85% report < 60 minutes/week of leisure time physical activity (MMWR, 2004**)**

## Recruitment/Enrollment

- 5 minute, all-employee presentation
- Sequential email invitations to employees
- Wall announcements
- 3 on-site information/enrollment sessions at lunch room
- Enrollment:
- 1. Sign Consent
- 2. Provide email address
- 3. Complete Baseline Health Assessment

## Setting and Participants

- Evaluate reach and acceptance:
- Health insurance company
- (claims processors, triage, actuarial, clinical)
- 960 employees >18 years
- 90% desk-top personal computers
- Web/email access
- Shared pc in lunch room

## Intervention

- Email Delivered:
- Monday-Friday “tips” on target behaviors
- Topics grouped by week
- 6 months
- October-March

## Intervention

- Each Tip includes:
**One** suggested behavior
- Motivation:  Gain-positive language
- Web Links:
- Information:  Literature Summary, citation
- Self-assessment  tool (individualize risk)
- Self-monitor (set and track goals)
- Share with friends/family/co-workers (support)

## Sample tip

**These Berries Are a Blast (Food and Nutrition)****Jun. 23, 2004  **Get a health blast by stocking up on the season's freshest strawberries. Experts agree: a diet rich in fruits and vegetables can reduce..._[read more](http://www.realage.com/Premium/report18k.aspx?mod=TIPARCH)_
- Source: _www.realage.com_

## Assessment

- Acceptance: email opened, web links 	used
- Participant attributes
- Fruit/Vegetable intake (NCI All day Screener)
- Physical Activity (IPAQ-short form)
- Stage of Change
- Intention to Change

## Assessing email use

- RealAge server delivers email
- Participant “clicks” to open email or web link
- RealAge server delivers HTML version
- Server records date and user by message topic

## Results: enrollment

- 40% of employees enrolled
- 388/960 employees;
- Participants roles:  CEO - sales - claims managers – housekeeping
- Baseline survey completion: 88%
- 343/388 final enrollment

## Results: e-mails opened

- Total of 129 emails delivered over 6 months
- Mean emails opened= 88 (68% of total)
- Employees		Emails Opened
- 10%			9 or fewer
- 50%			108 (83% of total)
- 35%			123 (95% of total)
**Summary:**
- Half of employees opened >80% of emails.
- One-third of employees opened 95% of emails.

## Slide 19

## Last email opened

- Employees		Last Date
- 11%			before 5 months
- 66%			last day of project
**Summary**:
- Two-thirds of employees open emails through last day of program

## Slide 21

## Web links used

- %Employees		**Last** Date
- 13%			1st month
- 22%			3rd months
- 63%			4th+ months
- Median links used =6
- Mean links used= 13
**Summary:**
- One-third using links in last month;
- Pattern reverse of email use

## Slide 23

## Characteristics of Users

## Gender and Race

|  | N | Mean # emails opened (NS) |
| --- | --- | --- |
| Female | 297 | 89 |
| Male | 44 | 84 |
| White/Caucasian | 307 | 90 |
| Non-White | 30 | 74 |

## Age

|  | N | Mean # Emails Opened (NS) |
| --- | --- | --- |
| 20-29 years | 17 | 96 |
| 30-39 years | 106 | 87 |
| 40-49 years | 128 | 87 |
| 50-59 years | 76 | 91**more web use |
| Over 60 years | 10 | 66** more web use |

## Education

|  | 
N | Mean # Emails Opened (NS) |
| --- | --- | --- |
| High school | 87 | 88** more web use |
| Some college | 142 | 92 |
| College degree | 78 | 89 |
| Post college | 37 | 77 |

## Stage of Change: Physical Activity

| 

Maintenance | N

70 | Mean # Emails Opened (NS)
91 |
| --- | --- | --- |
| Action | 36 | 91 |
| Next month | 121 | 87 |
| Next 6 months | 82 | 86 |
| No plan | 25 | 83 |

## Stage of Change: Fruit and Vegetable Intake

| 

Maintenance | N

72 | Mean # Emails Opened (NS)
93 |
| --- | --- | --- |
| Action | 22 | 85 |
| Next month | 129 | 88 |
| Next 6 months | 69 | 83 |
| No plan | 37 | 95 |

## Fruits/Vegetables Daily

|  | N | Mean # Emails Opened (NS) |
| --- | --- | --- |
| 2 or fewer | 111 | 85 |
| 3-4 | 102 | 87 |
| 5 or more | 122 | 94 |

## Physical Activity (days/week)

|  | N | Mean # Emails Opened (NS) |
| --- | --- | --- |
| Vigorous: none | 186 | 89 |
| Vigorous: 3-4 | 59 | 89 |
| Moderate: none | 123 | 89 |
| Moderate: 3-4 | 54 | 84 |
| Walking 10+min: none | 42 | 80 |
| Walking: 3-4 | 63 | 92 |

## Summary

- Broad, sustained use of email health messages in the worksite.
- Limitation:
- Cannot comment on worksites without easy computer access (ie line manufacturing, hospital nurses)
- Not tested off-hours or in retirees

## Next steps: RCT

- 19 worksites/ 1055 employees
- Mean enrollment= 20% employees
- (range: 15-40% employees)
- Baseline survey completion: 85%
- INTERVENTION CLOSED: April, 2005
- 6 month assessment: April-May 2005
- 12 month assessment: pending

## Next: Questions

- Behavior Change?
- Antecedents to change?
- Information
- Skills
- Reduce barriers
- Readiness/Intention

## Next: Research Questions

**Dose and Content?**
- Number per week? Fewer?
- Length of time?
- Content individualized?
- Design of messages?

## Retirees?

- Over 65 year olds online: increased 27% between 2000 and 2004.
- 8 million or 22% use internet
-  “There is a burgeoning group of Americans who are slightly younger than retirees and who are vastly more attached to the online world.  This Silver Tsunami ...has gained momentum.  As Internet users in their 50’s get older and retire, they are unlikely to give up their wired ways and therefore will transform the wired senior stereotype.”
- PEW Report; Older Americans and the Internet