HEALTHY WORKPLACES IN IRAN: EMPLOYEE HEALTH IS A GOOD INVESTMENTIn Iran, like most other countries, cardiovascular disease (CVD) is the most common cause of death and leads to heavy loss of productivity. The Isfahan Healthy Heart programme (IHHP) is a comprehensive community-based programme for CVD prevention, designed and conducted by the Isfahan Cardiovascular Research Centre (ICRC) with the cooperation of Provincial Health Centre, both are affiliated to Isfahan University of Medical Sciences. IHHP comprises 10 projects to reduce CVD risk. Its Worksite Intervention Project has changed employee habits and helped Iranian firms show that employee health is a good investment. Isfahan Health Heart Programme: Worksite Intervention ProjectThe five-year Worksite Intervention Project began in 2001. Targeting offices and factories in the Central Iranian cities of Isfahan and Najafabad, it involved some 13,000 workers in factories and 7,000 employees in workplaces as diverse as advertising agencies, electricity plants, media companies, steel mills, food manufacturing plants, transport companies, and government offices. Using both health promotion and environmental/policy change, the project aimed to improve nutrition in factory restaurants, educate employees on CVD risk factors, reduce smoking, and increase workers’ physical activity. Examples of activities included:
Some employers:
To reduce smoking among workers they:
Factories organized:
Getting “buy in” from management and workers“About half of the workplaces targeted chose to participate,” explained Prof. Nizal Sarrafzadegan, Director of the Research Centre and IHHP. “Initially we had to get management on board. We presented them the baseline data we had collected about the problem of cardiovascular disease in Isfahan and Najafabad: when they realized it really applied to their workers and their businesses, this got them interested. Some resisted, especially with interventions that cost more money or human resources, such as adding CVD risk factor assessment to annual screening, but often they eventually agreed as they gained confidence in the programme and saw its value.” Factory environmental health officers coordinated the activities at their worksites. “We didn’t tell them what to do – we trained them in the principles and possibilities, and they worked with their management to identify what would work using mechanisms already in place at their own workplace, and align health interventions with business policies and plans. These coordinators’ relations with the workforce were important for making the project work.” In some sites even workers were resistant: “Some didn't feel that it was the appropriate place to talk about health,” said Maryam Boshtam, ICRC staff member who is one of the Worksite Intervention Project Managers. Impact on workers and their workplacesOverall, more than 85% of the workers studied in the project changed some aspect of behaviour related to CVD risk. “While we had impact on some aspect of all risk factors, the strongest was on diet,” said Maryam Boshtam. This is the area where there were some of the most impressive institutional changes: “the largest factory in Isfahan set up a Healthy Heart Restaurant, a few years ago. Now it has increased to three restaurants and they still can’t meet the demand,” continued Ms Boshtam “and in some factories workers complain now if they don't get enough vegetables or other healthy choices.” Employees’ consumption of soft drinks and hydrogenated fat has decreased in Isfahan and Najafabad, and consumption of fruit and vegetables and white meat has shown a significant increase. These changes had an impact on employee’s CVD risk: the biggest impact was in lowering levels of LDL cholesterol and triglycerides; the reduction in waist circumference and systolic blood pressure was also statistically significant. Monitoring and evaluationThorough and systematic monitoring and evaluation enabled project staff to find approaches that work and adapt the ones that were less successful. Questionnaires for managers collected information on the human, financial or material resources invested in interventions, how they worked, whether objectives were achieved on time, how interventions were viewed by different stakeholders and how well they fit into existing systems. Checklists were used to monitor activities and outputs – things like what canteens served and how they cooked them. Questionnaires for workers were designed to evaluate the reach, success, impact, and sustainability of interventions: the target community was randomized and 50 workers were questioned by trained interviewers. Focus groups and interviews with different stakeholders helped identify successes and failures. This rich and varied information was “triangulated” to compare qualitative and quantitative research findings. Adapting interventionsFindings were fed back to managers who then often used them to improve interventions. “When we found out something wasn’t working or cost too much, we stopped doing it,” explained Ms Boshtam, “or at least took a different approach and then checked again to see the results. We often learned as much from the failures as the successes,” she admitted. “For example we published and distributed an ‘IHHP newsletter’ in factories, offices and schools, but process evaluation results showed that their messages didn’t reach workers, so we decided to send brief reports and feedback to employee newsletters; this worked much better. Factors of successThe Finnish National Institute for Health and Welfare conducted an external evaluation of the whole IHHP programme, which concluded that the worksite component was very successful in achieving participation from a large proportion of worksites in the city. “It is really a unique achievement that the project was able to involve so many worksites in the city. One reason is probably the way IHHP recruited management: not talking to managers one by one in their own offices, but gathering them in meetings with other employers. That helped develop a group dynamic, playing a bit on competition: once one firm made a commitment, there was a pressure on others to do the same”, said Dr Laatikainen (Finnish National Institute for Health and Welfare, and co-author of the independent evaluation of the project). She was also impressed by how, once engaged, the employers invested in making interventions work. “Much of the success of interventions depended on the knowledge and motivation of the in-house coordinators who designed, drove and monitored the programme. I was impressed at how willingly Iranian employers allowed them the time needed to really make interventions work. I wonder whether employers in Europe would be so generous with their human resources!” Sustainable changeThe interventions that changed the environment and made it easier for workers to make healthy choices, like changes in food served in canteens, were the aspects of the project that had the biggest impact. When interventions depended on workers investing energy or motivation or discipline, they were less effective: it is not easy to get people to go out of their way to make healthy choices. Prof. Sarrafzadegan, who oversees all 10 projects of the Isfahan Healthy Heart Programme, summed up some of the essential success factors “If your interventions require too many extra resources they will eventually fail, so you have to integrate them into something that already exists. You have to understand the business policies, plans and priorities and be able to identify the resources available and barriers. Only the management and others in the business know how to do this. So you need them to play a major role. The Project Managers or Directors were business insiders, but they did not have the capacity or resources to evaluate their activities – that’s where external input like ours is so vital.” Useful links | |||||||
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