An unhealthy lifestyle (e.g. insufficient daily physical activity, unhealthy diet, smoking, high alcohol consumption and low levels of relaxation) is related to several chronic diseases with high prevalence rates in the Netherlands like cardiovascular diseases, diabetes mellitus type II, respiratory diseases (e.g. asthma and COPD), depression and certain types of cancer [1
]. A well-known consequence of an unhealthy lifestyle is overweight [2
]. Currently, 30.5% of the Dutch working population is overweight and an additional 6% is obese [4
]. Furthermore, unhealthy and/or overweight employees show elevated sickness absence rates which significantly increase costs for the company [5
]. To ensure long-lasting productivity of employees and to prevent work disability an important component is adopting and maintaining a healthy lifestyle [6
The WHO states that the workplace directly influences the physical, mental, economic and social well-being of employees and in turn the health of their families, communities and society. Therefore, the workplace offers an ideal setting and infrastructure to support the promotion of health of a large audience [8
]. Furthermore, growing evidence is found for the effectiveness of worksite health promotion programs (WHPP) that promote a healthy lifestyle in general [9
]. Nevertheless, broad scale implementation of these effective WHPP in daily practice and across a wide range of settings often fails [13
]. In order to improve the implementation of WHPPs into daily practice, it is important to shift the focus from effect evaluations to the evaluation of the implementation process. Hence key determinants of success and failure could be obtained and addressed in future implementation. For this purpose, traditional evaluation designs (i.e. randomized controlled trials) that focus on effect evaluations are not sufficient. These evaluation designs do not provide critical information on the implementation process. So other study designs are required, which focus more on observational strategies. The complementary use of a systematic and real-time formative evaluation within an controlled trial can create a dual style approach whereby critical information on the implementation process over time can be obtained [18
]. A formative evaluation is an assessment that focuses on “the internal dynamics and actual operations of a program in order to understand its strengths and weaknesses and changes that occur in it over time” [18
]. It gives researchers insight into program implementation over time and employs a mix of qualitative and quantitative techniques. Formative evaluations emphasize the need for real-time monitoring of the implementation process, but is very time consuming [18
]. The amount of time that is needed to conduct a real-time formative evaluation could partially be the cause for the lack of such studies. However, investing time in effectiveness studies that are not used in daily practice and only include a posterior process evaluation that does not give insight into the important aspects of the implementation process, is also a waste of money.
Despite the lack of focus on studying the implementation process, researchers do acknowledge the fact that for improving the effectiveness and implementation of WHPP in practice, these programs should be systematically implemented in order to achieve successful implementation and continuation. For instance, Durlak and Dupre showed that the level of implementation (i.e. low or high implementation) affects the outcomes obtained by health promotion programs, whereby high implementation increased program success and could lead to greater effects on outcomes for participants [16
]. In addition, implementation success is for an important part dependent on an adequate fit of the program with the specific organizational context (i.e. implementation context) in which the program is implemented [16
]. The implementation context differs from one worksite to another because of inherent differences between worksites, which makes it difficult to implement effective WHPPs across different worksites [21
]. In order to take the implementation context into account it is important to involve the target population (i.e. employees) and implementers within the worksites in the development phase of the WHPP and to keep them involved throughout the whole implementation process. This allows the worksite to incorporate and adjust the WHPP and implementation strategy to their specific needs, interests and the existing setting, thereby increasing the chances of implementation success [22
Furthermore, in order to successfully implement WHPPs, programs need to pass through the four stages (i.e. dissemination, adoption, implementation and continuation) as stated in the diffusion of innovations theory [23
]. Four main categories of innovation determinants may influence the transition process from one stage to the next as potential barriers or facilitators for implementation (see Figure
): 1) characteristics of the socio-political context (e.g. fit with existing rules, regulations, and legislation), 2) characteristics of the organization (e.g. hierarchical structure, available expertise), 3) characteristics of the innovation (e.g. compatibility, relevance), and 4) characteristics of the adopting person/user (e.g. self-efficacy, degree of ownership) [24
]. The above described theory provides the key elements that should be addressed when implementing a WHPP successfully [23
]. However, this theory, along with other implementation theories, does not provide specific strategies or guidelines for implementation.
Figure 1 Framework presenting the innovation process and related innovation determinants (Fleuren et al., ).
As such, a new and systematic 7-step implementation strategy was developed that incorporates most of the fore mentioned aspects for successful implementation. This strategy also aims to maintain the implemented programs over time [26
]. The 7-step strategy is based on a ‘user-driven’ approach towards developing and implementing interventions that specifically address the capacities and needs of the target population at multiple organizational levels (i.e. management, project group, employees). User-driven within this context means that health objectives, interventions and implementation strategies are (co-)developed by members of the target population at different levels of the worksite. The 7-step strategy incorporates planning, implementation, evaluation and maintenance. The strategy ensures that the interventions will be tailored to the specifics of the worksite, thereby ensuring a fit with the implementation context. This increases possibilities for maintenance over time. The 7-step strategy has already been used in practice but whether this strategy is an effective and generic approach for developing and implementing WHPPs has never been studied systematically [28
Therefore the present study, called BRAVO@Work, describes the formative evaluation of this 7-step strategy under real-time conditions by an embedded scientist, with the aim to evaluate and monitor whether this 7-step strategy is a useful and effective strategy to successfully develop and implement a WHPP at two worksites, with a focus on healthy lifestyle changes. Furthermore, we aim to gain insight into factors that either facilitate or hamper the implementation process, the quality of the implemented lifestyle interventions and the degree of adoption, implementation and continuation.
This article describes the design and framework for the formative evaluation of the natural course of the development, implementation and maintenance of BRAVO@Work.