International Journal of Behavioral Medicine

https://doi.org/10.1007/s12529-018-9747-7

Effects of a Multi-Component Workplace Intervention Program

with Environmental Changes on Physical Activity among Japanese
White-Collar Employees: a Cluster-Randomized Controlled Trial
Kazuhiro Watanabe 1 & Norito Kawakami 1

# International Society of Behavioral Medicine 2018

Abstract
Purpose This study aimed to investigate effects of a flexible multi-component workplace intervention program for improving
physical activity among Japanese white-collar employees in a cluster randomized controlled trial design.
Methods A total of 208 worksites and nested employees were approached. Any worksite interested in a 3-month physical activity
promotion intervention and white-collar workers aged 18 years or older were eligible. The worksites were randomly assigned to
an intervention or a control, stratified by worksite size. The intervention worksites were offered an intervention program that
allows these worksites to select intervention components from a set of options, including environmental changes. The control
worksites were offered feedback and basic occupational health services. Physical activity level was measured using a self-
reported questionnaire at baseline and at 3 and 6 months of follow-up.
Results Three worksites (92 employees) were allocated to the intervention and five worksites (98 employees) to the control
worksites. The overall physical activity level in the intervention worksites significantly increased compared with the control
worksites (Coeff = 0.45, SE = 0.19, p = 0.018). For subgroup analyses, the intervention effect on the overall physical activity level
was significant among medium- and large-sized worksites but not among small-sized worksites.
Conclusion This trial showed a significant and positive effect of the intervention program on physical activity. The program is
unique because of its flexibility and feasibility. However, small worksites might receive less benefit from the program, indicating
a need for further support and/or new technologies.
Trial Registration UMIN Clinical Trials Registry (ID=UMIN000024069).

Keywords Worker . Health promotion . Ecological model . Behavioral change

Introduction outcomes have repeatedly been reported, including

Physical activity, which is defined as any body movement
produced by skeletal muscles resulting in energy expenditure
[1], is one of the most important health behaviors and a deter-
minant of physical and mental health [2–4]. Moreover, signif-
icant associations between physical activity and work-related
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s12529-018-9747-7) contains supplementary
material, which is available to authorized users.
* Kazuhiro Watanabe
kzwatanabe-tky@umin.ac.jp
1 ination of informational messages using newsletters, flyers,
Department of Mental Health, Graduate School of Medicine, The
University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033,
Japan
presenteeism, absenteeism, job stress, employee turnover,
and work ability [5, 6]. Thus, promoting workers’ physical
activity is indispensable for occupational health promotion
and for a sustainable workforce [7]. However, physical activ-
ity levels in the workforce population are usually low [8].
Intervention strategies to promote physical activity among
workers are thus required.
Many systematic reviews [9–18] have concluded that phys-
ical activity among workers is more effectively increased by
multi-component interventions at workplaces, including a
physical activity component and organizational changes, com-
pared with single-component interventions. Organizational
changes in workplace interventions include the use of prompts
for using stairs [12, 13]; involvement of families [12]; dissem-
and posters [11–13, 15]; promotion of active commuting
[16]; implementation of new policies encouraging physical

activity [9, 17]; and provision of employer incentives [11],
walking routes [12, 13, 15], and facilities and equipment for
physical activity. According to an ecological model [19], var-
ious multi-level factors, including environmental ones, could
influence specific health behaviors interactively across differ-
ent levels and domains. Therefore, a workplace environment
with multiple components incorporating both individual- and
organizational-level approaches may be effective in promot-
ing physical activity among workers.
The quality of evidence for the effectiveness of a multi-
component workplace intervention for the promotion of phys-
ical activity remains low owing to the lack of cluster random-
ized controlled trials (cRCTs). A few cRCTs [20–23] were
conducted in the USA and the UK, and they reported incon-
sistent results related to physical activity promotion. In addi-
tion, previous intervention programs could not be flexible be-
cause of their fixed components that required considerable
monetary and human resources. Although important in terms
of maintaining the intensity of the interventions, it is not fea-
sible and realistic that all worksites, especially those with lim-
ited resources, conduct the same intervention program with
the same components. In reality, offering the flexibility to
select and tailor program components is an important theme
for the successful implementation of health promotion inter-
ventions [24]. Therefore, further cRCTs are needed to inves-
tigate the effects of more flexible and more feasible programs
with environmental changes that aim to improve physical ac-
tivity among the working population.
This study aimed to investigate the effects of a new multi-
component workplace intervention program on improving
physical activity levels in Japanese white-collar employees
using a cRCT design. The newly developed program is unique
because it was designed to allow a participating worksite to
select components feasible at each worksite from a
predetermined list of actions to improve the workplace envi-
ronment comprehensively toward promoting physical activity.
We hypothesized that the overall, occupational, transport-re-
lated, and leisure-time physical activity levels among em-
ployees would be improve at the intervention worksites com-
pared with the control worksites.
Methods
Trial Design
This intervention study was a two-arm, parallel-group cRCT.
The randomization procedure was conducted at the cluster
(worksite) level. The clusters were worksites with white-
collar employees in Japan. After a baseline survey, the
worksites were randomly assigned to an intervention or a con-
trol group in a 1:1 ratio. The randomization was conducted
with worksites stratified by size (≤ 49, 50–299, and ≥ 300
Int.J. Behav. Med.
employees), permuted-blocked (blocked size = 2), and non-
blinded. Measurements were collected at the worksite and
worker levels, and analysis for evaluating the efficacy of the
intervention program was conducted at the worker level while
accounting for the cluster (worksite)-level effects. The proto-
col of the intervention was registered at the University
Hospital Medical Information Network (UMIN) Clinical
Trials Registry (UMIN-CTR, ID=UMIN000024069) and ex-
plained elsewhere [25]. This manuscript was reported accord-
ing to the guidelines in the Consolidated Standards of
Reporting Trials (CONSORT) for cRCTs [26].
Participants
A total of 208 worksites were approached in the Kanto area
through some of the health insurance associations and cham-
bers of commerce in the area, using snowball-sampling
methods. There were no inclusion or exclusion criteria for
the worksites; any Japanese worksite could participate in the
study if they were interested in the promotion of physical
activity. After the worksite representatives (i.e., presidents,
executive directors, and chiefs of human resources) agreed
to partake in the study, nested employees were recruited. An
average cluster size was set at 20 employees. Individual par-
ticipants were considered for inclusion if they were white-
collar workers (managerial, professional, technical, clerical,
and other job types that require desk work or sitting work)
employed by the included worksites and 18 years of age or
older. There were no exclusion criteria for participants en-
rolled in this study. The study protocol was ethically approved
by the research ethics committee of the Graduate School of
Medicine and Faculty of Medicine at The University of
Tokyo, Japan (No. 11230). Informed consent was obtained
from all participating representatives and employees.
Interventions
Worksites in the intervention group were offered the newly
developed intervention program for 3 months, consisting of
13 elements across the different components of the workplace
environment (Supplementary Table 1). Details of the develop-
ment and contents were described in the protocol of the study
[25]. Briefly, the program was developed based on a literature
review, a validated scale, and good practices promoting phys-
ical activity at Japanese worksites. A literature review [11, 17,
27] suggested three possible functions for the environmental
components: building awareness and social norms around
physical activity, enhancing accessibility for physical activity,
and enhancing individual cognitive-behavioral skills. A vali-
dated scale (the Environmental Assessment Tool (EAT)) [28,
29] was referred for measuring the workplace environment for
promoting physical activity to include more environmental
elements in this study. Good practices with environmental
Int.J. Behav. Med.
changes at Japanese worksites were obtained from qualitative
interviews at 23 Japanese worksites located in the Kanto area.
The interviews revealed good practices at Japanese worksites
with respect to promoting physical activity (Supplementary
Table 2).
As resources at the worksites are limited, seven elements
(numbers 1 through 7) were offered free of charge to the
participating worksites. The other six elements (numbers 8
through 13) were optional and offered with no funding from
the research team. Only the elements considered relevant/
feasible at each worksite were conducted. The coordinators
were consulted on the choice of elements to be conducted at
each worksite. In addition to the intervention program, feed-
back regarding the assessment of the amount of physical ac-
tivity both at the worksite and worker levels was provided
three times (baseline, 3 months and 6 months of follow-up
surveys). Basic occupational health service was offered at
each worksite.
Worksites in the control group were offered feedback at the
same time as the intervention group and the basic occupational
health service as the TAU. Worksites and employees enrolled
in the control group were put on a waiting list to receive the
same intervention program with the intervention worksites
after completing the 6-month follow-up survey.
Outcomes
Physical activity was measured using a questionnaire at the
baseline survey and at the 3- and 6-months of follow-up sur-
veys. All effects of the intervention program were evaluated
based on the worker-level variables.
Physical Activity
For the primary outcome, physical activity was measured
using the Japanese version of the Global Physical Activity
Questionnaire (GPAQ v2) [30]. This widely used scale has
been demonstrated to have acceptable reliability and conver-
gent validity in nine countries, including Japan [31]. The ac-
curacy of this self-reported measure is reported to be lower
than that of pedometers and accelerometers [31]. However, as
more than 800 participants were recruited to the study, the
GPAQ was used because it can measure physical activity out-
come at a smaller burden to respondents and a lower cost to
the research team [32]. Metabolic equivalents (METs) were
used as the unit of physical activity intensity. Overall physical
activity levels were assessed as ordinal variables in three
levels (low, moderate, high), per the analysis guide of GPAQ
[33]. For domain-specific physical activities, the participants
were divided into two categories (low and high) based on each
median. The amount of physical activity per week (MET-
hours/week) was also calculated as a continuous variable ac-
cording to the GPAQ analysis guide [33].
Sample Size Calculation
The required sample size was calculated taking into account
intra-class correlations (ICCs) of the outcomes nested by the
worksites [26, 34]. Sample sizes in cRCTs should be multi-
plied by design effect (1 + [m-1]ρ), where m is the average
cluster size and ρ is the ICC [34]. Based on previous studies
[28, 35], the estimated ICC for physical activity was set at 0.01
and cluster size, 20. An effect size (d) of the intervention
program for individual physical activity was set at 0.21–0.24
based on a previous meta-analysis [18] and a cRCT [21]. The
required sample size ranged between 436 and 569 employees
in each arm; thus, participants should be recruited from 22 to
29 worksites, for an α error probability of 0.05 and a power
(1-β) of 0.90, using G*Power version 3.1.9.2 [36].
Randomization
Enrolled worksites were randomized to an intervention or a
control group. The randomization was stratified into three
strata based on worksite size (≤ 49, 50–299, and ≥ 300 em-
ployees) because it is easier for large worksites to facilitate
health and welfare systems [28]. Permuted-blocked randomi-
zation (blocked size = 2) was adopted for equal randomiza-
tion. Each employee who participated in the study was not
notified of the result of the randomization; thus, assessment
of the amount of physical activity (self-reported) was blinded.
Meanwhile, the coordinators in the participating worksites
were notified of the randomization result. A stratified
permuted-block random table was created by an independent
biostatistician. This table was managed by a research assistant
who assigned worksites to interventions and was blinded to
the researcher. Enrollment was conducted by the coordinators.
Statistical Analysis
Multi-level latent growth modeling (LGM) [37] for categori-
cal variables using robust maximum likelihood estimation was
conducted as the main analysis method (Supplementary
Fig. 1). We investigated the significance of the coefficient
from a dummy variable for the intervention (control = 0, inter-
vention = 1) compared with the linear slope of physical activ-
ity levels as the effect of the intervention program. Intention-
to-treat analysis using full information maximum likelihood
estimation was conducted, including all employees who com-
pleted the baseline survey. For sensitivity analyses, multi-level
LGM was conducted, treating the amount of physical activity
as a continuous variable (MET-hours/week). Subgroup anal-
yses were also conducted, stratified by worksite size (≤ 49,
50–299, and ≥ 300 employees) and location (urban or subur-
ban/rural). When the LGM results were misspecifications or
improper solutions, an individual-level (two-level) mixed-

model analysis (random intercepts only for employee-level
analysis) was conducted.
Six-month effect sizes of the intervention were calculated
per outcome, according to the relative odds ratios between cat-
egories for the categorical variables (exponentials of estimated
coefficients [Coeff*2]) and Cohen’s d values for the continuous
variables. Cohen’s d values were calculated by dividing the
estimated differences of the amount of changes (Coeff) by the
pooled variances of the outcomes at baseline. Mplus version 7.4
[38] and PASW Statistics version 18 (IBM SPSS software)
were used for LGM and mixed-model analyses, respectively.
Changes to the Protocol
Two changes were made to the registered protocol [25] for
statistical analysis. First, in the analyses for the primary out-
come (physical activity), we originally planned to treat the
amount of physical activity as a continuous variable.
However, at the stage of statistical analysis when data collec-
tion was completed, we observed that the distributions of the
amount of physical activity were not normal but skewed. As
such, we categorized the amount of physical activity into high,
moderate, and low levels. We analyzed the sensitivity, but
with physical activity treated as a continuous variable. The
second change was made when the LGM yielded
misspecifications or improper solutions for the amount of
physical activity. Originally, we planned to conduct a three-
level mixed-model analysis when misspecifications or im-
proper solutions occurred in LGM. However, given the low
ICCs of the physical activity and the small number of partic-
ipating worksites, worksite-level random effects were not
properly estimated even when the three-level mixed-model
analysis was conducted. Therefore, an employee-level (two-
level) mixed-model analysis was alternatively conducted.
Results
Participant Flowchart
Figure 1 shows the participant flowchart in this study. Among
the recruited companies, eight companies (3.8%) agreed to par-
ticipate and completed the baseline survey. The other 200 com-
panies and worksites declined to participate in the study. The
major reasons cited for declining to participate were that the
employers and employees were busy, that participation was
burdensome, and that promoting physical activity was not a
priority in the worksites. We could not investigate the demo-
graphics differences between the worksites that agreed and de-
clined because we could not obtain informed consent to use
information related to the worksites that decline to participate.
From the eight participating worksites, 190 employees
were sampled and completed the baseline survey. An average
Int.J. Behav. Med.
cluster size among the eight worksites was 23.75 (SD = 12.4)
employees, ranging from 12 to 53. The response rates of the
individual employees within each worksite at baseline ranged
from 50.8 to 100.0% (M = 74.6%, SD = 16.2). As a result of
the stratified and permuted-blocked randomization, three
worksites and 92 employees were allocated to the intervention
group and five worksites and 98 employees, to the control
group. At the 6-month follow-up evaluation, three worksites
and 80 employees (87.0%) in the intervention group and five
worksites and 87 employees (88.8%) in the control group
completed the follow-up survey. During the follow-up, 12
employees from three worksites in the intervention group
and 11 employees from five worksites in the control group
dropped out for several reasons. The most frequent reason
for dropping out was transfer to a different worksite (n = 10),
followed by retirement (n = 5). The reasons for not completing
the follow-up surveys could not be assessed for the remaining
eight employees.
Recruitment
Recruitment and the baseline survey were conducted from
November 2016 to March 2017. The intervention and control
groups were followed up for approximately 6 months, with 3-
months of follow-up survey conducted from February to
June 2017 and the 5-month follow-up survey from May to
September 2017.
Baseline Characteristics
Table 1 shows the characteristics of the employees (n = 190)
and the worksites (n = 8) participating in this study at baseline.
In both groups, approximately 60% of the employees were
men, and most were full-time (86.8%) and daytime (96.8%)
workers. For worksite size, three worksites were categorized
as small-sized worksites (10–49 employees), three as middle-
sized worksites (50–299 employees), and two as large-sized
worksites (≥ 300 employees). The types of industries of the
worksites were services (three worksites), construction (two
worksites), medical and health care (one worksite),
manufacturing (one worksite), and transportation (one
worksite).
Implemented Elements of the Intervention Program
Three worksites in the intervention group implemented 6 of
the 13 elements of the intervention program (Supplementary
Table 3). All three worksites in the intervention group made
policy-making declarations (element 1), attached posters (ele-
ment 2), placed notifications for the intervention on intra-
website/electronic bulletin board systems (element 3), con-
ducted individual competitions (element 6), and provided
60-min single sessions on psychological education (element
Int.J. Behav. Med.
Fig. 1 Participant flowchart
7). Worksite A did not use prompts for using stairs (element 4)
because the worksite is located in a single-story building.
Worksite B did not conduct exercise programs (element 5)
owing to a lack of sufficient space within the worksite.
Worksite C did not conduct exercises either owing to difficulty
in securing a time slot for exercising. None of the three
worksites chose to implement any optional elements of the
intervention program. After the intervention, total EAT scores
increased by 6–11 points (M = 9.0 points, SD = 2.2) in the
three worksites, indicating that the operationally defined
workplace environment to promote physical activity
improved.
Effects of the Intervention Programs on Physical
Activity
Table 2 shows the frequencies and means (SDs) of the out-
comes at baseline and at the 3- and 6-months of follow-ups.
Regarding overall physical activity level, the proportion of
employees with a high level of physical activity increased at
the intervention worksites (from 13.0% at baseline to 20.7 and
21.5% at the 3- and 6-months of follow-ups), whereas that at
the control worksites was less increased (from 8.2% at base-
line to 10.6 and 6.9% at the 3- and 6-months follow-ups).
Table 3 shows the results of main and sensitivity analyses
for the levels and amount of physical activity. ICCs among
physical activities ranged from 0.02 to 0.23. For level of over-
all physical activity, the coefficient was positive and signifi-
cant (Coeff = 0.45, SE = 0.19, p = 0.018) for the intervention
dummy variable with respect to the linear slope of the out-
come. The effect size at 6 months of the intervention program
(Exp [Coeff*2]) was 2.47 (95% CI [1.17–5.22]). Coefficients
for levels of domain-specific activities were not significant.
For amount of physical activity as a continuous variable, all
LGM results indicated improper solutions owing to variances
that were not positive. Employee-level mixed modeling was
then conducted. All results for the outcomes were properly
solved. The coefficient was positive but insignificant
(Coeff = 1.68, SE = 1.78, p = 0.346) for the intervention dum-
my variable with respect to the linear slope of the amount of
overall physical activity. Coefficients for levels of domain-
specific activities were also positive but insignificant.
Subgroup Analyses
Table 4 shows the effects of the intervention program on the
outcomes stratified by worksite size and location. When strat-
ified by worksite size, significant positive effects of the inter-
vention were observed for the level of overall physical activity
among middle (Coeff = 0.79, SE = 0.22, p < 0.001) and large-
sized worksites (Coeff = 0.47, SE = 0.07, p < 0.001).
However, this effect was not significant among small-sized
 Int.J. Behav. Med.

Table 1 Characteristics of employees (n = 190) and worksites (n = 8) at baseline

Employee-level variables Intervention (n = 3) Control (n = 5)

n = 92 employees n = 98 employees

n or mean % or SD Missing (%) n or mean % or SD Missing (%)

Sex 0 (0.0) 1 (0.5)

Men 64 69.6 59 60.8
Women 28 30.4 38 39.2
Age, years 48.14 11.4 1 (0.5) 43.11 10.0 0 (0.0)
Education 0 (0.0) 1 (0.5)
Junior high school 6 6.5 0 0.0
High school 37 40.2 2 2.1
College 13 14.2 19 19.5
University 32 34.8 64 66.0
Graduate school 4 4.3 12 12.4
Employment status 0 (0.0) 1 (0.5)
Full time 73 79.3 91 93.8
Part time 1 1.1 1 1.0
Dispatched 1 1.1 1 1.0
Contract 16 17.4 5 4.1
Others 1 1.1 0 0.0
Occupation 0 (0.0) 1 (0.5)
Managerial 14 15.2 29 29.9
Clerical 39 42.4 44 45.4
Technical/professional 12 13.0 6 6.2
Others 27 29.3 18 18.5
Shift status 0 (0.0) 1 (0.5)
Daytime shift 86 93.5 97 100.0
Rotation shift 6 6.5 0 0.0
Night shift 0 0.0 0 0.0
Working hours 1 (0.5) 2 (1.1)
≤ 40 h/week 34 37.4 18 18.8
41–60 h/week 40 44.0 72 75.0
≥ 61 h/week 17 18.7 6 6.2
Worksite-level variables
Worksite size and location 0 (0.0) 0 (0.0)
10–49 employees, urban 0 0.0 1 20.0
10–49 employees, suburban and rural 1 33.3 1 20.0
50–299 employees, urban 1 33.3 2 40.0
50–299 employees, suburban and rural 0 0.0 0 0.0
≥ 300 employees, urban 0 0.0 1 20.0
≥ 300 employees suburban and rural 1 33.3 0 0.0
Workplace environment† 0 (0.0) 0 (0.0)
Physical activity assessment (32 points) 9.00 3.6 5.60 3.4
Parking/bike (4) 1.00 1.7 0.00 0.0
Signs/bulletin boards/advertisements (4) 1.00 1.0 0.80 1.1
Shower/changing facilities (6) 2.67 0.6 1.40 2.2
Stairs/elevator (4) 1.00 1.0 0.80 0.8
Physical activity/fitness facilities (14) 3.33 1.2 2.60 2.6
Organizational characteristics and support (36 points) 12.33 5.9 9.20 3.3
Site characteristics (4) 3.33 0.6 2.80 1.1
Int.J. Behav. Med.
Table 1 (continued)
Employee-level variables Intervention (n = 3)
n = 92 employees
n or mean
Work rules (6) 5.00
Written policies (6) 0.00
Health promotion programs physical activity (7) 1.67
Health promotion programs diet/nutrition (7) 1.67
Health promotion programs weight management (6) 0.67
†
Scores of workplace environment were calculated by EAT28
worksites (Coeff = 0.35, SE = 0.44, p = 0.424). In addition, a
significant and positive coefficient was observed for the level
of transport-related physical activity only among middle-sized
worksites (Coeff = 0.77, SE = 0.32, p = 0.015).
When stratified by worksite location, significant positive
effects of the intervention were observed for the level of over-
all physical activity at worksites in both urban (Coeff = 0.72,
SE = 0.23, p = 0.002) and suburban/rural (Coeff = 0.95, SE =
0.19, p < 0.001) areas. In addition, among the worksites in
suburban and rural areas, the effect of the intervention on the
leisure-time physical activity level was marginally significant
(Coeff = 0.72, SE = 0.37, p = 0.055). However, a significant
decline was also observed in the level of transport-related
physical activity after the intervention program (Coeff =
−0.59, SE = 0.27, p = 0.030).
Discussion
Our hypothesis was partially supported: the level of overall
physical activity increased among employees at the interven-
tion worksites significantly more than that among employees
at the control worksites. To the best of our knowledge, this
study is the first cRCT demonstrating a positive effect of a
multi-component workplace intervention program with envi-
ronmental changes on promoting physical activity among
white-collar employees in Japan. The intervention program
is unique because it was developed to be flexible, giving par-
ticipating worksites an opportunity to choose relevant ele-
ments, rather than requiring implementation of all elements,
so that all of the worksites could participate. The program
seems feasible for every worksite, regardless of their monetary
and human resources. The findings from this study should be
useful for occupational health promotion at worksites, includ-
ing worksites with low monetary and human resources, and
should contribute to the overall structures of the workplace
environment to promote physical activity in a more compre-
hensive manner. However, the intervention effect was smaller
and non-significant for small-sized worksites. These
Control (n = 5)
n = 98 employees
% or SD Missing (%) n or mean % or SD Missing (%)
0.0 4.60 0.9
0.0 0.00 0.0
2.1 1.20 1.6
2.1 0.20 0.5
1.2 0.40 0.6
workplaces might receive less benefit from the intervention
program.
The intervention program may be effective for improving
physical activity among white-collar employees. This finding
was consistent with those reported in previous systematic re-
views [9–18] and cRCTs in the USA [20, 21]. A workplace
environment with employer policy support, incentives, infor-
mational messages, exercise programs, and educational mes-
sages might increase the awareness of employees regarding
the importance of physical activity, enhance accessibility for
physical activity, and reduce barriers to translating them into
actual behavior. Although this study could not focus on how
the intervention program affected employees’ behavior, mech-
anisms will be investigated in future studies.
None of the intervention effects on three domain-specific
physical activities was statistically significant. This outcome
is not consistent with our hypothesis. The intervention effect
was positive only for occupational physical activity, but slight-
ly negative for transport-related and leisure-time activities.
Occupational activities include walking, using stairs, and car-
rying loads at work. Three [20, 21, 23] of four previous cRCTs
did not report intervention effects on domain-specific activi-
ties because they measured only overall physical activity.
Only one [22] measured leisure-time physical activity as the
outcome but reported a non-significant effect. The present
finding was consistent with this previous one [22]. Most
worksite intervention programs aim to build awareness of
and enhance accessibility to physical activity at the workplace,
such as with exercise programs and prompts for using stairs.
Thus, it is reasonable that such intervention programs would
be most effective in promoting the occupational physical ac-
tivity of participating employees rather than physical activity
in other domains. Another possible explanation for the non-
significant intervention effects on domain-specific physical
activities is that the activity levels were dichotomized by the
medians, which depended on the sample in this study, and
may not have been suitable cutoff points. More studies are
needed to explore meaningful cutoff points for domain-
specific physical activities in terms of their health effects.
Table 2 Frequencies and means (SDs) of outcomes at baseline and at 3- and 6-month follow-up in the intervention and control groups

Outcome Intervention Control

Baseline (n = 92) 3 months (n = 88) 6 months (n = 80) Baseline (n = 98) 3 months (n = 94) 6 months (n = 87)

n or M % or SD Missing n or M % or SD Missing n or M % or SD Missing n or M % or SD Missing n or M % or SD Missing n or M % or SD Missing

(%) (%) (%) (%) (%) (%)

Level of physical activity

Overall† 0 (0.0) 1 (1.1) 1 (1.3) 1 (1.0) 0 (0.0) 0 (0.0)
Lowa 48 52.2 35 40.2 29 36.7 43 44.3 36 38.3 33 37.9
Moderateb 32 34.8 34 39.1 33 41.8 46 47.4 48 51.1 48 55.2
Highc 12 13.0 18 20.7 17 21.5 8 8.2 10 10.6 6 6.9
Occupational‡ 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
(median = 0.00
MET-hours/week)
Low 67 72.8 52 59.1 51 63.7 88 89.8 82 87.2 76 87.4
High 25 27.2 36 40.9 29 36.3 10 10.2 12 12.8 11 12.6
Transport-related‡ 0 (0.0) 1 (1.1) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
(median = 5.33
MET-hours/week)
Low 54 58.7 44 50.6 43 53.8 39 39.8 34 36.2 30 34.5
High 38 41.3 43 49.4 37 46.3 59 60.2 60 63.8 57 65.5
Leisure time‡ 0 (0.0) 0 (0.0) 1 (1.3) 1 (1.0) 0 (0.0) 0 (0.0)
(median = 2.50
MET-hours/week)
Low 47 51.1 41 46.6 36 45.6 47 48.5 44 46.8 39 44.8
High 45 48.9 47 53.4 43 54.4 50 51.5 50 53.2 48 55.2
Physical activity (MET-hours/week)
Overall 21.94 31.2 0 (0.0) 30.00 37.4 1 (1.1) 27.81 31.0 1 (1.3) 21.10 21.6 1 (1.0) 23.10 27.7 0 (0.0) 23.40 30.2 0 (0.0)
Occupational 8.31 27.6 0 (0.0) 10.86 26.1 0 (0.0) 10.00 20.6 0 (0.0) 0.89 3.7 0 (0.0) 2.05 7.7 0 (0.0) 0.79 3.1 0 (0.0)
Transport-related 6.42 9.1 0 (0.0) 8.35 11.9 1 (1.1) 7.73 11.8 0 (0.0) 11.69 14.7 0 (0.0) 12.41 15.6 0 (0.0) 12.38 15.0 0 (0.0)
Leisure time 7.21 12.6 0 (0.0) 10.53 18.1 0 (0.0) 9.74 15.7 1 (1.3) 8.49 12.8 1 (1.0) 8.64 14.6 0 (0.0) 10.23 18.7 0 (0.0)

†
Level of overall physical activity was categorized according to the GPAQ analysis guide
‡Domain-specific physical activities were divided by the medians at baseline
a
Low, not meeting the criteria of high or moderate
b
Moderate, ≥ 3 days of vigorous-intensity activity with ≥ 20 min/day OR ≥ 5 days of moderate-intensity activity or walking with ≥ 30 min/day OR ≥ 5 days of any combination of walking or moderate- or
vigorous-intensity activities (MVPA) with ≥ 600 MET-minute/week
c
High, ≥ 3 days vigorous-intensity activity with ≥ 1500 MET-minute/week OR ≥ 7 days of any combination of walking or MVPA with 3000 MET-minute/week
Int.J. Behav. Med.
Int.J. Behav. Med.

Table 3 Effects of the intervention program on physical activity: main and sensitivity analyses

Outcome Intra-class correlation coefficient (ICC)† Coefficient of the intervention Effect size (6 months)

Value SE p value Coeff SE p value Value 95% CI

Main analysis: multi-level latent growth modeling for categorical outcome

Level of physical activity‡
Overall – – – 0.45 (0.19) 0.19 0.018 Exp (Coeff*2) = 2.47 [1.17–5.22]
Occupational – – – 0.49 (0.32) 0.32 0.125 Exp (Coeff*2) = 2.66 [0.76–9.32]
Transport-related – – – −0.15 (0.42) 0.42 0.718 Exp (Coeff*2) = 0.74 [0.14–3.87]
Leisure time – – – −0.03 (0.13) 0.13 0.847 Exp (Coeff*2) = 0.95 [0.57–1.59]
For improper solutions: mixed modeling (random effects only for employee level)
Physical activity (MET-hours/week)
Overall 0.11 0.03 < 0.001 1.68 1.78 0.346 Cohen’s d = 0.13 [− 0.15–0.41]
Occupational 0.23 0.04 < 0.001 0.85 1.35 0.530 Cohen’s d = 0.09 [− 0.20–0.37]
Transport-related 0.08 0.04 0.025 0.18 0.80 0.825 Cohen’s d = 0.03 [− 0.26–0.31]
Leisure time 0.02 0.02 0.511 0.45 0.95 0.638 Cohen’s d = 0.07 [− 0.21–0.36]

Values shown in italics are significant. Exp exponential

†
ICCs were calculated based on the scores at baseline
‡Level of overall physical activity was categorized according to the GPAQ analysis guide and those of domain-specific physical activities were divided
by the medians at baseline

The effects of the intervention differed depending on
worksite size and location. Regarding size, the intervention
program showed significant intervention effects for medium-
and large-sized worksites; the effect was less clear for small-
sized worksites. A possible reason for the difference could be
the quality of each element implemented depending on the
amount of resources of the worksites. The large-sized worksite
with enough resources might implement the elements more
efficiently. Although the program was developed to be feasi-
ble to worksites with limited resources, a smaller-sized
worksite may not be able to realize the full benefits of the
intervention program to improve physical activity among em-
ployees. Additional elements might be needed to make the
program more effective at smaller worksites: for example,
the intervention program may include dispatching a part-
time facilitator/coordinator for the training programs to a tar-
get worksite. Technological innovations, such as mobile ap-
plication tools or Internet of Things (e.g., wearable devices
connected to computer-based systems), might also help small-
er workplaces implement the program [39], as such technolo-
gy would require less human resources. Future research
should focus on small-sized worksites to develop a multi-
component program for improving the physical activity of
employees.
The worksite location affected the domains of physical
activities increased by the intervention. In general, it would
be easier to increase transport-related physical activity among
people in urban areas because the public transportation is
well-developed [40]. Employees of the intervention worksites
in urban areas may better use the public transportation system
to improve their transport-related physical activities.
Meanwhile, employees at the worksites in suburban/rural
areas are more likely to use their social and natural environ-
ment to increase leisure-time physical activity; the shorter
commuting time spent by suburban/rural workers may even
allow them to enjoy a longer leisure time. A significant in-
crease in transport-related physical activity was also observed
in middle-sized worksites (Coeff = 0.77, p = 0.015), but this
may be due to the effect of an urban setting, because all of
the middle-sized worksites in this study were located in urban
areas.
This study had several limitations. First, the number of
worksites participating was much lower than what was
predetermined. Most of the approached worksites (96.2%)
declined to participate; only eight companies agreed and par-
ticipated. This low acceptance rate was a major limitation of
the study. More efforts are needed to develop and implement
interventions that are more feasible and acceptable to em-
ployers. Given this limitation, the statistical power of this
study was not sufficient to detect the effect of the intervention
program on the outcomes. Second, as some of the elements
were not implemented in all the intervention worksites, the
feasibility and effectiveness of these elements are unknown.
Third, approximately 10% of employees who participated in
the baseline survey were lost to follow-up. This outcome may
have resulted in the underestimation of the intervention ef-
fects, if more employees with less improvement in physical
activity in the control worksites dropped out, or overestima-
tion, if this happened more in the intervention worksites.
Fourth, physical activity was measured based on the self-
 Int.J. Behav. Med.

Table 4 Subgroup analysis: effects of the intervention program on outcomes stratified by worksite size and location

Outcome Coefficient of SE p value Effect size (6 months)

the intervention
Value 95% CI

Worksite size: 10–49 employees (n = 3, 47 employees)

Level of physical activity†
Overall 0.35 0.44 0.424 Exp (Coeff*2) = 2.01 [0.36–11.02]
Occupational 0.37 0.26 0.151 Exp (Coeff *2) = 2.10 [0.76–5.79]
Transport- related − 0.40 1.71 0.814 Exp (Coeff *2) = 0.45 [0.00–369.44]
Leisure time − 0.19 0.94 0.842 Exp (Coeff *2) = 0.69 [0.02–27.28]
Worksite size: 50–299 employees (n = 3, 70 employees)
Level of physical activity†
Overall 0.79 0.22 < 0.001 Exp (Coeff*2) = 4.88 [2.05–11.66]
Occupational 0.43 0.46 0.352 Exp (Coeff*2) = 2.34 [0.39–14.01]
Transport-related 0.77 0.32 0.015 Exp (Coeff*2) = 4.66 [1.36–15.96]
Leisure time −0.25 0.18 0.159 Exp (Coeff*2) = 0.61 [0.31–1.21]
Worksite size: ≥ 300 employees (n = 2, 73 employees)
Level of physical activity†
Overall 0.47 0.07 < 0.001 Exp (Coeff*2) = 2.58 [2.00–3.32]
Occupational 0.85 0.49 0.081 Exp (Coeff*2) = 5.44 [0.81–36.45]
Transport- related − 0.57 0.44 0.198 Exp (Coeff*2) = 0.32 [0.06–1.81]
Leisure time − 0.47 0.38 0.217 Exp (Coeff*2) = 0.39 [0.09–1.73]
Worksite location: urban (n = 5, 104 employees)
Level of physical activity†
Overall 0.72 0.23 0.002 Exp (Coeff*2) = 4.25 [1.72–10.51]
Occupational 0.18 0.19 0.357 Exp (Coeff*2) = 1.42 [0.67–2.99]
Transport- related 0.47 0.31 0.127 Exp (Coeff*2) = 2.53 [0.77–8.36]
Leisure time − 0.34 0.19 0.067 Exp (Coeff*2) = 0.51 [0.24–1.05]
Worksite location: suburban and rural (n = 3, 86 employees)
Level of physical activity†
Overall 0.95 0.19 < 0.001 Exp (Coeff*2) = 6.73 [3.22–14.07]
Occupational − 0.05 0.20 0.802 Exp (Coeff*2) = 0.90 [0.41–1.97]
Transport-related − 0.59 0.27 0.030 Exp (Coeff*2) = 0.31 [0.11–0.89]
Leisure time 0.72 0.37 0.055 Exp (Coeff*2) = 4.20 [0.97–28.90]

Values shown in italics were significant. Exp exponential

†
Level of overall physical activity was divided according to the GPAQ analysis guide and those of domain-specific physical activities were divided by
the medians at baseline

reported questionnaire, causing informational bias and mea-
surement errors. Further cRCTs are required to use reliable
and objective measures of physical activity. Fifth, categorizing
the levels of domain-specific physical activities by the me-
dians may not be the best way, as previously discussed.
Sixth, the starting dates of the intervention program were dif-
ferent (from November 2016 to March 2017) among the in-
tervention worksites. As such, effects of seasonality could not
be controlled. Seventh, the effects of the intervention program
on low-intensity physical activity (e.g., yoga and stretching)
were not investigated in the study and remain unknown.
Eighth, the findings from this study may not be generalizable
for all workplaces in Japan, because this cRCT included only
eight worksites in the Kanto area from limited industries (e.g.,
services, construction, medical and health care, manufactur-
ing, and transportation) and only white-collar employees. The
findings may not be applicable to other regions, other
industries/occupations (such as public servants or school-
teachers), or blue-collar workers.
In conclusion, this study indicated significant and positive
effects of the newly developed multi-component workplace
intervention including environmental changes on the level of
physical activity at worksites in Japan. The study is the first
cRCT of its kind to be conducted in Japan and Asian coun-
tries. The developed program is unique because of its flexibil-
ity to choose relevant elements from a list of predetermined
Int.J. Behav. Med.
ones, and seems feasible for all worksites, including worksites
with low monetary and human resources. However, additional
support and/or new technologies, such as mobile applications
and Internet of Things, might be needed to make the program
work more effectively to improve physical activity in small-
sized worksites. Additional cRCTs should be conducted con-
sidering the limitations of the present study, such as the small
sample size and self-reported measurement for physical
activity.
Funding information The present study was supported by a Grant in Aid
for Scientific Research from the Japan Society for the Promotion of
Science (15J04085). The funders had no role in study design, data col-
lection and analysis, decision to publish, or preparation of the manuscript.
Compliance with Ethical Standards
This manuscript was reported according to the guidelines in the
Consolidated Standards of Reporting Trials (CONSORT) for cRCTs.
Conflict of Interest The authors declare that they have no conflict of
interest.
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