Cleaners’ Experiences with Group-Based Workplace Physical Training
This study investigates how work-site health promotion intervention, by involving group-based physical coordination training, may increase participants’ social awareness of new ways to use the body. Purpose: We investigated cleaners’ experiences with a one-year health promotion intervention involving group-based physical coordination training (PCT) during working hours. Design: We conducted a qualitative evaluation using method triangulation; continuous unfocused participant observation during the whole intervention, semi-structured focus group interview, and individual written evaluations one month post-intervention. We analyzed interview data using Systematic Text Condensation.
There is substantial evidence to conclude that physical activity has significant benefits for health. These benefits include a reduced risk of cardiovascular disease, type II diabetes, osteoporosis, and promotion of psychological well-being (Pedersen & Saltin, 2006). In order to improve cardio-respiratory and muscular fitness, and reduce the risk of the detrimental effects of physical inactivity, World Health Organization (WHO) recommends people to do at least 150 minutes of moderate-intensity aerobic physical activity a week (World Health Organization, 2010).
In contrast to persons performing leisure time physical activity, persons with high levels of occupational physical activity are shown to have low physical capacities (Holtermann et al., 2009a; Holtermann et al., 2010a), and high risk for musculoskeletal disorders, early disability retirement (Hannerz et al., 2004; Jensen et al., 2002) and cardiovascular mortality (Holtermann et al., 2009b). Especially workers with a mismatch between the individual capacity and the physical work demands are shown to have an elevated risk of impaired work ability (Ilmarinen et al., 1991) and cardiovascular disease mortality (Holtermann et al., 2010b).
The FINALE Clean Study aiming at preventing deterioration among cleaners, here named the Clean Study, is a Danish cluster randomized controlled trial (trial registration number: ISRCTN96241850). The term physical deterioration is defined as the health impairing effect originating from a mismatch between individual capacities and physical work demands (Holtermann et al., 2010a). The Clean Study investigated the preventive effect of group-based physical coordination training (PCT) (Jorgensen et al., 2010a) during working hours. The PCT consisted of a standardized PCT program with shoulder exercises, and postural strength exercises functionally relevant for traditional cleaning work tasks. See appendix 1 for a more detailed description of the PCT-exercises and randomization procedure.
The intervention lasted one year and was divided into two phases. During phase one (three months), participants received three instructor-supervised weekly sessions of 20 minutes. During phase two (nine months), the frequency of supervised training sessions was gradually reduced, with only one session per month the last six months. The reduction in supervision intended that participants and the workplace would take ownership of their training throughout the entire intervention and hopefully maintain their training after the intervention ended. As training took place in the workplace, and during working hours, we anticipated that the implementation of the training would affect working routines, and rely greatly on cooperativeness, and support from local top management and supervisors (Emmons et al., 1996).
The Clean Study was primarily interested in the effect of physical coordination training on sick leave obtained from participating companies’ annual registrations, objective physical strength measures, and work ability measured by Work Ability Index (WAI) (Holtermann et al., 2010a; Jorgensen et al., 2010a). However, we acknowledge that a positive and meaningful intervention process that positively influences feelings of control is crucial for participants, if they are to maintain a behavioral change (Hills & Byrne, 2006; Koelen & Lindstrom, 2005). By obtaining knowledge about participants’ training experiences (i.e., their expectations, feelings, and learning process) we may achieve more in-depth understanding of, whether participants perceived the intervention as meaningful, and/or why it was meaningful or not.
This qualitative explorative study investigates how a sub-sample of the Clean Study participants experienced the PCT intervention. The intention was to gain an in-depth understanding of how the individual made sense of the intervention and its influence on their working life (Wynn & Money, 2009).
We designed this study as a qualitative, exploratory and descriptive study.
At the initiation of this qualitative study, four training groups comprising 34 participants from three different public workplaces in and around the Danish capital, Copenhagen, had completed 12 months of physical coordination training in the Clean Study (RCT). One workplace had two training groups from two separate departments. The other two workplaces each had one training group. For a complete overview of the recruitment and cluster randomization in the Clean Study (RCT), see Jorgensen et al. (2010b).
For this study we used convenience sampling to select an actively involved training group with information-rich cases, who were willing and able to express their emotions and attitudes regarding the intervention in a focus group interview (Patton, 1990). Of the four training groups, the selected group (n=7) had completed the 12 month intervention, and had the highest attendance rate of the four groups during the first three months of the intervention (mean 81.3 %, range 59.4 100 %). See table 1 for detailed information on the group.
Table 1 Individual demographic characteristics of the focus group participants (n = 6)
The first author, LK, who co-instructed the PCT, carried out continuous participant observations along with the second instructor during the entire intervention period from September 2007 to September 2008. The observations were open and unfocused. Impressions were systematically recorded in the form of field notes. We analyzed data from the participant observations ad hoc in the sense that the observers presented their observations at weekly meetings at the research institution for the whole research team to discuss. The field notes became LK’s preconceptions of his experiences with participants and the PCT. The notes also served as inspiration in the development of an interview guide for a semi-structured focus group interview.
Semi-structured focus group interview
After the final training session, the instructors asked the participants if they were interested in discussing their intervention experiences in a focus group interview. All group participants (n=7) consented to participate. Interview guide: Based on the observations and the Clean Study design, we developed a semi-structured interview guide attempting to capture the participants’ experiences with a physical activity intervention in the workplace. Thus, themes revolved around participants’ experiences with physical activity, and specifically participants’ experiences with the workplace as the context for the intervention (i.e. relation to co-workers, organization of work tasks). Questions included participants’ motivation for joining the intervention, and how the intervention affected them, their colleagues, and co-workers. Other questions regarded participants’ daily routines including job qualities, pain, and which role the supervisor played in the intervention.
The focus group interview took place one month post-intervention in a small meeting room in the workplace. LK acted as moderator. Six participants were present. One participant did not show up, for unknown reasons. LK informed participants that they should consider the interview as an informal discussion on their exercise experience in the workplace. LK asked for permission to audio record the interview ensuring that participants would remain anonymous, and that no one from their workplace would gain access to the data. The focus group interview was held in Danish and lasted 55 minutes. At the end of the interview, LK asked if participants had any additional comments. LK also asked, if participants wanted to read and comment on the finished interview transcript. All participants declined, stating that they were not interested in reading the transcript. After the interview, participants filled out a brief questionnaire regarding their socio-demographic characteristics, and leisure time physical activity (Saltin & Grimby, 1968).
Individual unstructured written evaluation (training narratives): LK asked participants to write down a description of a typical training session, and to bring them on the day of the interview. LK encouraged participants to write the description individually, as they had experienced them, and as a narrative. The participants’ narratives provided subjective descriptions of the training experiences. We used to them to support statements, and validate final codes in the analysis of the focus group interview.
LK transcribed the interview verbatim in accordance with transcription conventions suggested by Crossley (2002; see transcription symbols in table 2). Last author, JM, validated the transcription by listening to the audio recording and reading the transcription simultaneously. Subsequently, LK translated transcription from Danish into English. Translations were once again validated by JM. As the study’s objective was to elicit human experience, data was analyzed using systematic text condensation by Malterud (2003), inspired by Giorgi (1994).
Table 2 Transcription symbols
[ ] indicates the point at which the current speaker is overlapped by another’s speech
[attempt] suggestions regarding uncertain transcription
( ) unintelligible speech
_ speaker’s emphasis
WORD loud utterance
[ ] transcriber added text e.g pause, sign, body movement
LK and JM each performed the four step analysis separately. First, we read the transcription to gain an overall impression while bracketing preconceptions known as familiarization. Secondly, we identified units of meaning (Giorgi, 1994). We grouped and temporarily coded meaning units that say something about the participants’ PCT experiences. Third, we condensed codes to abstract meaning. This was done by identifying meaning aspects from codes, and making artificial quotes (Malterud, 2003) using participants own words and phrases. Knowing that analyzing is highly susceptible to the researchers’ preconceptions, we discussed the codes and the abstract meanings, until we agreed on the final codes. We validated the codes against the field notes from the participant observation and the participants’ written evaluations. Fourth, we made descriptions based on the contents of the coded groups and artificial quotes. Descriptions reflect important experiences reported by participants. These descriptions are presented as results.
The interview results are categorized according to step two and three from the analysis and presented under the codes from step three. The reference number refers to the specific passage in the interview.
Motivation and overcoming barriers
When we asked participants about their motivation for joining the intervention, they justified their participation by claiming curiosity, and loyalty to their supervisors. As their supervisors had presented and encouraged them to participate in the intervention, they had signed on giving neither intervention process nor intervention outcomes much thought. They stated that the project sounded interesting. However, they were not able to express, why it sounded interesting.
(R, 23) Well, we don’t know why we signed up, because it was actually our employer who signed us up [
Participants exceeded bodily boundaries, as they learned to use their bodies in new ways. The physical coordination training was a gateway to a renewed awareness of their bodies’ potentials as more than a working tool. They stated that exercising loosened up their muscles, and gave them more energy and spirit for the rest of the day.
(N, 62) [I think, that after this program, I feel like burning my energy (…) I mean, I have felt that you can actually do something with your body, like you can feel it in your body that you can, right, so I want to do something extra [
Participants felt intimidated by the initial difficulties of the exercises, the fact that they required strength, coordination, and balance. Most participants were resistant at first, and felt uncertain about whether or not they would be able to learn the new exercises. However, with all colleagues having the same initial difficulties, familiarizing with the exercises became a common project, and the group experienced how their bodies adapted to the challenges. A female participant expressed how the initial intimidation was exchanged for a bodily mastery feeling.
(J, 530) [But none of us has ever tried the ‘plank’ [one of the exercises] before or tried those…. Well, you think “Gee!” But you can do it, right? Balance, right? You figure it out pretty quickly
Through training, the participants experienced muscle fatigue and subsequent muscle soreness. Their perception of pain was altered through training with muscle soreness as a positive indicator of efficient training. All participants were confident that training had been beneficial to them, and had strengthened their bodies. Two participants stated that their second objective test had shown a decrease in strength. However, they ascribed this strength decrease to not ‘having their best day’. Participants translated their newly achieved strength into new control and agency regarding their working routines. Two female participants describe how they used elements from the training in daily work situations
(R, 41) You have gotten a little stronger, I would say, because there are many of the things that you couldn’t do in the beginning that you can do now, right? I mean, it has changed the physique, fitness[
(J, 42) [Now you think, you work differently, or at least I do because of my back. You think more about lifting, for example, in the basement, right? “Wait”, you have to [showing how to lift with straight back and shoulders in position]. “Remember what the young people told us” [everyone agreeing]. You have to because otherwise it’s [her back] going to break again, and now we (?) for one year, where we have done gymnastics, and I can feel my back and my arms have gotten stronger… and my thighs.
Social ownership and exclusiveness
Participants felt that training contrasted their normal work routines. They claimed that their work tasks’ repetitive character caused strain on their bodies, and when they talked about the PCT, they used phrases like ‘to unwind’ and a ‘nice break from work’. According to the participants, training became a free space, and the physical element of training facilitated new ways of having fun and socializing with colleagues. Participants explained that they had to rearrange the furniture of the exercise room (a conference room) to be able to exercise. This brought them physically closer together, and they could ‘smell each other’s sweat’. The close physical relations enforced the existing work-related unity between participants, and they took ownership of the personal and social learning experiences. They considered a strong unity important for training adherence, and thus their improvements. Participants felt responsible for each other, and stressed the importance of reminding and supporting each other to continue exercising.
(O, 83) [If you are more [than one], you can push each other more, right?
Despite having limited time on exercise days, participants’ work tasks remained unchanged. Participants described that they had to pick up their work pace on exercise days, if they were to finish their work tasks in time. They also had to rearrange their social lunch break on exercise days. However, they did not perceive the extra load as stressful in general.
(S, 626) [I feel that you have to pick up your pace, when we have exercised [“Yeah”, general agreement], when you get back to work, because you lack time, right? But then you just step it up in the afternoon, right? [“Yeah”, general agreement] [
(LK, 627) [Has it been stressful to you (…)? [
(R, 628) [Well, we just had lunch, after we were done with that ½ hour of training, so it was just postponed (…) but that didn’t matter [
Participants felt fortunate to be able to take part in the physical coordination training. They experienced that non-participating colleagues were jealous of them, making their training exclusive and unifying. Through training they achieved new opportunities for planning their daily work around training, and even higher status in the workplace. They now compared themselves to other physically active colleagues (i.e. physicians), and pointed to inactive colleagues, who in their opinion could benefit from training. Although participants agreed on the potential benefit for all colleagues, one participant made the notion that not everyone was capable of completing the program, as it required both strength and endurance. She alluded to a colleague, who dropped out of the exercise intervention.
(R, 355) [And I think that our’s [exercise intervention] has been good, and the others have been really jealous when they have heard about our’s, right, because many of them wanted to[
(S, 356) [They wanted to join [
(J, 357) [We also had guests, L was there and [
(N, 358) [She really wanted to join [
(J, 359) [Unfortunately J couldn’t [
(N, 360) [But she wasn’t allowed to [
(R, 361) [J, he can’t do it; he’s too weak [
Participants felt privileged to be able to train during work hours. They also felt that they made a considerable contribution to the success of the intervention. Participants were proud that they managed to exercise without instructors, ‘doing it exactly as they were taught’. They wished to continue exercising after the intervention ended, and they expressed that they felt capable of instructing their non-exercising colleagues, if they had intervention exercise equipment, music, a designated room, and if supervisors allowed them to exercise during work hours. Participants stated their appreciation for the supervisors’ initial commitment to the intervention process. However, they expressed that they felt left on their own towards the end of the intervention. Participants did not understand the supervisors’ withdrawal. Participants felt that they had praised the intervention, and thus expected equal or more support towards the end. They stated that supervisors ought to let them exercise during work hours in the future, both because the supervisors had encouraged them to participate, and because both participants and workplace obviously benefited from it in terms of positive atmosphere and lowered sick leave.
(J, 309) [Well, I don’t know how our supervisors got involved with it, why it was offered (…) but it must have been to see, how it could affect, instead of physical strain, if it could strengthen our arms, legs, back.. call it what you want [
(R, 310) [In that regard, I think their engagement has been very positive, but I think that they… have been a little lazy regarding finding room for us and, I think, well, if they want us to continue, right, because there is in fact no room to be offered. Because then we have trained in here [a small narrow meeting room], and in here there’s no space, when we have all been here, right?
In summary, the analysis of training experiences in cleaners, who participated in PCT during working hours in the workplace, showed that participants altered their perception of their bodies’ potentials, and subsequently altered their working habits. They discovered new ways of socializing with colleagues, and unity was reinforced by the exclusiveness of the training. The physical coordination training provided a welcome but time-consuming break from normal work routines. The specificity of the exercises, requiring certain equipment and space, made the PCT unique. However, it also made training sustainment difficult after the intervention. Despite participants experienced ownership of and responsibility for the intervention, they expected support from their employer (i.e., time, place and equipment) to establish and legitimize a permanent training offer in their workplace.
The purpose of this study was to explore how cleaners, who had actively participated in group-based physical coordination training, experienced the intervention. The Clean Study measured the effect of the intervention by registration of quantitative measures, like sick leave, physical strength measures, and work ability. This method is relevant and needed in the evaluation and estimation of the effect. However, according to Glasgow et al. (Glasgow et al., 1999) such a traditional ‘efficacy’ paradigm does not address how well a program works in the world of busy, understaffed public health clinics, large health systems, or community settings (p. 1322). Thus, in this study, we wanted to give voice to the subjective and lived experiences of the participants, whose working routines and bodies were affected, and whose efforts are fundamental to the evaluation of the intervention. By observing and asking the participants, we intended to obtain a different kind of knowledge and evidence that goes beyond measures and numbers (Malterud, 2001), and provide an understanding of a phenomenon (i.e. PCT) in a real life context (Wynn & Money, 2009).
Participants’ all agreed that they had benefited from the PCT. They were willing and able to work harder to include training in their work day, and they claimed that training made them physically stronger, and even reduced their sick leave. These results may be viewed as an improved match between the worker’s capacities and the work demands, i.e. improved work ability (Ilmarinen et al., 1991) from a first person view.
Some participants stated that their self-perceived strength improvements were not supported by the Clean Study’s objective strength measures. However, those participants gave primacy to their own lived experiences, and ranged the objective measures second to their own experiences. This finding indicates that perceived strength as a measure for effect may be just as important to the participants as objective standardized measures, when future interventions like the Clean Study is evaluated.
Another finding is the participants’ understanding of their participation in a clinical intervention setup. The results demonstrate that participants’ motivation and possibility for participation, their learning, was dependent on supervisors’ support. Supervisors encouraged them to participate in the intervention, and they made the necessary arrangements regarding the initial structuring of the training. With support from supervisors, participants went from being a low priority group in the workplace to acquiring an exclusive higher status among their colleagues, and other co-workers. A feeling of being part of something exclusive supported participants’ practice, and participants praised the initial supervisor support. Phipps et al. (2010) found similar results in their study of workers at all levels in a medical center. They investigated interest and concerns of priority populations for work-site programs to promote physical activity. The mere offering of a physical activity program was regarded by some employees as a mental message that they were valued and cared for (Phipps et al., 2010).
Participants mutually engaged in the training, and with support from their supervisors they actively negotiated their perception and meaning of the physical coordination training over the course of the intervention. With reference to the concept of social learning proposed by Lave & Wenger (1991), by which learning is recognized as a social phenomenon constituted in the experienced, lived-in world, the intervention may be viewed as an invitation to learning of new competencies. Especially the social character of the PCT intervention may have served to unite the participants in the development of a community of practice. This implies that the participants formed a group of people sharing a concern or passion for something they do in this case the PCT exercises - and learn how to do it better as they interact regularly (Wenger, 2006). According to Wenger, in the community, members build relationships from mutual engagement in joint activities in their domain that enable them to learn from each other. By sustained interaction, members develop a shared practice, i.e. shared repertoire of resources like experiences, and stories. However, the participants’ learning, embedded in their community of practice, as this study shows, may be highly dependent on continued support from supervisors, and attention from researchers. The results of this study reveal important differences between implementation of health promoting activities in general and as in this casean intervention offered within The Clean Study’s randomized controlled trial design. In the case of an intervention, the learning may be viewed as an offer or even privilege on borrowed time. As the intervention came to an end, the transformation and ownership feeling acquired by the participants during the intervention proved fragile, and highly dependent on structural changes mainly initiated by other agents, the supervisors. Hugenholz et al. (2008) presented similar results in a study of a group of occupational physicians, who had undergone an intervention with an evidence-based approach to enhance their professional performance. The occupational physicians expected that it would be hard to sustain their improvements as access to full-text articles and management support seized after the intervention.
Our participants, however, were disappointed in their supervisors, because they felt that they had made an effort; not only for themselves, but also for the sake of the workplace. Thus, the supervisors ought to continue supporting them. The disappointment may be an expression of a lack of understanding of the implicit ending of an intervention, which provided unusual extra support for a limited time. However, it also indicates that although the ongoing intervention may have created a community of practice with substantial learning potential supervisors, researchers, and workers did not share the same interests. They were involved in the intervention for different reasons, and not mutually engaged in a long-term process. This process may otherwise have served to establish permanent changes in the working environment making the positive effects of the intervention more sustainable.
The Clean Study reached a low-priority group, cleaners (Jorgensen et al., 2010b). Additionally, in the Clean Study, there was a great potential for the physical coordination training, or a different physical-activity offer, to continue after the trial ended. The interest in continuing workplace physical activity was present among participants, and, furthermore, colleagues and co-workers had shown great interest in the PCT. However, as the trial design left no option for participants to continue the intervention activities, we may have left participants “all dressed up with nowhere to go”. Participants despite speaking very positively about the intervention itself maintained a disappointed attitude towards the way the intervention ended.
Future studies or health promoting programs ought to address this issue ensuring common expectations and goals of participants and supervisors, and researchers. This may require researchers to design interventions with workplaces instead of for them. As participants may create their own meaning of the intervention, we recommend future studies to consider a permanent option for continuation of the intervention in the workplace, if successful. Furthermore, if we omit participants’ own learning experiences of the training from our study evaluations, we may overlook important implicit health-promoting potentials of interventions. Thus we recommend the use of qualitative data along with standardized measures to obtain the in-depth understanding of how the intervention actually feels and is experienced by participants. Hopefully this allows all actors involved in workplace health promotion to form partnerships in the pursuit of mutual interests.
6. Methodological considerations
We chose focus group interview over individual interviews to study group-based PCT constituted in the experienced lived-in world. Thus, we consider the focus group interview itself an intervention in which meaning is negotiated between participants, including the moderator (Crossley, 2002). We focused on how participants experienced the intervention, and thus deliberately chose a group who had actively participated in the intervention, a high attendance rate during the first three-month intensive phase of the Clean Study, and who would be interested in talking about their experiences. The group’s high seniority in the current workplace indicates that they represent a resourceful part of the population.
We admit that because LK knew the participants beforehand, the risk of social desirability bias was present during the interview. We attempted to avoid major personal bias by method triangulation. To accommodate demands of reflexivity and bracketing in qualitative research (Malterud, 2003), LK wrote down his preconceptions, i.e. experiences with all participants and the physical coordination training prior to the interview. JM validated the field notes, interview guide, interview transcript, and the analyses. The relationship between participants and instructor may have facilitated a relaxed open atmosphere during the interview similar to the training sessions. This may have elicited deeper thoughts and feelings from participants (Brown, 1999), and possibly reflected the way they would discuss issues at work. Furthermore, the group’s high internal heterogeneity contributed to a rich discussion (Brown, 1999).
This study may well be criticized for just including one focus group interview. With demands for saturation, Brown (1999) recommends at least four different focus group interviews. However, according to Giorgi (1994) it makes no sense counting meanings unless the research question is quantitative: One could say that the phenomenon is present when its meaning is expressed, regardless of the form it takes (…) what matters is whether the meaning is present or not (p. 198-199).
We acknowledge that a PCT group from a different workplace may have experienced the PCT differently, thus could add to the understanding of the phenomenon. However, we believe that this study highlights essential elements from actively participating cleaners’ experiences with workplace physical activity. This makes the results from this study relevant for future studies.
In conclusion, this study shows that a work-site health promotion intervention involving group-based physical coordination training may increase participants’ social awareness of new ways to use the body. The intervention created the basis for a social learning environment; community of practice. However, the community of practice is on borrowed time as it is limited in time and place, and adherence appears too dependent on continued support from supervisors and instructors. Plans for implementation seem to be important elements for sustained effects of health-promotion interventions in the workplace.
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The FINALE Clean Study was a multifaceted cluster randomized controlled trial (RCT). Each workplace was a stratum. Workers were cluster randomized to physical coordination training (PCT), cognitive behavioral training (CBT), or reference, with clusters depending on work teams, groups working in close proximity of each other, or groups reporting to the same line-supervisor. Clusters were matched on sex, age, and job seniority. This present study only included participants from the PCT segment.The PCT aimed at strengthening stability and coordination of trunk and shoulder muscles. The program consisted of Pilates exercises (bracing, bridge, 4-point kneeling, horizontal side support, prone plank, vertical plank, and various Bodyblade exercises). Intensity levels of the exercises corresponded to 60-80 % of maximal muscle activity. Training took place in the workplace during work hours.