Cancer and other chronic diseases are the leading causes of death in the United States for working-age adults.
There are several behavioral risk factors that increase disease risk, including missed cancer screenings,
physical inactivity, poor eating habits, and tobacco use. Evidence-based interventions (EBIs) exist that improve
each of these risk behaviors, and many of these EBIs can be implemented in worksites where the majority of
U.S. adults spend most of their waking hours. There are significant disparities in access to worksite EBIs; large
worksites (more than 1000 employees) are much more likely to offer EBIs to their employees than small
worksites with less than 250 employees. The American Cancer Society (ACS) and the University of
Washington Health Promotion Research Center (HPRC) developed HealthLinks, a package of EBIs
appropriate and feasible for small worksites. We are currently completing a randomized controlled trial of
HealthLinks with more than 70 small worksites; results show that worksites in the HealthLinks arms
implemented significantly more EBIs at follow-up than worksites in the delayed control arm.
Now that we know HealthLinks is effective, we need a way to scale it up beyond the location of the trial. Local
health departments (LHDs) cover almost every community in the United States and most LHDs' missions
include preventing chronic disease. In a separate project, we pilot-tested training staff in six LHDs in
Washington State to deliver HealthLinks to worksites in their communities. We found that LHD staff
completed the training and recruited worksites to participate in HealthLinks; these worksites implemented
EBIs. The primary goals of this competing renewal are (a) to scale up HealthLinks by training staff in LHDs
across the United States to deliver HealthLinks to small employers in their communities, and (b) to further
implementation science by conducting a hybrid type III trial comparing the effectiveness and costs of two
different implementation strategies. We will achieve these goals through three specific aims, guided by the
HPRC Dissemination and Implementation Framework. We will conduct qualitative audience research with
state and local health department directors and local health department staff to refine our training and support
approaches (Aim 1); we will conduct a hybrid type III trial comparing standard and enhanced technical
assistance combined with online training for HealthLinks (Aim 2); and we will measure the costs of each
strategy, both to the local health departments and to the research team (Aim 3). The proposed activities will
increase the reach of HealthLinks across the United States to small employers with limited capacity for and
access to EBIs. These activities will also advance implementation science by measuring the impact and
costs of implementation strategies offering different levels of ongoing support. The findings from this project
may inform implementation strategies for other workplace health promotion programs focused on EBIs and
small worksites, as well as a variety of implementation efforts that include partnerships with LHDs.
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