No. 3, July 2004
Manufacturing Worksites That Employ Multiethnic, Low-wage Workforces Into a
Cancer Prevention Research Trial
Elizabeth M. Barbeau, ScD, MPH, Lorraine Wallace, MPH, Ruth Lederman,
MPH, Nancy Lightman, MM, Anne Stoddard, ScD, Glorian Sorensen, PhD, MPH
Suggested citation for this article: Barbeau EM,
Wallace L, Lederman R, Lightman N, Stoddard A, Sorensen G. Recruiting small
manufacturing worksites that employ multiethnic, low-wage workforces into a
cancer prevention research trial. Prev Chronic Dis [serial online]
2004 Jul [date cited]. Available from: URL: http://www.cdc.gov/pcd/issues/2004/
Worksites, including those that employ multiethnic, low-wage workforces,
represent a strategic venue for reaching populations at risk for developing
We surveyed 197 small manufacturing worksites prior to an effort to
recruit their workforces into a randomized clinical trial designed to test
the effectiveness of a cancer prevention intervention among multiethnic,
low-wage manufacturing workers. This paper assesses the external validity of
the trial based on three factors: the percentage of potential trial sites
excluded from consideration, the percentage of eligible worksites that
adopted the trial, and worksite characteristics associated with adoption.
We found no statistically significant differences between worksites
that adopted the trial and worksites that declined the trial with regard to
employee demographics, anticipated changes in workforce size, and perceived
importance and history of offering health promotion and occupational health
and safety activities.
Small manufacturing worksites present a viable venue
for reaching multiethnic, low-wage populations with cancer prevention
programs, although program adoption rates may be low in this sector.
Worksites that adopted the trial are likely to represent worksites deemed
eligible for the trial.
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Cancer risk associated with health behaviors and carcinogenic
occupational exposures is concentrated among working-class employees,
individuals with less education, and some racial and ethnic groups (1-14).
Worksites are a strategic venue for reaching these at-risk populations to
reduce cancer risk. Cancer prevention research in small manufacturing
worksites is particularly important because small manufacturing worksites
employ roughly 42% of all manufacturing workers (15), are less likely to
offer health promotion programs and protection from occupational health and
safety hazards (16-26), and have been largely understudied (27).
Furthermore, according to national survey data, some subgroups of the
workforce, including nonprofessionals, blacks, and individuals with less
education, were least likely to work for companies that offer health
promotion programs to employees (28). When programs are available, blacks
report the highest participation levels among all racial and ethnic groups
(28). These data highlight the importance of conducting
cancer prevention research in small worksites to address excess cancer risk
among workers of lower socioeconomic position and racial and ethnic
Within studies such as this one, it is critical that researchers assess
and report on worksite-level consent to participate, also known as adoption rate.
Glasgow et al recently introduced the RE-AIM (Reach, Efficacy or
Effectiveness, Adoption, Implementation, and Maintenance) model to assess
intervention impacts (29). This model includes a measure for adoption, in
adoption is measured as the percentage of eligible worksites that adopt or
test a health promotion program.
Adoption rates also are assessed for representativeness, or how well
worksites that elected to participate in a program represent all eligible
worksites. Representativeness is measured by comparing the characteristics
of eligible worksites that adopt a health promotion program to eligible
worksites that decline to adopt. Both assessments are critical to
establishing the external validity of worksite-based studies, that is, the
extent to which worksites recruited into trials represent other worksites
(30). This type of rigorous assessment of external validity, however,
Bull et al recently evaluated the external validity of worksite health
promotion studies (30). They reviewed intervention studies on dietary
change, smoking cessation, and physical activity published in 11 leading
the five years from
1996 through 2000. They discovered that, among the 24
published studies, only six (25%) reported the percentage of
eligible worksites that elected to participate in a program; only two
(8%) reported exclusion criteria; and none reported on representativeness.
In the two studies that reported exclusion criteria (30-32), the number of employees determined exclusion, and one also
excluded worksites based on turnover rates and non-English-speaking
Using the RE-AIM measures of adoption, our paper overcomes shortcomings
of prior worksite health promotion studies to report on the process and
results of worksite recruitment and worksite characteristics associated with
program adoption in Healthy Directions — Small Business
(HD-SB), a randomized, controlled cancer prevention trial among small-sized
manufacturing companies employing multiethnic, low-wage workforces. The
purpose of this paper is to assess the external validity of the trial, based
on the percentage of potential trial sites excluded from consideration, the
percentage of eligible worksites that adopted the trial, and the
characteristics associated with adoption.
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To assist the reader in interpreting the results of this report, we begin
with an overview of the HD-SB cancer prevention trial itself and then focus
on how we recruited worksites. The main question under investigation in
HD-SB is whether or not a cancer prevention intervention that integrates
health promotion and occupational health protection leads to significant
mean improvements in workers’ consumption of fruits and vegetables, levels
of physical activity, smoking cessation, and reductions in workers’
exposure to occupational carcinogens in small manufacturing worksites that
employ multiethnic, low-wage workforces. Participating worksites are
randomly assigned to either an intervention or a minimal intervention
control condition. The intervention worksites receive an 18-month
intervention focused on physical activity, diet, smoking cessation, and
occupational health and safety. The control worksites receive only smoking
cessation programs. Our institutional review board approved the trial
protocol; employee participation in the trial is voluntary.
The intervention is an integrated health-promotion/health-protection
model (33) based on social ecological theory (34,35). This model addresses
both workers’ personal behaviors and the hazards of their work
environments. Interventions are conducted at three levels: individual
workers (e.g., health education about diet, physical activity, occupational
health and safety), organization (e.g., worksite food options, programs to
support worker physical activity such as lunchtime walking groups,
occupational health and safety policies), and physical environment (e.g.,
reduction of carcinogenic exposures).
The study population for this report is manufacturing worksites. We used
the Dun and Bradstreet database to identify worksites with Standard
Industrial Classification codes in the manufacturing group (Group D)
that are located in and around a large northeast urban area in the United
States and that employ between 50 and 150 workers. We selected manufacturing
worksites because they are more likely than other worksites, such as those
in the service sector, to use potential carcinogens in work processes. The
worksite use of potential carcinogens allows us to intervene on cancer risks
related to individual health behaviors as well as occupational exposures. We
identified 224 companies in the Dun and Bradstreet database.
Pre-recruitment survey measures
After identifying the 224 companies, we conducted a pre-recruitment
worksite survey to determine eligibility for participation in the HD-SB
trial. The pre-recruitment survey took place from March through August
1999. Our study eligibility requirements included the following:
- Employing a multi-cultural or multiethnic population (defined as 25%
of workers being first- or second-generation immigrants or people of
- Having an employee turnover rate of less than 20% in the previous
- Being autonomous in decision-making power to participate in a study
(if part of a larger parent company).
The survey asked respondents to indicate the total number of employees,
the percentage of their workforce that was white and American-born, and the
percentage of employee turnover within the last three years. To determine
degree of autonomy, the survey asked respondents if they were able to make
their own decision on program participation. In addition,
the survey collected information about worksite characteristics (36) that we
hypothesized would be positively associated with adoption, including
perceived importance of and prior experiences with health promotion and
protection programs and a positive financial outlook. The survey also asked
respondents to rate their perception of the importance of health promotion
and occupational health and safety activities on a 5-point Likert scale, to
indicate if their worksite had previously offered such programs, and to say whether
they anticipated increases, decreases, or no changes in workforce size in
the next year (as an indicator of financial outlook).
Research staff placed phone calls to the 224 companies identified in the
Dun and Bradstreet database to verify contact information. We then mailed
the pre-recruitment survey to the CEO and director of
personnel/human resources with a cover letter requesting their assistance in
completing the survey as part of a research project to develop educational
health promotion and health protection programs for manufacturing
businesses. The letter contained no additional information about the
research project. We contacted non-responders by telephone within two weeks,
and research staff conducted the survey over the telephone. We attempted to
reach non-responders at least 10 times by telephone. We attempted to reach
both the CEO and director of personnel/human resources to maximize the
potential for response. If both responded, we accepted the responses of the
CEO only, thereby standardizing this aspect of data collection.
The mailed survey administration method yielded an unacceptably low
response rate (11%; n = 24). As a result, we shortened the pre-recruitment
survey and attempted to reach non-responders by telephone. The longer
version of the survey asked about factors that would assist us in planning
for intervention implementation, such as shift schedules, estimated
percentage of employees who speak specified languages, and barriers and
facilitators to worksite health promotion. We eliminated these questions to
create the shortened survey (Appendix), which focused only on the measures, reported
herein, that we hypothesized would relate to adoption. Research staff
re-contacted non-responders and administered the shortened survey by
telephone to either the worksite's CEO or director of
personnel/human resources, increasing the response rate to 88%.
Once we deemed a worksite eligible to participate in the HD-SB trial
based on the pre-recruitment survey, a member of the research staff
contacted the survey respondent by telephone to describe the research trial
and to assess interest in participating. If a company expressed
interest, we conducted an in-person, on-site recruitment meeting to describe
what would be required of participating companies, the specifics of the
intervention condition, and the process of randomization to intervention or
control condition. To participate, companies had to consent to allow
employees to take baseline and final surveys, to allow research staff to
conduct an industrial hygiene walk-through assessment of the worksite, and
to conduct additional surveys with management on occupational health and
organizational characteristics. If randomized to the intervention condition,
worksites also were asked to
- Permit between five and 10 employees to meet monthly as part of an
employee team designated to assist project staff with program
- Allow all employees at least 15 minutes per month during work time to
attend project intervention activities.
- Have a HD-SB staff industrial hygienist consult with management to
make plans for improving occupational health and safety conditions.
Once a company had agreed verbally to participate in the trial, a
research staff member and company representative signed a letter of
agreement stating participation requirements and indicating informed
consent, or adoption. Recruitment took place from September 1999 through
December 2000, with the first company beginning its 18-month intervention in
September 2000 and the last company beginning its intervention in December
2000. All interventions were concluded by June 2002.
Using data from the pre-recruitment survey, we determined the percentage
of worksites that did not meet eligibility criteria and the percentage of
worksites that met eligibility criteria and that adopted the program, and we
compared the characteristics of companies that chose to participate in the
trial with the companies that declined to participate. We calculated means
and proportions to describe the sample and conducted Student t-tests
(two-tailed) and chi-square tests for significance, with an alpha level of
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Of the 224 worksites, 197 (88%) completed the pre-recruitment survey and
131 (66%) of these met the trial eligibility criteria. Among the 66 (34%)
worksites deemed ineligible, reasons for ineligibility included not being
engaged in manufacturing (n = 15), size of workforce (n = 23), lack of
autonomy in decision making (n = 9), or insufficient percentage of workers
being first- or second-generation immigrants or people of color (n = 19). Of
the 131 worksites that met eligibility criteria, 26 consented to participate
in the trial, for an adoption rate of 20%. The worksites recruited to the
trial manufacture a range of products, including medical equipment, dog
food, specialty pumps, textiles for the automobile industry, and
electronics. Three of the worksites provide services to other businesses
(laundry and printing).
Characteristics of eligible companies (n = 131) that adopted the
intervention (n = 26) are compared with companies that declined (n = 105) (Table).
On average, among all eligible companies, about half of all employees
were persons of color and/or first- or second-generation immigrants to the
United States; approximately one half of the worksites anticipated
increasing the size of their workforce in the next year; approximately one
quarter had a history of offering health promotion activities; approximately
one quarter perceived such programs to be important (mean scores of 3.0 and
3.3 out of possible 5); most had a history of occupational health and safety
activities; and most perceived these to be very important (mean score of 4.5
and 4.4 out of possible 5). Worksites that adopted the program were slightly
more likely (differences not statistically significant) to have a larger
percentage of white and American-born workers; to anticipate an increase in
workforce size in the next year; to have offered health promotion and safety
programs in the past year; and to perceive health promotion as important. We
have no meaningful data on the small number of worksites that declined to
complete the pre-recruitment survey (n = 27) and so cannot compare them to
those that did.
An additional seven worksites consented to participate but withdrew prior
to the start of the intervention (categorized as decliners in presented
data), citing concern about lack of time to participate in the trial given
increasingly tight production schedules. These seven companies were also
slightly more likely to perceive health promotion as important and to have
offered health promotion programs in the past, compared to other eligible
worksites (differences not statistically significant). Later in the
trial, one worksite withdrew from the intervention condition and another
withdrew from the control condition; both cited lack of time as reason for
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This paper reports on the process and outcome of our efforts to recruit
small manufacturing worksites employing multiethnic, low-wage workforces
into a cancer prevention intervention trial. Trial eligibility criteria
excluded about 34% of worksites responding to our survey. Among eligible
sites, 20% (26 of 131) adopted the program, a rate similar to other cancer
prevention studies (13,33,37). An additional seven worksites initially
consented but withdrew very early in the trial. Among worksites eligible to
participate, we observed no statistically significant differences between
those that consented and those that declined to participate in the trial
with regard to workforce composition, anticipated expansion of the workforce
(financial outlook), and perceived importance and history of heath promotion
activities and occupational health and safety programs. In sum, we found
that the racial and ethnic composition of the workforce, financial outlook,
and perceived importance and experience with health programs were not
barriers to adoption in cancer prevention trials in this sample of
The study had a few limitations. First, the survey relied on self-reports
by a worksite representative, and we did not attempt to validate the
information provided. Second, using the RE-AIM measures, we attempted to
assess worksite participation in a cancer prevention research trial as a
proxy measure for adoption of a cancer prevention program. Participation in
a research trial is not the same as adoption of a program. And finally, our
pre-recruitment survey did not contain measures that allowed us to
characterize differences between adopters and decliners, suggesting that
additional measures may be needed, the development of which might rely on
qualitative, open-ended questions on factors that promote or inhibit
adoption. The survey administrators noted anecdotally that employer reasons
for adoption included having a family member with a history of cancer;
viewing participation as a low-cost, value-added benefit for employees
during a time of tight labor markets; wanting to take advantage of our
occupational health and safety expert consultations; and believing that a
healthy workforce is a more productive one. Common reasons noted by
employers for declining to participate were lack of time and poor
labor-management relations. These reasons may form the basis for
distinguishing adopters and decliners in recruitment surveys for future
Our findings have several important implications for the HD-SB trial and
for other future worksite-based trials. First, although our adoption rate
was 20%, a systematic assessment of the adoption rate using the RE-AIM
framework indicates strong external validity for HD-SB trial findings: we
found no significant differences between eligible worksites that adopted the
cancer prevention trial and those that declined. We may generalize the
findings of our main trial to other small manufacturing businesses that are
located in urban areas and employ multiethnic, low-wage workers. The
application of the RE-AIM measures for worksite adoption used here
represents a key strength of our trial: few prior studies have reported
explicitly on the percentage and representativeness of worksites that are
willing to adopt or try a health promotion program (32). Second, the
results provide guidance to future researchers and practitioners in
estimating likely rates of adoption and early withdrawals. When recruiting
small manufacturing worksites, which may be particularly vulnerable to
volatile economic conditions and production schedules, it may be necessary
to recruit additional worksites to allow for early withdrawals and avoid
threatening the trial’s statistical power. A related point is that when
attempting to reach worksites to assess eligibility for recruitment,
researchers ought to use a short survey instrument that they can administer
conveniently, preferably by telephone. Third, the high mean level of
reported importance of occupational health and safety programs among all
eligible worksites is noteworthy, suggesting that these programs may
represent an attractive intervention component for small manufacturing
businesses. This level of interest in health and safety has not been evident
in studies of larger manufacturing worksites (33,37).
Recruitment for this trial took place within a larger social context: the
decline of the U.S. manufacturing sector. U.S. manufacturing companies often
are in precarious financial situations, or they may perceive that they have
too little time to commit to a health promotion trial. On the other hand,
they may view such an endeavor as a “free” resource. Our anecdotal data
support both of these hypotheses, which can be subjected to rigorous
assessment in future trials.
Reducing racial/ethnic and class-based health disparities is a major
focus for the U.S. Public Health Service (12,38). Intervention research is
essential to developing effective methods for reducing the disproportionate
cancer risk associated with health behaviors and occupational exposures
among immigrant, multiethnic and multi-racial, less-educated, and low-wage
workers. Our results indicate that small manufacturing worksites are a
viable community-based channel for reaching low-wage, multiethnic
populations with cancer prevention programs, but that we can expect low
adoption rates within this sector. Future intervention studies in these
settings need to address the concerns of small businesses and to assess
systematically the worksite characteristics that promote participation in
trials and, ultimately, program adoption.
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Funding for this study is provided by National Cancer Institute grant
number 5 P01 CA75308-02 and Liberty Mutual Insurance Company. The authors
thank Kathleen Yaus for her assistance with literature reviews, Cora Roelofs
for her helpful comments on an earlier version of this paper, and Richard
Martins for administrative assistance.
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Corresponding Author: Elizabeth M. Barbeau, ScD, MPH, Department of
Society, Human Development and Health, Harvard School of Public Health,
Boston, Mass. Center for Community-Based Research, Dana-Farber Cancer
Institute, 44 Binney St, Boston, MA 02115. Telephone: 617-632-5390. E-mail:
Author Affiliations: Lorraine Wallace, MPH, Ruth Lederman, MPH, Nancy
Lightman, MM, Center for Community-Based Research, Dana-Farber Cancer
Institute, Boston, Mass; Anne Stoddard, ScD, Center for Community-Based Research,
Dana-Farber Cancer Institute, Department of Biostatistics, University of
Massachusetts, Amherst, Mass; Glorian Sorensen, PhD, MPH, Center for
Community-Based Research, Dana-Farber Cancer Institute, Department of
Society, Human Development and Health, Harvard School of Public Health,
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Comparison of Characteristics of 131 Eligible Worksites That Adopted or
Declined Cancer Prevention Intervention for Employees, Northeastern United
n = 105
n = 26
Mean percentage of workforce white and American-born
Proportion that anticipate increase in number of employees in next
Proportion that offered health promotion programs in past year
Proportion that offered safety programs in past year
Mean perceived importance of worksite health promotion programs in
company (1 = low; 5 = high)
Mean perceived importance of worksite safety programs in company (1
= low; 5 = high)
a No differences were found to be statistically
significant, based on Student t-tests (two-tailed) and chi-square tests.
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Telephone Survey of Small Manufacturing Worksites That Employ Multiethnic,
Low-wage Workforces, Northeastern United States, 1999
Hello, my name is ______________________. I am calling from Dana-Farber
Cancer Institute. We recently sent your company a questionnaire for a
project we are conducting with small businesses in the Boston area. The
questionnaire was called the “Health Survey of Small Businesses in
Massachusetts.” We have reviewed the survey and have made changes to
shorten it. Since we did not receive a completed survey from your company,
would you be able to take about five minutes now to answer a few questions?
Your Company’s Name:
Your Phone Number:
Your Fax Number:
I would like to thank you for your participation in the Health Survey of
Small Businesses. One of the purposes of this survey is to identify
potential participants for the Cancer Prevention in Small Businesses
project, funded by the National Cancer Institute. The goal of the
project is to develop a national model for worksite cancer
prevention. The study offers two years of health programming provided
by experienced staff at no cost to you. We will focus on healthy
eating, increased physical activity, and safety issues.
- Do manufacturing or production operations go on at this worksite?
- About how many permanent employees working 20 hours or more per week are
there in your company? Do not include temporary workers. (Total
- About how many of those employees would you say are blue collar or
directly involved in the manufacturing or production process? (Number)
- About how many are piece workers? (Number)
- Approximately what percentage of your workforce is represented by union(s)?
- About what percentage or your workforce is white/American-born?
- Do you anticipate your workforce will increase, downsize, or have no
change in the next year? (Check one only)
- In the past year, has your company offered any health promotion programs?
(Yes/No) Check all that apply. Use the following list as prompts:
- Nutrition classes
- Exercise classes
- Weight control classes
- Health fairs
- Smoking cessation classes
- Safety Programs
- Other (text)
- In the past year, has your company offered any safety programs? (Yes/No)
- About what percentage of your employees are currently covered by any
amount of company paid health insurance? (Percentage)
If you are talking to the Human Resource Director, skip to Question
- How important do you think it is to have worksite health promotion
programs in your company? For example, nutrition, exercise classes,
smoking cessation programs or material.
|Not at all important
- How important do you think it is to have worksite safety programs in your
|Not at all important
- In your opinion, how important does your company management
think it is to have worksite health promotion programs in your
company? For example, nutrition, exercise classes, smoking cessation
programs or material.
|Not at all important
- In your opinion, how important does your company management think
it is to have worksite safety programs in your company?
|Not at all important
- Are you able to make the decision to participate in a program like this
one on your own? (Yes/No) Who else would have to be consulted?
Thank you for your participation in this survey.
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