We developed a new evaluation method to identify promising practices for promoting healthy weight among employees at small and medium-sized worksites.We used a structured rating and selection process to select 9 worksites with approximately 100 to 3,000 employees from a pool of worksites with health promotion programs reputed to be exemplary. A site visit over 2 sequential half-days at each site included interviews with senior management, program staff, vendors, and wellness committees; observation guided by a written environmental assessment; and structured review of program data on health outcomes of wellness program participants. The team corroborated findings from interviews, observations, and reviews of aggregate data on health outcomes of participants. Using the site visit reports, the project team and a separate panel of experts identified worksite health promotion practices that were promising, innovative, feasible to implement in a variety of settings, sustainable, and relevant for public health.Innovative practices included peer coaching, wellness screening coupled with motivational interviewing and follow-up, free access to fitness facilities, and incentives such as days of paid leave for participation in wellness programs. Introduction of incentives was associated with higher participation rates. To build the business case for their programs, staff at several worksites used aggregate data on decreases in high blood pressure, serum cholesterol concentrations, and body weight in longitudinal samples of program participants.The evaluation method identified promising practices implemented at small and medium-sized worksites to promote healthy weight and related favorable health outcomes. Obesity is among the leading causes of preventable death in the United States , and itsA limited number of studies of worksite health promotion programs demonstrate success in reducing obesity . A systeThe evaluation project was not designed to establish firm conclusions about the effectiveness of specific practices; rather, we aimed to identify promising practices that merit additional, more rigorous study. We used a rapid evaluation method called Swift Worksite Assessment and Translation (SWAT), developed specifically to evaluate worksites one at a time (as opposed to comparing worksites to one another) by using predetermined criteria. We describe the process used to select 9 initial sites for SWAT assessments and present examples of practices that worksite health promotion experts deemed promising or innovative. We reflect on these examples and the observations we made at the 9 sites to stimulate thinking about worksite health promotion strategies in small and medium-sized worksites and potential areas for further research and evaluation.The SWAT evaluation method we used for this project was developed to rapidly assess worksite strategies to help employees attain and maintain a healthy body weight. A companion article in this issue of Preventing Chronic Disease  providesWe sent a brief description of the project and a personal invitation to participate to 41 small and medium-sized worksites that met the inclusion criteria defined by the SWAT method. Sixteen worksites responded, and we conducted brief telephone interviews to obtain information on the main components of their health promotion programs. We then prepared summaries of the telephone interviews and used coding to omit employer names and locations.The project team reviewed each of the 16 worksite health promotion program summaries and used a structured rating process to score each program to determine whether to recommend the site for a visit. Concurrent with this activity, 3 senior CDC staff members with expertise in worksite health promotion acting as an expert panel also scored the programs. If additional information was necessary to complete the ratings, we conducted brief follow-up calls to obtain such information.Funding was available to conduct up to 9 initial SWAT assessments; ideally, these would cover a wide variety of workplace settings. The project team selected the 9 worksites with the highest ratings based on a combined score of the project team and the CDC expert panel, after confirming that the 9 sites provided a range of organizational types and sizes. As shown in A 1-day site visit  at each worksite allowed the project team to assess the worksite health promotion program and to make observations firsthand. Structured topic guides were used for key informant interviews with 1) the health promotion director and staff responsible for delivering the intervention , 2) the data collector or analyst for the program , and 3) the human resources director, upper-level manager, or chief executive officer, that is, upper-level decision makers who supported or funded the program . At some sites, we had discussions with employee wellness advisory committees .During the interviews, we gathered data on worksite characteristics, including the size of workforce, the type of jobs or industry represented at the site, and employee sociodemographic characteristics. The structured topic guides included questions about the staffing for the health promotion/healthy weight practice, program resources, and operating costs. We also asked questions about the health promotion program objectives, activities, innovativeness, and factors that contribute to successful implementation and sustainability. The guides included a series of questions about program participation, including eligibility requirements, the percentage of eligible employees who participate, and whether specific groups are targeted at the worksite. To track program participation, we asked specific questions about which types of employees actually participate, what activities they participate in, the program-related variables that are measured and their frequency, and the program completion rates. We also asked about results from the program, including any changes in the worksite environment or policies or the weight and health-related behaviors of employees . Finally, we inquired about sources of support for healthy weight and for the program, including senior-level support and the community environment.Checklist of Health Promotion Environments at Worksites   .http://www.cdc.gov/nccdphp/dnpa/hwi/.We also used a structured form to guide our review of program documents that provided aggregate data on the health practices and health status of program participants. Interview guides for key informants and the environmental assessment checklist can be found at The project was designed for rapid assessment so that promising practices could be identified and, potentially, evaluated more rigorously. In keeping with privacy rules, we did not collect individual-level data or analyze it to verify the accuracy of the aggregate data on program participation, behavior, or health status shared by employers. We did, however, independently check that the interpretation of aggregate data on program participation or health status was described in our site visit reports in a manner that was consistent with accepted evaluation standards -23. TypiAfter each of the 9 site visits, we summarized written interview notes, the data inventory checklist and notes, and the environmental checklist completed during the site visit. Teams of 2 evaluators who made the site visits collaborated to synthesize the information in a descriptive report of each worksite program. In summarizing each site, we sought corroboration of evidence among sources, including consistency among respondents. We also examined consistency among respondent self-reporting, information in written documents, and observations made by site visitors. The site visit reports also provided detail on the contexts of the worksite and the community, program components, program participation, and evidence for program effects on weight and health. Furthermore, the reports described the strengths and limitations of aggregate data on participation and health status provided by the worksites. Draft site visit reports were then sent to each site to verify facts and add relevant information. As with the site selection process, the project team and the CDC expert panel used a structured rating process to score sites based on criteria defined in the SWAT method. Scoring criteria included feasibility of practice implementation in a variety of worksite settings; sustainability of the practice and of its apparent health effects; relevance for public health; and cost. Raters provided a final overall summary rating for each site.As a final step, the 3-member expert panel was asked to identify particular strategies or practices they considered to be promising or innovative on the basis of their knowledge of worksite health promotion. The following results reflect the expert panel's conclusions.Several innovative practices were identified by the expert panel. Individual levelExperts observed that several worksites offered high-tech wellness screening procedures and Web-based data-management systems, along with personal counseling about results. For example, participants could get periodic counseling, health risk assessments (HRAs), and rapid measurements of blood pressure, serum cholesterol concentrations , and obesity . These assessments were supported by Web-based data-management systems that allowed the health counselor to access screening information so participants could monitor their progress.Another feature of the programs identified by experts was the "high-touch" component, such as motivational interviewing, regular follow-up, and peer support. At a construction company, for example, participants in the employee wellness program met one-on-one with a health educator who was trained in motivational interviewing. The educator helped employees complete an HRA, review personal health risks, and set short- and long-term goals. All participants received a printout of their health risks, total health risk score, personal goal, and resources for health information related to that goal. Participants were required to meet with a health educator for 30-minute follow-up sessions several times throughout the year, as determined by their health risk category. At a manufacturing company, an occupational health nurse conducted personal monthly health check-ins with employees to discuss their progress toward self-selected health goals.Environmental levelThe expert panel observed that a number of the worksites had taken action to provide increased access to programs to boost participation. For instance, a community college provided free access for staff to use a fitness facility because they thought having staff exercise beside students helped to further the school's sense of community. One program increased the hours and locations in which health assessments and screening were provided, and another negotiated use of a fitness facility in a nearby hotel, to provide access to staff in an offsite location.Organizational levelExperts identified strong support from senior management as an important feature, and nearly all (8 of 9) programs we visited were deemed to have such support. For example, senior management spearheaded and started the program; directly encouraged employees to participate, participated in program activities, held organization-wide meetings to discuss the concept of wellness and to present program details, and said the wellness program was important for a healthy workforce. Many staff members in these programs used evaluation results to help sustain the interest of senior managers.Several programs encouraged mobilization of a health-promoting worksite culture. For example, a manufacturing company had visible encouragement and support from senior management. The program was spearheaded by the company president, who showed up at 8 am for weight-loss team weigh-ins. The community college program offered employee-led walking and jazzercise classes. Walking clubs were established to facilitate a primary goal of the community health care program — increasing the number of walking steps taken. Employees were trained to lead these clubs, and for doing so they earned activity points toward program monetary incentives.Promising practices related to wellness often involved changes in organizational policy. For instance, wellness was incorporated into the mission statement of the metal-finishing company. Staff at one worksite wrote requirements for nutritious foods into their criteria for selecting the vendor that operated the cafeteria. The cafeteria manager reported that with the introduction of healthier food choices, more people started using the cafeteria. The construction company gave employees notice that within 1 year, all construction sites would be tobacco-free and offered free counseling for smoking cessation and coverage for nicotine replacement therapy.and met their wellness goals. Most managers were placed in incentive compensation plans, with 10% of their bonus directly related to achieving their wellness goals. The small manufacturing company changed the structure of its benefits to promote them as incentives for program participation, so that the company's previous contribution toward health insurance deductibles was instead tied to attainment of specific health goals .Experts noted as innovative the use of financial incentives to encourage participation in programs. At the metal-finishing company, for example, wellness goals were tied to annual performance reviews. All employees were evaluated on safety, performance, and attendance, including wellness activities. Employees met expectations if they attended each quarterly health screening and exceeded expectations if they attended all quarterly screenings To further extend the social support component of their programs, several worksites encouraged participation of spouses of employees. In the aviation-support company, the wellness program was available to all employees and their spouses. If both participated in the annual health screening, they received a 10% discount on the health insurance premium. The construction company contributed approximately $600 per person to married employees toward their deductible only if both the employee and the spouse participated in the program. Providing for spousal participation was consistent with reinforcing employee participation. In most (approximately 60%) of the programs with participation rates of 70% or higher, spouses were allowed to participate in all program components.The expert panel members were also impressed by the ability of these small and medium-sized worksites to rapidly implement changes. For example, the small manufacturing company modified its program from a team competition, to an individual weight-loss program, to a screening program with financial incentives for meeting specific wellness goals and the intention to make the goals increasingly strict each year. The health care provider changed its incentive for participating in its wellness program from a $200 flex credit for health insurance coverage to a debit card allowing participants to earn up to $190 per year for participating in the program. Money earned could be spent anywhere, not just on health insurance. Then, the program added a disincentive; employees and spouses who were on the company's health plan but did not participate in the wellness program had to pay a surcharge on their health insurance premium of approximately $30 per pay period ($770 per year).Program staff at worksites used evaluation of participation and health effects to guide program development and build the business case to sustain the programs in terms of the resulting savings in health care costs. One method they used was to build in measures and procedures to assess and refine their programs.ParticipationTo refine program outreach and offerings, staff at some sites used data on participation as an early indicator of success. For example, a city government instituted an annual planning process with its wellness committee. On the basis of participation rates in various departments, coupled with responses to a survey of employees about program interests, management introduced the incentive of paid leave for up to 2 days for completing the HRA, having an annual health screening, and earning points through participation in ongoing wellness programs. The worksite staff reported that this change increased participation rates among men from 24% to 60% the year after this change was implemented. In addition, program staff frequently cited aggregate data on participant health outcomes to help build the business case for the program.Health effectsBehavior. Of the 9 wellness programs, 5 assessed changes in aggregate employee health behavior from HRAs. For instance, the health care provider shared aggregate data indicating that the percentage of participants who reported "exercising for at least 20 minutes" less than once per week decreased from 30% (202/679) in 2002 to 16% (108/679) in 2005. Because worksite program staff understood the limited reliability of self-reported behavioral data, they placed greater emphasis on measurement of health risk through more objective measures, such as biometric data .Weight loss, healthy weight, and health outcomes. Five of the 9 programs assessed longitudinal data on weight status, although the metrics varied. For example, program staff in a health care setting reported that 35% (122/353) of overweight participants (defined by the program as BMI >27.5 kg/m2) lost more than 4 pounds over 12 or more months. A construction company shared a report of aggregate data indicating that 16% of employee participants decreased their risk for being overweight (BMI >27.5 kg/m2) over a 2-year period compared with baseline. Program staff from a community health setting reported an average weight loss of 6 pounds per participant (N = 90) over a 1-year period.Five of the worksites had collected repeated cross-sectional or longitudinal data on blood pressure or serum cholesterol concentrations in aggregate data from health assessments. For example, the metal-finishing company reported data that showed that the percentage of participants with hypertension stages 1 and 2 (blood pressure ≥140/90 mm Hg) decreased from 17.4% in the first quarter of 2005 to 12.0% in the fourth quarter of 2005. The community college shared repeated, cross-sectional aggregate data showing reduction in high serum cholesterol concentrations from 16% of participants in 2003 to 10% in 2005. The construction company's aggregate data indicated that, over a 2-year period, in a longitudinal sample of approximately 2,000 employees, 20% decreased their risk for high cholesterol. In the absence of data from a comparison group, knowing how much of this change was attributable to program participation is difficult. Nonetheless, data on aggregate changes in physical health status were used to build the business case for the wellness program.To further build the business case for health promotion, several worksite programs also reported to state or regional worksite associations on changes in health care costs or on reduction in the rate of increase in health care costs since the wellness program was established. At worksites where this was done, the programs appeared to have more than paid for themselves, although determining how much of this change can be attributed to program participation is difficult. However, staff at one worksite used establishment of a wellness program as a rationale to convince their insurer to change the organization's insurance rating status, resulting in lower health insurance premiums.The goal of this evaluation was to identify promising practices for promoting healthy weight in small to medium-sized worksites. We used the SWAT rapid-assessment approach for evaluation — a middle-ground approach between informal assessment and resource-intensive rigorous research . AlthougConsiderable similarity exists between the small and medium-sized worksites we studied and larger worksites described in other studies; for example, both offer a combination of nutrition and physical activity programs for preventing and controlling overweight and obesity, as recommended by the Task Force on Community Preventive Services . SeveralThe 9 worksite programs we visited were nominated as having exemplary programs, and they were chosen because they showed promise. Hence, we caution against trying to generalize these findings to other worksites. Indeed, this project was not designed to provide generalizable findings but rather to identify promising practices that might merit more rigorous evaluation.Furthermore, the aggregate quantitative data on behavior and health status that the worksites shared with us had several limitations. Worksite staff tended to gather data on self-reported changes in behavior. Thus, it was difficult to know whether reported changes were associated with social desirability or with greater attention to and knowledge about the behaviors. Most worksites recorded measured (not self-reported) height and weight, yet change in weight status over time was not always analyzed and reported. Only a few programs reported longitudinal data, and in almost no cases were data available from comparison groups. The CDC expert panel members expressed a strong desire for more data or more rigorously analyzed data on program effectiveness, to help them better determine whether a practice was promising. They also noted the need for longitudinal data to demonstrate changes in health behavior or maintenance of weight loss.Recognizing the subjectivity of interview and observational data, we took several actions to increase our confidence in our findings. First, we used a variety of data sources to corroborate evidence. For example, worksites' aggregate program data on health outcomes was compared with the information we collected from key informant interviews and the environmental assessment conducted during the site visits. Next, we provided worksite program staff a draft site visit report and asked them to verify its accuracy. To assess the rating process of the experts who read the site visit reports and identified promising practices, the project team completed the same rating process and compared results for consistency.This evaluation project identified promising practices implemented at small and medium-sized worksites to promote healthy weight and related favorable health outcomes. Practices that appeared promising for small to medium-sized worksites included periodic health assessments tied to personal feedback and motivational interviewing, peer coaching, use of an occupational health nurse to check in monthly with employees, and changes in and promotion of benefits as incentives for program participation. This report suggests that more rigorous studies, such as randomized controlled trials, are merited to assess more thoroughly the effect of specific innovative and promising health promotion practices on health outcomes and to investigate whether these strategies could work for companies with fewer than 100 employees.


Popliteal venous aneurysms are uncommon but potentially fatal vascular disorders. They can be symptomatic or asymptomatic, mimicking different conditions. Popliteal venous aneurysms are possible sources of embolism.A 68-year-old woman presented at a rural primary health care unit in Crete, Greece, reporting local symptoms of discomfort in the right popliteal fossa with pain during palpation. Colour Doppler ultrasonography revealed local widening and saccular dilatation in the right distal popliteal vein. The diagnosis of a popliteal venous aneurysm was formulated.Popliteal venous aneurysms are rare conditions, but are potentially more common than usually thought in daily practice. Physician awareness and access to ultrasound examination may allow for early diagnosis, before the occurrence of any thromboembolic or other major complication. Popliteal venous aneurysms may cause fatal complications, such as pulmonary embolism and other thromboembolic episodes, ,2 if theA 68-year-old woman presented to her general practitioner with a history of local discomfort and swelling in the right popliteal fossa over the previous few months. Symptoms worsened during usual daily activities . The patient had a history of chronic bilateral venous insufficiency, with its onset after pregnancy. Bilateral saphenectomy (at different time points) was performed after years of suffering. Recurrence occurred in both lower extremities approximately 12 years after surgical management. The patient had a strong family history of varicose veins.Signs of chronic bilateral venous insufficiency were evident. Physical examination was positive for the presence of a soft mass, painful on deep palpation, in the upper part of the popliteal right fossa with no local signs of inflammation or murmur. Chest and abdomen examination was normal. No evident clinical signs of peripheral arterial angiopathy were detected. Arterial blood pressure, chest X-ray, oxygen saturation and electrocardiogram were normal. Colour Doppler ultrasonography was performed by a qualified radiologist. Real-time B-mode and colour Doppler ultrasonography revealed local widening and saccular dilatation (2.3 × 1.9 × 2.4 cm) in the right distal popliteal vein , and the popliteal vein should not be involved. Finally, in the case of a popliteal traumatic arteriovenous fistula there is a communication between the popliteal artery and popliteal vein through the lesion, depicted using colour Doppler ultrasonography. Popliteal traumatic arteriovenous fistula is characterised by continuous turbulent flow.Popliteal venous aneurysms are rare conditions but are potentially more common than usually thought in daily practice. This case report is interesting because the diagnosis was made before the occurrence of any thromboembolic or other major complication. The physician's awareness, atypical local symptoms deserving prompt clinical explanations and access to ultrasound examination enabled early diagnosis of this case.The authors declare that they have no competing interests.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.EKS, SK and CL conceived of the idea, designed and prepared the first outline of the manuscript, and revised its final version. IP carried out the ultrasound examination and provided technical content information. DK, NA and ET collected the available literature information and performed the review of the patient's medical record with helpful comments on the discussion. EKS prepared the point-by-point reply with contributions from CL. All authors read and approved the final manuscript.


Cases of true mycotic popliteal artery aneurysm are rare. Presentation is variable but invasive and non-invasive investigations collectively facilitate diagnosis and guide operative procedures. Definitive treatment generally utilizes surgical intervention with excision and reconstruction using autologous vein graft. Prolonged targeted antibiotic therapy is an important adjuvant.Streptococus pneumoniae endocarditis.We describe the clinical presentation, radiological investigations and strategies on the management of a 47-year-old Caucasian Irish man who presented with a mycotic aneurysm of the popliteal artery due to thromboembolisation from Streptococus pneumoniae highlighting the changing profile of causative microorganisms.Cases of true mycotic popliteal artery aneurysms are rare. To the best of our knowledge this is the first documented case of a popliteal artery mycotic aneurysm developing secondary to  Streptococus pneumoniae endocarditis.True mycotic popliteal artery aneurysm is a rare condition and its presentation is variable. Definitive treatment is generally characterised by excision and reconstruction using an autologous vein graft. We describe the clinical presentation, radiological investigations and management strategies employed in the case of a 47-year-old man who presented with a mycotic aneurysm of the popliteal artery (MPAA) secondary to thromboembolisation from Streptococus pneumoniae endocarditis vegetations. After a prolonged ICU course, the patient was eventually transferred to the ward with minimal neurological dysfunction. The patient, however, developed pain in his right calf 6 weeks after admission.A 47-year-old Caucasian Irish man was admitted to our intensive care unit (ICU) with multiple cerebral infarcts secondary to septic emboli from A clinical examination revealed a pyrexic patient with a swollen, pulsatile and tender right upper calf mass, palpable distal pedal pulses and foot drop Figure . A mycotThe contralateral popliteal artery was normal Figure . Urgent A curved incision over the right popliteal fossa revealed a saccular aneurysm of the below- knee popliteal artery involving the trifurcation. Proximal control was attained and the aneurysm opened, exposing a significant amount of haematoma and thrombus Figure . SamplesA femoral angiogram performed 2 weeks after the procedure demonstrated satisfactory graft segment flow Figure . No orgaAccording to Wilson's widely held classification, mycotic aneurysms are strictly defined as "infected aneurysms developing in a previously normal artery secondary to septic embolisation due to bacterial endocarditis" . Thus, aTo date there are fewer than 50 cases of "true" MPAA reported in the literature. The estimated male-to-female ratio is 11:3 with an age range of 2 to 81 years with the mean age of occurrence at 41 years old [MPAA customarily presents as a painful, tender, pulsatile leg swelling in pyrexic patients with a definitive or unsuspected infective focus . SymptomAlthough an estimated 3% of non-mycotic popliteal artery aneurysms can produce neurological symptoms and signs, possibly due to direct compression or occlusion of the vasonervorum arising from the popliteal artery , our patLaboratory studies are unhelpful in diagnosing MPAA and often indicate a non-specific leukocytosis or increased erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Blood cultures are positive in only 50% of reported cases, but negative blood cultures and Gram stains do not necessarily rule out a mycotic aneurysm Table .Non-invasive procedures such as colour-duplex ultrasonography, CT and magnetic resonance imaging (MRI) or angiogram can establish a diagnosis of postoperative alopecia areata (PAA) and provide information regarding the size, diameter, morphology (saccular morphology being suggestive of an infective aetiology) and its relationship to surrounding structures .Angiography, either conventional or digital subtraction, is important to demonstrate the status of the inflow and outflow vessels, hence guiding any operative approach ,5.CT and MRI as vessel imaging alternatives can be satisfactory, as in this case where the patient's temporary sepsis-related renal impairment precluded formal contrast angiography .Ankle brachial index (ABI) measurements provide an objective, measurable and repeatable index of ischemia. Broad-spectrum antibiotics should be commenced pre-operatively and continued for a variable period postoperatively. If no causative pathogen is identified, at least two synergistic agents should be employed. Since there are no clear guidelines regarding the duration of postsurgical therapy, a 6-week oral course seems to be a prudent approach ,10.in situ vessels or reversed superficial vein from the ipsilateral or contralateral lower (or upper) limb [MPAA generally mandates resection and revascularisation -8,10. Ther) limb ,10. Deeper) limb ).The literature includes only a few reports of amputation, failure of reconstructive procedure and the need for secondary reconstruction or amputation, which probably reflects an unwillingness to publish perceived treatment failures. It is thus reasonable to assume a total limb salvage rate, a 5-year patency rate and a primary and/or secondary amputation rate that are at least comparable with, if not worse than, those of non-mycotic popliteal aneurysms (in the region of 60-72%, 50-86%, and 18-27.5% and/or 28-40%, respectively [Mycotic popliteal artery aneurysm is a rare but potentially devastating condition. A high index of suspicion is therefore necessary. Invasive and non-invasive investigations facilitate diagnosis and guide operative procedures. Surgical intervention with excision and reconstruction using an autologous vein graft is the method of choice. Prolonged antibiotic therapy should initially be broad spectrum until pathogen identification can allow targeted therapy.ABI: ankle brachial index; CT: computer tomography; ESR: erythrocyte sedimentation rate; CRP: C-reactive protein; ICU: intensive care unit; MPAA: mycotic aneurysm of the popliteal artery; PAA: postoperative alopecia areata;Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.SK retrieved all clinical data and conducted the literature review. NOB and MOS supplied the radiological images and also contributed to the literature review. HPR and GK were major contributors to the overall writing of the manuscript. GF contributed to the literature review, performed the procedure described, supplied the clinical images and conducted the specimen analysis. All authors read and approved the final manuscript.


In the past decade in activities aiming at return-to-work (RTW), there has been a growing awareness to change the focus from sickness and work disability to recovery and work ability. To date, this process in occupational health care (OHC) has mainly been directed towards employees. However, within the working population there are two vulnerable groups: temporary agency workers and unemployed workers, since they have no workplace/employer to return to, when sick-listed. For this group there is a need for tailored RTW strategies and interventions. Therefore, this paper aims to describe the structured and stepwise process of development, implementation and evaluation of a theory- and practise-based participatory RTW program for temporary agency workers and unemployed workers, sick-listed due to musculoskeletal disorders (MSD). This program is based on the already developed and cost-effective RTW program for employees, sick-listed due to low back pain.The Intervention Mapping (IM) protocol was used to develop a tailor-made RTW program for temporary agency workers and unemployed workers, sick-listed due to MSD. The Attitude-Social influence-self-Efficacy (ASE) model was used as a theoretical framework for determinants of behaviour regarding RTW of the sick-listed worker and development of the intervention. To ensure participation and facilitate successful adoption and implementation, important stakeholders were involved in all steps of program development and implementation. Results of semi-structured interviews and 'fine-tuning' meetings were used to design the final participatory RTW program.A structured stepwise RTW program was developed, aimed at making a consensus-based RTW implementation plan. The new program starts with identifying obstacles for RTW, followed by a brainstorm session in which the sick-listed worker and the labour expert of the Social Security Agency (SSA) formulate solutions/possibilities for suitable (therapeutic) work. This process is guided by an independent RTW coordinator to achieve consensus. Based on the resulting RTW implementation plan, to create an actual RTW perspective, a vocational rehabilitation agency is assigned to find a matching (therapeutic) workplace. The cost-effectiveness of this participatory RTW program will be evaluated in a randomised controlled trial.IM is a promising tool for the development of tailor-made OHC interventions for the vulnerable working population. In the past decade in activities aiming at return-to-work (RTW), there has been a growing awareness to change the focus from sickness and work disability to recovery and work ability. In lineWhen looking at the development of participatory RTW interventions, these interventions have to date mainly been directed towards employees. But, wiThere are countries where sick-listing can only occur when an individual is gainfully employed. However, in the Netherlands the Sickness Benefits Act provides for workers who are sick-listed and have no (longer) an employment contract. When these workers, i.e. unemployed workers and temporary agency workers, fall ill they can apply for a sickness benefit at the Social Security Agency (SSA) and receive 70% of their last daily wage during the first two years of sickness absence. However, since there is no (longer) a labour agreement, there are no legislative mandates for these workers to be returned to their previous/last job.Temporary agency work can be considered an atypical and non-standard form of employment. First, there is a triangular relationship  between the worker, a company acting as a temporary work agency, and a user company in which the temporary work agency places the worker at the disposition of the user company. And second, the work is of a temporary nature without a labour agreement, this in contrast to a temporary worker with a fixed-term contract. In the Netherlands temporary workers with a fixed-term contract are viewed as employees and when sick listed the employer has to pay 100% of the daily wage.Sickness absence and risk for long-term work disability for sick-listed temporary agency workers and sick-listed unemployed workers is higher than for employees -19. One The successful participatory RTW program for employees 2–6 weeks sick-listed due to low back pain,15 was tIntervention Mapping (IM) describes the stepwise process for development of theory- and evidence-based and practise-based interventions -28. The The first step in IM is the needs assessment -27. The Step 2 of IM is important, because in this step the expected change or program outcome is stated, i.e. who and what will change as a result of the intervention? The main objective of the new program, i.e. the proximal program objective, was defined based upon the needs assessment (step 1) and a scientific analysis of the health problem. Identifying the health problem and associated determinants  in the new target group/population at risk, provided the basis of the new RTW program. Subsequently, performance objectives, learning objectives and change objectives were stated. Finally, matrices were created of these performance objectives, learning objectives and change objectives.The purpose of step 3 of IM is to select suitable theoretical methods and practical strategies to address the learning and change objectives formulated in step 2. Theoretical methods are techniques derived from theory and research, while a strategy is the practical application of a specific method. In selecting methods and strategies several routes may be taken based on experience with theory and practise. Reviewing of the literature showed that RTW of sick-listed temporary agency workers and sick-listed unemployed workers is a rare topic, therefore the general theory approach was used. In line with the development of a participatory RTW program for stress-related mental disorders, the AttNext, based on the review of literature, a brainstorm session in the project group, and input from key stakeholder derived from the semi-structured interviews, suitable methods and strategies were chosen. This resulted in a matrix, matching the selected methods and strategies for each determinant.In step 4 it is important to verify that the program content matches with the intended target group and program context. To assess the strengths and weaknesses of a participatory RTW program for sick-listed temporary agency workers and sick-listed unemployed workers, a context analysis was conducted. Semi-stStep 5 can be seen as a re-run through the previous IM steps, now focussing on objectives, methods and strategies to ensure the adoption and implementation of the participatory RTW program by the users. Anticipation of implementation is an important factor, ideally starting at the beginning of the IM process. In this step it is required to identify potential users, to formulate adoption and implementation performance objectives for the program users, and to select methods and strategies to achieve the necessary change in behaviour. To achieve successful adoption and implementation in this study, instruction and coaching sessions were held among the users, i.e. OHC professionals. This was supported by purposely developed syllabi with detailed information about the intervention, practical summaries and schemes, and practice material.Step 6 is the anticipation of process and effect evaluation. The list of proximal program objectives, i.e. the main objectives of the new program formulated in step 2, was used as a guidance for the evaluation of the participatory RTW program effects. This resulted in an evaluation plan with defined variables and corresponding evaluation measures.A longitudinal cohort study among sick-listed workers without an employment contract -41, consAmong the interviewed stakeholders, the need for a new and (cost-)effective RTW program for sick-listed temporary agency workers and sick-listed unemployed workers was commonly shared. Representatives of the SSA involved in policy regarding the Sickness Benefits Act argued that there should be more focus on RTW and on what a disabled worker still can do. Furthermore, decision makers from the SSA emphasized that there is a need for more uniformity and evidence-based interventions. Representatives of the SSA involved in policy regarding the Sickness Benefit Act and Unemployment Insurance Act underlined the need for starting earlier with OHC than current usual care, i.e. between 2 and 4 weeks after reporting sick. In addition, many of the stakeholders viewed also the absence of a workplace to return to a major obstacle for sick-listed temporary agency workers and sick-listed unemployed workers. And although there is a need for (temporary) adjusted work to facilitate RTW for these workers, this is not offered in practice. For the Dutch association of temporary work agencies (ABU) it was important to emphasize "the possibility for temporary work agencies to contribute to their social function and relevance by participating in RTW programs for these sick-listed workers". Since 2003 there is an official covenant between the SSA and the ABU, in which responsibilities for RTW of sick-listed temporary agency workers have been stated. Major themes are attention for the sick-listed temporary agency worker, offering a perspective regarding RTW, and reducing sickness absence. For the decision makers of the SSA and the ABU, minimizing the annual cost of benefit schemes was an important incentive. However, according to the ABU, in daily practice "temporary agency staff are judged on turnover, not on time-consuming rehabilitation support". Moreover, knowledge and experience regarding rehabilitation and RTW of sick-listed temporary agency workers were limited among the temporary agency staff. Structural communication to exchange information, knowledge and experience about OHC and RTW between the SSA and temporary agencies, was viewed as an important and crucial factor in the success of RTW programs for sick-listed temporary agency workers. One of the interviewed vocational rehabilitation agencies had a collaboration with several companies and offered directly available temporary workplaces. The other agencies relied on their network of potential employers, to supply a suitable (temporary) workplace. However, directly available workplaces among the employers in their network were rare. Because searching for a suitable (temporary) workplace and a willing employer takes time, as a result of the interviews it became evident that a financial incentive was needed for the vocational rehabilitation agencies. In figure Summarizing, based on the needs assessment it became clear that the strength of the participatory RTW program was thought to be the consensus procedure to stimulate an active role of the sick-listed worker, to enhance the motivation for RTW and to ensure an adequate match between the temporary work and the capacities/capabilities of the sick listed worker. The possibility of an actual workplace for therapeutic RTW was also viewed as an important key element. Taking into account appropriate incentives for all the stakeholders involved, it was believed to provide an important contribution in RTW of this vulnerable group of workers.Based on the needs assessment and a literature review the proximal program objective, i.e. the main objective of the new program, was formulated: reducing long-term sick-leave and occupational disability for temporary agency workers and unemployed workers, sick-listed due to MSD. Temporary agency workers and unemployed workers with MSD should RTW early and safely by reducing obstacles for RTW and by matching of personal capacities with work(place) demands. Obstacles for RTW can be related to the workplace, work organisation, working conditions, social relations, work environment , and personal abilities. In the absence of a workplace to return to, a matching temporary (therapeutic) workplace has to be created.Important stakeholders for a participatory RTW program for sick-listed workers without an employer appeared to be: the temporary agency worker or unemployed worker himself/herself, the OHC providers, i.e. the insurance physician and the labour expert from the SSA as well as the case-manager from the vocational rehabilitation agency or temporary agency. And finally, an important stakeholder in the new participatory RTW program was found to be the RTW coordinator, who is The selected performance objectives to reduce long-term sickness absence and occupational disability among temporary agency workers and unemployed workers sick-listed due to MSD are presented in figure personal determinants  and external determinants .After stating the performance objectives, the ASE model was used as a framework to describe factors influencing a change in behaviour, i.e. achieving (therapeutic) RTW of the temporary agency worker or unemployed worker. The identified determinants for each performance objective were divided into Finally, based on evidence from a literature review and the needs assessment, matrices were created of the stated performance objectives, and the formulated learning and change objectives. Table Suitable methods and strategies were selected based on a review of the literature, a brainstorm session in the project group, and input from key stakeholders derived from the semi-structured interviews. Next, these methods and strategies were incorporated in the new RTW program. In table From the interviews with the users, i.e. OHC professionals (insurance physicians and labour experts from the SSA), it became evident that clear information about and adequate training in using the participatory RTW program was considered important. To avoid delay in starting with the program, appointments had to be made to ensure a quick consult with the insurance physician and labour expert. Additionally, avoiding too much paperwork and supplying adequate computerised support to follow the RTW program were mentioned as relevant success factors. Realizing sufficient support by the staff of the SSA and a structural communication link between all participants by appointing case-managers were also seen as crucial elements. Furthermore, work pressure in daily practise was perceived high and the OHC professionals argued that explicit appointments had to be made with management to ensure sufficient time for implementing and using the new RTW program. Another important precondition was the presence of a RTW perspective for the sick-listed temporary agency worker or sick-listed unemployed worker, by offering an actual workplace for (therapeutic) RTW. In addition, the decision makers advised to ensure adequate overall implementation support by appointing a fulltime project manager. And the staff of the SSA emphasized the importance of having an independent person to guide the process towards a consensus based RTW implementation plan. Also, clear appointments about financial rewards for vocational rehabilitation agencies were seen as an important precondition to ensure the presence of RTW perspective for these vulnerable workers. Finally, from the perspective of the temporary work agencies it was important to have a worker who is directly employable. This meant that the RTW implementation plan could be matched with existing vacancies. The results of the semi-structured interviews and input from the 'fine-tuning' meetings with the OHC professionals, staff and management of the SSA were used to design the final participatory RTW program.Important elements from the needs assessment that have been incorporated in the RTW program are: the making of a RTW implementation plan with active involvement of the sick-listed worker and matching of possibilities with capacities; creating an actual (therapeutic) workplace; focus on what a disabled worker still can do; starting earlier with OHC; facilitating structural communication between the SSA, the temporary work agency and the vocational rehabilitation agency and; supplying a financial incentive for the vocational rehabilitation agency. In addition, as a result of the context analysis, i.e. the semi-structured interviews, the following items were incorporated: an appointment was made to ensure a quick consult with the insurance physician; an appointment was also made to ensure that the OHC professionals had sufficient time to work with the new RTW program; a specifically tailored computerised support system was developed; case-managers were appointed for structural communication between all parties involved and; a fulltime project manager was appointed.As a result of the needs assessment, the semi-structured interviews and input from the focus groups, the existing participatory RTW program for employees sick-listed due to low back pain was adapted and resulted in a participatory RTW program for temporary agency workers and unemployed workers sick-listed due to MSD. First, the sick-listed worker is an essential stakeholder. Another important stakeholder in the RTW program for sick-listed employees is the supervisor at the workplace. Since in most cases the sick-listed temporary agency worker or sick-listed unemployed worker has no employer, there is also no formal supervisor. For this group of sick-listed workers, the SSA is responsible to facilitate RTW: the insurance physician has the role of OHC professional and the labour expert has the role of case manager in vocational rehabilitation support. Thus, the labour expert of the SSA is the second important stakeholder in the new RTW program. Finally, a key role in the participatory RTW program was found for the RTW coordinator, who guiTo ensure that the (labour expert in the role of) case-manager in the participatory RTW program has sufficient information regarding the sick-listed worker, the sick-listed worker always has a consult with the labour expert before the start of the program. For practical reasons, and to minimize the inconvenience for the sick-listed worker, this consult directly follows the first consult with the insurance physician.To stimulate an active involvement of the sick-listed worker in the participatory RTW program, the insurance physician asks to make an inventory of RTW obstacles, whether it be work or non-work related, as a home assignment in the first consult. The sick-listed worker is also asked to indicate to what extent the obstacles can be influenced. This inventory can be used as a starting point in the interview with the RTW coordinator.Adequate introduction by the RTW coordinator is important. The RTW coordinator underlines his/her independence, and stresses that guiding the participatory RTW process with equal contribution of the sick-listed worker and the labour expert is his/her main goal.In the planned brainstorm session the RTW coordinator, the sick-listed worker and the labour expert formulate solutions/possibilities for suitable (therapeutic) work. These solutions/possibilities can include aspects regarding work content, workplace, work organisation, work conditions and/or work environment. Since there is (in most cases) no workplace to return to, an extra element was added to the program. To provide an actual workplace, agreements were made with four vocational rehabilitation agencies. Within four weeks after enlisting, the assigned vocational rehabilitation agency has to offer at least two suitable therapeutic workplaces matching with the RTW implementation plan. If these suitable workplaces are not offered within the four week period, the other vocational rehabilitation agencies are asked also to search for suitable workplaces.As a conclusion of the above mentioned brainstorm session, the RTW coordinator makes a report in which the main items of the participatory RTW process are described: a summary of prioritised obstacles for RTW, the consensus based solutions, and if possible a concrete work(place) profile. In this RTW implementation plan explicit arrangements are formulated, including a concrete time path. Who does what and when? This report is then sent to the sick-listed worker, the labour expert and the insurance physician. And finally, the RTW coordinator informs the case-manager of the assigned vocational rehabilitation agency.The vocational rehabilitation agency has the task to find a (therapeutic) workplace, matching with the profile in the RTW implementation plan. A financial reward is given by the SSA to the vocational rehabilitation agency for placement in a matching (therapeutic) workplace.The RTW coordinator evaluates approximately six weeks after making the consensus-based RTW implementation plan to see if everything is going according to plan. This is then registered in a final report and send to the sick-listed worker, the labour expert and the insurance physician.As mentioned above, important stakeholders were involved in development of the new participatory RTW program to facilitate successful adoption and implementation. Next, purposely developed instruction and coaching sessions were held among the users, i.e. OHC professionals. All involved professionals received a syllabus with detailed information about the program, the participatory RTW protocol, practical summaries and schemes, and practice material. An additional training was developed for the RTW coordinators. The coaching for all involved professionals focused on: content of the protocol, role of the insurance physician, role of the labour expert, placement in (therapeutic) work by the vocational rehabilitation agency, and a brief instruction regarding the for this project developed computerised support system. The additional training for RTW coordinators focused on: content of the protocol, role of the RTW coordinator with illustrations for each step, and practise with anonymous cases and reporting. All professionals were offered personal guidance with the first cases to facilitate working with the new RTW program. Also a follow-up session was held with all participating multidisciplinary teams separately, consisting of the RTW coordinator, the labour expert and the insurance physician, to discuss difficulties and problems with working with the new RTW program in practise. A second follow-up session was held with all involved professionals together, including staff and management. This session was aimed at briefly refreshing the content of the participatory RTW program and to practise with cases as the main purpose.Finally, to ensure adequate overall implementation support a project manager was appointed. Also a team to guide the process of implementation was formed, consisting of the researchers, representatives of the staff and management of the SSA, including the project manager, and representatives of the participating vocational rehabilitation agencies to facilitate adoption and implementation.The (cost-)effectiveness of the new participatory RTW program will be evaluated in a randomised controlled trial. In addition, the implementation process will be evaluated. The Medical Ethical Committee of the VU University Medical Centre  has approved the study protocol. Trial registration: NTR1047. The results will be described elsewhere.The aim was to describe the development, implementation and evaluation of a theory- and practise-based participatory RTW program for a vulnerable group among the working population, i.e. temporary agency workers and unemployed workers, sick-listed due to MSD. Following each IM step carefully, made it possible to tailor the existing participatory RTW program, taking into account the specific target group, the implementers, the users as well as the context in which the new participatory RTW program will be applied.IM proved to be a useful tool to map the path from needs and feasibility to a specifically tailored participatory RTW program. Because implementation of evidence-based interventions in OHC has been difficult, there is a need for systematic documentation of intervention development and implementation research. Going bAnother strength of this study is the use of the ASE model -31 as anIn addition, the new participatory RTW program was specifically tailored for the target group, the users and the context. By discussing with stakeholders e.g. in focus groups about important factors for innovations, such as potential advantage, complexity of the new program and compatibility with daily practise, we believe that this will enhance the success of future implementation.Finally, in our opinion, following a time-consuming intervention development process, i.e. IM, instead of choosing a more haphazard approach to intervention design, led to innovations that otherwise would have been missed. For instance, the development of a specifically computerised support system, and making of explicit appointments with the management to ensure sufficient time for the OHC professionals to work with the new program. We believe that following the IM process resulted in a combination of keystones to be incorporated in the new participatory RTW program, which will enhance the commitment of the stakeholders and the implementation of the intervention by tailoring the intervention to their needs and the specific context.In this study the contribution of the intended target group itself was relatively modest compared to other stakeholders. Because the program has to be carried out by the OHC professionals of the SSA, the majority of involved persons in IM were from the SSA. It is possible, that the IM process would have resulted in other changes of the participatory RTW program if temporary agency workers and unemployed workers, sick-listed due to MSD, would have played a larger role in program development. However, when looking at the results of a longitudinal cohort study among sick-listed workers without an employment contract -41, whicDevelopment of OHC interventions is a relatively rare described topic in the international literature. The few publications,52,53 arTo date, IM has been mainly used as a tool for the planning and development of health promotion interventions -27. ReceIn addition, further development of other occupational disability interventions for the vulnerable working population, i.e. workers without an employment contract, is needed. Since these workers do not have a permanent workplace/employer to return to when they are sick-listed, there is a need for new interventions which focus on RTW possibilities and which provide an actual RTW perspective for this group of workers. IM seems a promising tool to tailor new interventions to the specific needs and context and to enhance applicability and effectiveness of these programs.Following all IM steps resulted in a structured stepwise participatory RTW program for temporary agency workers and unemployed workers, sick-listed due to MSD. The implementation process and the cost-effectiveness regarding this new intervention will be evaluated in the near future.The results will be available in 2010.The authors declare that they have no competing interests.SJV, JHA and AJMS were involved in development of the participatory RTW program. SJV and JHA were responsible for the general coordination of the study and the implementation of the participatory RTW program. SJV drafted the manuscript. All authors have read and corrected draft versions of the manuscript and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Health messages may have the highest impact if they are given early in life. Therefore, the Dutch Ministry of Health identified pregnant women as a target population and initiated an innovative eHealth program to serve as a communication channel of health messages to pregnant women. The aim was to study the feasibility of implementing this eHealth program into standard midwifery care and to investigate use and user perceptions of the online program among pregnant women. All midwifery practices in Amsterdam affiliated with the Dutch Organization of Midwives (n = 25) were requested to implement the eHealth program within a pilot study from March to August 2006. Structured interviews were used to study feasibility of implementation among midwives. During the study period, 488 pregnant women registered themselves on the program website, after which monthly emails were sent to them. The emails were tailored to the stage of pregnancy and provided interactive questions plus answers on six topics and links to related websites. User statistics were registered until January 2007, and user perceptions were assessed with electronic questionnaires.P = .02), but the number of clicks to related websites was not associated with program perception (P = .32). The main improvement suggested by program users was to expand the information within the program. In total, 80% (20/25) of midwifery practices implemented the program. These midwives gave a short oral explanation about the eHealth program to their clients  and handed out an information brochure. After the pilot, 12 midwifery practices were willing to integrate the eHealth program into their standard care procedures. Regarding program usage, 84% (408/488) of the enrolled women accessed health information within the program. They opened 59% (1296/2213) of the quiz emails and accessed, on average, 16 topics (SD 11). Only 35% (143/408) of users used the hyperlinks to visit related websites. Most women perceived the eHealth information as easy to understand  and reliable , but only 39% (48/153) agreed that the information was available at the right time. Accessing more topics within the quiz emails was associated with a more positive perception of the program ( It is feasible to integrate an innovative eHealth program in standard midwifery care, and about half of the practices would like to continue doing so. Program users accessed a substantial proportion of available health information; however, user perceptions were mixed. Therefore, this eHealth program may be a feasible communication channel to promote a healthy lifestyle to pregnant women after suggested revisions have been carried out. Most women welcome health-related information during their pregnancy and search for pregnancy-related information on the Internet -3. The rIn the Netherlands, 85% of pregnant women start their maternity care at a midwifery practice , the eHeWe have performed a pilot study among almost 1400 pregnant women to study the feasibility of integrating the eHealth program into standard midwifery care. The process evaluation of this study is carried out in line with the RE-AIM model . This moTherefore, the purposes of this paper are (1) to study the feasibility of implementing an online healthy lifestyle program into standard midwifery care, including midwife perceptions of the program, and (2) to analyze use and user perceptions of the eHealth program among pregnant women. The results of both objectives served to further improve the program before its countrywide implementation.The program consisted of monthly emails containing a link to a quiz, with a maximum of six questions, tailored to the stage of pregnancy. The quizzes were stored on a website. On the program website women could register for the program and find more information about it. However, health-related information was only accessible through the emails. The content of the intervention program was especially developed for women with a low education level, by presenting the information in plain language and short text blocks, thus requiring only basic literacy skills. Five health-promoting institutes were responsible for the content of the topic of their relative expertise , and the Dutch Organization of Midwives was responsible for the content of the pregnancy topic. In this way, existing pregnancy-related information was brought together within one program.Each email was personalized with the first name of the participant and the number of weeks she was pregnant, and it contained one question from the quiz. The participant was invited to click on the specified link to find out the answer to that question. Clicking on this link automatically opened a new screen with the quiz.After opening the quiz screen, the six topics were displayed . Going o                    In the Netherlands, midwives are independent paramedical practitioners, qualified to provide full maternity care to women whose pregnancy and childbirth are uncomplicated. The primary task of the Dutch midwife is to monitor the health status of pregnant women and their unborn children. Because of their frequent contacts throughout pregnancy and because of their expertise, midwives are considered to be important information providers for pregnant women, especially for women pregnant with their first child. Therefore, midwifery practices are a unique platform to inform pregnant women about the existence of an eHealth program with relevant and reliable pregnancy-related information. Furthermore, it is likely that information about the eHealth program could easily be incorporated into standard care since general health and lifestyle information is already given during the first midwifery visit.All 25 midwifery practices in Amsterdam affiliated with the Dutch Organization of Midwives were requested to implement the eHealth program from March to August 2006. They were instructed to give oral information about the program and hand out an information brochure to all of their clients before the 16th week of pregnancy in order to motivate their clients to enroll in the eHealth program. The midwives informed 1382 women about the eHealth program, and 238 women (17%) subsequently registered themselves (at home) on the program website, as described in more detail elsewhere . In addiIn July 2006, the 25 midwifery practices were contacted by telephone to make an appointment for an interview. At this stage we checked if the practice had implemented the eHealth program. Practices that did not (actively) implement the program were asked a few short questions to discover why they did not participate. For the participating practices, a date was set for a structured interview. Preferably, the interview was conducted face-to-face within the midwifery practice with one or more midwives; when this was not possible, the interview was done by telephone. One midwifery practice was unavailable for the interview due to time restraints and personal circumstances of the midwives. However, the practice assistant gave a general impression of the implementation. The questions within the interview were categorized into four sections: implementation, program perception by midwives, points for improvement, and some general information about the midwifery practice. It took approximately 15-30 minutes to complete the interview. The answers of the midwives were summarized by the interviewer and manually recorded during the interview. To estimate the delivery rate of the program within the midwifery practices, the midwives were asked to record each client who was informed about the program on a specifically designed card. Furthermore, during the interview, the midwife gave an estimate of the number of clients visiting the practice.User statistics were registered until January 7, 2007, by a third party specialized in Internet technology  and included enrollment data, emails sent, quiz questions accessed, practical tips accessed, and related websites visited through hyperlinks within the program. A quiz email was considered as opened if at least one question was accessed. A self-completed questionnaire was used to assess participant characteristics at baseline.An online self-administered questionnaire was used to measure user satisfaction with the eHealth program. Invitations to complete the questionnaires were sent by email the week after the participants received the third quiz email, but no invitations were sent after the 40th week of pregnancy. The feedback questionnaire contained several statements about the program that could be rated on a five-point scale . Participants could also indicate which of the six lifestyle topics they enjoyed most and found most useful, and overall satisfaction was rated with a score between 1 (“very bad”) and 10 (“very good”). The questionnaire ended with an open-ended question (“What could we do to improve the program?”). The participants who gave feedback were divided into three groups based on their scores on five user perceptions of the program: interest, usefulness, timing, pleasantness, attractiveness  was assigned to each program user. The data from the baseline and feedback questionnaires were manually linked to an ID by means of name, zip code, and email address.Descriptive analyses using means, standard deviations, medians, and percentages were used to describe program use and user attitudes. Chi-square tests were used to detect associations between participant characteristics and user attitudes. Analysis of variance (ANOVA) with follow-up trend analyses was used to detect associations between user satisfaction and program use. Furthermore, linear regression analyses were used to examine the association between five individual perception components  and program use (dependent variable). SPSS version 12.0.1  was used for all analyses, and statistical significance was set at a level of 0.05.In the pilot project, 80% (20/25) of midwifery practices informed their clients about the program. The other practices did not implement the program, mainly because they considered the program unsuitable for the majority of their clients (highly educated or non-Dutch-speaking women). One practice reported time constraints as the main reason.The midwives in the 20 participating practices informed their clients about the eHealth program during a standard visit. They all handed out an information brochure, and, with the exception of one midwifery practice, they all gave a short oral explanation about the eHealth program . This waSuggestions to facilitate further implementation of the program were to use more promotion materials and to reconsider the moment most appropriate for giving information about the eHealth program.About half of midwifery practices (12/25) wanted to integrate the eHealth program into their standard care after the end of the study period. Five practices that did not implement the program during the study period would also not implement it after the study period. The other eight practices would not like to continue implementation and had more negative program perceptions than midwives from practices with a positive intention to continue implementation . The majDuring the study period, 488 pregnant women registered themselves on the program website, and 16% (80/488) of them enrolled but did not access any information available within the program; therefore, they are excluded from all further analysis. The baseline characteristics of participants are summarized in Program users (n = 408) received a mean of 5.4 (SD 1.6) quiz emails and accessed an average of 3.2 (SD 1.8) of those quizzes during their pregnancy . A minorNot all participants received three quiz emails and therefore did not receive an invitation to complete the feedback questionnaire (n = 32). Taking this into account, the response rate for the feedback questionnaire was 43% (163/376). Most women evaluated the program as easy to understand  and reliable , although only 39% (61/161) agreed with the statement that the information was available at the right time . Overall                    P = .81). A higher satisfaction with the program was associated with accessing more information within the program, although there was no significant association between satisfaction and the number of related websites visited (P = .32). There was no association between satisfaction and educational level (P= .21) or with any other personal characteristic shown in The participants who completed the feedback questionnaire were divided into three satisfaction groups based on their responses to the statements about the program . The thrP = .01; β = −2.2, P = .04, respectively) and tips . Women who found the program interesting or useful accessed about four more questions or tips than women who did not find the program interesting or useful. A higher perceived attractiveness of design was only associated with accessing more tips , with women who found the design most attractive opening about four more tips than women who did not find the design attractive. There were no associations between perception components and the number of emails opened or the number of related websites visited. When the five individual components were included simultaneously into one regression model, no significant associations with the number of questions opened were seen, while attractiveness of design was still associated with the opening of tips . Furthermore, all five components were associated with the overall rating.We used regression analyses to investigate the association between individual perception components and program use and found that higher perceived interest and usefulness were associated with accessing more questions  of midwifery practices implemented the program. However, this adoption rate may not be achieved with the countrywide implementation. Some of the midwives were actively involved in the development of the program, and there were personal contacts with the publisher of the online program, which probably increased the adoption rate. However, the study implementation was done in a real-life setting and shows promise for the future countrywide implementation since half of the practices would like to integrate the program in their future standard care. Unwillingness to continue implementation of the program was not related to practical barriers, but to how midwives perceived the program. More practices may integrate the program into their future standard care if it was emphasized that the program is designed to bring existing information together and that this feature helps women to gather all relevant information easily, since several midwives had a negative perception of the program because it contained little information that was not already available from other sources.The program users accessed, on average, 16 different health promotion messages during their pregnancy, which means that, in general, about half of the available health information was seen. Because user perceptions were mixed and several revisions were suggested, the program will be improved before the countrywide implementation, which may increase program usage.P< .001), tips (P < .001), and related websites (P= .02) than women who did not complete the questionnaire, and satisfaction was associated with more intensive use of the program. However, women who completed the questionnaire did not differ in baseline characteristics compared to women who did not complete the feedback questionnaire, with the exception of a more favorable smoking status among women who gave feedback. There was no association between education level and satisfaction with the program, although the program was designed specifically for women with a lower education. The frequent remark that the program hardly contained any new information was made by women with both a high and low education.It is thought that program satisfaction within the study is somewhat overestimated. The women who completed the feedback questionnaire accessed more topics (Our results showed that the perceived attractiveness of design was an important factor influencing program use.A strength of our study is that we studied feasibility of the program among both users and midwives using a combination of quantitative and qualitative data. The user perceptions are supplemented with objective usage data, which provide further insight into the program features that need improvement. Furthermore, the evaluation among midwives indicated that the implementation of the program is feasible in a real-life situation.In most midwifery practices several midwives work together. A limitation of the study is that the interviewed midwives might have had more positive attitudes toward the program than their non-interviewed colleagues. Therefore, we asked all midwives to register all clients to whom they gave information about the program. These data were used to estimate a more objective program delivery rate. The interviews gave insight into the reasons why midwives did not advocate integration of the program into standard care.Some midwives expressed concerns about the reach and effectiveness of the program. Indeed, previous work showed that disadvantaged women were least easily reached by the health information available in the eHealth program , and wheTo our knowledge, only one other eHealth program that made use of emails to promote health behaviors has been evaluated previously . This prTo our knowledge, there are no other studies that evaluate the feasibility of integrating an Internet program with health information within standard health care. One study introduced an eHealth program to general practitioners to support their patients with lifestyle changes. However, this study focused on practitioner views toward program usability and program design .It seems feasible to integrate an eHealth program into standard midwifery care. About half of midwifery practices would like to continue recommending an eHealth program to their pregnant clients, and hardly any practical barriers to implementation were reported. Program users accessed a substantial proportion of available health information; however, user perceptions were mixed. Therefore, this eHealth program may be a feasible communication channel to promote a healthy lifestyle to pregnant women after suggested revisions have been carried out. Further research should evaluate email intervals, user needs, and attractiveness of embedded links to optimize transfer and uptake of information.