Bruno Kesser Foundation

An interview with  Alberto Zanutto,  researcher eHealth Lab

Our way towards the age management

Key to Health was first experimented within the Bruno Kessler Foundation, targeting the more than 500 workers present within it, this experimentation began on February 17, 2017, being inaugurated by a special kick off meeting and will end in early October 2017. The intervention model proposed and tested by Key to Health aims to push workers to change a substantial part of their lifestyle and is divided into the following phases: 

All workers are offered an assessment of cardiovascular risk (RCV) and risk of incurring Type 2 diabetes (RD2) through an online questionnaire, formulated by the competent doctor of FBK together with the Operational Unit of Prevention and Safety in Work Environments (UOPSAL). All those who have filled in the questionnaire receive written feedback (via company email) from the competent doctor relating to their level of RCV and RD2 within 20 days. In the internal experimentation at FBK, 94 questionnaires were completed. 

All workers, who have or have not participated in the Risk Assessment phase, are offered to download and use TreCLifeStyle, in order to reduce the risk (if already present) or to prevent it. TreCLifeStyle is presented as an app with the main purpose of educating the worker to respect the Mediterranean diet, asking him to compile a daily diary on the basis of which the system provides indications and suggestions on changes to be made to one’s lifestyle. In the FBK internal experimentation, the app was used continuously, that is for more than a month, by about 40 workers. 

At-risk workers are given the opportunity to enter an intervention path supported by TreCLifeStyle and, jointly, by the competent doctor and a healthcare assistant. The doctor submits all the workers at risk identified through the Risk Assessment phase to two medical examinations. The first visit was aimed at deepening the data collected during the questionnaire. The second visit is scheduled for the end of the course and is aimed at analyzing the progress made by each individual participant and, secondly, assessing the medical effectiveness of the intervention. In the FBK internal experimentation, the participants in the prevention pathway selected were 19, chosen to be the most at risk among the 94 workers who completed the online questionnaire. 

In the FBK experimentation, the following actions were implemented: 

– Starting course for physical activity: carried out in collaboration with the FBK Employees’ Club, under the direction of a professional instructor for a total of 10 meetings. 

– “1000 steps in FBK” initiative, in which a 1 km post-lunch route around the Foundation buildings was shown and tested with the employees.

– Several seminars “Healthy and correct nutrition” and “Promoting Health & Longevity through Diet: Metabolic and Molecular Mechanisms” attended by about 65 people each.

Strengths and weaknesses of the chosen approach

The main strength of the project is that it brought the strategic agencies of this initiative around the table. that is, the province that deals with health management, including reference to prevention in the workplace, since we are an autonomous province. INAIL, which has its own sensitivity, therefore works a lot on events but also has an interest in prevention and wellbeing. The health company that has a specific office that deals with all prevention in the workplace and that refers to safety managers etc…And then we were there. We were a strategic technical partner in the sense that at the time a colleague who is no longer with us Francesco Miele, who has his training as a sociologist of organizations, had seen this space as an opportunity because we live on experimentation, science and deepen some questions related to the organizational way. So, a strong point was the partnership and the good mix of people around the table who wanted this type of initiative.

Another good result was having worked hard on the idea of motivation, promoting the well-being of prevention within logics that are not only medical but also motivational.

A third element I would say was having an external partner regarding safety at work, with which we experimented, who believed in us, who was sensitive to the initiative, indeed it continues to be, which in our case is a private body, called Progetto Salute, but which acts as a competent doctor who has collaborators on a plurality of companies and who therefore wanted to invest in this space. Because as you know the whole world of the competent doctor goes from the pure rigidity of regulation to trying some type of initiative 2.0 things like this. 

A 4 element … I would say that it was the possibility of working with the company, albeit indirectly, and here instead the weakness begins, that is, the extreme weakness of these initiatives when it comes to a public body that promotes them, then in fact the private body looks at the projects sufficiently or says “yes, beautiful but complicated things”, also because the historical dimensionality of Italian companies does not allow this type of development in a reasonably strong way. That is, the significant players are now 10 or 15 in Trentino, those who can have this type of attention in the workplace. There is much handicraft, tourism, very small business, and then the effect of an external service of this kind is always very low. 

In short, we say that the weakness is in the characteristics and in the context and also the lack of preparation: objectively our security officers have not prevention aims, they are within the dynamic of formal fulfillments, respect for the rules because then they were trained on. 

Another aspect of weakness is the software part; we had to supply the software part, but the project went well despite the software part. We had given an app to monitor the movements a little; this type of thing that is now very widespread but that four years ago was not yet so widespread. Our planning and design was not effective, but it had been effective as a repository of the people who had been tracked for a couple of weeks then they met a counselor, let’s say motivationally, about their commitment. 

The outcomes were a weight loss and very positive things but not so well studied as to be valid on a clinical or motivational level. However the software was criticized by everyone, it could not do what it had to do. Always it happens in the initial attempts. This has helped us fix some things. However, moving forward with the project, the quality of software recognized by users was irrelevant. Users have however recognized it as a clever thing: being able to go to the office, being able to be traced, has also allowed us to think about healthy eating. 

For example one thing that is not yet done but that came out quite clearly is that cafeteria never put the caloric value of the dishes they offer. So a person arrives in the cafeteria a little stressed, a little hungry, in the queue he sees a nice plate of pasta, he takes a nice portion and does not know that there are 1500 kcal in there and that he gets sleepy in the afternoon, in the evening does not go for a run. It is a calorie load that does not hold up in the long run. We have given a series of interesting indications also from this point of view. 

Tha “aha!” moment experienced during the process 

No “Aha” moment, something is born into logic of prevention, in other words, it is a strategy of the province of Trento, to make initiatives on prevention, which, as usual, are always a bit deficient … No, I would say that it started cold.

Activities to sustain this initiative

The design and testing of the Key to Health project was co-financed by INAIL and the Autonomous Province of Trento, for a total of 116,000 € for the 2017-2018 two-year period. 

Funding was essential for the creation of the app, for the scientific evaluation of the progress of the trials, for the coordination of the project, as well as for obtaining the performance of the competent doctor and the counseling service. The reproduction of the model in itself, however, would weigh on the organizations only as regards the costs of the medical and motivational intervention, for an approximate total of 450 € for each employee involved in the prevention process, of which: 230 € for the evaluation of questionnaires and initial and final medical examination; 70 € for the pedometer bracelet; 150 € for three hours of motivational interview.

Monitoring system of the effects

The project did one, two, official experiments … then actually we did 2 more. In these 4 experiments, we monitored with a mixed method: we used both rigid tools i.e. questionnaires administered before and after the initiative and semi-structured interview activity done to official players, flow regulators, things of this type but since the experiments were quite contained over time, the interviews were positive but objectively we are only interested in the prototypal capacity of the idea, not so much the clinical stability of the matter. 

We do not have clinical evidence on efficacy, but we have many motivational and organizational evidence. We collected personal records made at the end of the period or semi-structured interviews for the participants, for supporters of the initiative and for institutional players. 

On the site there is a bit of downloadable material and there is also the thing that interested us most, the most interesting product for us to produce was this manual we say in some way exhortative and, how to say, for the promotion of this type of initiative aimed at companies from which they can draw independently and we have left, in this case to the health company and the autonomous province of Trento, the possibility of being called for training or things of this type for free but so far we have not seen a particular of interest.

Beneficial effects of the initiative

The internal experimentation at the Bruno Kessler Foundation provided for an evaluation of the intervention model on the following levels: 

• user experience of the coaching system: through the administration of SUS questionnaires (System Usability Scale), we aimed to evaluate dimensions such as the ease and pleasantness of using technology, the learning required to become familiar with it, the ways in which this has become part of the users’ daily lives; 
• organizational sustainability of the interventions: by carrying out preliminary focus groups with top figures and workers and interviews with the workers involved, the frequency with which the participants took advantage of the interventions offered by FBK and the characteristics that pushed / hindered them were assessed participation; 
• medical efficacy: through medical visits (only for workers initially at risk) and distribution of questionnaires for the evaluation of the RCV and RD2, the aim was to evaluate the medical efficacy of the package offered by FBK.

At the moment, TreCLifeStyle seems to have been used continuously especially by the participants in the prevention pathway who perceived it as complementary to the face-to-face counseling interviews. TreCLifeStyle has been particularly appreciated for allowing the worker, through features such as the daily and weekly diary, to become aware of their eating habits and which of these are correct or incorrect. 

The persuasive side of the app is currently appreciated even if it is considered to be improved and, consequently, the main role of motivation for change is played by face-to-face counseling.

Personal recommendation

As a personal comment I can say that the experience we have had has been very positive to raise awareness in the system. The system-wide result was interesting. 

We understood that another key point is the competent doctors which are unfortunately not aligned for many reasons. 

Finally, the fact that we have carried out some tests in the public body, with the health company, and the competent doctors of the health company immediately put on the table the fact that there was a contractual problem underneath. 

That is, if they are hired to do one thing and we ask them to do others … because they had to do an initial monitoring interview that precisely allowed to manage the patient’s information and then collect at the end of the experiment, but this was out of contract, so this costs them effort, they don’t feel like it, it cannot be a widespread initiative. The usual Italian problem, so there is a problematic initiative, this thing cannot be done lightly. 

Another element of complexity in my opinion is the monitoring. There are many variables but they are very vertical: if one person wants to take something to run, you have something to run that is very well done but maybe the part of the diet is not well done. 

If you have the part of the diet well done, then the information to track movements or steps is not well recorded. 

There are many verticalities still struggling to be resolved. We are also exploring other projects of this kind but it is a small jungle because the user does not have the same number of steps that records another app because obviously algorithms can change the calculation of the steps depending on the sensor of the watch or the phone. 

It is a classic case of epiphanic matter at the moment on which there is a long way to go, above all of alignment between the user who uses the instrument, the designer who creates that instrument and the clinical outcome and impact of the clinical outcome of the health information that can be kept to itself or shared with the system.

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