Interventions for increased physical activity among office workers

Interventions for increased

physical activity among office

workers

Introduction

Human bodies are made for movement, and the positive association

between physical activity (PA) and health is well established (1,2).

Jeremy Morris (1910- 2009) was a British epidemiologist and a

pioneer in PA research. He found that the conductors on the London

double-decker buses had fewer heart attacks compared to their

sedentary driving colleagues. He published his results in the fifties,

and since then research on PA has mainly focused on PA on a

moderate to vigorous intensity level (3,4). Over the past decade, “the

drivers of the buses” have been more in focus, and a growing body of

research has identified sedentary behavior (SB) as an independent

risk factor for diseases like type 2 diabetes, cardiovascular disease

and cancer as well for increased mortality (5– 8). Over the last

decades the technical developments have led to major changes and

challenges in our society and in working life. The service sector has

grown bigger, sedentary work in office environments has become

more common, and lifestyle related illnesses characterized by

overweight and obesity are increasing. To promote health, it is

important to find ways to decrease SB and incorporate PA in office

settings, for example, by new office designs and by different types of

behavioral interventions.

Definitions of physical activity and sedentary behavior

Physical activity is a complex behavior defined as “any bodily

movement produced by skeletal muscles that results in energy

expenditure” (9,10). The term metabolic equivalent of task (MET) is

used to quantify the energy expenditure (EE) of an activity. MET is

the ratio of a person’s working metabolic rate relative to their

resting metabolic rate, and 1 MET corresponds to the EE when

sitting down resting (1 MET = resting EE 3.5 ml O2/kg/min) and the

MET value increases with increasing PA intensity (Figure 1) (11).

Sedentary behavior (from the Latin word sedere, ‘to sit’) is defined

as any waking behavior in a sitting, reclining or lying posture,

characterized by an EE

≤1,5 METs (12). The “SB pattern” is the manner in which SB is

accumulated throughout the day or week, i.e. the timing, duration

and frequency of sedentary bouts and breaks. “Sedentary time”

describes the total amount of SB, e.g. minutes per day or week,

while “sedentary bouts” describe periods of uninterrupted sedentary

time. “Light-intensity PA” (LPA) is performed at MET levels between

1.50 and 2.99 METs, for example slow walking or light household

chores (13). Moderate- intensity PA is performed at approximately 3-

6 METs (for example brisk walking), and vigorous-intensity PA is

performed at

>6 METs, for example running, aerobics, heavy shoveling, or

digging. Moderate PA (MPA) and vigorous PA (VPA) are usually

presented together as “moderate- to-vigorous PA” (MVPA) (11,13).

Physical activity and energy expenditure

EE has three components; 1) basal metabolic rate, 2) thermic effect of

food, and

3) PA. Basal metabolic rate represents approximately 60% of EE and

is correlated to body weight. The thermic effect of food, which is

“the cost” for digestion, absorption and transportation of nutrients,

contributes with about 10% to the total EE (14). PA results in

further increased EE and the increase is closely linked to the

intensity of the activity. PA has the possibility to increase EE to a

great extent, and for extremely physically demanding tasks the EE

can increase 10-20 times compared to the resting EE. The variations

of human EE are mostly related to the degree of PA (13). Non-

exercise activity thermogenesis (NEAT) is the energy expended

during non-exercise physical activities. Most NEAT activities, like

standing, walking or household chores, are performed at light

intensities (14), but there are also NEAT activities that could be

performed at more intense levels, like climbing the stairs or cycling

to work.

Figure 1. Energy expenditure at rest and for different types of work tasks, described

in METs. One MET corresponds to the energy expenditure when sitting down resting.

(Data from Ainsworth et.al 1993 (15). Illustrated by Niklas Hofvander.

Physical activity, sedentary behavior, and health

Relations between physical activity, sedentary behavior and

health Physical inactivity is defined as an insufficient PA level to

meet present recommendations for PA, for example, adults (≥18

years) not achieving 150

minutes of MVPA per week (12,16). Individuals not reaching the

recommended guidelines for MVPA are commonly defined as being

physically inactive.

Physical inactivity is related to increased risks of several non-

communicable diseases, and is considered to be the fourth leading

factor for global mortality (1). Adults who are physically inactive

have a 20-30% increased risk of all-cause mortality, compared to

those meeting the PA guidelines. PA is also important for EE and is

critical for maintaining energy balance and weight control and for

preventing obesity (16).

%SB

MVPA is strongly associated with decreased risks of diabetes,

ischemic heart disease, stroke, breast cancer, colon cancer and

depression (2,8,16). Several epidemiological studies, both cross-

sectional and prospective, have shown SB to be an independent risk

factor for premature mortality and diseases like type 2 diabetes,

cardiovascular disease, and some types of cancer (6,7,17). The

associated risks have shown to be strongest for type 2 diabetes. For

example, in a meta-analysis by Biswas et. al., the pooled HR was

1.910 for diabetes type 2 among those with the longest sitting time.

This study also showed that the increased risk associated with

sedentary time was generally of lower magnitude in persons also

participating in PA at higher activity levels compared with persons

with lower activity levels (6). Objective measurements of SB and PA

have made it possible to quantify the time spent at different activity

levels. PA behaviors of different intensity levels are interdependent,

and research indicates that replacing sedentary time with LPA could

be important in preventing obesity (14). Studies have estimated the

health impacts of replacing sedentary time with either LPA or MVPA,

by using isotemporal statistical models (18-20). This modeling makes

it possible to estimate the theoretical consequences of replacing one

behavior with another for a given amount of time (18). In summary, a

recurring finding in these studies, is that replacing sedentary time

with either LPA or MVPA is beneficial, but greater benefits are

gained from MVPA (18-20). As an example, Matthew et al. found that

replacing one hour of SB with LPA per day decreased mortality risk

by 18%, but replacing one hour of SB with MVPA decreased the

mortality risk by 42% (20). Even though isotemporal analyses only

provide estimates of potential benefits from reduced SB, they give

insights about disease outcomes that are difficult to evaluate in

intervention trials. Figure 2. shows the distribution of time during

waking hours from an Australian study (5).

MVP

A 5%

SB LPA MVPA

Figure 2. The distribution of time at different activity levels per day during waking

hours measured by using accelerometers. SB=Sedentary Behavior, LPA=light physical

activity MVPA=moderate-to-vigorous physical activity.

In contrast to the studies identifying SB as an independent risk factor,

a meta- analysis from 2016 showed that high levels of MVPA, 60-75

minutes per day,

compared to low levels of MVPA, seemed to eliminate the increased

mortality risk associated with high sitting time (21). Thus, even

though SB and PA can be described as separate behaviours, there is

still not enough evidence to conclude whether they are independent

or not in relation to health effects, and more research is needed to

understand the interactions between SB and PA (22,23).

Epidemiological studies that have examined the health effects of SB

have mostly been based on questionnaires, and the levels of activity

have mainly focused on questions related to exercise. Some of the

studies have also used television- watching time as a surrogate

measure of SB. Television-watching time as a measure of SB has,

however, been suggested to be associated with confounding due to

related snacking behavior (22,24).

Except for the total accumulation of SB, evidence suggests that the

way that sitting time is accumulated might be of importance for

metabolic function and health (7,25,26). Experimental studies have

shown that regularly interrupting sitting with light- or moderate

intensity PA resulted in a acute reductions in postprandial glucose

and insulin levels in overweight and obese adults (27,28). The

suggested explanation for this response is the “inactivity physiology

theory”, hypothesizing that frequent muscular contractions could

prevent the harmful effects that occur from muscular inactivity

when sitting (24,29). The effects of breaking up sitting with active

breaks seem to be more effective among individuals with lower

cardio-respiratory fitness (27,30). Even though the evidence for

breaking up SB is inconsistent, it might be of great importance for

promoting health. More research is needed to understand how

interrupted sitting affects health, both acutely and in the long-term

(19,22,24). An epidemiological study, using compositional data

analysis found, in agreement with the experimental studies, that

replacing SB with LPA could have long-term benefits for glycemic

control, and thereby contribute to preventing and managing

diabetes (26).

It has proven to be challenging to induce people to embrace physical

exercise, and a possible therapeutic option could be to focus more

on decreasing SB and increasing LPA for individuals not at all

interested in exercise. Increased LPA could thus be of great clinical

importance to public health. Despite research progress in the field of

SB, the evidence base is insufficient, and more research, preferably

based on objectively measurements, is needed to support public

health guidelines for sitting time (22,23). Time spent sleeping,

sitting, standing, or moving are all interdependent, and to get a

complete picture, the contribution of objective measurements will be

of high importance in future research.

Overweight, obesity and health

Weight increase is a result of an imbalance between calories

consumed and expended, and the energy surplus results in weight

gain. In recent decades the prevalence of overweight and obesity

has increased steadily, and is described as a pandemic development

(1,31). According to the Global Burden of Disease Study, 37% of

men and 38% of women have a BMI of 25 or higher (32). In North

America, 61% of the adult population are overweight or obese, and

Europe about 50% are overweight, whereof half of the overweight

women are obese (1). Since 2006, the increase in obesity among

adults seems to have leveled off in high-income countries, but the

increase seems to be continuing in low- and middle-income countries

(32,33). In Sweden, the prevalence of obesity has tripled since the

1980s, and 51% of the adult population are reported to be

overweight or obese (34). Data from the Västerbotten Intervention

Program show that 70% of men and 55% of women between 30 and

60 years in Västerbotten were overweight or obese in 2018. The

prevalence of overweight for men and women together between 30

and 60 years has increased from 36% to 38% from 1990 to 2018,

while obesity increased from 10% in 1990 to 24% in

2018 (35).

Overweight and obesity are associated with increased risks for

diseases like type 2 diabetes, cardiovascular diseases, some types of

cancer, Alzheimer’s disease, vascular dementia, musculoskeletal

disorders, depression and reduced life expectancy. Obesity might

also lead to decreased mental health and lower quality of life

(33,36). The economic burden of obesity is also extensive. In the US,

21% of total health care costs are related to obesity and obesity-

related conditions. In Europe, approximately 23% of medication

costs are related to overweight or obesity. A study on “healthy

obese” adults showed that obese persons, even if metabolically

healthy, showed a four-times greater risk to becoming disabled with

declines in functional ability and decreased independence in older

ages, compared to normal weight adults with similar health (37).

Employers also suffer economic consequenses from obesity-related

costs, due to an increase in total absent days and decreased

productivity among obese workers (33,38). It is therefore of great

importance to reduce and reverse the obesity-related burden

globally (1,39).

The increase in overweight and obesity is driven by a complex

combination of interacting factors related to diet, personal finances,

sociocultural aspects, metabolism, genetics, physical environment,

and individual lifestyle behaviors (36). Factors in the global food

supply system are considered to lead to overconsumption and a

subsequent weight increase. Over time, the availability of energy-

dense and more processed food has increased, and such products

are often inexpensive and effectively marketed (36,40). There are

individual differences in genotypes in relation to metabolism and

obesity, but even though these factors play a role, they cannot

explain the global increase of obesity prevalence during the last

decades (33,36). Socioeconomic factors are also related to the

prevalence of obesity. A recent study within the OECD countries

showed that educational level was inversely related to overweight

and obesity, particularly among women. The McKinsey Global

Institute suggests that different sectors (i.e. governments, retailers,

consumer-goods companies, restaurants, employers, educators and

healthcare providers) all must work together to achieve success

(41). In line with this, the World Health Organization (WHO) also

claims that different sectors simultaneously should address and

contribute to the production, distribution, and marketing of food and

shape environments that facilitate possibilities to be physically

active (1).

Due to the complex interplay between different factors, there is a

need to rely less on interventions on the individual level, such as

education and personal

responsibility, and instead focus more on environments and norms

in society (32), and to combine individual interventions with

environmental and societal changes (36).

Due to technological developments in society, PA demands have

decreased in different domains, during transportation, leisure, and

household chores, as well as at work (5,14,42). Variability in NEAT

could be one explanation for different levels of EE in humans, and is

dependent on the total activity in all domains.

Due to societal developments, the levels of NEAT have decreased. By

reassigning time spent sitting to more NEAT activities, daily EE

would increase, which would facilitate weight stability and thus

imply great benefits to public health (13). Regardless of weight, PA

is important for counteracting weight gain and for stabilizing and

slowing down health deterioration (37). PA has positive health

effects among overweight or obese individuals, and may play a more

important role in preventing ill health than previously believed

(43,44).

Physical Activity guidelines

PA is recommended to promote health, reduce the risk of chronic

diseases, prevent early death, and preserve or improve physical

capacity such as fitness and strength (16,45). Guidelines are

developed by experts under the Office of Disease Prevention and

Health Promotion in the US, and are based on the current

scientific evidence (46). The PA guidelines for American adults are

presented below:

1. Adults should move more and sit less throughout the day.

Some PA is better than none. Adults who sit less and do any

amount of MVPA gain some health benefits.

2. For substantial health benefits, adults should do at least 150

minutes (2 hours and 30 minutes) to 300 minutes (5 hours) a

week of moderate- intensity, or 75 minutes (1 hour and 15

minutes) to 150 minutes (2 hours and 30 minutes) a week of

vigorous-intensity aerobic PA, or an equivalent combination of

MPA- and VPA aerobic activity. Preferably, aerobic activity

should be spread throughout the week.

3. Additional health benefits are gained by engaging in PA

beyond the equivalent of 300 minutes (5 hours) of MPA

activity a week.

4. Adults should also do muscle-strengthening activities of

moderate or greater intensity that involve all major muscle

groups on 2 or more days a week, because these activities

provide additional health benefits.

Because the guidelines mainly focus of PA on a moderate to

vigorous level, it is thus possible to be both “physically active”

according to guidelines and still accumulate many hours of SB per

day. One example could be an office worker who predominantly sits

at work, commutes by car, and watches TV each evening, but who

jogs for 30 minutes five times per week (47).

The Swedish guidelines for PA are developed by YFA

(Yrkesföreningar för fysisk Aktivitet). In addition to the guidelines

above, the Swedish guidelines recommend that prolonged sedentary

time should be avoided. For those in

sedentary occupations or if sitting a lot during leisure, regular short breaks

with some muscle activity for a few minutes are recommended, even if

guidelines for PA are met (48).

The Inphact treadmill study (Paper I)

Study design

A 13-month randomized controlled trial of healthy overweight or

obese office workers (n = 80).

Recruitment

Participants were recruited from 13 office workplaces in the city of

Umeå, Sweden. Governmental agencies, municipal administrations,

and private sector employers were represented among the

workplaces. Most of the participants, 78%, worked in non-shared

cell offices, and 22% worked in open office landscapes.

Inclusion and exclusion criteria

To be included, participants should have mainly sedentary work

tasks, a BMI of 25–40 kg/m2, and be of age 40–67 years. Exclusion

criteria were severe depression and/or anxiety, chronic fatigue

syndrome, diabetes mellitus, severe cardiovascular disease, severe

kidney disease, musculoskeletal disorders with walking problems,

contraindications for PA, thyroid disease, pregnancy, and if being

away from the office more than one day per week. Participants had

to have an individual sit-stand workstation to be included.

Screening

Prior to inclusion in the study, the participant filled in a

questionnaire and a clinical investigation for health status was

performed by a doctor at a clinical research center at the University

Hospital of Umeå. Fasting blood samples were taken for analyses of

full blood count, lipids, electrolytes, plasma glucose, HbA1c, and

thyroid status. Participants assessed their daily sitting time using

the "Workforce Sitting Questionnaire" (125).

Randomization

The participants were randomized after the baseline measurement

to a control condition or an intervention with an active workstation

with a treadmill desk. Stratification was based on BMI.

The intervention

After randomization all participants received an individually

adapted health consultation with advice and recommendations on

diet and PA. They also got feedback on their personal results for

anthropometric measurements, blood pressure, lipids, and HbA1c

taken at baseline. Participants in the intervention group received a

treadmill desk at their individual workstation. They were

instructed to use the treadmill at the speed of their choice and to

gradually increase walking time. The goal was to use the treadmill

at least one hour per work day. At four time points during the

study period, participants in the intervention group received

booster e-mails from the research group (at 5–6, 19–20, 31, and 50

weeks after baseline). These e-mails included information

about health risks of excessive sitting as well as gains of PA and

aimed to encourage and inspire the participants to continue to use

the treadmills. The e- mails also repeated the study goal to use the

treadmill at least one hour per workday. Participants in the control

group proceeded working as before, sitting and/or standing

throughout the study.

Data collection and processing

Sedentary behavior and physical activity

Assessments of both SB and PA were performed at baseline and at 2,

6, 10 and 13 months. To be able to measure both SB and PA at

different intensity levels, we used both the ActivPAL and ActiGraph

accelerometers. To be able to evaluate the effect of total PA, and to

study possible compensatory effects, all waking hours were

assessed. During each measurement period, the participants

registered non-wear time and their usual sleeping- and working

hours in a log book. For both devices data had to include 4 days of

valid data (3 work days and 1 non-work day) to be eligible for

analysis.

Outcomes for sitting, standing, walking, breaks from sedentary time,

and number of steps were measured with the tri-axial accelerometer

ActivPAL3 and ActivPAL3 micro (PAL Technologies, Glasgow,

Scotland, UK). Participants wore the ActivPAL on the right thigh 24

hours a day for 7 consecutive days. The device was attached with a

surgical dressing, and removed only for water-based activities.

ActivPAL has been proven to provide valid, reliable, and sensitive

measurements on changes in body postures and steps (126,127).

ActivPAL has also been shown to be valid and sensitive in detecting

changes in sitting time and breaks from sitting (61,128,129). In

paper I, data were processed to provide outcome measures for work

time and total time on workdays and non- workdays. Data were

eligible for analysis if there were 10 hours of wear time, more than

500 steps, and 95% or less of the time in a sitting or standing

position per day (130).

Outcomes for LPA and MVPA were measured with the commonly

used tri-axial accelerometer ActiGraph GT3x-BT (ActiGraph,

Pensacola, Florida, USA).

Participants wore the device in a belt around the waist for 14

consecutive days, of which the ActivPAL was worn simultaneously

during the first week.

ActiGraph has been proven valid for measuring the duration,

frequency, and intensity of PA at different intensity levels (62). We

used a composite vector magnitude from all three axes (VM3). Using

accelerometer counts from all three axes, compared to only using

vertical axis counts, has shown stronger associations between PAEE

outcome variables and the doubly labeled water- technique (131).

The raw data were collected at 30 Hz, and an epoch length of 60

seconds was used. Non-wear time was defined by using a modified

version of the Choi algorithm, with 60 minutes of consecutive zero

counts, no spike tolerance, and a small 1-minute window length,

using VM3 (62). For the ActiGraph, data were analyzed if there were

10 hours of wear time. Cut-points for the different intensity levels

were based on the Freedson Adult VM3 (2011) algorithm (62,132).

Based on a small pilot study, we modified the cut-points for

LPA as 201–2689 counts per minute. We reported MPA and VPA

together as MVPA using the cut-point 2690 counts per minute

(Figure 6). In paper I, ActiGraph data were processed for total time

on workdays and non-workdays.

Figure 6. Example of accelerometer data output from the ActiGraph

GT3x-BT, measured over one day. The raw data illustrate the intensity of

the activity. The cut- points used in the Inphact treadmill and AOD study

are illustrated by the red lines.

Dietary intake

Dietary intake was recorded with a food diary, filled in for 4 days

per period of each PA measurement.

Body measurements and body composition

Length, weight, BMI, waist and hip circumference, sagittal height,

body composition measured with dual x-ray absorptiometry (DXA)

were measured at 0, 6, and 13 months.

Metabolic function and salivary cortisol

Systolic and diastolic blood pressure, salivary cortisol, and metabolic

variables, including an oral glucose tolerance test (75 g, glucose and

insulin analyses at baseline and after 30, 60, 90 and 120 min), lipids,

and HbA1c were measured at 0, 6, and 13 months.

Psychological health questionnaires

Assessments of depression and anxiety were made using the HAD-

scale (133) and perceived stress and energy were assessed using

the Stress-Energy- Questionnaire (134) at 0, 6, and 13 months.

The AOD Study (Paper II-IV)

Setting and recruitment

The AOD study was performed among office workers in a municipal

administration in the north of Sweden. The study had the overall aim

to evaluate work environment and health after a planned relocation

to two different office types, a flex office with ABW and a cell office.

Approximately 450 officials within the municipality were involved in

the office relocation. Before the relocation employees worked in two

different office buildings with traditional cell office designs.

Approximately 250 of the employees moved to a flex office with ABW

and 200 to a new office with a traditional cell office design.

Employees were allowed to participate in study procedures during

working hours. Prior to the study and the planned relocation,

information sessions at the workplace were held. In addition,

information was sent out by e-mail to all employees. The objective

measurements of SB and PA were described as a substudy of the

AOD study.

Study design and participants

The AOD study consisted of an open cohort, and all employees

involved in the office relocation were invited to participate and to fill

in questionnaires about working conditions, work environment, well-

being, health and PA. To be included in the substudy with objective

measurements of SB and PA (Paper II), the inclusion criteria were 1)

age 18–63 years, 2) working 75% or more, 3) spending more than

60% of work hours inside the office, and 4) not planning to change

workplace or retire during the study period. In paper III, an

exploratory analysis was performed of the cross-sectional data from

the 18-months of

follow-up. In paper IV, longitudinal data and mixed methods were

used to study the group that relocated to the flex office (Table 2).

The PA-promoting program

The development of the PA-promoting program was based on three

previously described theoretical models, Five Keys to workplace

health promotion, Social ecologic model of influence on physical

activity, and the Social cognitive theory (100,123,124). An ongoing

collaboration between the researchers and workplace

representatives ensured a participatory approach in the development

of the intervention program.

Lecture

All employees were invited to a lecture approximately one month

before the office relocation. The 45-minute lecture held by the

research staff aimed to increase awareness of the relationship

between SB, PA, and health, to initiate reflection and discussions,

and to inspire employees to pursue small behavioral changes.

Workshop for managers

A seminar for managers was held 5 months after the relocation. The

goal of the seminar was to repeat the importance of decreasing SB

and increasing PA, to discuss culture and norms regarding PA in the

organization, and to share ideas on how managers can lead by

example. The written workshop material was sent to the managers

by e-mail after the session.

Communication campaigns

Three communication campaigns were developed in collaboration

with voluntary employees who were recruited from “health

inspirers” within the organization. The campaigns were launched

between 10 and 17 months after the relocation, and they focused on

breaking up prolonged sitting, the importance of everyday PA, and

taking the stairs and/or using treadmill workstations if available at

the workplace. The campaigns also aimed to create reflection and

individual goal setting regarding behaviors for everyday PA, both at

work and during leisure time. For communication of the campaigns,

we used posters, table-top messages in the break spaces and

conference rooms, information on the workplace intranet and

communication via managers. More details on the content can be

found in paper II.

In total, intervention activities were rolled out over a period of 18

months, and they were separated in time from the measurement

periods and the office relocation. The same program and materials

were used for both office groups, and they got the same

information and activities at the same intervals in relation to their

office relocation.

Data collection

Table 3 gives an overview of the data collection in the AOD study,

and the data that were used in this thesis.

Table 3. Overview of data collection in the AOD-study.

Time point in

relation to relocation −6 m −1 m +6 m +11 m +18 m +20 m +24 m

Baseline Follow-

ups

Objective measures

of SB and PA xxxxx

Body measurements x x x

Questionnaires x x

Focus group interviews x

x Individual

interviews with

managers x

Interview with key persons x

Sedentary behavior and physical activity

We used the same methodology for measurements of SB and PA in

the Inphact treadmill study and the AOD study, with a few

exceptions. In the AOD-study participants measured SB and PA at 6

and 1 month before, and at 6, 11 and 18 months after relocation.

Participants reported time for getting up, going to bed, and working

hours day by day in a log book, and ActiGraph was only worn for one

week. In paper II data from both ActivPAL and ActiGraph were

processed for work- and leisure time on workdays, non-workdays,

and for total time measured time, including both workdays and non-

workdays.

Body measurements

Body measurements were performed at 6 months before and at 6

and 18 months after the relocation. Measurements were

performed at the workplace and participants wore underwear.

Standardized methods were used when measuring body height,

body weight, and waist- and hip circumference. For more detailed

information, see paper II.

Questionnaires

All employees involved in the office relocation were invited to

participate in a large survey with questionnaires at 6 months prior

and at 6 and 18 months after relocation. The questionnaires

included background variables such as age, gender, position at

work, employment rate, amount of computer-bound work tasks, and

office location. Health and lifestyle were registered with questions

about self-rated health, sleep quality, cognitive and musculoskeletal

symptoms, exercise habits, and smoking. Psychosocial aspects of the

work environment and feelings and experiences of physical, mental

and social well-being were assessed using the Work Experience

Measurement Scale and the Salutogenic Health Indicator Scale

(135,136). Usage of possibilities to be physically active at work (e.g.

standing while working, using a treadmill workstation, taking the

stairs) and perceived appreciation of using the active alternatives at

work were assessed by specific questions. Cultural and social

acceptance regarding sitting and moving at the workplace were also

registered. At 18 months after the relocation the questionnaire was

extended to contain some questions about the perceived

motivational impact of different components in the intervention and

questions about time spent on various work tasks.

Interviews

In paper IV, we studied the group that was relocated to the flex

office. Focus group interviews were conducted at approximately 6

and 18 months after the relocation. Individual interviews with

managers were conducted at approximately 20 months and a focus

group with key persons for the PA- promoting program and office

relocation were performed at 24 months after the relocation.

Recruitment to focus group interviews was performed by e-mail

invitations and convenience sampling. Recruitment to interviews

with managers and the key persons was done by personal invitations

by e-mail. Both focus group interviews and individual interviews

used a semistructured interview guide, they lasted about 60 minutes,

and they were performed by

researchers not involved in the development of the PA-

promoting program (137). Prior to the analyses, all interviews

were transcribed verbatim.

Data analysis

Quantitative analysis

In papers I and II, the analysis of objective measurements of SB and

PA and body measurements were performed by using linear mixed

models to test for interaction effects and within-group changes. In all

models, the participant was used as the random intercept. In the

Inphact treadmill study (paper I), SB and PA outcomes for total time

awake on weekdays was tested using three-way interactions

between group (intervention/control), time point (baseline, 2, 6, 10

and 13 months) and day of week (weekday or weekend). Further,

estimated means for work time, non-work time, energy intake, and

body measurements were tested using two-way interactions between

groups and between time- points. In the AOD-study (paper II), the

two baseline measurements were weighted, and two-way

interactions between groups (flex office and cell office) and time-

point (baseline, 6, 11, and 18 months) were used for all activity

outcomes. For body measurements the model included group (flex

office and cell office) and time-point (baseline, 6, and 18 months).

For analysis of total time of SB and PA (both weekdays and non-

work-days) in the Inphact treadmill study and the AOD-study, a two-

way interaction between groups and time- points was used. For both

studies, data for total time (both time on work days and non-work

days) were analyzed and are reported as standardized 16-hour day

values.

In paper III, cross sectional data from employees in both office

groups at 18 month’s follow up were analyzed. We included 53

participants with complete data for both questionnaires and

measurements of SB and PA in the analysis. Factor analysis of mixed

data is a generalized principal component method that allows for both

categorical and continuous data, and it was combined here with multiple

linear regressions. We used a Scree plot to determine the number of

dimensions. Interpretation of the combination of factors was done by

two of the authors.

In paper IV, questionnaire data from 152 participants were

included in the analysis. Wilcoxon matched-pair t-tests were used

due to the non-parametric nature of the data.

In papers I, II, and IV we used SPSS software v.24 (IBM Corp,

Armonk, NY, USA). In paper III, the analyses were performed in R

computing software, version

3.5.2. For all studies the significance level was set at ≤0.05.

Power analysis

In the Inphact treadmill study (paper I) participants were stratified

for BMI (25–30 and 30–40). A sample of 30 individuals in each

group gave 85% power to find a statistically significant difference of

30 minutes walking time per day

(standard deviation 60.8 minutes) (p<0.05). Forty individuals in

each group were included to compensate for an anticipated

participant drop out of 30%. In the AOD study (paper II), 84

individuals were needed, to compensate for an expected

participation drop-out of 20%, to achieve a power of 80%, and to

detect a statistically significant difference between groups of 30

minutes sitting time per day (p<0.05).

Qualitative analysis

Data from 12 focus group interviews at 6 and 18 months, and

interviews with managers (n=6) at 20 months and key persons

(n=2) at 24 months after relocation were included in the qualitative

data analysis (paper IV). In total, 70 individuals participated in the

interviews, whereof 19 of those participated in more than one

interview.

Data were analyzed using qualitative content analysis. We used a

deductive approach to the modified PE model previously described.

Data were coded, and categories of data emerged in relation to the

different elements in the model (138,139). Results were discussed

among the five authors, and preliminary results were also presented

and discussed with researchers who were well acquainted with the

AOD study.

Ethical approval

Because our studies collected data on health and aimed to affect

participants’ behavior, ethical applications were performed for

both studies. Both studies received ethical approval from the

Regional Ethical Committee in Umeå – the Inphact treadmill study

(No:2013/338-31) and the AOD study (No:2014/226- 31). According

to the Helsinki Declaration, participants were informed that

participation was voluntary and that they had the possibility to

withdraw their participation at any time during data collection. All

participants signed an informed written consent.

Results

Participants with objective measurements (Paper I & II)

Table 4 shows the demographic data for participants in the Inphact

treadmill study and the AOD study performing objective

measurements of SB and PA. The Inphact treadmill study comprised

more men compared to the AOD study. In the Inphact treadmill

study, 33% of the participants rated their health as very good or

excellent at baseline, and the corresponding number for the AOD

study was 49%. Half of the participants in the AOD-study and 45% of

the participants in the Inphact treadmill study reported that they

exercised twice a week or more at baseline.

In table 4, activity outcomes at baseline are presented standardized

to 8-hour workdays or 16-hour total awake time. In both studies,

approximately 50% of the time at work was spent sitting and 40%

standing. Participants in the Inphact treadmill study walked for

almost 10% of their workday at baseline, while participants in the

AOD-study spent about 8% of their workday walking at baseline.

Table 4 here

Walking time and PA intensity

Work time

In the Inphact treadmill study the intervention group increased their

walking time and number of steps at work compared to the control

group. The effects were largest in the beginning of the study. At 13

months, the intervention group walked 18 minutes (confidence

interval, 9 to 26) more per weekday compared to baseline, whereof

15 of those minutes took place at work, indicating that the main

effect of increased walking time was related to the intervention at

work.

In the AOD study a significant interaction effect was seen for

walking time at work (p=0.001). This was driven by a within-group

increase in walking time at work in the flex office group at all follow-

ups, while the cell office group showed a within-group increase of

walking only at the 11-month follow-up. Both groups showed within-

group increases in MVPA – the flex office group at all follow- ups,

and the cell office group at 11- and 18-month’s follow-up – but the

increases in the flex office group were greater, which resulted in a

significant interaction effect also for MVPA at work (p<0.001).

Non-work time

In the Inphact treadmill study, no interaction effects were seen

for MVPA during weekdays (p>0.05) or weekends (p>0.05). For

both weekdays and weekends, MVPA decreased within the

intervention group at all follow-ups, while the control group

decreased their MVPA at 13 months follow-up.

In the AOD study, both groups showed increased numbers of steps

and walking time at 11 month’s follow-up during leisure time on

weekdays. This increase returned to normal levels at 18 months.

Significant interaction effects were seen for walking time during

weekends (p<0.01), where the flex office group showed increased

walking time at all follow ups compared to baseline and the cell

office group remained stable. No interaction effects were seen for

MVPA during weekends (p>0.05), but the flex office group showed

increased MVPA at the 6- and 18-month follow-ups.

Total time - both workdays and non-workdays

Figures 7 and 8 show the relative time spent walking, standing and

sitting for total awake time for both workdays and non-workdays in

the Inphact treadmill study, where both groups spent 11% of the

total time walking at baseline. The intervention group increased

their walking time from 11% to 15% from baseline to the 2-months

follow-up, and for follow-up at 6-, 10, and 13 months walking time

stabilized at 13%. One percent corresponds to 9.6 minutes per day.

Intervention group for total time

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

Baseline 2 months 6 months 10 months 13

months Walking Standing Sitting

Figure 7. Relative time spent walking, standing, and sitting of the total

time, at the different time points in the intervention group in the

Inphact treadmill study.

Control group for total time

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

Baseline 2 months 6 months 10 months 13

months Walking Standing Sitting

Figure 8. Relative time spent walking, standing and sitting of the total

58 52 55 56 57

34 31 31

31 30

15 13 13 13

56 55 57 56 57

34 33 33 34 32

11 12 11 11 11

time, at the different time points in the control group in the Inphact

treadmill study.

Figures 9 and 10 show the relative time spent walking, standing,

and sitting for total awake time for both workdays and non-workdays

in the AOD study, where the flex office group walked for 11% and

the cell office group walked for 12% of the total time at baseline.

The flex office group increased their total walking time by 1% from

baseline to 18 month’s follow-up, while the cell office group

remained stable.

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

Flex office group for total time

56 55 55 55

33 31 32 33

11 12 13 12

Baseline 6 months 11 months 18

months Walking Standing

Sitting

Figure 9. Relative time spent walking, standing and sitting of the total

time, at the different time points in the flex office group in the AOD

study.

Cell office group for total time

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

Baseline 6 months 11 months 18

54 52 54 53

36 34 35 34

12 12 13 12

months Walking Standing

Sitting

Figure 10. Relative time spent walking, standing and sitting of the total

time, at the different time points in the cell office group in the AOD

study.

Intervention groupControl group

Flex Office Cell Office

MVPA in

In the Inphact treadmill study, there was a decrease in MVPA of 15

minutes per day from baseline to 13 month’s follow-up in the

intervention group and a decrease of 9 minutes per day in the

control group. In the AOD-study, there was an increase of 11

minutes per day from baseline to 18-month’s follow-up in the flex

office group, and an increase of 6 minutes per day in the cell office

group (Figure 11).

Inphact treadmill

study MVPA for

total time

AOD-study

MVPA for total

time

70 70

60 60

50 50

Baseline 2m 6m 10 m 13 m

Time-point

Baseline 6 m 11 m 18 m

Time-point

Figure 11. Estimated means and standard errors for MVPA per 16-hour

day, for total awake time in the Inphact treadmill study and the AOD

study.

Sitting and standing

In the Inphact treadmill study, the intervention group decreased

their sitting time at work at all time points except the 13-month

follow-up, while the control group remained at the same level over

the whole study period. None of the groups showed any changes for

standing time, neither at work or out of total time on weekdays or

weekends.

In the AOD study, no changes for total sitting time at work were

observed during the study. For standing time at work, no significant

interaction effects were seen, but standing within the flex office

group decreased at all follow-ups.

MVPA in

Flex Office Cell Office Flex OfficeCell Office

Breaks and patterns for sitting accumulation

In the Inphact treadmill study, interaction effects were seen for

breaks shorter than 3 minutes (p<0.001) and for breaks longer than

20 minutes (p<0.01). This was due to stability in break patterns at

work in the control group, while the intervention group decreased

their short breaks and slightly increased their long breaks. No major

effects for sitting accumulation patterns were seen for weekdays or

weekends.

In the AOD study, a significant interaction effect for break rate at

work was seen (p=0.001). This was driven by an increased mean

sitting duration and decreased break rate (number of breaks per

sitting hour) in the cell office group at 18 month’s follow-up, while

the flex office group remained stable for mean sitting duration and

break rate (Figure 12).

Mean sitting duration at

work

Breaks from sitting at work

Baseline 6 m 11 m 18 m

Time-point

Baseline 6 m 11 m 18 m

Time-point

Figure 12. Estimated means and standard errors for mean sitting duration

and breaks from sitting at work per 8-hour workday in the AOD-study.

Body measurements and metabolic function

In the Inphact treadmill study, self-reported daily energy intake

decreased within the intervention group at the 6-month and 13-

month follow-ups, but there was no interaction effect. No

interaction effects or within-group differences were found for

body measurements or body composition. No significant

intervention effects were found for metabolic function, salivary

cortisol, perceived stress and energy, anxiety, or depression

outcomes.

In the AOD-study, there were significant interaction effects for

weight (p=0.01) and waist circumference (p<0.05). This was driven

by weight increases within the flex office group at 18 month’s

follow-up and a decreased waist circumference within the cell office

group.

Minu

Exploration of underlying factors for SB and PA (Paper III)

From the first step of the analysis– the factor analysis of mixed

data – six dimensions emerged. Every dimension described a

combination of underlying factors that were interpreted and

presented as six character types. These character types were 1)

harmonic and healthy 2) disabled with poor health, 3) manager

who spend a lot of time in meetings and has very high workload, 4)

engaged with high workload, 5) employee with creative and

computer intense work, with high workload, and 6) employee with

high BMI, and creative and collaborative work.

The next step of the analysis – the multiple linear regressions –

showed that the character types that to a high degree were

“engaged with high workload” and “harmonic and healthy” spent

more time sitting and less time standing. The character type that to

a high degree were “engaged with high workload” spent more time

in prolonged sitting, while the character type describing employees

with “high BMI, and creative and collaborative work” tended to sit

less and stand more. “No statistically significant results were seen

for office type related to sitting, standing or walking at work. The

multiple regressions explained 22% of the variation in sitting time,

20.5% of the variation in standing time, and 17.7% of the variation in

walking time.

Process evaluation and PA behaviors in the flex

office (Paper IV)

This paper focused on the flex office group within the AOD study and

evaluated both the implementation process of a PA-promoting

program and self-reported and perceived PA behaviors at work. A

theoretical model for PEs and a mixed methods design, with

repeated questionnaires (n=152) and individual and focus group

interviews (n=70) were used in the analyses. Qualitative and

quantitative results were intertwined in the presentation of results.

In total 70 individuals (73% women) participated in interviews, and

16 of those were managers.

Among the questionnaire respondents, 67% were women and 47%

were over 50 years of age. A majority (60%) rated their general

health as very good or excellent.

Context

For contextual aspects, the category support for physical activity

described how the organization had a strong culture of encouraging

both posture variation and exercise. Sit-stand tables were available

already at baseline. The social acceptance for walking and standing

at work was high at baseline, where 71% reported that standing or

walking at work was socially accepted to a large extent, and this

further increased to 84% at 18 months (p=0.001). Employees

described how they appreciated that the office environment provided

possibilities for posture variation and walking. Musculoskeletal

discomfort, the habit of sitting, and an awkward feeling of “standing

out” were described as barriers for standing.

“But sometimes I think it is really nice to be able to just lean back. The

Pilates stool feels good for a while, but it also becomes static. And if you

stand too long you also get tired in the back. At least that is the case for

me. I want variation.”

The category environmental and ergonomic challenges describe

factors of influence for PA behaviors. During the study, the

organization needed to hire more employees. Due to this, the office

sometimes became crowded, and employees described walking

around the office to find a suitable workstation. This was perceived

as frustrating and time-consuming. The lack of workstations was

also mentioned as a barrier to workplace rotation.

”I would say that people are afraid of losing their workstation,

otherwise I think you would move much more.”

After relocation to the flex office with ABW, employees were

expected to rotate between workstations, depending on the task at

hand. However, ergonomic adjustments of chairs were perceived as

difficult and time- consuming, and were described as a barrier to

rotation. The tendency to avoid making the adjustments was

perceived to be a future risk for increased musculoskeletal

disorders.

“It is difficult to adjust the workstation every day. Sometimes I do it.

Sometimes I don´t have the energy. It´s annoying because it takes

time.”

“I am a little worried about this in the long run. We have such a nice

working environment, but since I think I am only going to sit for two

hours, and then move on, I do not care. But over time, my posture

might deteriorate, which might be a problem.”

Intervention

The category clarity in the organization describes how the

intervention was supported by both senior leaders and middle

managers and how all activities in the PA-promoting program were

performed as planned. Regarding motivation and responsibility to sit

less and move more, both employees and managers thought that it

was important that managers promoted PA and acted as role

models, but that the final decision to change behaviors was up to the

individual.

“Thus, we have a manager talking a lot about using the health and

wellness hour and that we should have walking meetings and things

like this. So, it is not the managers’ fault if I don’t do it.”

“I think one barrier is that some do not see their responsibility, it sounds

hard, but maybe I’m exaggerating a little. It is easy to become

comfortable and think that it is the employer who has to fix things. Here

we have the best possible opportunities, compared to other

organizations.”

The perception of the motivational impact from the different parts

of the PA- promoting program varied, but the physical

environment and the lecture had the highest ratings in the

questionnaires at 18 months, while managers’ behaviors and

communication campaigns had the lowest (Figure 13).

100

The office design The lecture

Workers'

behavior

Manager

behavio

Communicati

campaigns

Do not know Not at all To some extent Quite a lot To a great extent

Figure 13. Motivational impact of factors related to the PA-promoting

program reported at 18 months.

Behaviors

The category voluntary and involuntary physical activity described

how employees strived for variation, how the equipment and

activities were stimulating and how they walked to find a suitable

workplace. The category mediators described how employees always

put their productivity in the first room and that how the pursuit of

physical comfort influenced their behaviors.

“I don´t use the traditional chairs any more; I stand up or use Pilates

stools and pallets. It doesn't work with a chair because then I would have

to spend half the day adjusting it.”

At baseline, 72% took the stairs daily and 38% stood while working

individually on a daily basis. Standing and walking meetings were

unusual. The most appreciated possibilities to be active at work

were to take the stairs, walk or cycle to meetings outside the office

and to stand while working individually.

There were no changes in the reported frequency of standing while

working individually between baseline and 18 months, but the

reported appreciation of standing while working decreased (p<0.01).

At 18 months it was reported as more common to stand at meetings

(p<0.001) and the frequency of breaks from sitting during meetings

increased from baseline to 18 months (p<0.01) (Figure 14).

Breaks from sitting during meetings, %

Never Seldom Sometimes

Often Baseline 18

months

Figure 14. Frequency of breaks from sitting during meetings at baseline and 18 months.

At 18 months the treadmills were used by 12% of the employees.

Employees thought that the most suitable work tasks for the

treadmill were reading, checking e-mails or walking while having

a phone conversation. Barriers to using the treadmills were noise

and difficulties in finding compatible work tasks. Another barrier

was perceived motion sickness when walking.

“Because they make a bit of annoying noise. Maybe they should be

placed on the same floor, next to each other, and they can be noisy

together.”

“I have back pain, so personally the use of the treadmill workstations

has saved me.”

The reported usage of stairs increased in the flex office after

relocation (p<0.001) and the stairs were perceived as more

positive to use compared to before relocation (p<0.001).

“I take the stairs much more often now. The stairs are nicer, but

they are also naturally placed. One does not even think about the

elevator.”

Mental models

In the process evaluation model used in our study, mental models

relate to openness and readiness for change, motivation for change,

and perceptions of an intervention. The category balance of

communication intensity described perceptions of the PA-promoting

program. There were reflections on the timing for the program, were

a need of supporting activities in order to handle the challenges of

transition to ABW, like using different digital tools, clarifying rules or

further adjusting the office interior design.

“It is exciting to try new ways of working. But there has been much

more focus on the opportunities to stand or sit at the desk than the

aspects of working in an activity-based manner. We must learn more

about that.”

A few employees were of the opinion that there had been an

unbalanced focus on performed activities in relation to the needs for

health promotion. They thought that the focus on SB and PA had

been too strong, and stress- management activities were requested

instead. The challenge of balancing the amount of communication

about PA was discussed, related to both equality and inclusiveness,

and employees described that employees with disabilities might feel

excluded, by not being able to be that physically active. It was also

described that too much focus and messages on SB and PA could be

provoking and create an opposite effect. There were also a few

reflections on the PA-promoting program as a compensation for a

perceived deterioration of the work environment.

“To talk about physical activity and have treadmills is all good, but we

cannot discriminate. We must ensure that everyone feels welcome.”

“I take responsibility for my health. I think it feels a bit contrived.

For me, it is contrived, and a bit like we do this to compensate for

something else.”

The category openness for activity described how there was a

consistent acceptance for, and a striving to incorporate more bodily

movement so long as productivity was not affected. It also highlights

that trust from leaders is important, the possibility to try alternate

ways of working, and that it takes time to incorporate behavior

changes.

“You have to feel trust. With time, we will find our ways.”

Discussion

We have shown that it is possible to increase PA among office

workers. In the Inphact treadmill study, the intervention group

increased their walking time and number of steps compared to the

control group. Notably there was a compensatory effect, with

decreased MVPA during non-work time within the intervention

group at all follow ups, while the control group only showed a

decrease at the 13-month follow-up. In the AOD study no changes in

sitting time at work were observed, while walking time and number

of steps increased, especially in the flex office group. No

compensatory effects for PA were seen during leisure time. The

exploratory study showed that a complex combination of factors,

such as self-reported health, job scope, and workload influenced PA

behaviors among office workers. The PE revealed that all activities

in the PA- promotion program in the AOD study were performed as

planned and that the program had strong leadership support. This

study also suggests that the timing of the intervention to some

extent came in conflict with needs related to the office relocation,

and it describes the challenge of finding a suitable balance in health

messaging at the workplace.

Sedentary behavior and physical activity

Sitting and standing at work

In papers I and II, the results showed that participants sat for

approximately 50% and stood for 40% of their time at work at

baseline. Previous intervention studies among office workers have

shown sitting levels of 64%-67% at long-term follow-ups (65,80,81).

Sit-stand tables are common in Sweden, but also when compared

with Swedish studies our results differ for sitting and standing times.

A longitudinal study by Hallman et al. where all participants had sit-

stand tables showed that they sat on average 70% of their work time

at baseline, and at 12 months after relocation to flex offices with

ABW, no changes in total sitting time were seen (64). In a Swedish

cross-sectional study, the participants sat for 60% of their work time

(74). We did not observe any significant reductions of sitting time,

and our results might indicate a ceiling effect for the amount sitting

time can be reduced in office workers.

The low levels of sitting and high levels of standing in our studies

were probably due to the availability of sit-stand workstations in

combination with regular reviews of the workplace ergonomic work

environment. In studies evaluating barriers, facilitators and

possibilities to decrease sitting and increase PA among office

workers, the physical environment and furniture design have been

highlighted as barriers (140–142), which means that the starting

point in our studies differed from many other studies. In Sweden sit-

stand tables are standard for purchase in many workplaces, and the

legislation requires employers to perform regular risk assessments

of the work environments (143). The risk assessments are usually

performed by safety inspections by representatives within the

organization or staff from the occupational health

care provider. During these safety inspections it has become a

tradition to encourage employees to vary between sitting and

standing. Initially this tradition aims to reduce the risk of

musculoskeletal symptoms related to sitting but it might be so, that

the increased media attention and awareness about the risks of SB

have further increased the utilization of the possibility to stand at

work. Another possible explanation for our results could be that the

recruited organizations had an interest in health promotion among

employees and thus the health awareness among participants was

high. The interview data from the AOD study confirmed that there

was a strong organizational culture to promote health. Already

before the study, employees were stimulated to be physically active

through exercise, and also variation between sitting and standing as

well as active transport was encouraged and facilitated.

In the interviews employees described how they appreciated and

used the possibility for variation between sitting and standing

because both postures were perceived as static after a while. Similar

results are reported in experimental studies in office settings, where

short-term effects on discomfort from prolonged standing have been

investigated. Prolonged standing led to increased musculoskeletal

pain (144,145), but sitting for prolonged periods also seems to cause

short-term musculoskeletal symptoms (147). Previous qualitative

studies have also described that standing could be perceived as

uncomfortable and tiring, and thereby a barrier for standing

(74,77,141). A systematic review of laboratory studies showed that

standing for prolonged periods resulted in increased musculoskeletal

symptoms. To avoid the risk of getting symptoms from standing, the

authors recommend not to stand for more than 40 minutes at a time

(147). A review and meta-analysis on the impact on low back

discomfort from using sit-stand workstations, showed that sit-stand

workstations might reduce low back pain, and the possibility to

control the ratio of sitting to standing transitions was of importance

for the result. This indicates that the reduction of low back pain is

greater when workers can change their body posture by their own

choice (148). In line with this, multicomponent intervention studies

have shown decreased symptoms from lower back and/or neck-

shoulder when standing time at work increased (81,95). The results

in paper III indicated that employees with poor health were prone to

sit less and to stand more than healthy coworkers. To speculate, this

might be due to the fact that people with musculoskeletal disorders

to a higher degree use the opportunity to vary between sitting and

standing as a way to cope with their symptoms, and that people with

poorer health might be more easily reached with interventions aimed

at reducing SB. To summarize, it seems to be important to provide

possibilities for posture variation in office settings, and the variation

intervals should be self-chosen and controlled by the individual.

The objective measurements of SB and PA in papers I and II were

reported as estimated mean values, and the wide SD suggests wide

interindividual variations for all activity outcomes. This was

somewhat confirmed in the interviews in the AOD study, where some

employees described how they always sat while working, others most

often stood, and some varied between sitting and standing. In

previous qualitative studies, computer-based work and work

pressure have been reported as barriers for standing

(140,142,149,150), and the

results from the exploratory analysis are in line with these results,

where the character type that were “engaged with high workload”

spent more time in prolonged sitting. These results are also in line

with productivity aspects described in the interviews, where

emplyees described that they forgot to take breaks during meetings

or did not utilize the health and wellness hour during intense work

periods. The results in paper III also showed that the character types

that to a high degree were “harmonic and healthy” and “engaged

with high workload” spent more time sitting and stood less. This

result was somewhat unexpected. It might be likely to think that

health-promoting lifestyle activities at work usually attract

employees who are already the most active and healthy, but our

results for sitting and standing points in the opposite direction.

Similar results are described in previous qualititative studies. Flint

et al. (151) reported that regular exercisers or individuals with small

children were less motivated to reduce their sitting time at work,

and Nooijen et al. (74) found that a higher proportion of younger

workers, that could be assumed to have better health, reported that

they thought standing was uncomfortable and tiring, and they were

less motivated to stand at work. To conclude, our exploratory results

contribute by describing underlying factors within character types

explaining different patterns for sitting and standing at work.

Patterns for sedentary behavior

As previously described, accumulation patterns of sitting time could

be of importance for metabolic response and health (7,27,28).

Standing during meetings and phone calls, walk-and-talk meetings,

and screen-based prompts have been described as feasible

possibilities to decrease sitting and break up prolonged sitting

(74,140,142,149). Although the PA-promoting program highlighted

the importance of breaking up prolonged sitting and taking breaks,

no group effects or within-group changes were seen for time spent in

prolonged sitting in the AOD study. In activity-based flex offices,

workers are supposed to move between different workstations

depending on the work task at hand, and theoretically this could

increase breaks from sitting. We hypothesized that breaks from

sitting time would increase in both groups, with greater changes in

the flex office. Contrary to our hypothesis, no changes in break rate

were seen in the flex office group, but the mean sitting period

increased, and the break rate decreased in the cell office group.

During the study period, many refugees arrived in Sweden, and to

manage the reception of refugees the organization hired more staff.

This could imply that the social service workers working in the cell

office, had an increased workload, which could be an explaining

factor for longer sitting periods and less breaks from sitting in the

cell office. The interviews revealed that employees in the flex office

perceived no need to change workstations, and found it difficult and

time consuming to do so, and thus they usually used the same

workstation all day. They also described how they, to facilitate their

work, often worked in the same area in the office as their closest

colleagues. Thus, they did not use different spaces but changed

locations in the office just as before the relocation, for example,

when attending meetings or during breaks. This could somewhat

explain the stability in break rates in the flex office group also after

the relocation. In line with our findings, stationary behaviors in

activity-based flex offices are described in a report from Leesman,

presenting data from more than 11,000 office workers from 40

activity-based workplaces around the world (152). That report

identified four types of mobility groups: the camper (30%) who

performs most activities at a single workstation and rarely uses

other office locations, the timid traveler (41%) who performs the

majority of activities at a single workstation but sometimes uses

other locations in the office, the intrepid explorer (19%) who often

switches between locations in the office, and the true transient (10%)

who always switches between locations in the office (152). The

reason for being stationary is discussed to be due to a work profile

that does not benefit from the flexible environment, while the

intrepid explorers and true transients have adopted and benefit from

the central concepts of working in an activity-based manner and are

mobile in their space use (152). Hoendervanger et al. (153) reported

that the reasons for choosing the same workstations might be having

homogenous tasks or work that require collaboration with the same

colleagues. We have no data on how often employees changed

workstations, but the results described by both Leesman and

Hoendervanger are also confirmed in the interviews in the AOD

study. Even though it is claimed that employees should move more in

flex offices, Hallman et al. did not observe any changes in total

sitting time or sitting accumulation patterns among office workers

moving to activity-based flex offices (64). To summarize, many

factors might influence how sitting time is accumulated, but the

claim that people working in flex offices take more breaks from

prolonged sitting is not supported by our results, and should not be

viewed as scientifically proven.

Physical activity at work and compensatory effects

While cardiovascular health benefits might be achieved by replacing

sitting time with standing, it has been suggested that, to address

overweight and obesity, sitting might need to be replaced with

ambulatory activities, such as walking or running (154). Both of the

intervention studies in this thesis led to increased walking time

during working hours, but the Inphact treadmill study resulted in

compensatory effects with decreased MVPA, while the AOD study

showed no decrease, and rather a slight increase in PA during

leisure time.

Because compensatory effects from worksite interventions vary

between studies, it seems to be important to include intervention

components targeting both work and leisure time. Just as the results

in the two studies in this thesis differ in terms of compensation

effects, previous studies have also shown conflicting results. A

Swedish study, using questionnaire data, found that people changing

from sedentary to physically active occupations compensated by

exercising less, while people changing from physically active to

sedentary occupations compensated by exercising more during

leisure time (155). Two Finnish studies using hip-worn

accelerometers show contrasting results. Both studies aimed to

decrease SB both during work and leisure, and one of the studies

showed reduced SB and increased PA only during leisure time (156),

while the other study showed decreased SB and increased PA at

work, but compensatory effects with decreased PA during leisure

(157). However, there are also studies, including multicomponent

interventions, and/or the installation of sit-stand desks or treadmill

workstations, where no compensatory effects have been observed

(65,158). In the AOD study, the response to the PA program could to

some extent have been achieved by active initiatives like lunch walks

or increased utilization of the health and wellness hour. Because the

PA-promoting program was performed in both office types, the more

pronounced increase in steps, walking time, and MVPA seen in the

flex office group, could also depend on differences in office design

and desk sharing. In the interviews, employees described how the

office became crowded and how they had to walk around the office

to find a workstation. Because all employees shared all spaces in the

office, the total walking distances were probably also longer

compared to only walking in a regular corridor. Similar to our

results, a Swedish study also found unchanged sedentary patterns

but increased walking after relocation to flex offices, although the

results differed between office sites, suggesting that effects might be

site specific, and depend on the size and the design of the building

(64). In the AOD study, longer walking distances in the flex office,

difficulties in finding a workstation, and walking to look for

colleagues could thereby have contributed to the increased walking

time at work. If the increased walking in the flex office was spread

out over various occasions, such as going to the centralized printer

room, or looking for a workstation, they might not be perceived as

conscious initiatives specifically aimed at being physically active.

This might have facilitated the transmission of the PA-promoting

program’s message to be active also during leisure, putatively

explaining the small additive effects during leisure in the AOD study.

In the Inphact treadmill study, the intervention group increased

their walking time during weekdays by 18 minutes per day, wherof

15 minutes during worktime, indicating that the main effect was

related to the workplace intervention. At the same time, a decrease

in MVPA was observed at all follow- ups in the intervention group on

both weekdays and weekends, while the control group only had

decreased MVPA at 13 months. The decrease in MVPA in the

intervention group might be a compensatory effect related to the

intervention. Compared to the PA-promoting program in the AOD

study, treadmill use in the Inphact treadmill study might have been

perceived as more consciously planned and carried through, which

could have led to a compensatory effect that was more or less

reflected upon and voluntary by participants. For total time, at 13

month’s follow-up compared to baseline, the decline in MVPA was

15 minutes per 16-hour day (15 × 7 = 105 minutes per week) in the

intervention group, and 9 minutes per day in the control group (9

× 7 = 63 minutes per week). Even if the activity levels at 13 month’s

follow-up in the Inphact treadmill study were still meeting the PA

guidelines, the decrease in MVPA could have negative effects on

health on the long run. This decrease could be discussed to occur for

different reasons. When recruiting for this kind of study,

participation might be more attractive for individuals who are

struggling to maintain weight balance. In the beginning of the study,

the motivation and enthusiasm to be in the program could be high,

but might decline over time, which is often seen in long-term

lifestyle interventions (159). Furthermore, the decrease might

depend on social desirability during the first measurement periods,

showing more “true” behaviours during the last measurements.

The different characteristics of the intervention types in the Inphact

treadmill study and the AOD study might explain the differences in

compensatory effects. While the Inphact treadmill study was more of

a single-character intervention, the PA-promoting program in the

AOD study targeted different ways to be active at work, but also

emphasized leisure time PA and active commuting. To be able to

evaluate mutual effects between domains of PA, it is important to

evaluate effects both at work and during leisure, using objective

measurements in future studies.

LPA, MVPA, and what is just enough?

SB and MVPA are separate behaviors, but for health outcomes it is

not clear whether they are independent or not. Because most people

are both sedentary and active at different times, it is important to

understand how SB and PA at different activity levels interact and

affect health. In 2016 Ekelund et al. (21) published a meta-analysis

based on self-reported data. Their study focused on effects from

leisure time and recreational PA, and showed that the mortality risk

was offset for those who sat for many hours a day but also were

highly physically active (about 60-75 minutes per day), compared to

those that sat a lot, but had low levels of PA. This suggests that

exercise might buffer the harmful risks of excessive sitting, but more

studies are needed to clarify the independent and joint effects of SB

and PA (23). A recent meta-analysis (44) investigated the relations

between objectively measured PA and all-cause mortality. The meta-

analysis was based on data from eight studies, with approximately

36,ooo participants, with a mean age of 62.6 years and a median

follow-up period of 5.8 years. The study showed that all intensities of

PA led to reduced risks for death, and the maximal risk reductions

were seen at 375 minutes of LPA and 24 minutes per day of MVPA,

while SB over 9.5 hours per day significantly increased the risk of

death. In line with studies based on self- reported PA, the risk

reductions were greatest when the least active quartile was

compared to the second least active quartile. Interestingly, the effect

sizes were considerably larger than in studies using self-reported

data. In our studies, the participants spent on average between 345

and 395 minutes of their total time in LPA and about 50 minutes per

day in MVPA, which is in line with or above the levels presented as

providing maximal risk reductions. A limitation when using mortality

as an outcome is the relatively short follow-up period and the

possible risk of a reversed causation. Participants with low levels of

PA could, due to illness, be inactive already during the assessments,

and this makes it difficult to directly apply these results to our study

populations.

A study using compositional data analysis and objectively measured

SB and PA found that the strongest positive effects for BMI, waist

circumference, triglycerids, plasma glucose, plasma insulin and

blood pressure were related to the proportion of time in MVPA. This

study also showed that diabetes risk markers became more

favorable when replacing SB with LPA (26). The conclusion from

this study was that MVPA is the most important target for

intervention, but transferring time from SB to LPA might lessen the

negative effects of low MVPA-levels. To speculate, it might be so

that even though walking time increased at work in the intervention

group in the Inphact treadmill study, the compensatory decline in

MVPA, might have led to a

detoriated effect from total PA. For future studies, a higher walking

speed might be needed, and focus on preventing compensatory

behaviours for MVPA are recommended. An increased walking speed

might on the other hand compromise productivity when walking

faster than the self-chosen speed (160).

Office workers might be exposed to excessive sitting that is harmful

for health, but occupational groups with high physical demands have

also been shown to have increased risk for ill health and

cardiovascular disease (161,162). In 2018 Coenen et al. (163)

published a review and meta-analysis that assessed the association

of high-level occupational PA (OPA) with all-cause mortality. Their

study showed that men with high OPA had an 18% increased risk of

all-cause mortality, compared to the group with low OPA. The risk

increase remained after adjustments for confounders such as leisure

time PA and socio economical status, presenting a potential PA

paradox. The reasons for this paradox are yet not known, but it is

suggested that it might depend on different factors, for example, on

the fact that OPA is of too low intensity or too long durations to

maintain or improve cardiorespiratory fitness. OPA also often

includes heavy liftning which elevates 24-hour blood pressure, and

that the recovery periods are often too short (164). Coenen et al.

(163) suggests that PA guidelines should differentiate between

occupational and leisure time PA. Further studies are needed to

determine the optimum level of PA at work and at leisure.

Anthropometry and metabolic measures

Studies show that the greatest gains from increased PA are seen

among those who are the most inactive (44,165). In the Inphact

treadmill study, no changes in anthropometric or metabolic

outcomes were seen. Even though all participants had a BMI 25

and were 40 years of age, they were metabolically healthy, and the

increase of walking time at work might not have been intensive

enough to lead to significant improvements in health. As previously

mentioned, the compensatory effect in the Inphact treadmill study,

with a decline for total time MVPA in the intervention group might

also explain the lack of effects.

Because humans tend to increase in weight as they age, it might

also be of interest to consider whether a long-term use of treadmills

might be useful to maintain weight stability, rather than to lose

weight. Our intervention lasted 13 months, which is a long-term

study, but even longer interventions might be needed to be able to

detect possible positive effects on health variables when adding LPA.

Previous studies have shown that effects on postprandial glucose

and insulin levels from active breaks from sitting, have been

stronger among individuals with lower fitness and lower insulin

sensitivity (27,28,30). The participants in the intervention group

decreased their frequency of short breaks during the intervention,

which might also be an explanation for the lack of results on the

metabolic outcomes.

In the AOD-study, the waist circumference decreased in the cell

office group at follow-ups 2 and 3, even though their increase in PA

was quite modest. On the other hand, the flex office group, which

showed a more prominent increase in PA simultaneously increased

in weight, BMI, and waist circumference. It is hard to interpret these

results, but they might have been influenced by factors, such

as food intake among the participants or an increased muscle mass,

which were not measured in this study.

The importance of contextual understanding

By highlighting facilitators and barriers to being physically active at

work, but also by scrutinizing the implementation of the PA-

promoting program, the PE of the AOD study contributed to an

understanding of underlying causes of the study results. Other

studies have described the importance of leadership

encouragement and social support as both possible barriers and as

facilitators, depending on the existing culture and norms within the

organization. (74,140,142,149). In the AOD study, the leadership

encouragement for being physically active was strong and social

acceptance was high. Due to the availability to sit-stand desks, the

strong organizational culture, and the awareness of the benefits of

posture variation already before baseline, the need for the

intervention could be argued. The intervention also somewhat came

in conflict with the perceived need to learn new working methods

related to the concept of ABW.

In the interviews with key persons and some of the focus groups, the

difficulty to find the “just right” frequency and amount of

communication about SB and PA was discussed. The focus on PA was

also reflected on as a difficult balancing act regarding equality,

inclusiveness, personal integrity, and responsibility. In the

interviews, managers described an ambivalence regarding how much

to emphasize the importance of PA, and they thought that the final

decision on behaviour is up to the individuals. Similar to our results,

managers in a Dutch study described how the organization can

provide possibilities and encourage PA, but the final decision on

behavior must be up to the employee (141). The ethical perspective,

and the aspects of equality and inclusiveness, is to our knowledge,

despite its importance, not previously described as an aspect to

consider in SB intervention development. These results indicate the

need for a thorough understanding of the local conditions before

intervention planning, both in research and in organizational

practice. The conditions and the starting point for SB and PA in an

organization can differ considerably, both in terms of culture, work

tasks and physical environment, which means that the intervention

designs could, and probably should, vary between organizations. The

importance of understanding the local conditions before

interventions, and of having a participatory process during

intervention development is confirmed by our results. Even though

we used a participatory approach, our results indicate that we did

not fully succeed in finding the “just right” level. These results show

the complexity of fitting the content of an intervention to actual

needs and of getting the right timing, dose, and frequency of the

communication within the organization. Because the relocation to a

flex office with ABW meant that employees would have to learn to

work in a new way, it might have been better to deleniate the PA-

promoting program. The new office could have been equipped with

furniture facilitating posture variation and PA when equipping the

office, just as it was, but it might have been more appropriate to

postpone the other activities in the program. The performance of

lectures, workshops with managers and communaction campaigns

might have been perceived and

received in another way if they had been performed in a later, more

stable phase. It might even be worth considering whether

interventions should be developed differently also within

organizations due to different work tasks and physical

environments in different sections in order to actually target what

works for different people under different circumstances.

PA is described as a complex behavior, which is reflected in the

results from the exploratory analysis (paper III) and the interviews

(paper IV). SB and PA at work seem to be influenced by

interpersonal, environmental, and organizational aspects in

combination with workload and work tasks, which emphasizes the

importance of assessing and evaluating underlying factors for

intervention results. Future studies can be designed with these

results in mind. By collecting data with a broad perspective, these

variables could be used when evaluating intervention effects,

because they might affect the outcomes. As an example, our results

from the exploratory study indicate that work tasks, workload,

intensity of computer work and musculoskeletal disorders might be

mediators, that to some extent might explain the causal pathway for

change in PA behaviors. The results from the PE suggests that

information about conflicting initiatives, leadership support, and

conditions in the physical environment are also of interest.

Methodological considerations

A strength of this thesis as a whole, is the use of results from two

long-term interventions studies, combined with exploratory analysis

and a PE study with mixed methods. When used together, the

different types of data and methods provide a comprehensive view

of interventions to increase PA and decrease SB in office settings.

Study design and participants

The main strengths of the Inphact treadmill study were the

randomized controlled design, the long-term follow-up, and the

repeated measures of SB and PA for both workdays and non-

workdays. Due to the randomization of individuals, instead of

clustering by organization, there might have been a contamination

effect between participants in the intervention versus the control

group, which is a limitation. It would also have been desirable to

have data on how much the intervention group actually used the

treadmills. The main strengths of the AOD study were the

prospective controlled design, the long-term follow-up, and the

repeated objective measures of SB and PA. In the AOD-study there

was no possibility for randomization, neither on the group or

individual level, which is a limitation. The combination of a

relocation and performance of the PA-promoting program,

complicates the possibility to draw conclusions on the reasons for

the effects of the program. Through the qualitative data and the PE,

we could to some extent evaluate the effect contributions of the

different parts of the PA-promoting program and the effect of office

type.

Further strenghts of both studies were the use of both ActivPAL and

ActiGraph, which made it possible to evaluate both body postures

and intensity levels of PA

with high validity. The use of different time filters for both workdays

and non- workdays made it possible to evaluate compensatory

effects. When using accelerometers, the cut-points used for defining

MVPA are absolute and do not consider the fitness level of an

individual. In our study we used vector magnitude and 2,690

counts per minute to define MVPA for all participants (166). Due to

interindividual variability of fitness, this cut-point could, for

individuals with high cardiorespiratory, mean that some of the time

defined as MVPA might actually be LPA, and for individuals with

low cardiorespiratory fitness, this might mean that some of the time

defined as LPA might be MVPA. Santos Lozano (167) have

suggested a MVPA cut-point 3,208 counts per minute for adults. If

we had used a higher cut-point, our result might have shown less

time in MVPA and more time in LPA. We based our decision of cut-

points on a review (62), and the idea was to use a cut-point for

vector- magnitude that had been previously used in the literature,

and thus would facilitate the interpretation of our results in

comparison with other studies.

Individually tailored cut-points are suggested to give a more

accurate measurement of an individual’s activity levels, which could

reduce the risk of over- or underestimating PA in different activity

levels. Although the application of individualized cut-points is not

always feasible, it should be considered whether results can and

should be adjusted for some type of assessment of cardio-

respiratory fitness (63). In both studies, data on the utilization of the

health and wellness hour during work hours as well as perceived

motivation and self-efficacy for PA behavior change would have been

desirable.

Participants in both studies had more or less of a pre-understanding

of the risks of sitting, both through media attention on risks from SB

during this period and the brief information presented in the

recruitment procedure. This might have influenced the recruitment

to the studies and might have been more pronounced in the Inphact

treadmill study. Participants with BMI 25 were recruited to this

study, and the study included a thorough health investigation. In the

Inphact treadmill study, participants accepted the obligation to

increase their PA at work by one hour per day, and it is possible that

individuals who were interested in health-related questions, or who

were motivated to change their lifestyle were more prone to sign up

for participation.

The development of SB interventions among office workers

Both interventions in this thesis were based on theories and

targeted both environmental, organizational and individual factors.

The development of the PA-promoting program in the AOD study

had a participatory approach, which is recommended for a

sustainable and contextually costumed intervention (46). Renaud et

al. (168) recently published a study performed among office workers

who had long-term availability of sit-stand workstations. Three user

groups were identified – the non-users, the monthly to weekly users,

and the daily users. The daily users perceived standing at work as

healthier and more appealing, and standing made them feel more

energetic and productive compared to the non-users. The non-users

perceived the use of sit-stand workstations to be distracting,

uncomfortable, and impractical compared to the other user groups.

According to the aim of the study, the researchers developed

a new set of questions, including questions on background

characteristics, the frequency of use of the sit-stand workstations,

self-reported SB and PA, and perceptions of barriers and facilitators

to using the sit-stand workstations. For future studies, this set of

questions could, as a whole or partly, be used to tailor future

interventions aiming to reduce occupational sitting, both for

practitioners and in research. In addition, questions regarding

motivation to reduce sitting at work, organizational culture and

leadership support for health promotion, and social acceptance for

standing or walking in the office could be measured.

Traditionally, primary prevention interventions are directed to

people who are generally healthy, and the aim is to maintain health

or to prevent disease occurance, while secondary prevention is

directed to people with risk factors related to their lifestyle, that

might lead to long-term risk of illness. In previous multicomponent

interventions aiming to decrease SB, individual counseling has been

included as one important intervention component (65,81,95). The

cost- effectiveness of individual counseling, compared to health

information provided to all employees, is of interest in assessing the

return on investment for the intervention. The results from recent

years, where for example active breaks have been shown to have a

greater effect on blood glucose levels among people with poorer

metabolic health suggest that it might be of interest to consider the

return on investment from different intervention types and

intensities. It could be conceivable that it is more justified to offer

individual coaching to individuals with more pronounced risk factors,

while it might be sufficient to stimulate and inspire employees who

are in good health through environmental support and cultural

support, combined with information. However, this might lead to

employees who are overweight or obese could feel that they are

being singled out as as problematic. In future research it would be of

interest to consider the health economic aspects of different types of

SB interventions, in relation to subgroups with different health

status.

Data analysis

We used linear mixed models for analyzing our objective data for SB

and PA. It could be questioned whether this is the best approach,

because these analyses report each outcome separately. Times spent

in different PA behaviors are codependent, meaning that if one

behavior increase another decrease. To be able to determine the

most advantageous distribution of sleep, rest, and PA at different

intensity levels, the data should preferably be collected and analyzed

with a 24-hour perspective. Compared to more traditional analytical

procedures compositional data analysis might be used to evaluate

the distribution of different activities that sums up to a constant

value (26,170). This statistical approach might might increase the

likelihood of identying the optimum distribution of activities over a

certain time period and thus provide a basis for development of

guidelines for SB, PA, and sleep.

In paper IV we used qualitative content analysis with a deductive

approach to analyze the interview data (139). We have sought to

strengthen the trustworthiness of the results. The credibility was

strengthened by the fact that

the focus groups included many employees, and both men and

women of different ages were represented. In addition, managers

and key stakeholders were interviewed, and quarterly meetings

between the researchers and the project leaders for the relocation

were held (171). During the analysis we had regular meetings

between the researchers, in order to compare and discuss the

analyzed results. Researchers had different competencies, which

broadened the perspectives of the results, and discussions continued

until consensus was reached. To further strengthen the

trustworthiness, preliminary results were presented to researchers

in the AOD study, who had a good overview of the study as a whole

(139). To facilitate the reader’s interpretation of the transferability

of results, we have described the settings, participants, and

contextual details. The qualitative and quantitative results are

integrated, which complements and further strengthens the

trustworthiness. The results in paper IV are presented according to

recommendations for how to report mixed- method studies (172).

Ethical considerations

There is an ethical risk in implementing lifestyle-related

interventions in working life. This could, for example, mean that

employees might perceive a social expectation or pressure to

participate from managers or co-workers. In a research study in a

workplace setting, feelings of guilt towards the researchers might

also arise if recommendations of the study obligations are not met,

and this might also lead to difficulties in cancelling one’s

participation in the study. In the Inphact treadmill study,

participants with BMI 25 were recruited.

Signing up for the study might have been perceived as a sensitive

issue, because weight might be related to feelings of shame, and

this is important to consider in many steps of the research process

such as during recruitment, when performing measurements, during

data handling, and in the dissemination of results (173). In the AOD

study, results from questionnaires and interviews were repeatedly

fed back to the organization and employees on a group level.

This allowed for the organization to continuously make changes,

and this transparency strengthened the ethics of performing data

collection for a long period of time.

Organizations have many reasons to promote health among

employees – such as cost-saving aspects, maintenance of a

sustainable employability in light of the ageing workforce, and

building a positive company image – by providing good employement

practices (174). In an editorial article, Allegrante and Sloan discuss

possible ethical dilemmas that may arize related to lifestyle

interventions at the workplace (175). They describe how

professionals who are developing and implementing interventions in

the workplace might encounter moral dilemmas such as whether

their loyalty lies with the employed individual or the client of the

service (the employer). There might also be a risk that, even though

the intentions are good, screening for health risk factors, might lead

to job discrimination (175). In the interviews, the aspects of integrity

and equality were reflected on, in relation to intervention intensity.

These reflections demonstrate the challenge to design health

messages in the workplace.

Implications for working life

Regardless of office type, a supportive workplace culture and a

stimulating physical environment are paramount for promoting PA at

the office. A supportive culture can include managerial support,

positive attitudes and social acceptance towards stand and walk

behaviors while working. A supportive interior design makes it easy

to choose whether you want to sit, stand, walk or ride a bicycle when

performing your tasks. On top of this, interventions to further

increase PA can be performed. Our results showed a large variation

in movement behavior between individuals. These variations are due

to many different factors, such as motivation, musculoskeletal

disorders, workload, work tasks and general health. Since employees

appreciate and use different approaches to increase workplace PA,

we recommend offering a variety of opportunities to stimulate both

the physical environment and activity participation. In this context,

the activities could target both posture variation and the use of light

PA during work, for example, by using treadmill workstations or

office workstation bikes, as well as possibilities to be active in MVPA.

The prerequisites for PA in organizations can differ substantially.

When tailoring intervention activities, both in research and in

organizational practice, it is important to thoroughly assess local

conditions and organizational needs. Assessments should include

both cultural and environmental aspects, such as the possibility for

posture variation, stair use and walking while at work. Our results

showed no changes in sitting time at work despite increased PA

stimulation both through environmental and activity opportunities,

which may indicate there is a ceiling effect to further decreased

sitting. To assess whether an intervention is needed, sitting and

standing behaviors, usage of sit-stand tables, and exercise habits

should be assessed. Further, information should be collected about

what kind of PA the employees consider important and feasible to

incorporate both at work and during leisure. Intervention planning

should be conducted as a participatory process, with representatives

from different parts of the organization.

Flex offices may lead to increased walking, but our results showed

office workers were not more likely to break up prolonged sitting

periods when working in the flex office with ABW compared to

when working in a cell office. Prior to a transition to a flex office

with ABW, it is important to purchase equipment that is robust and

easy for employees to adjust, to make it feasible for workers to

properly tune each workstation to their individual ergonomic needs

when changing workstations. If treadmill workstations are

installed, placement should be carefully planned to avoid noise

disturbances in surrounding areas.

To conclude, a supportive culture, a stimulating physical

environment, ergonomic knowledge and stimulating activities that

are tailored to the specific context can create sustainable positive PA

behaviors among office workers. It is important to provide a range of

possibilities for increasing physical activity at the workplace so

employees can choose what suits them best without interfering with

their productivity.

Future research

It is important to further study the relationship between PA

intensity levels and health effects using objectively

measurements to provide a solid base for guidelines about SB

and PA at work and during leisure, as well as to further

investigate the interaction between work and leisure PA.

Additional studies are needed to determine whether there is a

ceiling effect for sitting time among office workers and, if one

exists, to determine the minimum time.

Assessment of the impact of alternative office environment designs,

e.g. meeting rooms and lounge areas, on PA, perceived

collaboration and creativity are required.

There is a need for studies that include health economic

evaluations to assess the possible return of investment of

decreasing SB and increasing PA among office workers.

A study to evaluate the instantaneous effects on arousal,

energy levels and creativity of breaking up prolonged periods

of sitting, standing or walking in office workers, and to assess

whether any such effects are related to productivity in office

settings.

Conclusions

It is possible to increase PA in office settings in the long-term.

A multicomponent PA-promoting program did not result in

any changes in sitting time at work among office workers,

where everybody had sit-stand tables before the

intervention.

Our results suggest a possible ceiling effect for the amount

sitting time can be reduced in office workers.

There is a risk of compensatory behaviors with decreased

MVPA when walking time is increased or when using

treadmill workstations during work hours.

When intervening at work, it is important to promote PA

also during leisure.

Social acceptance for PA and breaks during meetings

could increase following a PA-promoting program in the

workplace.

The interventions that were performed in this thesis,

among office workers who already were quite active led

to increased PA in the workplace, but no improvements

in body measurements.

A complex combination of underlying factors, such as work

tasks, work load and musculoskeletal symptoms are of

influence for PA behaviors among office workers.

A facilitating physical environment, leadership support,

knowledge, and a strong organizational health culture, can

create positive and sustainable PA behaviors among office

workers.

To tailor a worksite intervention, a thorough understanding

of the context, current status on SB and PA behaviors,

organizational needs, and a participatory approach are

needed.

Acknowledgements

On the roller coaster ride of PhD studies, a lot of guidance and

support is needed, and it has been a great pleasure too meet so many

competent, generous, and humble people during these years.

My supervisors,

My main supervisor Lisbeth Slunga Järvholm. Thanks for including

aspects on SB and PA in the AOD study, and for taking me under

your wings. Your support has been extraordinary and you have been

everything I could have asked for as a supervisor. Thanks for your

faith in me, for letting me go my way to try things out. Thanks also

for the small talks on other things than research – what exercise

classes to join, berry-picking, or whether we are still able to do the

bridge pose.

Tommy Olsson, many thanks for bringing me on board. I did not

think this was for me, but maybe it is. I am grateful for the

opportunity to take part in your clear thinking and experience as a

supervisor. Your on-the-spot feedback and questions are always

delivered at the just right level and in relation to personal

readiness.

Therese Eskilsson, thanks for your calm and patient support

when I tend to run a little too fast trying to reach my goals, for your

suggestions on the structure of writing and for nice company in

London.

Fredrik Öhberg, thanks for the nice discussions and support

during data processing and statistical analysis. I have really

appreciated your thoughtful support in stressful situations.

Co-author Annchristine Fjellman Wiklund, thanks for your gentle and

generous guidance in the somewhat chaotic process of presenting

mixed methods results. Thanks to David Olsson for statistical

support and characterizing co-authorship. Thanks also to all co-

authors in paper I, Andreas, Julia, Ellen, Rebecka, Maria, Ann, Carl

Johan, Patrik, and James Levine. It has been inspiring to work with

so many competent specialists, all contributing by their strengths,

making the sum more than its parts.

The members of the AOD research group – Maria Nordin, Anita

Pettersson- Strömbäck, Christina Bodin Danielsson, Maria Öhrn,

Mette Harder. Hugs and kisses for all the high-ceiling discussions,

roars of laughter, and social support along the way. If we could

start over, I would join! No more words needed.

Mette, I am so grateful for having the possibility to get to know you.

Your ability to put words on your architectural thinking has been an

eye opener. Your focus and likeable personality have made our

collaboration a fruitful joy for me, and I hope we will get the

possibility to proceed with our collaboration in some way in the

future.

Frida, we walked more or less side by side during these years.

Thanks for your strength on the details and technical aspects, and

the patience to guide me into it. Thanks also for all the small talks,

feedback, sighs, tears and laughs. We should do more with our data.

Let´s keep on walking…. Hopefully hä årnsh sä!

All our study participants deserve deep bows and thanks for their

patience in performing repeated measurements and providing

information during interviews. Special thanks to Elisabeth

Österlund, Eva-Britt Persson, and Gunilla Edman at the

municipality of Örnsköldsvik. Without your enthusiasm and

patience, this thesis would not have been possible.

Previous and former PhD students and lecturers in the Department

of Physiotherapy. It has been a pleasure to feel welcome for lunches

and seminars with colleagues. Special thanks to Anna Sondell, my

Croatia-thesis-writing- partner, for a nice week with brisk morning

walks, lots of concentrated work, discussions about kappa-writing,

laughs, and lovely dinners.

All members in Tommys research group, thanks for including me in

your group! I highly appreciate all great methodological discussions

and enthusiastically detailed feedback on presentations.

Thanks to Fredrik Jonsson for statistical support. Jennie Jackson,

thanks for your energizing visits, language-checks and Mendeley-

support.

There is a lot of administration along the way, thanks to Kristina

Lindblom, Gunveig Österman and Elin Lindahl for your support.

Your sence of service is outstanding. Thanks also to Catrin

Johansson and Lennart Jonsson for assistance in the

administration of the questionnaires.

Thanks to all my colleagues at the Department for Work and

Environmental Health at Västerbotten County Council, and the

Section of Sustainable Health. I am grateful for the opportunity to

embrace your enthusiasm and your broad and deep knowledge and

perspectives on occupational health. Special thanks to Ingvar for

following me as an examinator. I have appreciated our discussions,

your technical advice on writing and suggestions for how to scare

the anxiety- ghosts away. Thanks also to Hans for thoughtful follow-

ups on how things are going.

Family and friends,

Karin, thanks for always listening and for all the fun we do.

Mum and Dad, thanks for midweek dinners, for teaching me to take

responsibility and do my best, and for giving me the strength to

dare to try new things.

Albin, Jonathan, and Jens. Thanks for the extra support, hugs,

and patience during the last period. You are the best. What

would I be without you?

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Theses written by

physiotherapists Umeå

University 1989-2019

1. Birgitta Bergman. Being a physiotherapist - Professional role, utilization of time

and vocational strategies. Umeå University Medical Dissertations, New Series no 251,

1989 (Department of Physical Medicine and Rehabilitation)

2.Inger Wadell. Influences from peripheral sense organs on primary and secondary

spindle affe- rents via gamma-motoneurones - A feedback mechanism for motor

control and regulation of muscle stiffness. Umeå University Medical Dissertations,

New Series no 307, 1991 (Department of Physiology)

3.Jessica Elert. The pattern of activation and relaxation during fatiguing isocinetic

contractions in subjects with and without muscle pain. Arbete och hälsa 1991:47.

Diss. 1992 (sammanfattning). (Departments of Clinical Physiology, National Institute

of Occupational Health and Physical Medi- cine and Rehabilitation)

4.Gunnevi Sundelin. Electromyography of shoulder muscles - The effects of pauses,

drafts and repe- titive work cycles. Arbete och Hälsa, 1992:16. Diss.

(sammanfattning). (Departments of Anatomy, National Institute of Occupational

Health, Division of Work and Environmental Physiology, Divisions of Occupational

Medicine and Applied Work Physiology and Occupational Medicine)

5.Birgit Rösblad. Visual and proprioceptive control of arm movement - Studies of

development and dysfunction. Diss. (sammanfattning) 1994 (Department of

Paediatrics)

6.Charlotte Häger-Ross. To grip and not to slip - Sensorimotor mechanisms during

reactive control of grasp stability. Umeå University Medical Dissertations, New

Series no 429, 1995 (Department of Physiology)

7.Lars Nyberg. Falls in the frail elderly – Incidence, characteristics and prediction

with special re- ference to patients with stroke and hip fractures. Umeå Medical

Dissertations, New Series no 483, 1996 (Department of Geriatric Medicine)

8. Margareta Barnekow-Bergkvist. Physical capacity, physical activity and health -

A population based fitness study of adolescents with an 18-year follow-up. Umeå

University Medical Dissertations, New Series no 494, 1997 (Departments of

Physiology and Technology, National Institute for Working Life and Epidemiology

and Public Health)

9.Britta Lindström. Knee muscle function in healthy persons and patients with upper

motor neurone syndrome. Umeå University Medical Dissertations, New Series no

505, 1997 (Departments of Physical Medicine and Rehabilitation and Clinical

Neuroscience)

10. Monica Mattsson. Body Awareness - applications in physiotherapy. Umeå

University Medical Dissertations, New Series no 543, 1998 (Departments of

Psychiatry and Family Medicine)

11. Hildur Kalman. The structure of knowing. Existential trust as an

epistemological category. Umeå studies in the humanities. 145, 1999 (Department of

Philosophy and Linguistics

12. Hamayun Zafar. Integrated jaw and neck function in man: studies of

mandibular and head-neck movements during jaw opening-closing tasks. Umeå

University Medical Dissertations, New series no 74, 2000 (Departments of

Odontology, Clinical Oral Physiology and Centre for Musculoskeletal Research,

National Institute for Working Life, Umeå)

13. Lillemor Lundin-Olsson. Prediction and prevention of falls among elderly

people in residential care. Umeå University Medical Dissertations, New Series no

671, 2000 (Department of Community Medicine and Rehabilitation, Physiotherapy

and Geriatric Medicine)

14. Christina Ahlgren. Aspects of rehabilitation – with focus on women with

trapezius myalgia. Umeå University Medical Dissertations, New Series no 715, 2001

(Department of Public Health and Clinical Medicine, Occupational Medicine)

15. Ann Öhman. Profession on the move - changing conditions and gendered

development in physiotherapy. Umeå University Medical Dissertations, New series

No 730, 2001 (Departments of Community Medicine and Rehabilitation,

Physiotherapy and Public Health and Clinical Medicine, Epidemiology)

16. Kerstin Söderman. The female soccer player – Injury pattern, risk factors

and intervention. Umeå University Medical Dissertations, New series no 735,

2001 (Departments of Surgical and Perioperative Sciences, Sports Medicine, and

Community Medicine and Rehabilitation, Physiotherapy)

17. Lena Grönblom-Lundström. Rehabilitation in light of different theories of

health. Outcome for patients with low-back complaints – a theoretical discussion.

Umeå University Medical Disserta- tions, New series no 760, 2001 (Departments of

Public Health and Clinical Medicine, Epidemiology, and Community Medicine and

Rehabilitation, Social Medicine)

18. Kerstin Waling. Pain in women with work-related trapezius myalgia.

Intervention effects and variability. Umeå University Medical Dissertations, New

series no 762, 2001 (Departments of Public Health and Clinical Medicine,

Occupational Medicine, and Community Medicine and Reha- bilitation, Physiotherapy)

19. Eva-Britt Malmgren-Olsson. Health problems and treatment effects in patients

with non-specific musculoskeletal disorders. A comparitson between Body Awareness

Therapy, Feldenkrais and Individual Physiotherapy. Umeå University Medical

Dissertations, New series no 774, 2002 (Department of Community Medicine and

Rehabilitation, Physiotherapy and Department of Psychology)

20.Jane Jensen. Fall and injury prevention in older people living in residential care

facilities. Umeå University Medical Dissertations, New series no 812, 2003

(Department of Community Medicine and Rehabilitation, Physiotherapy and Geriatric

Medicine)

21. Anncristine Fjellman-Wiklund. Musicianship and teaching. Aspects of

musculoskeletal dis- orders, physical and psychosocial work factors in musicians

with focus on music teachers. Umeå University Medical Dissertations, New series

no 825, 2003 (Department of Community Medicine and Rehabilitation,

Physiotherapy)

22.Börje Rehn. Musculoskeletal disorders and whole-body vibration exposure among

professional drivers of all-terrain vehicles. Umeå University Medical Dissertations,

New series no 852, 2004 (Department of Public Health and Clinical Medicine,

Occupational Medicine)

23.Martin Björklund. Effects of repetitive work on proprioception and of stretching

on sensory mechanisms. Implications for work-related neuromuscular disorders.

Umeå University Medical Dissertations, New series no 877, 2004 (Department of

Surgical and Perioperative Sciences, Sports Medicine Unit, Umeå University, The

Center for Musculoskeletal Reseach, University of Gävle, Umeå, and Alfta

Forskningsstiftelse, Alfta)

24.Karin Wadell. Physical training in patients with chronic obstructive pulmonary

disease – COPD. Umeå University Medical Dissertations, New series no 917, 2004

(Departments of Community Medicine and Rehabilitation, Physiotherapy; Public

Health and Clinical Medicine, Respiratory Medicine and Allergy, Surgical and

Perioperative Sciences, Sports Medicine)

25.Peter Michaelson. Sensorimotor characteristics in chronic neck pain. Possible

pathophysiologi- cal mechanisms and implications for rehabilitation. Umeå

University Medical Dissertations, New series no 924, 2004 (Departments of Surgical

and Perioperative Sciences, Sports Medicine Unit, University of Umeå, Southern

Lappland Research Department, Vilhelmina, Centre for Musculo- skeletal Research,

University of Gävle, Umeå)

26.Ulrika Aasa. Ambulance work. Relationships between occupational demands,

individual characteristics and health related outcomes. Umeå University Medical

Dissertations, New series no 943, 2005 (Department of Surgical and Perioperative

Sciences, Sports Medicine and Surgery, University of Umeå and Centre for

Musculoskeletal Research, University of Gävle)

27. Ann-Katrin Stensdotter. Motor Control of the knee. Kinematic and EMG studies

of healthy individuals and people with patellofemoral pain. Umeå University Medical

Dissertations, New series no 987, 2005 (Department of Community Medicine and

Rehabilitation, Physiotherapy)

28.Erik Rosendahl. Fall prediction and a high-intensity functional exercise

programme to improve physical functions and to prevent falls among older people

living in residential care facilities. Umeå University Medical Dissertations, New

Series no 1024, 2006 (Department of Community Medicine and Rehabilitation,

Geriatric Medicine and Physiotherapy)

29.Michael Stenvall. Hip fractures among old people. Their prevalence, consequences

and complications and the evaluation of a multi-factorial intervention program

designed to prevent falls and injuries and enhance performance of activities of daily

living. Umeå University Medical Dissertations, New Series no 1040, 2006

(Department of Community Medicine and Rehabilitation, Geriatric Medicine and

Physiotherapy)

30.Petra von Heideken Wågert. Health, physical ability, falls and morale in very old

people: the Umeå 85+ Study. Umeå University Medical Dissertations, New Series

no 1038, 2006 (Department of Community Medicine and Rehabilitation, Geriatric

Medicine and Physiotherapy)

31. Karl Gisslén. The patellar tendon in junior elite volleyball players and an

Olympic elite weightlifter. Umeå University Medical Dissertations, New Series no

1073, 2006 (Department of Surgical and Perioperative Sciences, Sports Medicine

Unit)

32.Gerd Flodgren. Effect of low–load repetitive work and mental load on sensitising

substances and metabolism in the trapezius muscle. Umeå University Medical

Dissertations, New series no 1130, 2007 (Department of Surgical and Perioperative

Sciences, Sports Medicine Unit, Centre of Musculoskeletal Research, University of

Gävle, Umeå, and the Department of Community Medicine and Rehabilitation,

Rehabilitation Medicine)

33.Staffan Eriksson. Falls in people with dementia. Umeå University Medical

Dissertations, New series no 1135, 2007 (Department of Community Medicine and

Rehabilitation, Physiotheraphy and Geriatric Medicine)

34.Jonas Sandlund. Position-matching and goal-directed reaching acuity of the upper

limb in chronic neck pain: Associations to self-rated characteristics. Umeå University

Medical Dissertations, New series no 1182, 2008 (Department of Surgical and

Perioperative Sciences, Sports Medicine Unit, Umeå University, Centre of

Musculoskeletal Research, University of Gävle, Umeå)

35. Gunilla Larsson. Motor function over time in Rett syndrome-loss, difficulties

and possibilities. Umeå University Licentiate Thesis, 2008 (Department of

Community Medicine and Rehabilitation, Physiotherapy)

36.Charlotte Åström. Effects of vibration on muscles in the neck and upper limbs.

With focus on occupational terrain vehicle drivers. Umeå University Medical

Dissertations, New series no 1135, 2008 (Department of Community Medicine and

Rehabilitation, Physiotherapy)

37. Ellinor Nordin. Assessment of balance control in relation to fall risk among

older people. Umeå University Medical Dissertations, New series no 1198, 2008

(Department of Community Medicine and Rehabilitation, Physiotherapy)

38.Bertil Jonsson. Interaction between humans and car seat. Studies of occupant seat

adjustment, posture, position and real world neck injuries in rear-end impacts. Umeå

University Medical Dissertations, New Series no 1163, 2008 (Department of Surgical

and Perioperative Sciences, Sports Medicine Unit)

39.Jenny Röding. Stroke in the younger. Self- reported impact on work situation,

cognitive func- tion, physical function and life satisfaction. A national survey. Umeå

University Medical Disserta- tions, New series no 1241, 2009 (Department of

Community Medicine and Rehabilitation, Physiotherapy)

40.Therese Stenlund. Rehabilitation for patients with burn out. Umeå University

Medical Disserta- tions, New series no 1237, 2009 (Department of Public Health and

Clinical Medicine, Occupational and Enviromental Medicine)

41. Elisabeth Svensson. Hand function in children and persons with neurological

disorders. Aspects of movement control and evaluation of measurements. Umeå

University Medical Dissertations, New series no 1261, 2009 (Department of

Community Medicine and Rehabilitation, Physiotherapy)

42.Helena Nordvall. Factors in secondary prevention subsequent to distal radius

fracture. Focus on physical function, co-morbidity, bone mineral density and health-

related quality of life. Umeå University Medical Dissertations, New series no 1252,

2009 (Department of Community Medicine and Rehabilitation Physiotherapy and

Department of Surgical and Perioperative Sciences, Orthopaedics)

43.Ingela Marklund. Intensivträning av nedre extremitet för personer med stroke–

effekter och upplevelser. Umeå University Licentiate Thesis, 2009 (Department of

Community Medicine and Rehabilitation, Physiotherapy)

44.Ulrik Röijezon. Sensorimotor function in chronic neck pain. Objective assessments

and a novel method for neck coordination exercise. Umeå University Medical

Dissertations, New series no 1273, 2009 (Department of Community Medicine and

Rehabilitation, Physiotherapy, Centre of Musculoskeletal Research, University of

Gävle, Umeå)

45.Birgit Enberg. Work experiences among healthcare professionals in the

beginning of their professional careers. A gender perspective. Umeå University

Medical Dissertations, New series no 1276, 2009 (Department of Community

Medicine and Rehabilitation, Physiotherapy and Department of Public Health and

Clinical Medicine, Epidemiology and Public Health Sciences)

46.Per Jonsson. Eccentric training in the treatment of tendinopathy. Umeå University

Medical Dissertations, New series no 1279, 2009 (Department of Surgical and

Perioperative Sciences, Sports Medicine Unit)

47.Taru Tervo. Physical activity, bone gain and sustainment of peak bone mass.

Umeå University Medical Dissertations, New series no 1282, 2009 (Department of

Surgical and Perioperative Sciences, Sports Medicine, Department of Community

Medicine and Rehabilitation, Geriatric Medicine, Department of Community

Medicine and Rehabilitation, Rehabilitation Medicine)

48.Kajsa Gilenstam. Gender and physiology in ice hockey: a multidimensional study.

Umeå Univer- sity Medical Dissertations, New series no 1309, 2010 (Department of

Surgical and Perioperative Sciences, Sports Medicine Unit)

49.Margareta Eriksson. A 3-year lifestyle intervention in primary health care.

Effects on physical activity, cardiovascular risk factors, quality of life and

costeffectiveness. Umeå University Medical Dissertations, New series no 1333, 2010

(Department of Community Medicine and Rehabilitation, Physiotherapy and

Department of Public Health and Clinical Medicine, Epidemiology and Public Health

Sciences)

50.Eva Holmgren. Getting up when falling down. Reducing fall risk factors after

stroke through an exercise program. Umeå University Medical Dissertations, New

series no 1357, 2010 (Department of Community Medicine and Rehabilitation,

Physiotherapy and Department of Public Health and Clinical Medicine, Medicine)

51. Tania Janaudis Ferreira. Strategies for exercise assessment and training in

patients with chronic obstructive pulmonary disease. Umeå University Medical

Dissertations, New series no 1360, 2010 (Department of Community Medicine and

Rehabilitation, Physiotherapy)

52. Sólveig Ása Árnadóttir. Physical activity, participation and self-rated health

among older community-dwelling Icelanders. A population-based study. Umeå

University Medical Dissertations, New series no 1361, 2010 (Department of

Community Medicine and Rehabilitation, Physiotherapy)

53. Maria Wiklund. Close to the edge. Discursive, embodied and gendered stress in

modern youth. Umeå University Medical Dissertations, New series no 1377, 2010

(Department of Public Health and Clinical Medicine, Epidemiology and Global Health

and Department of Community Medicine and Rehabilitation, Physiotherapy)

54.Catharina Bäcklund. Promoting physical activity among overweight and obese

children: Effects of a family-based lifestyle intervention on physical activity and

metabolic markers. Umeå University 2010 (Department of Food and Nutrition)

55. Helene Johansson. En mer hälsofrämjande hälso- och sjukvård: hinder och

möjligheter utifrån professionernas perspektiv. Umeå University Medical

Dissertations, New series no 1388, 2010 (Department of Public Health and Clinical

Medicine, Epidemiology and Global Health)

56.Håkan Littbrand. Physical exercise for older people: focusing on people living in

residential care facilities and people with dementia. Umeå University Medical

Dissertations, New series no 1396, 2011 (Department of Community Medicine and

Rehabilitation, Geriatric Medicine and Physiotherapy)

57. Marlene Sandlund. Motion interactive games for children with motor

disorders. Umeå University Medical Dissertations, New series no 1419, 2011

(Department of Community Medicine and Rehabilitation, Physiotherapy)

58.Ann Sörlin. Health and the Elusive Gender Equality. Can the impact of gender

equality on health be measured? Umeå University Medical Dissertations, New series

no 1420, 2011 (Department of Public Health and Clinical Medicine, Epidemiology and

Global Health)

59.Björn Sundström. On diet in ankylosing spondylitis. Umeå University Medical

Dissertations, New series no 1440, 2011 (Department of Public Health and Clinical

Medicine, Reumatology)

60.Gunilla Stenberg. Genusperspektiv på rehabilitering för patienter med rygg- och

nackbesvär i primärvård. Umeå University Medical Dissertations, New series no

1482, 2012 (Department of Community Medicine and Rehabilitation, Physiotherapy

and Umeå centre for Gender Studies)

61. Mia Conradsson. Physical exercise and mental health among older people -

measurement methods and exercise effects with focus on people living in residential

care facilities. Umeå University Medical Dissertations, New series 1537, 2012

(Department of Community Medicine and Rehabilitation, Geriatric Medicine)

62.Mattias Hedlund. Biomechanical and Neural Aspects of Eccentric and Concentric

Muscle Performance in Stroke Subjects. Implications for resistance training. Umeå

University Medical Dissertations, New series no 1510, 2012 (Department of

Community Medicine and Rehabilitation, Physiotherapy)

63.Joakim Bagge. TNF-alfa och neurotrophins in achilles tendinosis. Umeå

University Medical Dissertations, New series no 1538, 2013 (Department of

Integrative Medical Biology, Anatomy and Department of Surgical and Perioperative

Sciences, Sports Medicine)

64.Gunilla Larsson. Motor development, mobility and orthostatic reactions in Rett

syndrome. Loss of function, difficulties and possibilities. Umeå University Medical

Dissertations, New series no 1566, 2013 (Department of Community Medicine and

Rehabilitation, Physiotherapy)

65.Ludvig J Backman. Neuropeptide and catecholamine effects on tenocytes in

tendinosis development. Studies on two model systems with focus on proliferation

and apoptosis. Umeå University Medical Dissertations, New series no 1572, 2013

(Department of Integrative Medical Biology, Anatomy and Department of Surgical

and Perioperative Sciences, Sports Medicine)

66.Sven Blomqvist. Postural balance, physical activity and capacity among

young people with intellectual disability. Umeå University Medical Dissertations,

New series no 1579, 2013 (Department of Community Medicine and

Rehabilitation, Physiotherapy)

67.Eva Tengman. Long-term consequences of anterior cruciate ligament injury.

Knee function, physical activity level, physical capacity and movement pattern.

Umeå University Medical Dissertations, New series no 1631, 2014 (Department of

Community Medicine and Rehabilitation, Physiotherapy)

68.Andre Nyberg. Single limb exercises in patients with chronic obstructive

pulmonary disease. Feasibility, methodology, effects and evidence. Umeå University

Medical Dissertations, New series no 1645, 2014 (Department of Community

Medicine and Rehabilitation, Physiotherapy)

69.Maria Strömbäck. Skapa rum. Ung femininitet, kroppslighet och psykisk

ohälsa – genusmedveten och hälsofrämjande intervention. Umeå University

Medical Dissertations, New series no 1655, 2014 (Department of Community

Medicine and Rehabilitation, Physiotherapy, Clinical Science, Psychiatry and

Umeå Centre for Gender Studies, National Research School for Gender Studies)

70.Joakim Bjerke. Gait and postural control after total knee arthroplasty. Umeå

University Medical Dissertations, New series no 1664, 2014 (Department of

Community Medicine and Rehabilitation, Physiotherapy)

71. Elisabet Sonntag-Öström. Forest for rest. Recovery from exhaustion disorder.

Umeå University Medical Dissertations, New series no 1667, 2014 (Department of

Public Health and Clinical Medicine, Occupational and Environmental Medicine)

72. Maria Sehlin. Resistance breathing with PEP and CPAP. Effects on

respiratory parameters. Umeå University Medical Dissertations, New series no

1674, 2014 (Department of Surgical and Perioperative Sciences, Anaesthesiology

and Intensive Care Medicine, Department of Community Medicine and

Rehabilitation, Physiotherapy, Department of Radiation Sciences, Biomedical

Engineering)

73. Petra Pohl. Falls in older community-dwelling women and men: risk factors

and safety strategies. Fall risk awareness, fear of falling, and preferred exercise

properties from a gender perspective. Umeå University Medical Dissertations,

New series No 1692, 2015 (Department of Community Medicine and

Rehabilitation, Physiotherapy)

74.Gudrun Johansson. Clinical and kinematic assessments of upper limb function in

persons with post-stroke symptoms. Umeå University Medical Dissertations, New

series No 1722, 2015 (Department of Community Medicine and Rehabilitation,

Physiotherapy)

75. Camilla Sandberg. Physical performance, physical activity, body composition

and exercise training in adults with congenital heart disease. Umeå University

Medical Dissertations, New series No 1758, 2016 (Department of Public Health and

Clinical Medicine, Medicine, Department of Community Medicine and Rehabilitation,

Physiotherapy)

76.Tobias Stenlund. Seated postural reactions to mechanical shocks. Laboratory

studies with relevance for risk assessment and prevention of musculoskeletal

disorders among drivers. Umeå University Medical Dissertations, New series No

1780, 2016 (Department of Community Medicine and Rehabilitation, Physiotherapy)

77. Anna Bråndahl. Rehabilitation after stroke with focus on early supported

discharge and post- stroke fatigue. Umeå University Medical Dissertations, New

series No 1817, 2016 (Departments of Public Health and Clinical Medicine,

Medicine, and Community Medicine and Rehabilitation, Physiotherapy)

78.Lars Berglund. Deadlift training for patients with mechanical low back pain: a

comparison of the effects of a high-load lifting exercise and individualized low-load

motor control exercises. Umeå University Medical Dissertations, New series No 1806,

2016 (Department of Community Medicine and Rehabilitation, Physiotherapy,

Department of Surgical and Perioperative Sciences, Orthopaedics)

79.Peter Flank. Spinal cord injuries in Sweden: studies on clinical follow-ups.

Umeå University Medical Dissertations, New series No 1824, 2016 (Department

of Community Medicine and Rehabilitation, Rehabilitation Medicine)

80.Annika Toots. Gait speed and physical exercise in people with dementia.

Umeå University Medical Dissertations, New series No 1866, 2016 (Department

of Community Medicine and Rehabilitation, Geriatric medicine and

Physiotherapy)

81. Cecilia Wahlström Edling. Musculoskeletal disorders in music teachers and

their view on young music student’ health – Visions and reality in contradiction. Umeå

University Licentiate Thesis 2017. (Department of Community Medicine and

Rehabilitation, Physiotherapy and Umeå Centre for Gender Studies)

82.Åsa Svedmark. Neck pain in women – Effect of tailored and impact of work

environment. Umeå University Medical Dissertations, New series No 1916, 2017

(Department of Community Medicine and Rehabilitation, Physiotherapy)

83.Anna Stecksén. Stroke thrombolysis on equal terms? Implementation and ADL

outcome. Umeå University Medical Dissertations, New series No 1917, 2017

(Departments of Public Health and Clinical Medicine, Medicine, and Community

Medicine and Rehabilitation, Physiotherapy)

84.Kristina Hörnberg. Aspects of physical activity in rheumatoid arthritis.

Associations with inflammation and cardiovascular risk factors. Umeå University

Dissertations, New series no 1949, 2018 (Department of Public Health and Clinical

Medicine, Rheumatology)

85.Elisabeth Pietilä-Holmner. Multimodal Rehabilitation of Patients with Chronic

Musculoskeletal Pain, focusing on Primary Care. Umeå University Medical

Dissertations, New series No 1970, 2018 (Departments of Community Medicine and

Rehabilitation, Rehabilitation medicine)

86.Sara Lundell. COPD in primary care. Exploring conditions for implementation

of evidence- based interventions and eHealth Care. . Umeå University Medical

Dissertations, New series No 1982, 2018 (Departments of Community Medicine

and Rehabilitation, Physiotherapy) and Radiation Sciences, Radiation physics and

Biomedical Engineering)

87.Frida Bergman. Active workstations – a NEAT way to prevent and treat

overweight and obesity. Umeå University Medical Dissertations, New series No 1981,

2018 (Departments of Public Health and Clinical Medicine, Medicine and Community

Medicine and Rehabilitation, Physiotherapy)

88.Haleluya Moshi. Traumatic spinal cord injuries in rural Tanzania. Occurrence,

clinical outcomes and life situation of persons living in the Kilimanjaro region. Umeå

University Medical Dissertations, New series No 1988, 2018 (Departments of

Community Medicine and Rehabilitation, Physiotherapy.)

89.Claes Göran Sundell. Low back pain in Adolescent Athletes. Umeå University

Medical Dissertations, New series No 2014, 2019 (Departments of Community

Medicine and Rehabilitation)

90.Jonas Markström. Movement strategies and dynamic knee control after anterior

cruciate ligament injury. Umeå University Medical Dissertations, New series No 2040,

2019 (Departments of Community Medicine and Rehabilitation, Physiotherapy)

91. Viktoria Wahlström. Interventions for increased physical activity among office

workers. Umeå University Medical Dissertations, New series No 2053, 2019

(Departments of Public Health and Clinical Medicine, Section for Sustainable

Health)

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