Copyright © 2015 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited Process Evaluation of the Nationwide Implementation of a Lifestyle Intervention in the Construction Industry Susanne C. Tonnon, MSc, Karin I. Proper, PhD, Hidde P. van der Ploeg, PhD, Johannes R. Anema, PhD, and Allard J. van der Beek, PhD Objective: The aim of this study was to monitor the national scale up of the effective lifestyle intervention Health Under Construction in the Dutch construction industry. Methods: Data were collected on seven process indicators, ie, reach, dose delivered, dose received, fidelity, competence, satisfaction, and barriers. Results: The intervention reached 2.4% of the target group. Thirty-eight percent of the participants received five to seven consultations and 41% discussed all six intervention components. None of the counselors attained motivational interviewing proficiency. Participants perceived their counselor as competent and were satisfied with the inter- vention. Counselors were moderately satisfied with the intervention and experienced various barriers. Conclusions: Even though important con- ditions for scale up were met, the implementation was characterized by a low reach, a high drop-out rate, and a low quality of the counseling technique. BACKGROUND C ardiovascular disease (CVD) is the most common cause of death globally and one of the biggest contributors to the global burden of disease. 1 Finding effective ways to prevent CVD is a priority of policy makers worldwide. 2 There is growing evidence that lifestyle interventions can reduce CVD risk factors, such as smoking cessation and increased physical activity. 3–6 However, interventions with proven efficacy in a controlled setting often fail to produce such results due to implementation failure in daily practice. 7–11 Dutch construction workers have a higher prevalence of CVD risk factors than the general population. 12,13 To reduce their CVD risk, the lifestyle intervention Health Under Construction (HUC) was developed in 2006. 14 The HUC intervention promotes behav- ioral change regarding physical activity and a healthy diet through individual counseling. Employees are screened by an occupational physician (OP) for their CVD risk during a periodic medical examination (PME). Employees with an elevated CVD risk are referred to a lifestyle counselor trained in motivational interviewing (MI). The HUC intervention was shown to be effective in a randomized controlled trial (RCT) in 2010. 15,16 On the basis of the results of the trial, it was decided to implement the HUC intervention at a national level. There are various factors that determine whether or not an intervention is suitable for large-scale implementation. 17,18 The intervention needs to be proven effective and effect sizes should be relatively large, because a reduction in effectiveness should be expected after implementation in a less-controlled setting. Further- more, the intervention should be adaptable and generalizable to various settings without compromising the fidelity of the pro- gram. 17,19 Intervention costs and cost-effectiveness need to be known, as well as its acceptability and resources, infrastructure, and expertise that are necessary for implementation. 17 Scaling up should be monitored and evaluated, so that a program can be adapted according to evaluations and changing circumstances. Finally, implementing organizations need to be willing to imple- ment the intervention on top of their usual workload. 19 The HUC intervention met various conditions for scalability. First, the intervention was proven effective in a RCT. 15,16 The nation- wide implementation took place in the same context and with the same target group as the trial, which meant that implementation costs, necessary resources, infrastructure, and work force were known. A cost-effectiveness study and a process evaluation had been performed alongside the trial, and the intervention was adapted according to the results of those studies. 20,21 For example, the trial process evaluation showed that 20% of the eligible employees decided to participate and that the counselors’ MI proficiency could be improved. Therefore, the screening procedure was made more user friendly and the MI training was expanded. On the basis of the screening procedure, in daily practice, the OP should make the referral to the counselors; however, in the RCT, both screening and referral were performed by the research team. The analysis revealed a problem that this would be a critical implementation element. Hence, shortly before the nation- wide implementation, an additional study on the barriers and facil- itators was performed. 22 On the basis of the finding that OPs were hampered in making a referral by administrative tasks tied to the intervention, the administrative tasks for OPs were minimized. The question was whether or not these preparations would lead to favor- able implementation results. Thus, the aim of the present study was to perform a process evaluation of the nationwide implementation of the HUC intervention. METHODS Design A process evaluation was performed over a period of 2 years (January 1, 2013 until January 1, 2015). Qualitative and quantitative data were collected among eligible employees and lifestyle coun- selors. The Medical Ethics Committee of the VU University Medical Center Amsterdam decided that it was unnecessary to seek ethical approval for this study. Setting The intervention was implemented by the national institute Arbouw, which seeks to improve working conditions and work ability in the Dutch construction industry. At the time of the study, Arbouw contracted 25 commercial occupational health services (OHS) to perform PMEs and follow-up interventions, including the HUC intervention. Each OHS assigned professionals to the HUC training, which consisted of the modules: 1) MI technique, 2) From the Department of Public and Occupational Health, EMGOþ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands (Ms Tonnon, Dr Proper, Dr van der Ploeg, Dr Anema, Dr van der Beek), Body@Work, TNO-VUmc, Amsterdam, Netherlands (Dr Proper, Dr van der Beek), and National Institute for Public Health and the Environment, Centre for Nutrition, Prevention and Health Services, Bilthoven, The Nether- lands (Dr Proper). This study was funded by the Netherlands Organization for Health Research and Development (ZonMw). The authors report no conflicts of interest. Address correspondence to: Susanne C. Tonnon, MSc, VU medisch centrum, Amsterdam, Netherlands (s.tonnon@vumc.nl). Copyright ß 2015 American College of Occupational and Environmental Medicine DOI: 10.1097/JOM.0000000000000628 e6 JOEM  Volume 58, Number 1, January 2016 ORIGINAL ARTICLE