Results are presented mainly according to intervention components with quantitative and qualitative data from the questionnaires integrated throughout the results together with the themes identified from the focus groups (shown in Table 2.) Figure 1 shows the flow of participants through the randomised controlled trial.
Educational seminar and leaflet
Only seven intervention participants (14%) did not attend the seminar face-to-face and were sent an audio recording instead. From those who had attended the seminar, questionnaire data (Table 3) showed strong agreement between the respondents that the seminar was delivered at an appropriate level (94% agreed or strongly agreed) and was an appropriate length (95% agreed/strongly agreed). Importantly, 93% felt that the seminar increased their awareness of the health consequences of too much sitting and 95% felt it motivated them to make a change to the amount of time they spend sitting.
Open-ended questionnaire responses were requested concerning understanding the key seminar messages. Of the 52 respondents, 40 provided comments, with three main questionnaire themes emerging:
- standing and breaking up sitting is desirable to prolonged sitting
- excessive sitting is bad for your health
- exercise may not offset the detrimental effects of prolonged sitting.
In the focus groups, some participants discussed how knowledge learned from the seminar had a powerful impact on their understanding and attitude toward excessive sitting at work [Level 1 Main Theme – Attitude and behaviour change regarding reducing sitting at work].
I’m quite aware of the effects of sitting all day but I think it’s not until you sit there and actually listen to all the information that you think okay yes this can actually have a huge impact (Intervention participant, focus group 4)
For the educational leaflet provided, 89% of questionnaire respondents said that they had read it. The content was seen as appropriate (88% rating agree/strongly agree). Most (88%) felt that the leaflet increased their awareness of the health consequences of too much sitting and 82% said it motivated them to make a change to the amount of time they spent sitting.
Though participants were given a choice of desk, they chose roughly evenly between the two models (60% chose a Varidesk platform and 40% the electric workstation). The purchasing and delivery of the workstations took longer than planned, so many of the participants would have only had the workstation installed for ~1 month prior to the 3 month follow up visit. Table 4 presents the quantitative feedback on the workstation. At 6 months, all those responding said that they have used the workstation at least once during the first 6 months, with all but three respondents reported using the workstation at least a few times per week (33%) or everyday (67%). In the first month of installation, 67% used it every day, with similar rates between desk type. The majority of participants did not find their workstation obtrusive to completing work tasks at 6m (69%) and 12m (67%). Questionnaire data showed that respondents were not self-conscious when using the workstations (84% and 88% at 6m and 12m respectively), nor did they think their colleagues minded when the workstation was being used (98% at 6m; 99% at 12m). These data were supported in the focus groups with participants highlighting that their non-participant colleagues did not impact on their use of the height-adjustable workstation [Level 3 sub-theme – social influence].
The people who didn’t have the desks, they didn’t say anything or, like it wasn’t awkward to stand up at any point in the office or anything like that, it was fine (Intervention participant, focus group 3)
Questionnaire respondents were asked how they scheduled the use of their workstations, such as specifying certain times or for particular tasks. At 6m, 44% reported scheduling often or very often, with a slight drop to 36% at 12m. The mixed responses were reinforced by the focus groups with some people stating that they had set times/periods when they used their desk, such as first thing in the morning or in the afternoon, but for some people it was used more randomly or when their body felt like it needed a change in posture [Level 1 Main theme – perceptions of the benefits of standing; Level 3 sub-theme – feedback and prompts].
I come in the morning and I automatically put my desk up. I’ll stand until I’m starting to feel ……I’m not standing properly. So I’ll just sit down, but then when I’m taking phone calls or particular slots for e-mails I then stand (Intervention participant, focus group 4)
My back lets me know when I need to stand up (Intervention participant, focus group 1)
Regarding perceptions of whether the workstations helped the participants reduce their sitting time, 95% and 94% of questionnaire respondents reported agreement at 6m and 12m respectively. Agreement was high and broadly similar at 12m between the electronic workstation (100%) and for the Varidesk (92%). However, it was also evident from the focus group discussions that some people stood for prolonged periods at their desk despite regular posture change being recommended [Level 3 sub-theme – sitting less at work and Level 1 Main theme – perceptions of the benefits of standing].
I had a period of time when I’ve come in every morning and lifted it up and I’d stand at it until I’d had enough. You know sometimes it was two hours and then I’d put it down and think I’m done for the day now (Intervention participant, focus group 1)
I stand for ages… but I like that, it feels really good for me (Intervention participant, focus group 3)
At 6m and 12m, questionnaire respondents were asked to write comments concerning what was positive about using their workstation. From 69 and 79 statements provided at 6m and 12m respectively, six main themes emerged:
- musculo-skeletal and posture: better posture and fewer aches and pain, especially in neck, shoulders, and back
- mental benefits: better cognitive functioning and work productivity (e.g., ‘feel more productive’, ‘allowed me to concentrate and focus’), enhanced mood (‘feel my mood has improved’), and improved feelings of energy and alertness (e.g., ‘re-energises me’, , ‘felt more alert throughout the day’)
- more movement: ‘I am more likely to move about the office if standing’
- general health benefits: ‘feel more positive about my health’
- social norms and benefits: ‘more are willing to stand if I am standing’
- increased choice: ‘gives me the option’.
Additional themes concerned ‘comfort and utility’ at 6m (e.g., ‘more comfortable standing’; ‘easy to use’), and ‘ergonomics’ at 12m (e.g., ‘more natural eye line to the screen’).
Musculo-skeletal outcomes were also reflected in the data from the focus groups [Level 3 sub-theme – reduction in musculoskeletal problems]:
Prior to this study, I did have problems with my shoulder and I’ve found standing does alleviate that because when you’re with your mouse like that of at the keyboard, and now standing, it’s different, your hands are lower, and I’ve not had a problem with my shoulder since the study (Intervention participant, focus group 6)
Many focus groups participants described how standing up during tasks led to increased productivity and confidence [Level 3 sub-theme – productivity]:
I feel I work better, I work faster when I am standing up, to be honest, when you are sitting down, you are sort of just there (Intervention participant, focus group 6)
Busy and stressful before, I just had hundreds of emails hitting me, phone calls, doctors coming in, there was so much, but even then, I still stood up during then, I thought, actually, it made me feel like that different mindset… I felt more confident standing up… I felt I could deal with things. (Intervention participant, focus group 3)
As the SMArT Work Intervention was a cluster design, where groups of people within the same office group were randomised to the same group, if one person was standing up (at their desk or elsewhere), this would often remind other colleagues to also stand up. Therefore, a knock-on effect of colleagues standing regularly was evident, thus creating a culture shift, as illustrated by these comments from the focus groups [Level 1 Main theme – creating an incidental socio-cultural environment of standing at work]:
In the environment when there’s lots of people standing up, you know, one person stands up, you know, then it’s oh yes, I need to stand up, too (Intervention participant, focus group 6)
I think it’s like a culture of, like, in an office where everybody is doing the same thing then it’s almost like an instant reminder, you know, maybe I should be standing at the same time and, you know, where it’s like a team sort of thing you get into sort of, like, a routine where everybody will be standing at some point, you know, during the day, and encourages it (Intervention participant, focus group 6)
Questionnaire respondents were also asked to write comments concerning what was negative about using the workstation at both 6m and 12m. The main issue that emerged concerned the lack of space on the desk and concerned papers and files falling off, and a lack of space for handling multiple papers. These comments were exclusively in reference to the Varidesk. Other negative issues mentioned were musculo-skeletal (e.g., ‘initial low back pain’; ‘initial leg pain’; ‘feet can ache’), ergonomic (e.g., ‘uncomfortable when typing a lot’; ‘sometimes couldn’t type when standing’; ‘wires would get caught’), social issues (e.g., ‘feel awkward when standing and talking to others who are sitting’), and additional work issues (e.g., ‘remembering to use the workstation’; ‘change to established work pattern’). This was also highlighted in the focus groups by some participants.
Initially it was the lack of space. Because it was a two-tiered system, when you did stand up there was not much space to put your paperwork on (Intervention participant, focus group 2)
The questionnaire findings (Table 5) showed the use of the Darma cushion and associated ‘app’ was moderate at 6m; 55% reported using it since it was given to them and few planned to use it in the future. Assessing over the past 6m, users of the Darma cushion reported varied responses, with 39% reporting infrequent use, while 37% reported daily use. Only a small percentage (15%) of participants viewed their feedback on the app frequently. Only 11 (20%) reported using the cushion in the last 6 month at the 12m time point, with 18% reporting infrequent use, 36% using it ‘a few times per week’, and 45% reporting daily use. The use of the Darma cushion was initially reasonable with 68% reporting daily use in the first month. The cushion vibration function was used by 62% and 46% of those that reported using the cushion in the past 6 months at the 6m and 12m time points respectively, with most (87% and 70% at 6m and 12m respectively) reporting it to be useful.
Ratings were provided on a number of characteristics of the Darma cushion at 6m and 12m. These are shown in Table 6. Data from the 32 participants using the cushion in the first 6 months suggested that it was easy to use (71% agreement), was not obtrusive (54%), it increased awareness (69%), and encouraged less sitting (66%). The small sample using the Darma cushion at 12m reported it as easy to use, largely unobtrusive, it increased awareness, although only 54% agreed it decreased sitting.
Focus group discussions on the topic suggested participants found other ways to set prompts, including using the Varidesk computer/phone app and Google Chrome Stand Up! Timer [Level 2 sub-theme – prompts].
I’m using the computer prompt [Google Chrome Stand Up! Timer] now because I didn’t get on too well with the cushion (Intervention participant, focus group 6)
It helped a lot [Varidesk phone app], you could set the time, if you needed that regime at the start, you could say I am going to stand up for half an hour and then down again (Intervention participant, focus group 3)
At 6m and 12m, reasons given in the questionnaires for not using the cushion centred on lack of comfort, technological issues with the app and phone (e.g., syncing, storage and battery problems), length of charging lead and other reasons. The latter included a perception by some that it was not needed and that they could implement their own behaviour change without it. Similar comments were also made in the focus groups [Level 3 sub-theme – cushion]:
It was very uncomfortable [and] it ran out of batteries so I never recharged it (Intervention participant, focus group 3)
The lead is really short, you had to plug it in, I think once it died…. (Intervention participant, focus group 3).
Some also reported that they used it initially but didn’t need it once using the height-adjustable workstation became more of a habit [Level 2 sub-theme – factors that promote standing and habit formation]:
I did at the very start but then after that I actually found, because I was generally pretty good with my standing desk that I didn’t really see the requirement for the cushion (Intervention participant, focus group 7)
I think to start with, I had to use those timers and things to remind myself to stand up, but now it is just so natural…I just stand up until I feel like sitting down again or I stand up when I feel like I need to stand up” (Intervention participant, focus group 3)
Sitting Time Diary
Table 7 presents the quantitative responses to the diary. Most questionnaire respondents reported that they either never used or no longer used the diary to keep a record of their sitting (91%) nor used it for goal-setting (93%) within the first 6m. Similar data were found for 12m.
Reasons for not using the diary, including for goal-setting, were given in open-ended comments and included perceived lack of time and time pressure of their job (e.g., ‘work pressures – didn’t think about it’), forgetting, not finding it useful (e.g., ‘didn’t see point’; ‘doesn’t work for me’), and motivation (e.g., ‘effort of completing outweighs benefits’). Similar responses emerged from the focus groups (Level 3 sub-theme – diary):
I think realistically you are probably not going to carry a paper diary around with you…it became another thing to either forget, like keep up with. And you always have your phone on you, so it’s easier just to write things on your phone (Intervention participant, focus group 3)
Some participants, however, stated in their questionnaire open-ended responses that they did not use the diary because they felt they did not need it. Some stated that their height-adjustable workstation was enough to encourage them to sit less, while others had created their own routine and habit (e.g., ‘stand when work allows me’; ‘I usually stand in the morning’).
Feedback on Sitting Time
A large majority of the questionnaire respondents were in agreement, at both time points, that receiving feedback on their sitting time helped them think about their sitting, highlighted that they could be sitting too much, motivated them to change, helped plan and set goals, and was useful for reviewing progress (Table 8). Some of these findings were also discussed by focus group participants. [Level 3 sub-theme – feedback].
You could see, in the information put in front of you, this is the chunk of your day sat down, you go ‘Oh my God’, and then you go ‘I need to make sure I stand up more (Intervention participant, focus group 4)
‘Progress Chats’ (i.e., coaching) with Research Team Staff
All but 1 of the participants who were left in the study at 12 months had all 4 coaching sessions (n=62). There were 72, 65, 65, and 63 participants participating in the 1st, 2nd, 3rd and final coaching sessions, respectively. At 12m only, participants were asked in the questionnaire to reflect on the coaching and support provided by research staff through the ‘progress chats’ that were provided (see Table 9). Participants reported that the chats helped them formulate plans (90%), helped them stay on track (90%), motivated them (94%), help them find solutions (87%), and provided support often enough (93%).
Other Lifestyle Changes
The questionnaire results showed other lifestyle changes were made by 39% of intervention participants in the first 6 months. Of those reporting the nature of such changes, 10 were positive (e.g., signing up for gym membership), and seven were negative (e.g., illness).
Facilitators and Barriers to Behaviour Change
Though the desk appeared to positively impact on behaviour change by providing participants the opportunity to stand whilst working, the lack of space on the Varidesk platform did appear to put participants off changing the desk position. This was mentioned by 50% of those reporting negative issues at 6m and concerned papers and files falling off, and a lack of space for handling multiple papers.
However, during the focus groups, many reported that this led to strategies to enhance the tidiness of their desk, thus creating a positive outcome [Level 3 sub-theme – changes in work style].
My desk, for the first two or three days, it was slightly awkward, because I was working more narrowly. My arms weren't in the same places as they would have normally been in to operate the mouse. But very quickly, you got over that, and now I don't… well, within a week, I didn't even notice anything different about it. And it keeps everything very contained on your desk, and actually, encourages me to be a little bit more tidy, so that I can lift it and put it down without causing an avalanche (Intervention participant, focus group 1)
Other barriers to standing at both 6 and 12m from the questionnaire data were musculo-skeletal (e.g., ‘initial low back pain’; ‘initial leg pain’; ‘swollen ankles and feet’), ergonomic (e.g., ‘uncomfortable when typing a lot’; ‘sometimes couldn’t type when standing’; ‘wires would get caught’), and additional work issues (e.g., ‘remembering to use the workstation’; ‘change to established work pattern’; ‘feel awkward when standing’).
From the focus group findings, some participants commented on how the length of the intervention [Level 3 sub-theme – length of intervention] gave them time to adjust to a different way of working [Level 3 sub-theme – changes in work style], by incorporating standing (e.g. alternating from to sitting and standing), which over time made them aware of the work benefits.
This has been quite a fundamental change, it’s made me think very differently about workspaces, environment, the way I interact with other people, you know. … I’ve actually changed the way I work with my devices, and that means how I work with people, and the information and conversations I’m having, all that’s changed, so to make that [change] all in one go would be hard, and it’s needed a time period (Intervention participant, focus group 6)
But you soon adapt. You just remember when you pull it up [the desk] to move your paperwork in a bit, and put it in the right position (Intervention participant, focus group 2)
I concentrate better when I am standing up than when I am sitting down …. If you have a difficult conversation on the phone, sometimes standing up is better because that way you are more confident as well (Intervention participant, focus group 2)
Regarding barriers to behaviour change, focus group participants felt that if they were having a stressful day or were engrossed in a certain tasks then they felt that they either needed to sit down or would simply forget to break up their sitting [Level 2 sub-theme – aspects of the job].
I think it is hard to stand on stressful days. That’s what I found. You know, if there is a lot of stress in the office then it is difficult because you tend to sit. You’re fed up. (Intervention participant, focus group 5)
Sometimes if you get involved in a bit of work or whatever, a few hours can go by like two or three and then you are like oh I have just been sat here for three hours, I haven’t even left my desk (Intervention participant, focus group 3)
The culture of sitting in meetings was highlighted as a barrier in the focus groups, with participants suggesting managers should show support or roll out policy to stand more at work [Level 1 Main themes – wider/policy changes at work: barriers to behaviour change]. Participants did not feel comfortable or confident to stand in meetings, particularly those meetings involving senior staff and/or when the does not recognise the importance of regularly standing.
Everyone has to be standing, otherwise the attention is on you, if you’re the one person standing in a meeting (Intervention participant, focus group 3)
I think manager buy-in is critical in this study. Because obviously if your manager is not supportive of you standing most of the time, then it can have a negative impact. And the interesting bit was if we [participant and manager] had meetings, we would have stand-up meetings. These tended to be much shorter and much focused as opposed to when you’re sat on a round somewhere in a meeting room (Intervention participant, focus group 4)
But I think, yes, like you say, if you can get your manager to, yes, incorporate a ten-minute stand-up session in the middle, then that would be the best way to go (Intervention participant, focus group 4)
The coding of 41 open-ended questionnaire responses from 22 control participants who completed the questionnaire led to six main themes concerning lifestyle changes during the project: lifestyle changes (positive), lifestyle changes (negative), less physical activity, more physical activity, diet changes, and other changes. Several said that they had moved house and this had caused a negative disruption to their lifestyle and health. Others reflected on positive lifestyle changes, including joining a weight management service. For physical activity, a significant number of comments reflected changes for both increasing and decreasing physical activity. A few stated positive efforts in changing their nutrition. Overall, a large number of life events were mentioned and these appeared to have both positive and negative effects on lifestyle and health.
The second question asked whether being part of the study, despite being in the control group, had affected their sitting behaviour at home or work. Coding of 30 responses from 16 control participants led to four main themes: sit less, move more, change diet, and awareness. The sit less theme reflected a number of changes control participants had made during the trial, including ‘I consciously get up from my desk frequently’, ‘make effort to stand more at certain tasks’, and ‘more aware at home – do not sit for too long’. Others reported an emphasis on moving more, reflecting sub-themes of using self-monitoring (e.g., ‘I count my steps daily’), incidental (e.g., ‘increased my stair use’), and exercise (e.g., ‘I try to walk at lunchtime’). Being part of the project seemed to create greater awareness in some control participants, mainly around sitting. This was reflected in a reduction for daily sitting time in control participants at 3 month follow up, although not at further follow-up .
Finally, participants in the control group were asked whether any changes were made to their lifestyle after receiving health test results from the assessments. From 37 responses, 22 (60%) said that the tests did not have any impact on their lifestyle.
It became apparent from the focus groups that the feedback they received from the health measures at baseline, 3, 6 and 12 month follow up was a key motivator to staying in the study [Level 2 sub-theme – feedback from health measures].
It does make you more aware of, you know, the BMI and everything really…Its just to be aware of the whole , like, you’ve sort of had an MOT, haven’t you…Every four months you have one, which I think is good (Control participant, control focus group 2)