Effects of Physical Activity and Counselling Interventions on Health Outcomes among Working Women in Shanghai: A randomized controlled trial

Background (cid:0) Working women in Shanghai are a special group with a high risk of suffering work stress and burnout. They were disturbed by the work-family conicts, which resulted in lower health-related quality of life (HRQoL), higher job stress and burnout. This study evaluated the potential physical activity and counselling intervention effects on health outcomes of working women in Shanghai participating in a group- or an individual-based physical activity and counselling intervention compared to a control group. Methods (cid:0) Participants were randomly recruited from eight communities of Shanghai using the stratied cluster sampling method. A sample of 121 female workers was used in this study. They were randomly divided into three groups: a control group and two intervention groups (individual-based and group-based intervention). The two intervention groups accepted 12-week moderate physical activity and counselling intervention. Subjective perceptions of work stress, burnout, and HRQoL were measured before and after the intervention. Results (cid:0) In the control group, no signicant difference was found between participants for stress (p = 0.752) and burnout (p = 0.622) before and after the experiment. However, the HRQoL value decreased after the experiment, with the mean value falling from 91.59 to 87.10. After the experiment, the values of stress and burnout decreased, and the value of HRQoL increased in the two intervention groups. At the intervention’s completion, there were signicant differences compared the two intervention groups to the control group separately regarding changes in burnout and HRQoL (all p < 0.01). For stress, the group-based intervention group exhibited a signicant difference compared to the control group (p < 0.01), while the individual-based intervention group did not exhibit a signicant difference compared to the control group (p = 0.128). Conclusion: Physical activity and counselling intervention delivered either in a group or individual format could reduce burnout and improve HRQoL of working women in Shanghai, and the group interventions were more effective than those targeted at individuals. Most studies addressed Few studies investigated the impact of physical and counselling interventions on working women’s health outcomes (e.g., stress, burnout, and quality of life), in a specic city, such as Therefore, the primary purpose of this study is to investigate the effect of a physical activity and counselling intervention on health outcomes of working women in Shanghai with data collected at baseline and 12-week follow-up assessments. This study evaluated the potential of a physical activity and counselling intervention to decrease work-related stress and burnout and improve health-related quality of life of working women participating in a group- or individual-based physical activity and counselling intervention compared to controls.

insu cient time, skills, and social support [5]. As a consequence, working women must spend more time and energy on arduous and stressful work to keep pace with the city's development [6]. Stress is a physical and/or mental reaction that occurs when the external environment or working conditions are perceived to be uncontrollable and threatening [7]. It can occur because of the type of occupation, one's status and position within the occupation, gender composition within the occupation and gender differences in interpreting stress [8]. Stress can inspire certain individuals, however, excessive stress has a severe impact on women's working performance and has been related to various negative mental and physical health outcomes, such as increased stress, job burnout [9,10]. Prolonged stress can contribute to employment absenteeism, increased health expenses, and ultimately reduced work effectiveness and income [11]. In recent years, burnout has come to be regarded as a common work-related phenomenon. The most widely accepted de nition of burnout is that of Maslach and Jackson: "a psychological syndrome of emotional exhaustion, depersonalization, and reduced accomplishment that can occur among individuals who work with other people in some capacity" [12]. Different from job stress, burnout exhibits a multidimensional symptom, which is partly related to a high initial level of motivation, and primarily results from a breakdown in adapting to prolonged stress [13]. Studies demonstrated that high work demands, job strain, and lack of social support at work are the main psychosocial contributors to burnout [14], and high job demand and low levels of control have been associated with high levels of burnout in women [15]. How to perform and harmonize both duties well has been a heavy burden for working women.
Physical activity and exercise behavior play an important role in improving an individual's perception of health-related quality of life (HRQoL) [16]. HRQoL is a multidimensional concept that includes the individual's physical health, psychological state, social relationships, and environment [17]. Studies have demonstrated that physical activity can contribute to alleviating negative health-related outcomes, which could signi cantly improve the quality of life of working mothers [18]. Further research showed that higher levels of leisure-time physical activity (LTPA) were signi cantly related to higher levels of HRQoL in both men and women [19]. Besides, exercise can result in increased functional capacity, improved mood, increased self-esteem, better adjustment to illness, decreased distress, improved body image, decreased fatigue and emotional distress, and reduced depression and anxiety [20]. Naumann et al. proved this with their experiment, in which all healthy participants achieved signi cant improvements in physical and psychological HRQoL domains relative to no-exercise controls, and a moderate positive effect of exercise interventions was found for overall HRQoL in participants [21]. Exercise interventions (such as running, biking, walking, and dancing) can effectively improve physical functioning, reduce stress and burnout, and enhance physical and psychological well-being [22]. As for the speci c form of exercise intervention, the Social Cognitive Theory emphasis on individual initiative, it advocates an individual is able to manage and control his or her life rather than passively accepting or changing themselves to adapt to the environment. However, in the eld of health promotion, the group and social combination effect that seems more important than the individual function that has always been emphasized [23,24]. In addition, a study indicated that the group exercise format may offer participants additional bene ts through greater social support, greater group cohesion, and comradeship by sharing the same physical and psychological challenges while there were also other references that had shown the opposite opinion, which insisted that individual intervention was more effective [21]. Apart from exercise intervention, multilevel intervention also displayed signi cant improvements in depressive symptoms and social support [25].
As of 2013, there were 7.52 million female workers in Shanghai [26]. Although several intervention studies have been performed on female populations, most of them primarily focused on outpatients or individuals with certain chronic diseases [27,28]. Only a limited number of intervention studies have focused on working mothers [29,30]. In addition, according to the Reciprocal Determinism of Social Cognitive Theory, behavior, human internal factors (such as cognitive factors, emotional factors) and the environment are interrelated and mutually determined [31]. Participants' internal factors such as emotion and cognition will also affect their behavior except for the external environment, which means improving participants' personal emotions and their awareness of the bene ts of physical activity during the intervention may cause better activity participation. That's what inspired the setting of physical activity intervention combining with counselling. Most studies only addressed single health outcomes, such as HRQoL, depression or physical performance. Few studies investigated the impact of physical activity and counselling interventions on working women's health outcomes (e.g., stress, burnout, and quality of life), particularly in a speci c city, such as Shanghai. Therefore, the primary purpose of this study is to investigate the effect of a physical activity and counselling intervention on health outcomes of working women in Shanghai with data collected at baseline and 12-week follow-up assessments. This study evaluated the potential of a physical activity and counselling intervention to decrease work-related stress and burnout and improve health-related quality of life of working women participating in a group-or individual-based physical activity and counselling intervention compared to controls.

Method Participants
Participants were working women randomly recruited from eight communities in Shanghai China using the strati ed cluster sampling method. Participants were either friend-referrals or self-referrals based on advertisement and recruitment events in communities. They were gathered in the Sports Health Service Center of Shanghai University of Sport for screening. The sampling inclusion criteria were: aged 25 to 60 years, Shanghai residents, not retired, without joint or muscular abnormalities, and having the ability to participate in exercise and complete the health outcomes questionnaires. A total of 70 participants were needed for this study to reach a power of 80% at an alpha level of .05 based on a statistical power analysis to detect an effect size of ES = 0.25 [32].
A total of 225 individuals initially displayed an interest in participating in the study. Of them, 135 completed the baseline measures and were randomized into three groups: group-based intervention group (Exp_G, n = 46), individualbased intervention group (Exp_I, n = 44), and control group (Ctrl, n = 45). The participants in the group-based intervention group were randomly allocated with each group of 6-8 women. Of the 135 randomized participants, an additional 14 participants were lost at the 12-week follow-up. Five participants dropped out from lack of interest, and four dropped out because of schedule/time con icts. In addition, ve cited family/personal issues that prevented continuing participation. Finally, 121 working women who met the inclusion criteria were enrolled in the study and completed the pre-and post-measures ( Fig. 1). This study obtained the approval of the ethics committee at Shanghai University of Sport. All participants signed consent forms before they joined the study and were provided a full explanation regarding the purpose and potential bene ts/risks of the study, con dentiality, and their right to withdraw from the study. To characterize the participants in this study, self-reported personal information on age and race were obtained using questionnaires.

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The Chinese version of the Psychosomatic Tension and Relaxation Inventory (PSTRI) was used to measure stress [33]. This inventory consists of 50 items rated on a Likert scale from 1 (never) to 5 (always). The total score on the 50 items was used to measure the level of perceived stress. Higher PSTRI scores indicated higher levels of stress. In this study, the Cronbach's alpha of this scale was .95.

Burnout
Job burnout was measured by the 15-item Maslach Burnout Inventory-General Survey (MBI-GS) developed by Maslach and Jackson [12]. The survey consists of three dimensions: emotional exhaustion (5 items), professional e cacy (6 items), and cynicism (4 items). All the items were rated on a Likert scale from 1 (never) to 7 (every day). Lower scores on the dimension of professional e cacy and higher scores on the dimensions of cynicism and emotional exhaustion denoted higher levels of job burnout. The Chinese version of the MBI-GS was translated back into English to test language validity. The Chinese MBI-GS exhibited good reliability and validity and was widely used in Chinese populations [34]. In this study, the Cronbach's alpha coe cient for the total scale was .71. The Cronbach's alpha coe cients of emotional exhaustion, cynicism, and professional e cacy were .86, .79, and .90, respectively. HRQoL HRQoL was measured by the Chinese version of the Quality of Life Scale-Brief [17], which was modi ed from WHOQOL-100 and translated into Chinese. The scale consists of 26 items and includes four dimensions: physical health, social relationships, psychological status, and environment. Each item was rated on a ve-point Likert scale (1 = very dissatis ed; 5 = very satis ed). Item scores for each dimension were coded/recoded and summed to obtain the total HRQoL score, with a higher total score indicating a better quality of life. In this study, the Cronbach's alpha coe cients of physical health, psychological, social relationships, and environment were .76, .72, .75, and .79, respectively.

Procedure
The participants who signed the consent form were directed to the Sports Health Service Center of Shanghai University of Sport to complete the physical tness tests and baseline self-reported questionnaires on work stress, burnout, and HRQoL. All the devices for physical tness tests were from TKK Company of Japan, except for the devices for Bone Mineral Density (BMD) and VO 2 Max tests. BMD was measured at the femoral neck, total hip and lumbar spine L1-L4 using dual-energy X-ray absorptiometry (DXA) (Lunar Prodigy, GE Lunar, Madison, USA). TheVO 2 Max test was performed on a treadmill which began with a warm-up running for 5 to 10 min followed by an incremental running test until volitional exhaustion. The participant was equipped with a breath mask that covered the nose and mouth and a heart rate monitor worn on the chest. Oxygen uptake was measured using an indirect calorimeter (COSMED, Trentino, Italy). Subsequently, the participants were randomly assigned to one of three groups: group-based intervention (n = 41), individual-based intervention (n = 40), or waitlist control (n = 40). Randomization was completed by an independent investigator who was not involved in data collection or intervention delivery. For all groups, follow-up data were collected in the same manner as the baseline data immediately after the three-month intervention. During the 12-week study duration, the control group did not receive any speci c instructions relative to physical activity (i.e., they were free to continue their regular routines and exercise if they wished). This study was approved by the study venues.

Intervention
In our study, there were four intervention-related variables: intervention type, intervention frequency (i.e., times per week), the number of weeks, and the hours per session. The latter 3 variables were considered as indexes of the intensity of the intervention. Two different exercise interventions were involved: (1) an individual-based intervention delivered in an individual format and (2) a group-based intervention delivered in a group format.
The intensity of the individual exercise intervention group was three times per week for 45-60 min per session. The goal for each participant was 150 min of physical activity per week with moderate intensity. Each exercise program was individualized according to baseline health, tness levels, and personal goals. Three parts were included in the individual exercise program: warm-up, cardiovascular training (cycling, cross-training, brisk walking), and a cool-down period. The group exercise cohort also exercised three times per week for 45-60 min per session, with a similar target goal of 150 min per week of moderate intensity physical activity. The group exercise program also consisted of three parts: warm-up, cardiovascular training (cycling, cross-training, brisk walking), and a cool-down period. Although they participated in the same exercise activities, group-based intervention group held team-focused activities, such as competitions among different groups or tasks that needed to be done together, thereby helping to foster team cohesion. All exercises were led by the same accredited exercise instructors.
The principle of counselling intervention was client-centered, which means all the activity launched was based on the needs of each participant. Facilitating disclosure of feelings and anxieties, clarifying issues and providing reassurance and support for the women as required were the duty of the counsellor. The individual and group counselling interventions were both conducted once a week for one hour, and the group counselling intervention was in groups of six to eight women. General themes covered were the following: work-family con icts, stress, burnout, anxiety, selfe cacy, and health-related quality of life. The counselling happened at the end of the third exercise intervention every week. In the study period of 12 weeks, there was no speci c exercise or counselling that participants in the control group needed to engage in.

Data Analysis
The data were analyzed using Statistical Product and Service Solutions (SPSS 22.0, SPSS Inc.) software. Descriptive statistics were calculated for all variables. Data normality was veri ed by using the Kolmogorov-Smirnov test. Multivariate analysis of variance (MANOVA) with repeated measures was performed between different groups to examine differences at baseline and after the 12-week intervention. To account for multiple testing, Bonferroni corrections, with adjusted CIs, was performed to investigate the differences between groups. An alpha level of .05 was used to determine statistical signi cance. Effect sizes (ESs) were calculated utilizing the mean and standard deviation (.2 or less is a small ES; approximately .5 is a moderate ES; .8 or more is a large ES) [35].

Results
No signi cant difference was found between groups for demographic characteristics, body fat rate, sitting stretch, reaction time, VO 2 Max, Bone Mineral Density, and BMI (Table 1). There were no adverse reactions to participation in the exercise or counselling intervention. To compare the impact of exercise and counselling intervention on health outcomes between different groups at baseline and at the post-intervention time point, a MANOVA with repeated measures was performed. As the p-value of Mauchly's Test of Sphericity was less than 0.05, the Multivariate Test results were used to examine the difference between groups. In this study, the effect of Pillai's trace was chosen to reveal the signi cance of the main effects of 'time' and 'group' and the interaction effect of 'time x group'. The multivariate tests results were shown in Table 2. Pairwise comparisons were conducted to compare the pre-and post-differences between different groups (Table 3). In the control group, no signi cant difference was found between participants for stress (p = 0.752) and burnout (p = 0.622) before and after the experiment. However, the HRQoL value signi cantly decreased after the experiment (p < 0.01), with the mean value falling from 91.59 to 87.10 (Table 3). After the experiment, the values of stress and burnout decreased, and the values of HRQoL increased in the groupbased intervention group and individual-based intervention group (Table 3) Pairwise comparisons were also performed to compare the differences between different groups at baseline (pre-) and after (post-) the 12-week intervention (Table 4). There were no signi cant differences between different groups for all the variables before the experiment (all p > 0.05) ( Table 4). At the intervention's completion, there were signi cant differences compared intervention groups (group-based intervention group and individual-based intervention group) to control group separately regarding changes in burnout and HRQoL over time (Exp_G vs. Ctrl: p < 0.01, p < 0.01; Exp_I vs. Ctrl: p < 0.01, p < 0.01). For stress, the group-based intervention group exhibited a signi cant difference compared to the control group (Exp_G vs. Ctrl: p < 0.01), while the individual-based intervention group did not exhibit a signi cant difference compared to the control group (Exp_I vs. Ctrl: p = 0.128). Regarding the HRQoL subscales, social relationships (Exp_G vs. Exp_I: p < 0.01) exhibited a signi cant difference between the two intervention groups, with the group-based intervention improving signi cantly more than the individual-based group (Exp_G vs. Ctrl: p < 0.01, Exp_I vs. Ctrl: p = 0.215) ( Table 4). Table 4 Pairwise comparisons between three groups at baseline (pre-) and after the 12-week intervention (post-) (N=121) Notes. EE: emotional exhaustion, PE: professional efficacy, PH: physical health, Psy: psychological, SR: social relationships, Env: environment; Exp_G = group-based intervention group; Exp_I = individual-based intervention group; Ctrl = control group; ** p< .01, *p< .05.

Discussion
As hypothesized, at the end of the 12-week intervention, signi cant differences in health outcomes were observed in  both exercise groups except the stress value in the individual-based intervention group. However, no signi cant difference was found in the control group except that the HRQoL value decreased, perhaps because the participants in the control group did not participate in scheduled exercise or counselling during the 12 weeks. Participants enrolled in a group or individual exercise program exhibited signi cant reductions in their total scores for stress and burnout. They also exhibited signi cant improvements in their total scores for health-related quality of life compared to noexercise controls (Table 3). This nding was consistent with previous studies [13,36]. Bettaieb et al (2015) found that physical activity could contribute to alleviating negative health-related outcomes and signi cantly improve healthrelated quality of life among working women [37]. The results from literature and this study suggest that regular physical activity is positively related to HRQoL outcomes and that physical activity and counselling (group or individual) interventions are effective for working women in Shanghai. Thus, programs to promote regular exercise should be developed and encouraged for these women to prevent stress and burnout and improve their health-related quality of life.
Anne-Marie Slaughter's essay "Why Women Still Cannot Have It All" emphasized the challenges faced by working mothers [38]. Bettaieb et al. put forward that social load, physical and mental workload signi cantly in uenced the quality of life [37]. Pairwise comparisons performed in this study revealed that the group-based exercise intervention resulted in greater reductions in stress and burnout and greater improvements in HRQoL outcomes than the individualbased intervention (Table 3). Group exercise format may offer additional bene ts through greater social support, greater group cohesion, and comradeship between group members sharing the same physical and psychological challenges [38]. Combined with the result of Mailey's research that similar physical activity barriers and facilitators had expressed by working mothers and fathers, we think that future intervention may consider targeting mothers and fathers in tandem to make policy or offer welfare to them so as to reduce the heavy burden and increase physical activity of women [29].
Group cohesion was de ned as "a dynamic process re ected by the tendency of a group to stick together and remain united in the pursuit of its instrumental objectives and/or for the satisfaction of members' collective needs" [39]. Better social well-being and health outcomes may be achieved by group-based exercise and counselling interventions rather than individual-based exercise and counselling interventions. In addition, Sushames and Jannique observed that the physical activity level was signi cantly associated with health-related quality of life [40]. This nding agreed with a study by Gottleib and Wachala, who found that group interventions had more positive effects on participant psychological well-being by improving nearly every HRQoL domain [41]. Therefore, working women were encouraged to participate in group activities, such as team or outdoor extending activities, and follow the physical instructors' advice. Only with professional guidance can the more obvious intervention effects be obtained.
Social support was de ned as those activities performed by an individual that aid another person in reaching a desired goal and can be classi ed into four types of support-related exercise behavior: instrumental support, informational support, emotional support, and appraisal support [42]. Social support can help to increase physical activity and can be provided at an individual level by family, friends, or others who furnish encouragement to strengthen an individual's motivation to be physically active. Participants who feel rejected and lonely and thus dissatis ed with their social support may have poor emotional health and a poor perception of HRQoL [43]. Meanwhile, the physical and mental components of the HRQoL were the important factors associated with work ability. Tavakoli-Fard et al.'s research found that work ability of a majority of women was moderate, which meant that both physical and mental health of working women should be emphasized [44]. Health authorities and policy makers can use the ndings mentioned above to develop and implement programs to promote women's engagement in health-promoting behaviors and thereby, improve their quality of life.
Increased cohesion may also result from the facilitated social support received when exercising with other participants with a similar health condition [45]. It has also been reported that factors such as sharing experiences with other participants and being encouraged to exercise in group-exercise programs are important in terms of increasing compliance and the psychological comfort of the exercisers [36]. Exercising in a group rather than individually can provide additional bene ts, such as forming a collective identity with other group members, improving one's self-image by the reconceptualization of physical behavior, and motivating one to be physically active [22].
However, the ndings of this study did not agree with the results of a study by Naumann et al. (2012), who observed that a group exercise intervention did not improve the social well-being score more than the individual exercise setting [21]. The lack of signi cant improvement in the social well-being domain in the group exercise intervention could be attributed to the fact that the design of a group exercise program may not have involved su cient social interaction to create psychosocial improvements over and above those of the individual program. Thus, group intervention did not take full advantage of group dynamics. In this regard, one could recommend incorporating more social aspects during the group intervention, such as group exercise goals in which all participants contribute to achieving the nal goal, to capitalizing on group dynamics and to avoiding training individual participants in isolation [46].

Limitations
This study suffered from several limitations. First, this is an intervention outcome study with a relatively small sample size, which limits the coverage of the ndings. Second, all the health outcome measures were based on self-reports. Therefore, the participants may have over or underestimated their levels of work stress, burnout, and HRQoL. In terms of intervention effect, only completer analyses are presented. As data were not presented on women's jobs or education, the intervention might have been more effective in women with certain occupations or education level. It is unclear whether the intervention effect could be relevant to participants' occupation or education level. In addition, it is hard to differentiate whether the intervention effect was caused by exercise or counselling. Future study needs to design a separate experimental group, which only has exercise intervention so as to examine the different effects of the two elements. Third, the participants in this study were drawn from Shanghai, China's economic center. Therefore, the ndings of this study cannot be generalized to working women in other Chinese cities because of the differences between these cities and Shanghai. Finally, because of the short-term intervention, we could only evaluate the intervention effects on health outcomes at the 12-week follow-up assessment. Therefore, a longitudinal study should be performed to determine whether physical activity and counselling intervention bene ts are sustainable in the long term. Future studies could also be conducted on which exercise program, and of what intensity and duration, would be the most feasible and effective at improving the health outcomes of working women in Shanghai and other cities.

Conclusion
This study examined the effects of a 12-week physical activity and counselling intervention on health outcomes of working women in Shanghai. This study's ndings revealed that a physical activity and counselling intervention delivered either in a group or individual format could reduce stress and burnout and improve health-related quality of life among the working women compared to controls. In addition, participants exhibited better bene ts in the social well-being domain when exercising in groups rather than individually. Our ndings suggest that interventions aimed to improve these women's perceived abilities to cope with stress from home and work, such as regular exercise and developing strong social support, are likely related to lower stress and burnout and higher HRQoL. Despite the study's limitations, several of our ndings agreed with previous studies, thus con rming our study's validity and encouraging us to believe that we may have provided a new perspective on the impacts of physical activity and counselling intervention on working women's health outcomes.

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