754585
research-article2018
WHSXXX10.1177/2165079918754585Workplace Health & SafetyWorkplace Health & Safety
vol. XX ■ no. X
Reducing Commercial Truck Driver BMI Through
Motivational Interviewing and Self-Efficacy
Juanita L. Wilson, DNP, CRNP, MSN, MHA, COHN-S1
COHN-S/CM, FAAOHN3
Abstract: Obesity is recognized as a national and global
health epidemic. Commercial truck drivers (CTDs) have a
higher obesity rate and lower life expectancy compared
with the general population. CTDs work sedentary jobs
with long hours that pose barriers to healthy eating and
regular exercise. An evidenced-based practice (EBP)
change project that used motivational interviewing (MI) and
education regarding diet and exercise over a 4-week period
was found to have a positive impact on CTDs behavior.
Results revealed an increase in aggregated self-efficacy for
weight loss (14.8%, exceeding the benchmark of 11%). For
aggregated body mass index (BMI), CTDs lost a mean of
0.65 kg/m2, over a 4-week period which was statistically
significant at p = .0001. The results suggest a short-term MI
intervention can be effective when implemented as a clinical
standard for CTDs.
Keywords: commercial truck driver, obesity, motivational
interviewing, self-efficacy, weight loss, health promotion
O
besity is a growing public health concern affecting all
ages and socioeconomic groups both nationally and
globally; the United States has the highest prevalence
of obesity in the world (Wills, Fehin, & Callen, 2011). In the
United States, commercial truck drivers (CTDs) have a 15%
higher rate of obesity compared with the general population
(Apostolopoulos, Sonmez, Shattell, Gonzales, & Fehrenbacher,
2013). The clinical problem of obesity among CTDs is a leading
health indicator with both national and global implications
(Parks, Chikotas, & Olszewski, 2012). To address the problem of
obesity in CTDs, an evidenced-based practice (EBP) change
project was implemented over a 4-week period. The project
used motivational interviewing (MI) and education about diet
DOI: 10.1177/2165079918754585. From 1Medcor Inc., 2Chatham University, and 3Bloomsburg University. Address correspondence to: Juanita L. Wilson, DNP, CRNP, MSN, MHA, COHN-S,
Medcor Inc., 714 Columbia Avenue, Sinking Spring, PA 19608, USA; email: juanitakantner@yahoo.com.
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2018 The Author(s)
Workplace Health & Safety
Professional Pr actice
, Debra M. Wolf, PhD, MSN, BSN, RN2, and Kimberly A. Olszewski, DNP, CRNP,
and exercise to improve CTDs’ self-efficacy and decrease
participants’ body mass index (BMI).
Background
Obesity is a precursor of mortality and chronic illnesses in
the United States and worldwide. At least 2.8 million individuals
die each year as a result of overweight and obesity (World
Health Organization, 2015). According to the Centers for
Disease Control and Prevention (CDC; 2015a), obesity is
measured using BMI, calculated by dividing weight in kilograms
by the square of height in meters (kg/m2). The CDC considers a
BMI of 30 or greater as obese. Interestingly, Faghri and Buden
(2015) have identified a positive association between workers’
BMI and stressful job schedules and work conditions.
Sedentary lifestyles, availability of food, and larger portions
of food are the main causes of weight gain in Americans (Fisher
& Al-Oballi Kridli, 2014). Commercial truck driving is considered
a sedentary job with long hours sitting and driving. The
sedentary nature of driving long hours predisposes CTDs to
limited physical activity and unhealthy food choices leading to
weight gain and obesity. Lemke and Apostolopoulos (2015)
reported that life expectancy for CTDs is 16 years less than the
general population; Thompson (2007) reported CTDs have a
30% to 50% greater chance of developing chronic health
conditions (e.g., myocardial infarction, cerebrovascular accident
[stroke], diabetes, obstructive sleep apnea, hypertension, and
hyperlipidemia; CDC, 2015b). These conditions are costly and
significantly higher for obese CTDs at US$1,944 annually
compared to US$1,131 for truck drivers of normal weight
(Martin, Church, Bonnell, Ben-Joseph, & Borgstadt, 2009).
Motivational interviewing (MI) is one approach found to
positively impact obesity. MI is a form of behavior therapy that
can result in individual behavior change in some situations.
Individuals are guided by a professional in setting goals to
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achieve behavior change. During MI sessions, individuals
discuss how to achieve behavior change, the importance of
reaching goals, and the consequences of choosing not to
change behaviors. Low, Giasson, Connors, Freeman, and Weiss
(2013) noted that MI is a method of behavioral counseling that
impacts obesity by supporting positive behavior change and
may benefit those workers who perceive obstacles to losing
weight, and are resistant to changing behaviors.
Literature Review
Through a comprehensive review of the literature, MI was
validated as a clinical intervention to promote weight loss.
Several studies found that when motivation and self-efficacy
were both addressed, both concepts were key indicators in
weight loss and healthy lifestyle (Fisher & Al-Oballi Kridli, 2014;
Greaves et al., 2008; Hardcastle, Taylor, Bailey, & Castle 2008;
Low et al., 2013; Meybodi, Pourshrifi, Dastbaravarde, Rostami, &
Saeedi, 2011; Vanbuskirk & Wetherell, 2014; Warziski, Sereika,
Styn, Music, & Burke, 2008; Wong & Chen 2013).
A systematic review by VanBuskirk and Wetherell (2014)
evaluated 12 randomized controlled trials (RCTs) with nine
positive results for MI and weight loss. The meta-analysis of
body weight reduction from the RCTs found a mean effect size
of 0.47 that approached significance (p = .07). Overall, the
findings indicated that MI was effective at promoting behavior
change to achieve weight loss, and the researchers suggested as
few as one MI session could be effective.
Similar to MI, evidence supported self-efficacy for weight
loss. An 18-month behavioral weight loss study by Warziski et
al. (2008) examined a total of 170 individuals’ level of self-
efficacy, meaning their ability to maintain a diet and lose
weight. The outcome of the study revealed that self-efficacy was
associated with weight loss (p = 0.02), and an average weight
loss of 4.64% of baseline weight was achieved as well as an
11.7% increase in self-efficacy. According to Miller and Rollnick
(2002), self-efficacy is an essential component of MI.
Meybodi et al. (2011) investigated the effectiveness of MI to
increase self-efficacy for weight loss. Thirty overweight and
obese Iranian women were randomized to either an MI
intervention group or control group. The MI intervention group
received four MI sessions, and the control group did not receive
any intervention. After 2 months, the participants in the
intervention group showed significant reduction in BMI (p =
.001) and improvement in self-efficacy (p < .05).
Method
A 12-week institutional review board (IRB)–approved EBP
change project was conducted in a health clinic located in
eastern Pennsylvania. Workers employed at a global battery
manufacturing plant were invited to participate in the project
if they were age 18 years or older, male or female, and
inclusive of all races and ethnicities. Participants were
recruited through flyers and posters displayed at the clinic
and the plant. Approximately 400 CTDs were employed at the
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Mon 2018
plant and receive care at the clinic. Total time requested of
each participant was approximately 2 hours over a 4-week
period. The project implementer (PI) met with each
participant individually during the first week of the project
when the initial MI and educational sessions were scheduled.
During the following 2 weeks, the PI called each participant
to evaluate their progress, offering support and guidance.
During the fourth week, the PI met in person with each
participant for a final individual MI session to review
individuals’ progress, reinforce goals, distribute educational
materials, and address any questions participants had. The
overall goal of the project was to increase self-efficacy and
decrease BMI.
A modified version of the Weight Efficacy Lifestyle
Questionnaire (modWEL-tool) was used to measure self-efficacy
pre- and post-MI intervention. The modWEL-tool is comprised
of 24 questions using a 10-point Likert-type scale. Participants
were asked to quantify self-efficacy on a scale of zero (0) to
nine (9), with 0 being no confidence and 9 being complete
confidence. For scoring purposes, the questions were grouped
in seven subscales: Negative Emotions, Availability, Social
Pressure, Physical Discomfort, Positive Activities, Exercise, and
Genetics. Mean modWEL-tool total scores were computed by
summing all items and dividing by the total number of items.
Subscale scores were computed by summing the items for each
of the seven subscales and dividing by the number of items in
the subscale. Overall group mean scores were calculated by
summing all participants’ scores and dividing by 24, the number
of questions. Individual subscales were calculated by summing
item scores for each subscale and dividing by the number of
items for each subscale. The tool was administered during the
first and last individual MI sessions.
Schulz and McDonald (2011) modified the original Weight
Efficacy Lifestyle Questionnaire (modWEL-tool), adding four
questions related to exercise and genetics to create a 24-item
questionnaire. By adding four questions, information was
gathered specific to exercise and genetics. The authors noted
that using the modWEL-tool did not change the internal
consistency of the tool (Cronbach’s α = .93). In 2015, Ames,
Heckman, Diehl, Grothe, and Clark also demonstrated statistical
and clinical validity for the original Weight Efficacy Lifestyle
Questionnaire (WEL-tool) for measuring self-efficacy related to
weight loss in multiple studies.
The original WEL-tool was created in 1991 by Clark, Abrams,
Niaura, Eaton, and Rossi to assess individual self-efficacy for
weight loss; the tool has been used in multiple studies for over
two decades. The WEL-tool measures individuals’ confidence or
self-efficacy to control eating behaviors with higher scores
reflecting greater self-efficacy. The WEL-tool has been found to
have acceptable validity (p < .05) and reliability (p < .05-.0001)
in several studies (Ames et al., 2015; Clark et al., 1991; Hays,
Finch, Saha, Marrero, & Ackerman, 2014; Rejeski, Mikhalko,
Ambrosius, Bearon, & McClelland, 2011). Content validity was
confirmed by Ames et al. (2015) and Cronbach’s alpha of .92
established internal consistency reliability.
vol. XX ■ no. X
Participant’s height, weight, and BMI were calculated at the
first and last individual MI sessions. Paired t tests were used to
determine whether changes in BMI and self-efficacy were
achieved. A p value of .05 indicated statistical significance.
Theoretical Framework
Key to the design of the project was the Rosswurm and
Larrabee model (1999), a framework to guide project design.
The model offered organized steps that have been used
successfully in primary care settings which are similar to some
occupational health settings. The six steps of the Rosswurm and
Larrabee model include assessment, linking the problem to the
intervention, synthesizing evidence, designing change, and
evaluating change. Basically, the model guided the practice
change by linking the clinical problem to an intervention,
providing structure for implementation of the intervention and
the evaluation, and disseminating outcomes.
A second framework used to guide project design was
Bandura’s social cognitive theory (SCT) which evolved from his
original social learning theory (Bandura, 1977). Bandura’s SCT
focuses on the learner’s cognitive perspective and the
components of self-regulation and self-efficacy (Bandura, 1977).
Principles of behavior modification originated from SCT in
which person, environment, and behavior interact reciprocally
(Butts & Rich, 2011). Bandura believed self-efficacy to be the
most important and influential aspect of behavior change
(Bandura, 1977). Self-efficacy refers to individuals’ confidence in
their ability to successfully reach a goal by being motivated to
overcome obstacles (Zulkowsky, 2009). Self-efficacy can
increase or decrease motivation to achieve a goal. The goals for
this EBP change project were to increase self-efficacy,
promoting weight loss and reduction in BMI.
Butts and Rich (2011) explained that individuals learn health
behaviors within the context of family and community; health
behaviors are influenced by the environment. The most
important component of behavior change is individuals’
perceptions of their state of health, and the role of occupational
health nurses includes raising awareness of healthy behaviors
and supporting behavior change (Butts & Rich, 2011). The
application of SCT to practice was applied to this project when
occupational health nurses offered MI to CTDs to increase
self-efficacy, ultimately affecting CTDs’ ability to decrease BMI.
Results
Nineteen of 400 CTDs volunteered and completed the
project, a response rate of 4%. All participants were male,
between the ages of 26 and 69 years (mean age: 44.8 years).
Reported ethnicity was 95% (n = 18) Caucasian and 5% (n = 1)
Hispanic.
Differences between initial and final aggregate BMI were
calculated and then compared with an accepted benchmark
(i.e., a decrease in BMI of 0.5 kg/m2). For this population,
average height is 70 inches, so a decrease in BMI of 0.5 kg/m2
is equivalent to 3.5 pounds of weight loss. Across the expected
Workplace Health & Safety
range of height for this project (60-80 inches), a decrease in
BMI of 0.5 kg/m2 is equivalent to 2.6 to 4.5 pounds of weight
loss. The CDC (2015c) recommended healthy weight loss as 0.5
to 2 pounds per week (2-8 pounds over a 4-week period),
which included the range of weight loss targeted as the
benchmark for this study.
The second outcome was an increase in CTD self-efficacy. A
benchmark was established based on two studies that explored
self-efficacy and weight loss using the WEL-tool questionnaire.
The studies found similar results with an approximately 11%
increase in total questionnaire scores reflecting an increase in
self-efficacy (Hays et al., 2014; Warziski et al., 2008). Based on
these outcomes, an aggregate mean of 11% increase in the
postintervention group total scale score was used as the
benchmark for overall self-efficacy.
Table 1 presents total and subscale aggregate mean scores
for weight, BMI, and self-efficacy. Statistically significant results
were found for weight and BMI (p < .0001) and total self-
efficacy (p < .0002). Interestingly, six of the seven subscales
were also statistically significant with p values ranging from
.0002 to .038. The one subscale that was not statistically
significant was Genetics. Figure 1 displays percentages of
participants who (a) gained weight (>0.5 kg/m2 increase in
BMI), (b) maintained weight (stayed within 0.5 kg/m2 of
baseline BMI), or (c) lost weight (<0.5 kg/m2 decrease in BMI).
Overall, 84% of participants showed improvement.
The second outcome was to achieve an increase in overall
self-efficacy. Figure 2 displays percentages of participants who
did or did not have changes in overall levels of self-efficacy. The
figure reflects calculated percentages of participants who (a)
had a decrease in overall self-efficacy, (b) had small increases in
self-efficacy (<11% increase), and (c) had large increases in
self-efficacy (>11% increase). Of the 19 participants who
completed the project, 52.6% reached benchmark. In addition,
31.6% of participants experienced an improvement in overall
self-efficacy but did not reach benchmark. In overall group
comparison, the mean change in overall self-efficacy was 14.8%,
which was greater than the benchmark of 11%. Paired t tests
suggested the changes in overall self-efficacy were statistically
significant (p = .0002).
In summary, the majority of participants (52.6%) met the
benchmark of 11% increase or greater in self-efficacy as well as
73.7% of CTDs met the benchmark for BMI reduction. Pretest
and posttest self-efficacy showed a statistically significant
increase of 14.8%, greater than the benchmark (p = .0002).
Paired t tests of grouped means (self-efficacy) revealed
statistically significant differences (p < .05) in total outcomes for
six of the seven subscales of the modWEL-tool questionnaire
including Negative Emotions, Availability, Social Pressure,
Physical Discomfort, Positive Activities, and Exercise.
Discussion
The project was successfully implemented but did require
modification to the original plan. The PI determined that the
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Table 1. Mean Change in Self-Efficacy Items From Before and After Motivational Interviewing Among CTDs (n = 19)

Pre Post Change Mean %

M (SD) M (SD) M (SD) change p valuea
Weight Pounds 253.7 (47.9) 249.2 (48.2) −4.5 (3.0) −1.8 <.0001
BMI kg/m2 36.07 (5.93) 35.43 (5.91) −0.65 (0.44) −1.8 <.0001
Self-efficacy Overall 5.59 (1.45) 6.42 (1.04) 0.82 (0.78) 14.8 .0002
Negative Emotions 5.76 (2.22) 6.58 (1.75) 0.82 (0.96) 14.2 .0017
Availability 4.89 (2.07) 5.87 (1.91) 0.97 (1.15) 20.0 .0017
Social Pressure 5.58 (1.99) 6.80 (1.43) 1.22 (1.22) 21.9 .0004
Physical Discomfort 6.92 (1.39) 7.43 (1.08) 0.51 (0.99) 7.4 .037
Positive Activities 6.55 (1.73) 7.53 (1.12) 0.97 (1.21) 15.0 .0025
Exercise 5.18 (2.30) 6.05 (1.96) 0.87 (1.69) 16.8 .038
Genetics 2.50 (1.73) 2.53 (2.07) 0.03 (1.45) 1.2 .938

Note. BMI = body mass index.

a
Results of paired t test using .05 p value.

Figure 1. Percentage of participants with change in BMI. Figure 2. Percentage of participants with change in
Note. BMI = body mass index. overall self-efficacy.

original recruiting timeline needed to be extended from 7
weeks to 9 weeks, due in part to the summer timeframe for
project implementation and many CTDs and health center staff
on vacation. Fortunately, no limitation to the recruitment
timeline was included in IRB approval. Another challenge was
scheduling CTDs. Due to the nature of the CTDs’ erratic travel
schedules, PI flexibility was required; the PI saw participants
when it was convenient to their schedules. Often, visits and
phone calls with CTDs were scheduled early in the morning,
late in the evening, or on weekends to accommodate
schedules. Having only one health care provider for this project
was another challenge and not necessarily practical due to the
need for flexibility with CTDs’ schedules. Another limitation
was the homogeneity and small sample size of the study
sample, for 19 of the participants were Caucasian males.
Finally, the participant population may not represent all CTDs
and all companies that employ CTDs; the feasibility of applying
an MI intervention to every CTD worksite has not been
determined. These limitations create uncertainty as to whether
the same outcomes would be achieved for CTDs employed in
other organizations.
Due to the time constraints of the 14-week project plan, the
PI was unable to extend the intervention with the CTDs. More
studies are needed to validate the effectiveness and
sustainability of MI to promote weight loss with CTDs. The PI
recommends that additional MI sessions be offered as well as
data collection at 3 months, 6 months, 9 months, and 1 year
post intervention. Engagement, support, and relationship-
building that may occur with more MI sessions and monitoring
could promote sustained weight loss for CTDs.

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The PI used various forms of technology to enhance EBP
outcomes. For example, the PI introduced several diet and
exercise apps and exercise videos on YouTube. The PI used an
iPad to review and discuss recommended websites and apps for
diet and exercise education. After completion of the EBP change
project, the PI recommended several services offered by the
employer to sustain weight loss. The CTDs could take advantage
of discounted services provided by the employer such as national
and local gym memberships and Fitbit purchase discounts. In
addition, the employer offered CTD participants who completed
the project paid registration fees for Weight Watchers (WW)
online to assist in sustaining success with their weight loss goals.
The WW program offers mobile tools such as an app that tracks
individual food intake, weight, and exercise. This type of
technology provides convenience for individuals who travel. The
sustainability of weight loss and obesity management for CTDs is
vital to the health and safety of this population.
The positive findings from this EBP change project add to
the potential knowledge occupational health practitioners can
extend to current employees whose jobs require travel for
extended periods of time or who have limiting physical activity
opportunities. Occupational health practitioners must consider
the needs of all employees in the workplace to prevent and
treat obesity.
Future Implications for Clinical Practice
Future practice implications from this project revealed that
MI can promote health behavior change in clinical and worksite
settings and should be considered to address obesity for mobile
populations. The use of various forms of technology (e.g., cell
phones and apps) should also be considered when addressing
worker obesity. Occupational health practitioners can engage
mobile employee populations (e.g., CTDs and marketing and
sales personnel) by using technology to provide education and
monitoring. For example, the occupational health practitioner
could reach CTDs with text messages to schedule MI sessions.
MI sessions along with diet and exercise education could be
offered using a tablet or laptop that had voice over Internet
protocol (VoIP) broadband capability. Internet videos can
support diet and exercise education, and apps could be used to
track progress with weight loss. These strategies could improve
worker engagement challenged by travel schedules.
Using MI in combination with diet and exercise education,
and technology to engage participants in healthy decision
making is a cost-effective and easy-to-implement solution to the
obesity epidemic. These interventions should be considered
useful not only to CTDs but also for the population at large.
Conclusion
An EBP change project was conducted at a workplace with
CTDs. MI is a compelling intervention that can reduce obesity.
MI explores individuals’ motivations to change health-related
behaviors by asking questions to determine desire, ability,
reasons, and need for change (DARN; Miller & Rollnick, 2002).
Workplace Health & Safety
MI supports self-efficacy, a prerequisite for changes in diet and
exercise. Overall, the project was an effective approach to
increase self-efficacy and reduce BMI.
Acknowledgments
The authors gratefully acknowledge the consultation,
participation, and contributions of Laurie Heagy, MPH, RN,
COHN-S, Medical Services Manager, East Penn Manufacturing.
ORCID iD
Juanita L. Wilson https://orcid.org/0000-0001-8778-5231
Conflict of Interest
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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Author Biographies
Juanita L. Wilson is an Associate Vice President of Operations for
Premise Health managing onsite occupational health clinics
across the nation. Dr. Wilson is an AANP board certified nurse
practitioner and a Certified Occupational Health Nurse
Specialist from the American Board of Occupational Health
Nurses. In addition she has a Master of Science degree in Health
Care Administration.
Debra M. Wolf is an Associate Professor of Healthcare
Informatics and Nursing at Chatham University located in
Pittsburgh, Pennsylvania. Dr. Wolf is the Program Coordinator
for the Master of Science in Healthcare Informatics (MHI)
program. In addition, she is an independent healthcare
informatics consultant supporting healthcare institutions and IT
vendors integrate new technology into a health setting. Dr. Wolf
has published numerous articles, book chapters and coauthored
a book titled Social Media for Nurses: Educating Practitioners
and Patients in a Networked World.
Kimberly A. Olszewski is the Nurse Practitioner Program Director
& Associate Professor at Bloomsburg University in Bloomsburg,
PA, and is Vice President and Nurse Practitioner at Mid State
Occupational Health Services Inc. in Lewisburg, PA. Dr.
Olszewski is an ANCC board certified adult nurse practitioner
and is a Certified Occupational Health Nurse Specialist and
Case Manager from the American Board of Occupational
Health Nurses.