BE Intent gets a stamp of approval on Workplace Wellness Programmes
We are thrilled that our desktop well-being programme includes and exceeds many of the recommendations in the latest report from the Ministry of Health (MOH) into Workplace Health Promotion Programmes.
This is a great report and is an ideal place to start when you are looking to implement or evolve a workplace wellness programme in your organisation.
The Ministry of Health commissioned Nina Russell to conduct a literature review to:
- explore the rationale for why wellness should be promoted at work
- identify the benefits to both employers and employees
- investigate what is effective in a workplace health programme
The report confirms many of the known positive financial benefits of a healthy workforce, such as reduced abseeteeism, turnover and workplace accidents, and increased quality of work, engagement, recruitment and retention. But most importantly it also strongly supports the psychosocial benefits experienced by our own clients, such as positive moods, state happiness and reduced stress, that are inherent to our unique programme.
Our mission to make workplace wellness fun, simple, cost effective and beneficial (to both employers & employees) is again endorsed by the report as it identifies key issues associated with the effectiveness of workplace programmes. Our desktop/web based programme enables businesses to easily implement, communicate and authentically live a healthy culture on a daily basis without the need for additional staff, large costs or staff downtime.
Click here to download this report as a pdf
Organise a time to meet with us, or attend a webinar online live demostration and discussion
Workplace Wellness - A Literature Review for NZWell@Work, February 2009
Prepared for the Ministry of Health by Nina Russell (nina@russellresearch.co.nz)
You can read the full document here and you can go to a specific section by clicking on one of the links below:
Executive Summary
The Ministry of Health commissioned this literature review on Workplace Health Promotion (WHP) programmes to support the development of NZWell@Work and to be a useful resource for designing and planning WHP programmes.
Aims
The specific aims of this review were to explore the rationale for why wellness should be promoted in the workplace, to identify the benefits to employers and employees of WHP programmes and/or interventions, and to understand ways to make wellness initiatives effective in the workplace (specifically those relating to healthy eating [with supporting breastfeeding in the workplace as a subset of healthy eating] and physical activity [i.e. healthy action]).
Wellness Defined
'Health' and 'wellness' are terms often used interchangeably. Reardon (1998) defines wellness as "a composite of physical, emotional, spiritual, intellectual, occupational, and social health; health promotion is the means to achieve wellness" noting that issues in any of these areas can adversely affect the other areas (Reardon, 1998).
Workplace health promotion (WHP) programmes have been referred to in many different ways, for example: wellness, health promotion, health management, and health and productivity programmes (Goetzel and Ozminkowski, 2008). Goetzel and Ozminkowski (2008) define workplace health promotion (WHP) as "employer initiatives directed at improving the health and well-being of workers and, in some cases, their dependents". In this report, WHP programmes are viewed as a means to achieve both individual and workplace wellness.
Whilst individuals may have the ultimate responsibility for the behaviours they do (or do not) engage in that affect their health, they can be supported to reduce risk behaviours if provided with the right tools, strategies and environment to support their wellness (World Economic Forum, 2007).
Examples of WHP Interventions
Examples of WHP interventions include; stress management, smoking cessation, weight management, back care, health screenings, nutrition education, workplace safety, prenatal and well baby care, CPR and first aid classes, and employee assistance programmes (EAP), work/life balance policies, flexi-time, exercise/fitness groups, discounts to local fitness facilities, healthful food choices at work meetings, events, and training programs, family friendly policies and facilities (such as bicycle racks, showers, gym equipment) (Fronstin, 1996; Cuthell, 2006; Pratt et al, 2007).
Rationale for Promoting Wellness in the Workplace
There is a two-way relationship between employees' health and workplaces, employee health affects the workplace and the workplace affects the health of employees (Abbot et al, 2007).
The workplace is a pivotal location for promoting and supporting wellness; in terms of importance, the workplace is matched only by the education system as the most effective front line approach to preventing chronic disease and promoting health (Plotnikoff et al, 2005; Centers for Disease Control and Prevention 2003, in World Economic Forum, 2008b).
There are a number of reasons why the workplace is advantageous for health promotion, including (but not limited to); ease of access to a large number of people, existing infrastructures in the workplace (e.g. communication channels, teams), the cost-efficiency of WHP programmes relative to clinical or community based programmes and the opportunity to address multiple levels of influence, including individual, interpersonal, organisational and environmental factors on health.
Clear Evidence of Benefits of WHP
A joint report by the WHO and the World Economic Forum notes there is clear and persuasive evidence that many WHP programmes targeting non communicable disease have been successful at improving employees' health by reducing risk factors, increasing employees' fruit and vegetable consumption, improving employee engagement and productivity, and producing return on investment (through cost savings and increased productivity) (World Economic Forum/WHO, 2008).
Benefits to Employers from WHP (Wellness) Programmes
The benefits to employers include (but are not limited to):
A healthy, happy and present workforce:
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Reduced absenteeism and presenteeism (Allen, 1993; Makrides, 2004; Shaw et al, 2007; Hemp, 2004; Aldana, 2001 in Goetzel and Ozminkowski, 2008; Goetzel and Ozminkowski, 2008; World Economic Forum, 2008d)
Improved employee engagement, recruitment and retention (Sangster in Ghent, 2004; Pricewaterhouse Coopers, 2008)
A happier, more resilient workforce (Pelled and Xin, 1999 in Thøgersen- Ntoumani et al, 2005; Thøgersen-Ntoumani et al, 2005)
A positive workplace culture (Equal Employment Opportunities Trust, 2007)
Improved industrial relations (Addley et al, 2001).
Increased employee performance and productivity (Addley et al, 2001; World Economic Forum, 2007; Shaw et al, 2007; Nurminen, et al, 2002 in Brand, 2006; Shepard, 1983 in Makrides, 2004).
Financial benefits including:
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Reduced health care costs (Allen, 1993; Partnership for Prevention, 2005; World Economic Forum, 2008)
Reduced costs relating to absenteeism and presenteeism (World Economic Forum, 2007; Harvey, 2008a)
Return on investment (from improved productivity [i.e. increased innovation or efficiency] or cost savings [i.e. reduced workplace accidents, fewer staff absences, greater staff retention meaning recruitment and training costs are minimised) (Addley et al, 2001, Chapman, 2006, Goetzel and Ozminkowski, 2008)
Research has shown that the economic return on investment for various WHP programmes ranged from $1.50USD to $5.96USD saved for every $1US spent (Chapman, 1996, Wellness Councils of America, 1995 and Makrides et al, unpublished, all in Makrides, 2004; Whitmer, 1995, Bachmann 2002, Ozminkowski, 1999 in Bachmann, 2002 all in Burton, 2008).
Benefits to Employees from WHP (Wellness) Programmes
The benefits to employees include (but are not limited to):
Health benefits of WHP (including physical well-being and clinical health improvements such as reduced cholesterol, reduced risk of chronic disease, reduced incidence of musculoskeletal disorders) (Thøgersen-Ntoumani and Fox, 2005; Pelletier, 2001 in Moy et al, 2006; Moy et al, 2006; Chapman, 2006; Kreis and Bodeker, 2004 in ESRC, 2006; Shaw et al, 2007; and World Economic Forum, 2008b).
Increased mental well-being, energy and resilience, reduced stress and depression, and increased quality of life (Biddle et al, 2000; Taylor, 2000, Fox, 2000 all in Thøgersen-Ntoumani et al, 2005; Brand et al, 2006; Hanway, 2005 in Partnership for Prevention, 2005; Broadhead, 2008; Harvey, 2008a; Renaud et al, 2008).
Financial benefits (e.g. including reduced expenditure on medical costs and receipt of incentives) (Hanway, 2005 in Partnership for Prevention, 2005).
Improved job satisfaction (Hanway, 2005 in Partnership for Prevention, 2005).
Ways to Make Wellness Initiatives Effective in the Workplace
Pelletier (2005) notes the challenge for organisations today is no longer whether or not WHP programmes should be implemented but rather how they should be designed, implemented and evaluated to achieve optimal benefits (i.e. health and cost-effectiveness).
Careful Planning and Informed Design
Careful planning is required to determine the WHP programme content, scope and approach. This includes undertaking a needs assessment to understand the organisations challenges (e.g. organisations culture and physical environment [i.e. health supporting or not?] and employees' health issues) and opportunities (e.g. existing structures such as employee representatives who can support the implementation of WHP initiatives).
Formative research (e.g. focus groups with employees on perceived motivators and barriers to any proposed WHP initiative) is useful to undertake at the design stage as it provides data about both employees and the settings in which the research is to be implemented (Cook, et al, 2001; Webber et al, 2007).
Long-term Focus and Strategic Goals
During the WHP design stage it is important to have a long term focus and set strategic goals (i.e. linked to the organisations overall objectives). Having employees' health as a strategic objective of an organisation reflects WHP programmes core role in an organisations business strategy (Cuthell, 2006). WHP programmes need to be seen as integral to the operation of business, as opposed to a series of ad hoc one off initiatives (Cuthell, 2006).
Creating a Culture of Health (E.g. a Culture Supportive of WHP)
Developing a true culture of health can significantly increase participation in WHP programmes (Huckabee 2005 in Partnership for Prevention, 2005). The World Economic Forum (2007) notes the execution steps in the creation of a support system for WHP programmes are having active leadership and a healthy environment.
Active Leadership - Senior managers need to be committed and supportive of WHP programmes. Providing managers with information on the costs of poor health and chronic disease, and the values and benefits of wellness to the organisation so they understand its importance is useful in obtaining leadership-buy-in (Ryan et al, 2008). Additionally having clear goals and performance measures (including return on investment) that are regularly reported on at the board level are likely to assist in maintaining management support. Managers may require training in order to understand their role in workplace wellness (e.g. as an influencer and enabler).
Healthy Environment - An important part of creating a support system for a WHP programme is to modify the physical work environment to reflect the organisation's wellness goals (e.g. provide healthy options for vending machines and cafeteria menus, healthy food in meetings, have ergonomic furniture, signs supporting use of the stairs, showers, bicycle racks, quiet rooms, fitness facilities etc) (Huckabee 2005 in Partnership for Prevention, 2005; World Economic Forum, 2007). As well as the physical environment it is important to consider other aspects of an organisation (e.g. workplace culture, workplace relationships, workloads, policies etc).
Maximising Employee Engagement and Participation
Generating high levels of employee engagement and participation is essential to the success of all WHP programmes (Chapman, 2006, Goetzel and Ozminkowski, 2008). Participation can be increased through the use of tailored interventions (e.g. based on an individual's stage of readiness for change, employee demographic characteristics or health risk assessments), having a participatory approach to WHP (e.g. involving employees in programme design and implementation), and using incentives and rewards to encourage participation and minimise programme attrition.
Communication Strategy
Having an appealing communications strategy is also necessary to foster and maintain employees' interest and participation in the WHP programme. Creating a brand or programme identity for the WHP programme helps establish credibility and appeal (Ryan et al, 2008). A variety of communication channels should be used in order to take into account the different ways people learn.
Research and Evaluation
Research and evaluation is integral to successful programmes. It is important that programmes have clear goals and systematically document their results relative to their goals. New information reinforces and expands on previous material (e.g. characteristics of successful interventions) and provides data necessary for a WHP programme to evolve. As well as shaping programmes, research can assess a programme's success by measuring its outcomes (short to long-term).
As organisations spend money on WHP programmes, they must be sure they are effective (World Economic Forum, 2007) this requires evaluation of employee participation, and the short term and long term strategic aims of the intervention (Pricewaterhouse Coopers 2008). It is also necessary to identify and collect cost and benefit data in order to undertake financial impact modeling (Pricewaterhouse Coopers, 2008). The World Economic Forum (2008b) recommends that data collection use online assessments where possible, be employee-centric (e.g. respectful of privacy/confidentiality and easy to participate in), proactive (with WHP programmes having measurement built into their framework), and importantly provide accurate information which allows organisations to understand the efficacy of any interventions.
Successful WHP Programmes
Based on the literature, the following outlines the components of successful WHP programmes (design and implementation).
Aspects of successful WHP programme design:
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Being based on theory (e.g. on improving self efficacy, stage of change etc)
Having clear goals and objectives (linked to organisational objectives)
Being comprehensive (i.e. holistic, multi-component)
Including tailored/targeted interventions (based on employee characteristics)
Focusing on modifiable risk factors (e.g. things employees can change like diet and level of physical activity) and improving employees' self efficacy (belief in their ability to achieve certain outcomes)
Promoting the inclusion of existing social support systems (e.g. involves spouses/family) and the creation of new social support systems (e.g. weight loss teams, sports teams)
Including a participatory approach to development and implementation (i.e. involving employees - using peers for design, promotion, and delivery)
Offering flexibility (e.g. holding additional sessions in work time at different times of day, offering different options for participation)
Including health risk assessments/screenings.
Having a long term focus
Removing barriers to participation
Including research and evaluation.
Aspects of successful WHP programme implementation:
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Fostering networks and partnerships (e.g. potential wellness collaborators)
Using a variety of communication/education strategies
Including environmental support (e.g. environmental modifications such as healthy foods in vending machines, signage promoting healthy behaviours, provision of facilities such as bicycle racks, showers and changing rooms)
Including the use of incentives and rewards
Having strong management support (e.g. endorsement, resourcing and policy sign-off).
1 Background, Aims, and Methodology
The Ministry of Health commissioned this literature review on Workplace Health Promotion (WHP) programmes to support the development of NZWell@Work and to be a useful resource for designing and planning WHP programmes.
1.1 Aims
The aims of this literature review were as follows, to explore:
The rationale for why wellness should be promoted in the workplace
The benefits to employers and employees of WHP programmes and/or interventions
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Health benefits
Financial benefits
Psychosocial benefits (e.g. those relating to workplace culture)
Organisational benefits (e.g. reputation).
Ways to make wellness initiatives effective in the workplace (specifically those relating to healthy eating [with supporting breastfeeding in the workplace as a subset of healthy eating] and physical activity [i.e. healthy action]), including:
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Encouraging employee participation in initiatives
Maintaining participation in initiatives
Implementing WHP programmes
Effective interventions (characteristics of successful/promising interventions)
Research and evaluation
Overcoming barriers and challenges
Leading practice in WHP
Considerations for success.
1.2 Methodology
Resources for this literature review were sourced via database searches through the Ministry of Health and the Department of Labour (as noted below). Additional references were supplied by the Ministry of Health and SPARC, and sourced via the internet.
Databases searched through the Ministry of Health library included; AMED, British Nursing Index, MEDLINE, PsycINFO, British Nursing Index, The Cochrane Library, Australian/New Zealand Reference Centre, AusportMed and AMI.
The search terms1 used for the Ministry of Health databases search included:
Obesity or overweight or weight gain and
Physical activity or lifestyle or exercise or dance or aerobics or fitness or sport and
Physical environment or built environment and
Health or diet or nutrition and
Fruit and/or vegetable and
Breastfeeding or breast-feeding and
Ethnic or minority groups or populations or Maori or Pacific Islander
Intervention or programme or promotion and
Prevention or intervention and
Community or program or project and
Workplace or employment setting and
Effect or evaluation or assessment.
Databases searched through the Department of Labour library included; HSELINE (Health and Safety Executive Line), MHIDAS (Major Hazard Incidents Data Service), RILOSH (Ryerson International Labour, Occupational Safety and Health Index), CISDOC (CISDOC contains information about occupational safety and health publications, including summaries of their content, organized in "records"), NIOSHTIC2 (a searchable bibliographic database of occupational safety and health publications, documents, grant reports, and other communication products supported in whole or in part by the National Institute for Occupational Safety and Health [NIOSH]), OSHLINE (OSHLINE provides extensive coverage of journals and reports in all aspects of occupational health and safety, and indexes the journal literature from mid-1998 to present) and MEDLINE OEM Subset (Medline subset of Occupational and Environmental Medicine).
The search terms used for the Department of Labour databases search included:
Obesity or Overweight or Weight Gain or Weight Loss or Weight Management or Physical Activity or Lifestyle Change or Exercise or Dance or Aerobics or Fitness or Sport or Health Promotion or Diet or Nutrition or Built Environment or Physical Environment or workplace culture and
Prevent or intervention or programme or project or initiative or workplace policy and
Workplace or employment setting or human resources.
1.2.1 Terms Used
The term 'intervention' in this report is used as an overarching term to refer to any workplace health promotion activity, initiative or strategy, regardless of form (e.g. intervention could refer to environmental modifications such as food labeling or refer to physical activity counselling sessions).
The following terms are used interchangeably:
workplace and worksite
workplace health promotion and workplace wellness (defined in Section 2.0).
2 Workplace Wellness - Context Setting
To provide context for this report, in this section the following topics will be canvassed:
Defining wellness
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Individual wellbeing
Workplace health promotion
Healthy workplaces
2.1 Wellness Defined
The World Health Organisation (WHO) defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (cited in United Health Foundation, 2007).
'Health' and 'wellness' are terms often used interchangeably. Reardon (1998) defines wellness as "a composite of physical, emotional, spiritual, intellectual, occupational, and social health; health promotion is the means to achieve wellness" noting that issues in any of these areas can adversely affect the other areas (Reardon, 1998). Mills (et al, 2007 in World Economic Forum 2008b) states that wellness is "an active process through which people become aware of, and make choices towards, a more successful existence."
Whilst individuals may have the ultimate responsibility for the behaviours they do (or do not) engage in that affect their health, they can be supported to reduce risk behaviours if provided with the right tools, strategies and environment to support their wellness (World Economic Forum, 2007).
There are a number of well developed intervention strategies for preventing premature mortality and illness associated with chronic disease; typically these strategies have focused on positive behaviour modification in four key areas - physical activity, nutrition, smoking, and alcohol use (Simpson et al, 2000). The workplace provides a unique place to access employed adults. (Simpson et al, 2000).
2.2 Workplace Health Promotion (WHP)
The workplace is a pivotal location for supporting wellness; in terms of importance, the workplace is matched only by the education system as the most effective front line approach to preventing chronic disease and promoting health (Plotnikoff et al, 2005; Centers for Disease Control and Prevention 2003, in World Economic Forum, 2008b).
Wellness in the Workplace
Wellness in the workplace has three components (Pricewaterhouse Coopers, 2008), as follows:
Occupational health and safety requirements (e.g. interventions designed to protect employees from occupational hazards based on government policy and statutory requirements)
Management of ill health (e.g. 'reactive interventions' including return to work schemes, disability management, and rehabilitation)
Prevention and promotion (e.g. health promotion activities [i.e. good nutrition, physical activity, smoking cessation], healthy environment [i.e. wellness teams, policies, physical environment including provision of showers/lockers, gym facilities, etc], work/life balance, time/stress management schemes, etc).
Workplace health promotion (WHP) is concerned with all three components.
Workplace Health Promotion
Historically, workplace health promotion (WHP) programmes have been referred to in many different ways, for example: wellness, health promotion, health management, and health and productivity programmes (Goetzel and Ozminkowski, 2008). The use of the term 'workplace health promotion' was chosen for this report as it is seen to be inclusive and best reflecting the means to achieve wellness. Also, 'workplace health promotion' is the term used by the World Economic Forum and the World Health Organisation. The term programme in this report refers to the overall framework of any workplace health promotion activities; the 'umbrella' under which the interventions sit. In this report, WHP programmes are viewed as a means to achieve both individual and workplace wellness.
Goetzel and Ozminkowski (2008) define workplace health promotion (WHP) as "employer initiatives directed at improving the health and well-being of workers and, in some cases, their dependents".
A more expansive definition of a WHP programme (referred to as a workplace wellness programme by the author) follows "an organised programme in the workplace that is intended to assist employees and their family members in making voluntary behaviour changes which reduce their health risk, improves their health knowledge and enhances their individual productivity and wellbeing" (Absolute Advantage, 2006 in Health and Human Performance Ltd, 2007).
Ideally, wellness programmes focus on the promotion of wellness (fitness, mental health, healthy weight etc) and not just the prevention of disease or illness (Reardon, 1998).
Wellness Platform or 'umbrella' for WHP initiatives
WHP can be feasibly linked to broader efforts in the workplace to support employee health for example, employee assistance programmes (EAP), and disability management programmes (Sorensen et al, 2002, Williams and Westmorland, 2002, DeJoy and Southern, 1993 all in World Economic Forum, 2008d).
Ryan (et al, 2008) notes that there is a growing trend for the concept of 'wellness' to be the platform for a range of employee health related initiatives (e.g. ergonomics, occupational health, disease management and prevention, wellness coaching etc).
Wellness at the Corporate Level
The World Economic Forum (2008b) states that the concept of 'wellness' at the corporate level is often misunderstood; because wellness is a broad term there can be differing views as to what is and is not included as wellness. For example, one organisation might view activities designed to improve staff morale (e.g. team building social activities) as part of their 'wellness' offering whereas another organisation might only regard activities directly related to physical health (e.g. vaccinations, onsite gym, healthy food offerings etc) as part of their 'wellness' offering. Ideally, 'wellness' would have a consistent definition that was used across organisations; this would support measurement of wellness and promotion of best practice (i.e. comparison of wellness interventions and dissemination of findings).
At the organisational level, the World Economic Forum (2008b) suggest wellness be defined in an active manner as follows: "corporate wellness could be described as an active process through which organisations become aware of, and make choices towards, a more successful existence. For both the individual and the organisation, the concept of wellness is one where active steps can be taken that reduce chronic disease and mitigate its debilitating impact on personal lives and organizational productivity".
Seed (2006) undertook a research project with n=200 human resource professionals to determine a market-based definition of 'workplace wellness' in New Zealand. Most organisations surveyed believe workplace wellness refers to both the "physical and psychological wellbeing of employees" (Seed, 2006). Examples of physical initiatives included massages, flu jabs, nutrition seminars, ergonomics, physical environment modifications etc and examples of psychological initiatives includes stress management, interventions to deal with addictions (quit smoking, drug and alcohol initiatives), work life balance, and social/cultural programmes (Seed, 2006).
Healthy Workplaces
A healthy workplace is defined by three things; a safe and healthy physical work environment (e.g. no occupational hazards), its organisational culture (e.g. attitudes, values and beliefs that affect the mental and physical well-being of employees such as respect, appreciation and work/life balance), and its personal health resources (e.g. the opportunities and flexibility the organisation provides to support employees' efforts to improve or maintain their personal health practices or lifestyle such as flexi-time, stress management training, and nutrition interventions etc) (Burton, 2008).
Abbot (et al, 2007) believes healthy workplaces are more than just about getting staff to be physically healthy they also "seek to create a culture in which employees feel good about going to work by addressing work-life balance, fatigue management, healthy working relationships, employer engagement and morale" (CBC, 2006 in Abbot et al, 2007).
Examples of WHP Interventions
Examples of WHP interventions include; stress management, smoking cessation, weight management, back care, health screenings, nutrition education, workplace safety, prenatal and well baby care, CPR and first aid classes, and employee assistance programmes (EAP), work/life balance policies, flexi-time, exercise/fitness groups, discounts to local fitness facilities, healthful food choices at work meetings, events, and training programs, family friendly policies and facilities (such as bicycle racks, showers, gym equipment) (Fronstin, 1996; Cuthell, 2006; Pratt et al, 2007).
Some organisations choose to tailor their wellness programmes to suit different types of employees (e.g. will run a programme for senior management that focuses on specific health risks and run a more broad based approach for other employees) (Pricewaterhouse Coopers for the World Economic Forum, 2007). Some introduce wellness programmes to senior managers first before rolling the programme out to the wider organisation, if the intervention was well received by the managers this staged approach can assist with promotion of the intervention.
Ad Hoc Approach to Wellness
Organisations tend to take an ad hoc approach to wellness (as opposed to having a structured approach in place [which includes measurement and is linked to key business objectives]). For example, research by Seed (2006) found 55 percent of New Zealand organisations surveyed take an ad hoc approach to wellness. Similarly, a 1999 study (by the US Office of Disease Prevention and Health Promotion) of WHP in the United States reported that 90 percent of workplaces offered employees at least one type of WHP activity; the key word being 'activity', most organisations had no organising overarching framework for these programmes (Linnan, 2008 in Goetzel and Ozminkowski, 2008).
Primary, Secondary and Tertiary Disease Prevention
WHP programmes can have three prevention levels, supporting primary, secondary and tertiary efforts (Reardon, 1998; Goetzel and Ozminkowski, 2008):
Primary prevention (awareness raising) - programmes that encourage fitness and exercise, healthy eating, weight management, stress management, moderate alcohol consumption etc
Secondary prevention (lifestyle changes) - health promotion directed at those who are already at high risk because of certain lifestyle behaviours. E.g. smoking, sedentary, poor nutrition, excessive alcohol consumption
Tertiary prevention ('disease management') - these programmes exist indefinitely and are directed at employees with existing ailments such as asthma, cardiovascular disease, cancers, depression, etc with the aim of getting better or slowing the progression of the disease (Pencak, 1991 in Reardon, 1998; Goetzel and Ozminkowski, 2008).
Two Main Types of Programmes (Disease Management/Prevention and Risk Reduction)
There are two main types of wellness programmes; management of behavioural risks (risk reduction) and management of specific diseases (World Economic Forum, 2007; Goetzel and Ozminkowski, 2008).
Wellness programmes that seek to manage behavioural risks - primary and secondary prevention (i.e. risk factor reduction). This is a broader approach, focusing on unhealthy lifestyle choices (e.g. sedentary lifestyle, smoking etc) (World Economic Forum, 2007). The most important modifiable risk factors for chronic diseases are poor diet, inadequate physical activity and tobacco use (World Economic Forum, 2007).
Programmes designed to manage specific diseases are appropriate if the target employee population consists mostly of 'high-risk' individuals (e.g. development of a programme to tackle illnesses such as type 2 diabetes and heart disease, as well as disease management includes how employees can reduce their risk factors for these diseases) (World Economic Forum, 2007).
Criticisms of WHP
In the past, WHP interventions were criticised for having an individual employee focus. Interventions tended to be solely directed at individuals changing their behaviour without regard to the contributing role of physical (e.g. ergonomic features, facilities) and psychosocial workplace environments (e.g. social support, social norms2 related to healthy behaviours) to employee health (Biener et al, 1999; Makrides, 2004; Abbot et al, 2007).
WHP interventions have evolved from only focusing on individual behaviours and lifestyle change to an approach that now considers both employee and organisational health (Makrides, 2004). However, whilst WHP may have evolved conceptually into a holistic, integrated means of health promotion that considers both individual and organisational factors (Chu et al, 2000 in Minerva Research, 2007) in practice most WHP programmes continue to target individual employees (e.g. for smoking cessation programmes there is little focus on employees working conditions that may contribute to the desire to keep smoking [i.e. smoking behaviour of colleagues, workplace stress etc]).
2.3 Impact of Chronic Disease
In order to fully appreciate the importance of promoting wellness it is useful to look at the impacts of chronic disease.
Death and Disability
Chronic diseases (e.g. respiratory, cardiovascular disease, cancer, diabetes,) are a leading cause of death and disability around the world, this is despite the fact many chronic diseases can be prevented through improved nutrition, physical activity and smoking cessation (World Economic Forum, 2007). In developed countries, risk factors for chronic disease (e.g. obesity, workplace stress, sedentary lifestyles etc) are increasing.
Economic Cost of Chronic Disease
The economic cost of chronic disease alone is immense, yet remains largely unrecognized - acute care conditions receive more attention - yet chronic care accounts for three-quarters or more of healthcare costs (Critelli et al, 2008). Some examples of the substantive economic costs associated with the risk factors for chronic disease and occurrence of chronic disease are listed below:
The cost of obesity to employers is substantial (e.g. rising health insurance premiums, decreased productivity, increased absenteeism and disability), One estimate ranks obesity above both smoking and drinking in its impact on health and health costs (Sturm, 2002 in Benedict and Arterburn, 2007).
In the US absenteeism costs associated with obesity cost a total of US$4.3 billion per annum (Cawley et al, 2007).
In New Zealand, chronic obstructive pulmonary disease (COPD) is estimated to cost $102-192 million in direct health costs (excluding personal costs and those relating to home based care)3.
It is estimated that if there were a 10 percent reduction in mortality from cancer and heart disease this would save the US $10.4 trillion dollars per annum (Murphey and Topel, 2005 in World Economic Forum, 2007).
Depression is second only to heart disease in contributing to reductions in productive and healthy years of life (Murray and Lopez, 1996 in Harter et al, 2002).
Diabetes used a third (32%) of Medicare resources in the US and is ranked as one of the biggest problems in the EU (Critelli et al, 2008). In New Zealand the estimated cost of Type 2 Diabetes in 2001 approached $400million and is predicted to rise to more than $1000 million by 2021 (estimation by PriceWaterhouse Coopers Ltd) 4.
It is estimated that from 2005 to 2015 China, Russia and India each stand to lose on average International$ 200 to 500 billion in national income due to death from heart disease, stroke and diabetes (World Economic Forum, 2007).
Prevention, as opposed to cure, offers the most potential to reduce the healthcare costs of chronic diseases (Critelli et al, 2008). The World Health Organisation estimate that at least 80 percent of type 2 diabetes, premature heart disease and stroke, and 40 percent of cancer in New Zealand could be prevented by undertaking regular physical activity, having a healthy diet, and avoiding tobacco products5.
Prevention of Chronic Disease
Of the projected 388 million people deaths worldwide from chronic disease in the next decade, the World Health Organisation estimates 36 million of these deaths could be avoided (World Economic Forum, 2007). Most chronic illness has a behavioural component i.e. changing certain risk behaviours (smoking, excessive alcohol consumption, lack of exercise, poor diet) will decrease health problems (Critelli et al, 2008).
Physical activity has an important role to play in the reduction of chronic diseases. Physical inactivity contributes to a range of chronic illnesses (e.g. including but not limited to, type II diabetes, coronary heart disease, back pain, depression) (Plotnikoff et al, 2005). Data suggests that around seven percent of the total disease burden in Australia is due to physical inactivity (Shaw et al 2007). Despite the recognised benefits of activity (improved health and fitness, reduced disease risk etc) most of the industrialized world does not get enough physical activity to meet public health guidelines6 (Plotnikoff et al, 2005).
Global Strategy on Diet, Physical Activity and Health (DPAS)
The World Health Organisation developed the 'Global Strategy on Diet, Physical Activity and Health (DPAS)7 as a response to the growing global burden imposed by chronic diseases. The goal of DPAS is to "promote health by guiding the development of an enabling environment for sustainable actions at individual, community, national and global levels which, when taken together, will lead to reduced disease and death rates related to unhealthy diet and physical inactivity" (World Economic Forum 2008d).
DPAS also states that "workplaces are important settings for health promotion and disease prevention. People need to be given the opportunity to make healthy choices in the workplace in order to reduce their exposure to risk. Workplaces should make possible healthy food choices and encourage physical activity" (WHO 2004 in Leurent, 2008)8.
A joint report by the WHO and the World Economic Forum notes there is clear and persuasive evidence that many WHP programmes targeting non communicable disease have been successful at improving employees' health by reducing risk factors, increasing employees' fruit and vegetable consumption, improving employee engagement and productivity, and producing return on investment (through cost savings). (World Economic Forum/WHO, 2008).
2.4 The Workplace as an Avenue to Promote Wellness
As noted earlier, the workplace is an important health promotion location for accessing adults. There is a two-way relationship between employees' health and workplaces, employee health affects the workplace and the workplace affects the health of employees (Abbot et al, 2007). There are also benefits for both employees and employers from WHP (discussed in detail in Section 3.0).
Burton (2008) notes that employee wellness in the workplace is the combined result of a) what workers bring with them to the workplace (hereditary factors, personal resources, health practices, attitudes and values; and b) what the workplace does to employees once they are there (organisation of work, physical and psychosocial environment). The employer has control over what the workplace does, and also has some sway on the first factor (e.g. can influence health practices, attitudes etc) (Burton, 2008).
Some reasons why the workplace is an important and useful location for successful wellness programmes and disease prevention strategies are listed below and overleaf:
Ease of access - the workforce is a large, discrete population, relatively easy to access (World Economic Forum, 2007; Shaw et al, 2007; Addley et al, 2001; Plotnikoff et al, 2005; Moy et al, 2006; Goetzel and Ozminkowski, 2008). Furthermore, WHP allows access to people who may not traditionally access medical advice (e.g. young males). Also the workforce may provide access to employees' family and friends (allowing health promotion messages to be spread into wider community).
Amount of time spent at work - typically adults spend more time at work than any other setting (e.g. around a third of their day) (Matos, 2004; World Economic Forum, 2007; Shaw et al, 2007).
Changing work profile - work is becoming increasingly sedentary and this change increases the risk of chronic disease (World Economic Forum, 2007). People with high daily levels of sitting are significantly more likely to be overweight or obese than those with low levels of sitting (Brown et al, 2003). Also, for many roles, there is no longer a clear delineation between work and life, with technology making people available around the clock (Harvey, 2008a). This may result in increased stress levels and a greater need for stress management programmes or stress reduction via participation in physical activity.
Ongoing stress can result in many different negative outcomes, such as increased absenteeism, presenteeism, short and long-term disability, poor health choices (e.g. smoking, excessive consumption of alcohol), mental illness such as depression, health insurance claims, increased employee turnover, increased accident rates, increased errors, reduced quality of work, increased number of grievances or lawsuits, and decreasing employee satisfaction and commitment (Burton, 2008).
Existing infrastructure in workplace - employers often have existing infrastructure which they can utilise allowing them to offer relatively low cost interventions (World Economic Forum, 2007) (e.g. communication channels, intranet, human resource personnel, teams).
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Established channels of communication, making information exchange with employees relatively straight forward (Plotnikoff et al, 2005; Goetzel and Ozminkowski, 2008).
Workplaces have existing support networks and structured teams9, providing opportunity to develop norms of behaviour (Plotnikoff et al, 2005). Workplaces can encourage sustained peer support and peer pressure (e.g. competitions) to engage in WHP (Pencak, 1991 in Reardon, 1998; Moy et al, 2006).
Measurement is often practical - key organisational wellness outcomes (e.g. reduced turnover and absenteeism) can be determined with the use of existing HR data collection systems (Goetzel and Ozminkowski, 2008). In addition, organisations can tap into existing staff surveys to gauge staff satisfaction and morale.
Convenient and cost-efficient - workplaces are convenient and accessible for workers and often cost less than programmes offered in clinical settings. (Glants and Seewald-Klein, 1986, Pelletier, 1996, Sorensen and Himmelstein, 1992 all in White, 2007).
Vested Interest of employers/workplace - there are a number of benefits to employers/workplaces as a result of WHP.
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Workplaces are affected by employees' unhealthy lifestyle practices which also contribute to absenteeism, health insurance claims, presenteeism, short-and long-term disability, depression, and accidents (Burton, 2008). Promoting alternative healthy lifestyles reduces these negative outcomes.
Wellbeing programmes have been shown to increase employee productivity, retention, job satisfaction, innovation, and staff morale (for more information on the benefits refer Section 3.0 of this report).
Employee engagement - senior management's interest in and support for employee wellbeing is considered one of the top drivers for securing employee engagement (which in turn is linked to employees discretionary effort in the workplace e.g. 'going the extra mile') (Equal Employment Opportunities Trust, 2007; Burton, 2008) and staff retention.
Allows for comprehensive holistic approach - in the workplace it is possible to use a holistic approach to worker health by addressing multiple levels of influence, including individual, interpersonal, organisational and environmental factors that may have an impact on individual behaviours directly or indirectly (Hunt, 2007; Stokols et al, 1996 in World Economic Forum, 2008d).
Workplaces provide many opportunities to promote wellness including offering health risk assessments, behavioural counselling, health education, healthy food options in cafeterias, vending machines and meetings, incentives for participation in WHP, organised physical activity (subsidised team sports, onsite facilities) and promotion of incidental physical activity (e.g. use of stairs), and employee social networks (Benedict and Arterburn, 2007; Goetzel and Ozminkowski, 2008).
WHP can be aligned with organisation goals - the objectives of health promotion can be aligned with an organisations overall mission (because good worker health can improve productivity, innovation, profitability, corporate image etc) (Goetzel and Ozminkowski, 2008). Making wellness a business goal is also likely to increase organisational support for achieving positive wellness results.
Offers an inclusive approach to health promotion - WHP at the organisational level is inclusive of all employees and avoids any implied blame for individuals for with health issues (Hillier et al 2005).
Social responsibility (improving the quality of life of employees, their families, the local community and society as a whole) - a number of European organisations regard wellness programmes as a duty of corporate social responsibility (World Business Council for Sustainable Development in World Economic Forum, 2007). Demonstrating social responsibility may improve an organisation's reputation.
Barriers for Employers to Investing in WHP Programmes
Some employers choose not to invest in WHP despite compelling data that wellness programmes can result in positive outcomes (Goetzel and Ozminkowski, 2008; Pricewaterhouse Coopers, 2008). The reasons Goetzel and Ozminkowski (2008) put forward as to why some employers do not support existing or new workplace wellness interventions include:
Being philosophically opposed to interfering with their employees health decisions (i.e. seeing them as part of employees private lives)
Considering wellness programmes as a luxury as opposed to having a key strategic business purpose
Viewing WHP interventions as distracting for employees, objectionable to unions (i.e. spending money that could be used for employee wage increases)
Others may believe in the intrinsic value of wellness programmes but do nothing because they are discouraged by a lack of best practice examples, a lack of resources to implement a WHP programme and the perceived difficulty/expense and/or time needed to prove positive outcomes to senior managers
Abbot et al, 2007 notes competing priorities may be another issue for employers.
Why Employers are Choosing to Invest in WHP
Employers, who do implement WHP, see wellness interventions as more than a business cost, regarding it as an investment in human capital (Goetzel and Ozminkowski, 2008). Pricewaterhouse Coopers (2008) note that some employers have identified definite demographic, societal and economic reasons for implementing WHP programmes, these are listed below:
an aging workforce10 (interventions are needed to keep people well and productive for longer)
a workforce that has expectations around work-life balance initiatives
a changing work profile (e.g. work becoming more sedentary, longer working hours and being time-poor, and technology increasing peoples' availability [Harvey, 2008a])
increasing costs of ill-health and rise in chronic disease
external pressure from government11 (Department for Work and Pensions and the Department of Health, 2008). (in a bid to reduce burden on public services such as increased cost of chronic disease on public health systems)
pressure from other businesses such as corporate social responsibility and competition to recruit and retain employees.
Pricewaterhouse Coopers (2008) conclude by noting that workplace wellness makes commercial sense. A review of 55 case studies showed the majority of organisations (45 out of 55) said wellness programmes had reduced sickness absence, between a quarter to a third of organisations noted benefits such as reduced staff turnover, reduced accidents/injuries, and improved employee satisfaction. Most of the financial benefits recorded for organisations take the form of cost savings rather than increased revenue.
The next section of this report examines the benefits of WHP in more detail.
3 Benefits of Workplace Wellness
This section reviews the benefits of workplace wellness for employers, employees and the wider community (including positive economic, social and physiological outcomes and benefits).
A review undertaken by Voit (2001) reported that structured WHP programmes, that include a variety of physical activity initiatives, health education classes, outreach and one-on-one counselling with follow-up contact have proven to be the most beneficial in terms of both employee and employer satisfaction.
Similarly, Chapman (1996, in Riedel, 2001) noted that well designed WHP programmes with multiple dimensions (with a minimum of at least three of the following types of interventions: smoking cessation, physical activity, weight management, and nutrition education, stress reduction/management, medical self-care, high blood pressure control, cholesterol reduction, cardiovascular disease prevention, prenatal care, back pain/injury prevention) provide both economic benefit to sponsor organisations and reduces health risk prevalence (and thus improves health) amongst employees.
3.1 Employer Benefits of Workplace Wellness
Employers who offer effective WHP programmes experience a number of organisational benefits, as detailed below and overleaf.
3.1.1 Positive Changes as a Result of WHP Interventions
Reduced absenteeism - WHP programmes targeting physical activity and diet have been shown to result in fewer days absent from work (Allen, 1993; Makrides, 2004; Shaw et al, 2007; Aldana, 2001 in Goetzel and Ozminkowski, 2008; Goetzel and Ozminkowski, 2008; World Economic Forum, 2008d). Some examples of this are provided below:
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In one organisation following the 'Kiwi workplace challenge' - (a 12 week activity event created by Azion corporate wellness services) absence over the duration of the challenge was reduced by 50 percent relative to the same time period the previous year (Harvey, 2008a). In terms of financial benefits this translated to an investment of NZ$77 per person returning a saving of approximately NZ$250 per participating employee (Harvey, 2008a).
Following the introduction of effective WHP programmes Prudential Insurance reported a 59 percent reduction in absenteeism and Canadian Life Insurance reported a 43 percent decrease in absenteeism (Allen, 1993).
Riedel (2001) also notes that exercise programmes for lower back pain reduce absenteeism and that smoking cessation programmes (if successful) may also reduce incidental time away during the working day spent on smoking breaks.
Reduced presenteeism - presenteeism refers to 'being at work but not being on the job' (i.e. functioning to full capacity) because of illness or other medical conditions (e.g. seasonal allergies, migraine, depression, gastrointestinal disorders etc) (Hemp, 2004). Presenteeism is not about being lazy, rather it is about genuine health issues impacting an individual's ability to fully function; presenteeism can cut individual productivity by a third or more (by both slowing employees down and increasing the number of mistakes they make), and appears to be more costly than absenteeism (Hemp, 2004). There are a number of studies that have shown the benefits of an influenza vaccination in terms of reducing both absenteeism and presenteeism (Riedel, 2001; Hemp, 2004). The provision of hay fever medicine to employees has also been shown to be worthwhile in terms of gains in productivity (Hemp, 2004).
Reduced workplace accidents - lower accident rates (Addley et al, 2001).
Improved industrial relations - reduction in industrial relation disputes (Addley et al, 2001). Furthermore, if unions are involved in the promotion of WHP programmes this is likely to strengthen employer-union communication and relationships.
Increased performance and productivity - (Addley et al, 2001; World Economic Forum, 2007; Shaw et al, 2007; Nurminen, et al, 2002 in Brand, 2006; Shepard, 1983 in Makrides, 2004). WHP programmes can also increase energy levels of staff (Shaw et al, 2007); employees health is 'a performance driver' (Partnership for Prevention, 2005). Hemp (2004) notes at the core of wellness programmes is the 'belief that healthy employees are an asset meriting investment' and that (for example) employers 'will see greater improvement in efficiency if you treat workers' asthma than if you install a new phone system'.
One example of increased employee performance is a study by Unileaver which found initiatives to prevent chronic disease in employees increased productivity and reduced absenteeism; a sub group of employees who were assisted with stress/pain management and positive sleep patterns were found to be around nine percent more efficient at work and have less time off work relative to the control group (vielife/IHPM Health and performance research survey cited in World Economic Forum, 2007). The economic benefits of this for Unileaver were conservatively estimated at 3.73 pounds sterling for every pound sterling spent (vielife/IHPM Health and performance research survey cited in World Economic Forum, 2007).
Another research project undertaken by the Harvard Medical School and the Institute for Health and Productivity Management (in Financial Times, 2005 in ESRC, 2006) suggests that the healthiest quarter of the workforce is nearly a fifth (18%) more productive than the least healthy quarter.
Quality work outputs - Hillier (et al, 2005) note the indirect benefits of employee wellness includes improved quality of outputs, greater innovation and creativity and increased intellectual capacity12.
Improved employee engagement - employees who are engaged with their work are more productive (Hillier et al 2005).
Improved staff recruitment and retention - WHP programmes can assist in attracting, retaining and motivating employees (Nardelli 2005 in Partnership for Prevention, 2005; Hillier et al 2005; World Economic Forum, 2007; World Economic Forum 2008; Abdulwadud and Snow, 2008; Harvey, 2008a). Staff turnover (during a comprehensive WHP programme13) has been found to be reduced by as much as 54 percent (Renaud et al, 2008).
Staff recruitment and retention is important in competitive labour markets - research undertaken by Seed (2006) found that recruitment was the top Human Resource issue facing New Zealand organisations14. A survey by the American Association of Nurses in 2003 (in World Economic Forum, 2007) found that 60 percent of employees regarded wellness programmes as a good reason to stay with their employer.
WHP programmes attract and maintain employees through two mechanisms; firstly as an individual employee benefit that increases an organisation's offering beyond salary (Harter et al, 2002; Harvey, 2008a), and secondly, by improving an organisations' image (Allen and Leutzinger, in press) (e.g. corporate social responsibility) thus making employees feel more loyal/prouder of the organisation and the organisation an 'employer of choice' (Sangster in Ghent, 2004; Pricewaterhouse Coopers, 2008). Being an 'employer of choice' is a goal that has been identified by the State Services Commission to "ensure the State Services is an employer of choice attractive to high performers, who are committed to service and the achievement of results"15.
3.1.2 Financial Benefits
An organisation's economic and social sustainability cannot be achieved without a 'well workforce' (Hillier et al 2005); the financial benefits to employers of WHP programmes are listed below and overleaf.
Reduced health care costs - (Allen, 1993; Partnership for Prevention, 2005; World Economic Forum, 2008). For example, a study undertaken at General Motors by the University of Michigan noted the inverse relationship between a health risk assessment and their annual medical expenditure - i.e. as the wellness score increased the health care costs decreased (Wagoner, 2005 in Partnership for Prevention, 2005).
Reduced costs relating to absenteeism and presenteeism (World Economic Forum, 2007; Harvey, 2008a) including reduction in sick pay (Allen, 1993) and increased performance and productivity (World Economic Forum, 2007). The influenza vaccination reduces both absenteeism and medical costs and shows very high return on investment resulting from decreased illness, absenteeism and presenteeism (Riedel, 2001; Hemp, 2004).
For example, a review of evidence based research articles on WHP programmes which included 14 evaluation studies that examined absenteeism, found that WHP programmes reduced sick leave between 12 and 36 percent, resulting in a saving of up to 34 percent in absenteeism costs (Kreis and Bodeker, 2004 in ESRC, 2006). The authors summarised that for every pound sterling spent on promoting health in the workplace, up to 2.5 pounds sterling could be saved for organisations (Kreis and Bodeker, 2004 in ESRC, 2006). Another review (Chapman, 2005 in Goetzel and Ozminkowski, 2008) drew similar conclusions as to the reduced costs resulting from participation in WHP programmes, noting cost savings (from medical and absenteeism costs) of 25 to 30 percent lower than average over a study period of 3.6 years16.
Return on Investment (ROI) - (from improved productivity or cost savings) most WHP studies note positive financial results (Chapman, 2006, Goetzel and Ozminkowski, 2008). The Canadian government's corporate wellness programs returned $1.95-$3.75 per employee per dollar spent17. A review by Makrides (2004) stated the economic return on investment (ROI) reported for various WHP programmes ranged from $3.50 saved to $5.96 saved for every dollar spent (Chapman, 1996, Wellness Councils of America, 1995 and Makrides et al, unpublished, all in Makrides, 2004).
Burton (2008) listed some examples of ROI from WHP programmes, as follows:
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Canada Life Insurance saved $3.43 for every $1 spent on its fitness (physical activity) programme (Whitmer, 1995 in Burton, 2008)
University of Michigan, for every $1USD spent on WHP programmes, savings were estimated at $1.50 to $2.50USD (Bachmann 2002 in Burton, 2008)
Citibank, for every $1USD Citibank spent on its WHP programme, savings of $4.56USD were recorded (Ozminkowski, 1999 in Bachmann, 2002 in Burton, 2008).
A randomised trial (that included an economic evaluation) of a WHP programme (a workplace physical activity and diet counselling intervention) showed a positive ROI over a two year period (Proper et al 2004, in World Economic Forum 2008d). In the first year the WHP programme (at a cost of €430 per participant per year) lowered costs due to sick leave by €125 per participant leading to a net annual loss of €305 per participant, in the year following the intervention, costs due to sick leave were lowered by €635 per participant in the intervention group (as compared with control participants), resulting in an annual net saving of €235 per participant (Proper et al 2004, in World Economic Forum 2008d).
3.1.3 Psychosocial Benefits
The following psychosocial benefits from WHP programmes have been noted.
Improved employee morale - engaging employees in WHP programmes sends a clear message that they are valued and results in improved morale (Addley et al, 2001; Abdulwadud and Snow, 2008; Harvey, 2008a).
A happier, more resilient workforce - exercise has been shown to be positively related to self esteem; high self esteem (and other positive affective states) can make employees more resistant to stress-related illnesses and absenteeism (Pelled and Xin, 1999 in Thøgersen-Ntoumani et al, 2005; Thøgersen-Ntoumani et al, 2005).
Improved employee performance - increased self esteem also has implications for the success of organisations through improved job performance (Judge and Bono, 2001 in Thøgersen-Ntoumani et al, 2005).
Benefits of happier employees - there are psychological benefits of WHP programmes (e.g. participation in physical activity improving employee's mood and outlook). Spector's (1997 in Brand, 2006) "happy-productive worker hypothesis" is based on the inverse of the fact that being unhappy makes employees absent more often and produce less quality work (Brand, 2006).
Positive impact on workplace culture - increasing team work and communication (Harvey, 2008a). There is a strong relationship between work-life culture and discretionary effort (e.g. being prepared to put in extra effort to complete work) (Equal Employment Opportunities Trust, 2007). Spector's (1997 in Harter et al, 2002) review suggests satisfied employees are more cooperative and helpful to their colleagues, more punctual and time-efficient, show up for more days of work, and stay with organisations longer than dissatisfied employees do.
Improved rapport and enjoyment - the intervention group in a study on the Canada Life Assurance Company employee fitness programme reported they had better rapport with their coworkers and generally enjoyed their work more (Shepard, 1983 in Makrides, 2004).
Increased job satisfaction - research indicates job satisfaction is important for the prevention of illness, the maintenance of health, and also to job performance (e.g. efficiency) (Judge et al, 2001 in Thøgersen-Ntoumani and Fox, 2005).
Stress reduction - (Burton, 2008). One example of an effective WHP aimed at reducing workplace stress was the Somerset County (UK) Council 'Quality of Working Life' initiative. Recognising it had a problem with absence levels (some of which was related to work-related stress) the Somerset County Council set up the 'Quality of Working Life' initiative in 2001 (this involved participation by key staff, conducting a stress audit, using the results to implement relevant interventions, and monitoring their cost and effectiveness). The initiative resulted in a reduction in sickness absence levels (from 10.75 days in 2001-02 to 7.2 days in 2004-05), that represented a total net saving of approximately £1.57 million over two years18.
3.1.4 Specific Benefits of WHP Supportive of Breastfeeding
The following lists some of the benefits employers may expect as a result of WHP programmes that are supportive of breastfeeding (NB there is some overlap with these benefits and the benefits found by WHP programmes generally).
Reduced absenteeism - this may be because of the better health of the mother's children as a result of the protective properties of breast milk (both in itself and in limiting contact with other potential contaminants) (Raju, 2001; National Business Group on Health, 2008; Abdulwadud and Snow, 2008).
Female staff retention - breastfeeding support in the workplace promotes loyalty to the organisation and improves worker retention after maternity leave meaning skilled and experienced workers are not lost (Bar-Yam, 1998; Raju, 2001; National Business Group on Health, 2008; Australian Breastfeeding Association in Wallace, 2008). In some instances a workplace supportive of breastfeeding may promote an earlier return from maternity leave (National Business Group on Health, 2008).
Cost savings - according to a 2001 U.S. Department of Agriculture (USDA) study, if breastfeeding rates were increased to match those recommended by the Surgeon General/ Healthy People 2010 goals, an estimated US$3.6 billion (in year 1998 dollars) could be saved in healthcare costs, lost earnings of parents, and costs of premature mortality (Weimer, 2001 in National Business Group on Health, 2008).
Increased productivity - supporting breastfeeding may result in increased productivity through improved morale, less work absenteeism (because breastfeeding protective against some infant illnesses) and retention of experienced employees post maternity leave (Dodgson et al, 2004; Cohen, 1994, Cohen, 1995 both in Abdulwadud and Snow, 2008; Abdulwadud and Snow, 2008).
Positive workplace culture - having a supportive employer (and a family friendly culture) improves job satisfaction and morale (Abdulwadud and Snow, 2008; Australian Breastfeeding Association in Wallace, 2008).
3.2 Employee Benefits of WHP Programmes
Employees who engage in effective WHP programmes experience a number of benefits, as detailed below and overleaf.
Positive Changes as a Result of WHP
Improved physical fitness - effective programmes have shown an increase in physical activity levels (Renaud et al, 2008) and consequently improvement in cardio- respiratory fitness (Brand, 2006, World Economic forum, 2008d).
Knowledge gained - increased knowledge and awareness of health/healthy lifestyles (Pelletier, 2001 in Moy et al, 2006) including improved nutrition knowledge (Cook et al, 2001) and the steps required to achieve positive health changes.
Improved nutritional practices - increased consumption of fruit and vegetables, reduction of unhealthy fats in diet (Cook et al, 2001, World Economic forum, 2008d, Renaud et al, 2008, Goetzel and Ozminkowski, 2008).
Weight loss - reduction in body weight using BMI measurements (Stamler et al, 1989, Nisbeth et al, 2000 both in World Economic Forum, 2008d, Addley et al, 2001), also reduced body fat percentage (World Economic Forum, 2008d) and decreased waist circumference (Atlantis et al, 2006).
Being smokefree - reduced tobacco consumption or smoking cessation (Renaud et al, 2008, Goetzel and Ozminkowski, 2008). For example, a smoking cessation programme using counseling and medication at Union Pacific Railroad recorded just under a third of smokers (29%) had quit smoking after six months (Leutzinger et al, 2001 in Partnership for Prevention, 2005).
Moderated alcohol consumption - positive change in drinking behaviours i.e. reduced alcohol consumption (Addley et al, 2001).
Health Benefits of WHP
Promotes physical well-being (Thøgersen-Ntoumani and Fox, 2005). A WHP initiative called the 'Kiwi Workplace Challenge' reported improvements to employees' physical well-being including reduced blood pressure and cholesterol, improved energy levels and sleep quality (Harvey, 2008a). alcohol consumption - positive change in drinking behaviours i.e. reduced alcohol consumption (Addley et al, 2001).
Clinical health improvements (Pelletier, 2001 in Moy et al, 2006, Chapman, 2006), (e.g. reduction in cholesterol, Moy et al, 2006).
Reduced risk of chronic disease - Engaging in positive healthy lifestyle behaviours (e.g. improving physical activity and dietary habits) reduces risk factors (e.g. hypertension, obesity, sedentary lifestyle, and smoking) for chronic diseases such as cardiovascular disease19, ischaemic stroke, type 2 diabetes and certain cancers (Pelletier, 2001 in Moy et al, 2006; Kreis and Bodeker, 2004 in ESRC, 2006; Shaw et al, 2007; World Economic Forum, 2008b).
Some of the reported changes are modest, however even small changes in behaviour, when observed across a whole population, are likely to result in significant effects on disease risk (Rose, 1989, Rose, 1992 both in WHO/World Economic Forum, 2008). For example, Tosteson (1995, in World Economic Forum, 2008b) notes that population-wide initiatives designed to reduce serum cholesterol are cost effective in community-level interventions if the serum cholesterol is reduced by only two percent.
Reduction in carpel tunnel syndrome (risk factors for this condition include being overweight and sedentary) (Allen, 1993).
Reduced risk of musculoskeletal disorders - increased physical activity can result in both a reduced risk of musculoskeletal disorders (Shaw et al, 2007) and a decreased occurrence of musculoskeletal disorders (World Economic forum, 2008d). Increasing physical activity also is useful for pain management - as it has been shown to reduce neck and upper limb pain (Bernaards et al, 2006).
Promotes mental well-being - participation in physical exercise promotes mental well-being (Biddle et al, 2000 in Thøgersen-Ntoumani et al, 2005) for example; improved mood, reduced anxiety, improved self perceptions and improved self esteem (Biddle et al, 2000, Taylor, 2000, Fox, 2000 all in Thøgersen-Ntoumani et al, 2005), and increased quality of life (Brand et al, 2006).
Being healthier and in-work empowers people (e.g. social inclusion, financial independence etc) and increases their self confidence, dignity (Department for Work and Pensions and the Department of Health [UK], 2008), and overall life satisfaction (Hanway, 2005 in Partnership for Prevention, 2005).
Energy and resilience - positive healthy lifestyles increase energy levels and resilience to workplace pressures (Broadhead, 2008, Harvey, 2008a, Hanway, 2005 in Partnership for Prevention, 2005).
Stress/depression reduction - results from a comprehensive WHP programme ('Take Care of Your Health!') found a reduction in employee's self-reported stress levels and feelings of depression (Renaud et al, 2008). This is an important aspect of WHP as depression is the biggest source of disability worldwide (Critelli et al, 2008).
Financial Benefits
Reduced expenditure - improved lifestyle choices can make employees financially better off by reducing medical costs (Hanway, 2005 in Partnership for Prevention, 2005) and personal expenses (e.g. money saved through not buying cigarettes for a pack-a-day smoker is around NZ$3,600 per annum).
Increased employer expenditure - organisational savings from a healthier workforce may mean there is more money available to spend on employees (e.g. on training and personal development) (Highsmith, 2005 in Partnership for Prevention, 2005).
Receipt of incentives - participation (and achievement) in WHP programmes may result in employees being awarded financial incentives.
Psychosocial Benefits (e.g. those relating to workplace culture)
Increased enthusiasm at work - exercise participation was also directly linked with enthusiasm at work (those exercising said they were more enthusiastic) (Thøgersen- Ntoumani et al, 2005).
Improved job satisfaction (Hanway, 2005 in Partnership for Prevention, 2005) resulted in happier employees and workplaces.
Benefits of WHP Programmes that are Supportive of Breastfeeding
Benefits for the mother - improved maternal health including reduction in certain cancers (e.g. breast and ovarian) (Bai, 2008, Abdulwadud and Snow, 2008). The Collaborative Group on Hormonal Factors in Breast Cancer (2002 in National Business Group on Health, 2008) report that women who breastfeed decrease their risk of breast cancer 4.3 percent for every 12 month increment of breastfeeding over her lifetime.
Benefits for the child - protection against gastrointestinal and respiratory illnesses, decreases eczema, reduced likelihood of being overweight in later life or developing type I and II diabetes (Kramer, 2001 in Abdulwadud and Snow, 2008; Ip, et al, 2007 in National Business Group on Health, 2008; Bai, et al, 2008).
3.3 Community Benefits of Workplace Wellness
Effective WHP programmes can result in a number of community/society level benefits, as shown below.
WHP programme reach (within the workplace) - WHP programmes contribute significantly to public health by reaching diverse groups with diverse needs (e.g. young males, breastfeeding mothers, different ethnic groups, people with a disability etc) who may not be accessing any health promoting activities or information elsewhere (Crump et al, 2001).
WHP programme reach (external to the workplace) - WHP can have influence outside of the workplace, potentially influencing the health not only of employees but also their wider social circle (family and friends) (Addley et al, 2001, Whitehead, 2006 in Shamian and El-Jardali, 2007).
Reduced burden on public services - less demand for health services (e.g. a reduction in the blood cholesterol of employees decreases the incidence in coronary events, breastfeeding has health benefits for the mother e.g. reduced cancers and infant) (Moy et al, 2006; Department for Work and Pensions and the Department of Health [UK] 2008, Riedel, 2001).
Economic benefits - supporting economic performance by supporting people to be healthier and in work (Department for Work and Pensions and the Department of Health [UK] 2008). A healthy workforce reduces social deprivation and child poverty (Department for Work and Pensions and the Department of Health [UK] 2008) (e.g. a person can earn more money in work than out of work on a sickness/invalids benefit.
Community wide positive benefits of WHP supporting breastfeeding - reduced economic and environmental burden to society resulting from decreased need to dispose of cans, packaging and bottles associated with formula feeding (Raju, 2001). Breastfeeding also contributes to a more productive workforce; research has shown that breastfeeding mothers have fewer absences, as their infants are sick less often20.
3.4 Potential Costs of Ignoring Workplace Wellness
It makes intuitive sense that employees who are unhealthy and stressed employees will cost an organisation something in terms of absences from work and decreased productivity (Burton, 2008). This section examines the potential costs (financial and other) of ignoring workplace wellness (i.e. not having a WHP programme [or an effective programme]).
Employee's health risk profile impacts on the workplace - employers who have modifiable risk factors (cigarette smoking, sedentary lifestyle, overweight/obese, poor diet, high stress etc) are more likely to be absent from work, have higher rates of disability, and be less efficient (Addley et al, 2001, Goetzel and Ozminkowski, 2008).
The indirect costs of poor health on the workplace (e.g. absenteeism, presenteeism [i.e. lower work output]) are potentially two to three times higher than the direct medical costs of treatment (Edington and Burton, 2003; Burton et al, 2004, Pelletier et al, 2004 and Goetzel et al, 2004 all in Partnership for Prevention, 2005, Goetzel and Ozminkowski, 2008). The World Economic Forum (2008) estimates that productivity losses are as much as 400 percent more than the cost of treating the chronic disease (and that it is the conditions that co-occur with chronic diseases [e.g. depression, fatigue, sleeping issues etc] that may have the greatest impact in terms of cost on productivity) (World Economic Forum, 2008).
Increased absenteeism - literature review showed overweight or obese employees have more sick leave or disability use (Schimer et al, 2006). Another study found workers with diabetes had twice the number of days off work than those with no chronic conditions (Oestreich, 2005 in Partnership for Prevention, 2005).
Cost of absenteeism and presenteeism - research by Conversa Global in 2005 estimated that workplace absence (due to absenteeism, illness and injury) costs New Zealand businesses almost $1 billion dollars per annum (Conversa Global, 2005 in Southern Cross, 2008, Broadhead, 2008).
The costs of absenteeism includes direct costs (e.g. sick pay, cost of temporary staff), and indirect costs on other employees such as stress, quality lapses due to overwork, decreased morale and additional administrative duties for Human Resources (Southern Cross, 2008).
The impact of presenteeism includes increased errors/quality issues, reduced on the job performance and output (Nardelli, 2005 in Partnership for Prevention, 2005).
Unhealthy workplaces make employees sick - poor conditions in the workplace 21 can cause stress and make poor health worse (Department for Work and Pensions and the Department of Health, 2008). A poor psychosocial environment (e.g. organisational culture, support, communication, workloads, relationships etc) at work, can have a substantial negative impact on employees' health, safety, and well-being (Abbot et al, 2007, Burton, 2008). For example, poor psychosocial environments have been associated with an increased incidence of illness; including three times the amount of back pain and conflict, and five times more injuries, mental health issues, and certain cancers (CBC, 2006, NLHBA, 2005, Plummer et al, 2000 in Abbot et al, 2007).
Workplace stress - workplace stress has effects on both individuals and organisations. Stress is associated with the uptake of risk behaviours (e.g. such as smoking, lack of exercise, excessive drinking), stress is also associated with decreased at-work performance through issues such as lack of concentration, increased errors and accidents, as well as being a risk factor for some chronic diseases) (Riedel, 2001, Hillier et al 2005). In organisations stress results in increased absenteeism, high staff turn-over, industrial relations issues, and performance issues such as lack of innovation (Riedel, 2001, Hillier et al 2005, Abbot et al, 2007.).
In the UK, stress is the single largest causal factor for workplace ill health in the public sector, responsible for approximately half of all work days lost due to work- related sickness22. The UK Health and Safety Executive (1999 in Hillier, et al, 2005) stated that work-related stress in the UK cost:
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employers around 350 to 380 million pounds sterling per annum
wider society around 3.7 to 3.8 billion pounds per annum (UK Health and Safety Executive,1999 in Hillier, et al, 2005) (NB this cost is likely to be greater still, as newer information estimating the number of days lost to stress has more than doubled [Jones et al, 2003 in Hillier, et al, 2005]).
Further, job stress increases the risk of musculoskeletal injuries, accidents, physical and mental illness, substance abuse and smoking, all of which can have negative impacts in the workplace (e.g. costs, increased absenteeism and presenteeism) (Shamian and El-Jardali, 2007).
Disengaged staff - symptoms of disengagement include reduction in quality of outputs, missing targets, staff turnover increases, increased absenteeism, decreased innovation, (Hillier et al, 2005). Additional costs of disengaged staff relate to the subsequent staff turnover and include increased costs of recruitment and training new personnel (Hillier et al, 2005).
Cost of staff turnover - costs of replacing employees includes time (for recruitment and training, along with downtime whilst new employee gets up to speed) and money (advertising, costs associated with interviewing new staff [i.e. staff cost, reimbursement for travel etc]) (Burns, 2008). High turnover also costs an organisation in terms of losing workplace knowledge and intellectual property; in addition staff changes can place extra stress on remaining staff (Burns, 2008).
Impact of increasing rates of chronic disease - more chronic disease resulting in more health costs (a particular issue with an aging workforce) (Partnership for Prevention, 2005), and lowered productivity.
Costs of ill health - It is estimated in the UK that musculoskeletal disorders were responsible for 9.5 million lost working days in 2005/06 (Health and Safety Executive, 2007, University of Surrey, 2006 both in Pricewaterhouse Coopers, 2008).
The total yearly costs of neck and upper limb symptoms (symptoms frequently reported by computer users) in the Netherlands due to decreased productivity, sick leave, chronic disability for work and medical costs were recently estimated at 2.1 billion euros (Bernaards et al, 2006).
In the UK, approximately 13.8 million working days were lost in 2006/07 due to work- related stress, anxiety and depression (Health and Safety Executive, 2007 in Pricewaterhouse Coopers, 2008).
Consequences of increased public health care costs - rising public health care costs can result in businesses having heavier tax burdens which can threaten their marketplace competiveness (World Economic Forum, 2007). Further, increasing public health costs reduces the funds available for other areas of public investment (e.g. education, infrastructure such as roads and technology) and threatens sustainability efforts (World Economic Forum, 2007, PricewaterhouseCoopers, 2008).
4 Implementation Lifecycle of a Wellness Programme
Below is a brief overview of the steps involved in the implementation cycle of a WHP Programme. The execution of these steps along with potential challenges faced at each phase of the implementation (and ways to overcome these challenges) are discussed in this section.
Step one: Undertake a needs assessment
Step two: Design stage (formative research, wellness goals and interventions)
Step three: Create a support system (active leadership and healthy environment)
Step four: Implementation (including employee engagement, communications, and incentives and rewards)
Step five: Evaluate and monitor (measurement of behavioural changes, health outcomes and productivity, modifications to the programme as required) (World Economic Forum, 2007).
This section looks at the implementation cycle of a WHP programme as outlined by the World Economic Forum. Employers report they face three main issues when implementing a WHP programme; evaluation and monitoring, the use of incentives, and creation of a supportive environment (World Economic Forum, 2007).
4.1 Needs Assessment
Ryan (et al, 2008) notes the early steps for planning new programmes include obtaining a mandate for the wellness initiative, composing the wellness team, and conducting research and discovery (a needs assessment).
The purpose of a needs assessment is to understand challenges and opportunities within an organisation and use this information to determine what the WHP programme content, scope and approach (design, implementation and evaluation) will be (World Economic Forum, 2007).
The most successful WHP programmes are those specifically designed to meet the needs of employees (Pricewaterhouse Coopers, 2008). A thorough needs analysis that will support the design of a relevant WHP programme includes the following:
Gathering and reviewing workplace population demographics and turnover trends (Ryan et al, 2008).
An assessment of existing resources (e.g. wellbeing offerings) and how they are (or are not) meeting employees needs (Harvey, 2008a; Pricewaterhouse Coopers, 2008).
Investigation of employees' health needs, motivations, barriers and readiness for change, including specific risks and priorities in relation to workplace wellness (Sabinsky et al, 2007, Pricewaterhouse Coopers, 2008). Employee health checks are useful for baseline planning (e.g. a good report should highlight particular areas of risk e.g. large number of staff with high blood pressure or large number of smokers [Southern Cross, 2008]). A health risk assessment (HRA) looks at health behaviours, biometrics may be collected, it also can be used to collect information about employees' readiness for change, perceived level of self-efficacy, or other psychosocial factors that affect willingness or ability to change behaviours (Goetzel and Ozminkowski, 2008).
An organisational assessment (e.g. environmental audit) to understand what policies and facilities are in place that enable or inhibit workplace wellness.
The information obtained in the needs assessment will help shape the WHP programme design (Goetzel and Ozminkowski, 2008).
Challenges of Needs Assessment
Needs assessment are resource intensive and need to be conducted regularly as part of evaluation (World Economic Forum, 2007). It is important to note that risk is not static; organisations need to undertake needs assessment on a continuous basis to understand the (changing) health challenges their employees face (Hanway, 2005 in Partnership for Prevention, 2005).
It can be challenging to obtain employee participation in the needs assessment process. Employees may be worried about confidentiality of health risk assessments or surveys (Hemp, 2004; World Economic Forum, 2007; Goetzel and Ozminkowski, 2008). Employees with significant health risks may not take part in health risk assessments or surveys because they do not want to expose those health risks to their employer (Goetzel and Ozminkowski, 2008).
Overcoming challenges of a Needs Assessment
In order to overcome the challenge of needs assessments being resource intensive, leadership support is required (World Economic Forum, 2007). Support may be obtained by explaining the value of the needs assessment in providing baseline health data for calculation of return on investment (World Economic Forum, 2007).
Encourage employers to shift their planning focus from costs of WHP to the total value of health (Meads, 2005 in Partnership for Prevention, 2005). Meads states employers should understand that their investment in health is 'free' in so much as the resources employers invest in WHP will likely be matched by the return in lower health care utilization, reduced absenteeism and presenteeism, increased productivity and staff retention (Meads, 2005 in Partnership for Prevention, 2005).
To overcome employees' fears about the confidentiality of health risk assessments and surveys the following can be done:
Ensure that the data collection is confidential (Fronstin, 1996) this can be done by outsourcing the data collection and having employee anonymity and confidentiality as a contractual clause with the contracted agency.
Employees may be more willing to participate in baseline (and post) intervention measures if they receive their own individual health assessments to assist them track their own health and goals (Lidbury in Marsden, 2008). Employees can be assured that employers would only receive aggregate data (i.e. at the organisational level), this is useful to employers because it allows them to identify health and wellbeing risks for the organisation and target programmes and allocate resources accordingly (Lidbury in Marsden, 2008).
Communicate the confidentiality of data collection to employees (World Economic Forum, 2007).
Incentivise participation in baseline measures (Hemp, 2004). A strong incentive for participation is if employees believe the organisation genuinely cares about their wellbeing, this feeling can be encouraged by high-profile wellness and employee assistance programmes within the organisation (Hemp, 2004).
4.2 Programme Design
This stage of the WHP programme implementation cycle involves determining programme goals, the types of intervention to use, and the level of intensity (based on the scope and severity of need) and key performance indicators that evaluate process, outcomes and impact (World Economic Forum, 2007; Pricewaterhouse Coopers 2008). Programme design typically requires enlisting specialist help to develop and produce content for the WHP programme (World Economic Forum, 2008c).
During the programme development stage it is important to do the following:
Use the needs assessment data to target intervention(s) - use information obtained from the needs assessment to shape the programme into something relevant to employees (e.g. if needs assessment data shows that having a sedentary lifestyle is a common issue amongst employees then the design of the WHP programme needs to focus on increasing employees physical activity i.e. providing opportunities for employees to become active, overcoming barriers to activity etc).
Include measurement in the programme design - it is important that the programme design includes the concept of continuous improvement (World Economic Forum, 2007). This requires measurement, so it is necessary that research and evaluation is built into the programme at the programme inception (Ryan et al, 2008). Performance indicators will continue to be identified and refined as programmes evolve (Pricewaterhouse Coopers 2008). A well thought out evaluation plan for ongoing assessment and data collection activities is useful in that it builds credibility for the WHP programme (Ryan et al, 2008) by providing the data needed to assess the success of the programme and identify areas requiring modification.
Consider options - consider the range of wellness initiatives and providers and assess which options would best meet the organisations needs and priorities (Pricewaterhouse Coopers, 2008).
Set goals - know what the organisation is aiming to achieve, by when and also how this can be measured. Communicate these goals to employees, one example of a programme based on its goals is the General Electric Company (GEC); GEC has a 'health by numbers' programme that asks staff to achieve four personal numbers "zero for smoking, five for fruit and vegetable servings per day, 10,000 for steps taken per day and 25 for their target BMI" (Williams, 2008).
Have a long-term view - a long term strategy is crucial (ongoing behaviour change and maintenance of healthy lifestyle is an ongoing process). McAlear (in Ghent, 2004) recommends that organisations decide what they are going to do at least a two year basis. A long term view is also necessary for data collection (WHP programmes need ongoing monitoring to assess short, mid and long term changes and benefits).
Undertake formative research - formative research is an essential component in the development of WHP programmes (Cook, et al, 2001; Webber et al, 2007; Fletcher et al, 2008; Sabinsky et al, 2007). Formative research consults with employees about potential WHP programmes (content and delivery) and provides data about both employees and the settings in which the research is to be implemented, it helps to identify mediators and moderators that could influence the process of behaviour change and the primary outcome (e.g. demographic variables, preferences for WHP topics, stress levels, environmental supports and/or barriers for eating and physical activity (e.g. supportive/unsupportive line manager), self efficacy, stages of change, and social support (Cook, et al, 2001; Webber et al, 2007).
For example, if an organisation had decided to focus on increasing employees' physical activity then formative research could be undertaken to determine whether employees would prefer team activities or whether they had a preference for solo activities. Formative research could also be used to assess receptiveness to using an online personal trainer programme, wearing a pedometer or using a fitness facility.
Workplace examples of formative research and the types of information provided to assist programme design are listed below:
Formative research for a WHP programme in a primary school setting revealed that personnel were not interested in too many educational seminars rather they wanted active participation and interaction, this information was used to design a programmed with a delivery style that would appeal to the target audience (Webber et al, 2007).
Formative research for a WHP programme focusing on physical activity was undertaken for both blue and white collar employees, this research identified barriers and motivators for taking part in the programme (Fletcher et al, 2008). For both blue and white collar employees work scheduling and work conflicts resulting in a lack of time for participation (Fletcher et al, 2008). Other barriers for white collar workers included long work hours, fear, lack of knowledge and instruction (Fletcher et al, 2008). Shift work was a barrier for blue collar employees along with concern about potential injuries, and negative perceptions around workplace physical activity programmes (e.g. not right for them, already active at work etc). For both types of workers social support and being self motivated were enabling factors, improved health was seen as a motivating factor and for white collar workers only appearance and weight loss were motivators.
Formative research for a WHP programme focusing on weight reduction sought to explore the motivation and perceived barriers to weight loss for overweight males aged 25 to 44 years (primarily unskilled workers) (Sabinsky et al, 2007). Main barriers were lack of motivation, negative perceptions of a slimming diet (e.g. 'rabbit food') and of dieting/weight loss being seen as feminine themes (Sabinsky et al, 2007). Males wanted to be slim and healthy but the main motive for weight loss was a desire to be more effective and an asset in workplace (Sabinsky et al, 2007). This research highlighted what interventions (goal setting, health practices, information and communications) this subgroup should focus on, i.e. not on leanness and good health but rather on increased effectiveness and performance with specific emphasis on the workplace (e.g. improved ability of running faster or longer, managing work better, being more efficient at work) (Sabinsky et al, 2007).
Devine (et al, 2007) undertook formative research for their "Images of a healthy worksite" intervention (which seeks to provide easy access to healthy foods and encourage physical activity). For the formative research Devine (et al, 2007) used an adapted version of the PRECEDE healthy model (this is a component of the PRECEDE-PROCEED model and looks at the "pre" factors to introducing workplace wellness and includes undertaking various assessments as follows:
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A social assessment (i.e. canvassing employees' views of the relationships between work, health and weight as they relate to overall quality of life) (Devine et al, 2007).
An epidemiological assessment (including genetics, dietary behaviour, and the workplace food and eating environment [e.g. type and cost of food available in cafeteria]) (Devine et al, 2007).
Educational and ecological assessments of the worksite; this involves understanding enablers (motivating factors e.g. feedback towards certain behaviours) and barriers (e.g. policies, line managers practices etc) that help or hinder behaviours (healthy eating and exercise) or environmental changes (such as availability and cost of food on offer, taste of food, not having refrigerated vending machines etc). As well as enablers and barriers, the assessment sought to understand any reinforcing behaviours (i.e. employees' motivation for certain behaviours including any pressure to work long hours, miss lunch breaks etc) (Devine et al, 2007).
Administrative and policy assessments - reviewing organisational policies to assess available resources/support that could help or hinder an intervention (e.g. policies on food provision in the workplace [vending machines, caterers to be used, cafeteria etc]) (Devine et al, 2007).
The aim of the afore mentioned formative research was to gain a broad understanding of the socio-cultural role of food and eating among employees, and also employees perceptions of feasible and culturally acceptable workplace environmental intervention strategies (Devine et al, 2007). Devine (et al, 2007) reported that the PRECEDE model was a useful WHP planning tool which provided a practical basis for formative individual, group, and observational data collection and analysis which in turn usefully informed the design of planned environmental intervention strategies targeted at the particular workplace of interest (Devine et al, 2007).
One study looking at introducing a WHP physical activity programme undertook formative qualitative research using the "Theory of Planned Behaviour" in order to understand the different beliefs employees had about increasing physical activity (e.g. behavioural, normative and control beliefs) (Ajzen, 2002 in Prosser et al, 2007). An example of questioning on behavioral beliefs is "what would be good or bad about increasing physical activity at work?", questioning on normative beliefs asks about approval/disapproval of the proposed activity, and questioning on control beliefs asks about barriers/enablers (Ajzen, 2002 in Prosser et al, 2007). The information gained is useful and provides real life situations to be considered in the design and execution of interventions in the workplace (i.e. motivating/enabling factors, barriers to overcome etc) (Prosser et al, 2007).
Challenges of Programme Design
There are many challenges when designing WHP programmes, the two main challenges relate to participation and resourcing, as follows:
Making WHP programmes relevant and attractive to ensure high levels of employee participation (World Economic Forum, 2007).
Working with available resources, which may limit the extent of the programme (World Economic Forum, 2007).
Overcoming Challenges of Programme Design
Undertaking a needs assessment and formative research (to explore employee needs/readiness to change [World Economic Forum, 2007], preferred delivery style, perceived barriers/motivators, best method/messages for communication, etc) and using this information to tailor the programme will ensure it is relevant and attractive to employees. Taking a long term view of the programme evolution and starting with a small number of fun and effective initiatives may increase participation and employee support for the programme (instead of trying to do too much too soon) (Harvey, 2008a).
Aligning workplace wellness goals with the organisations business strategy will demonstrate to employees that the programme is taken seriously by senior management (even if working with a limited budget). The issue of limited resources can be addressed through innovation and low cost interventions - WHP programmes do not have to be expensive, the following are examples of low cost ways workplaces can target obesity (National Business Group in Health in Grossman, 2004. Grossman, 2004):
Offering healthy food choices in cafeterias, vending machines and meetings
Offering employees a health risk assessment
Providing nutritional information on cafeteria selections (e.g. fat content, calories etc)
Providing on-site educational classes about nutrition, healthy lifestyles, stress management and other weight-related 'triggers'
Offering recognised weight loss programmes such as Weight Watchers at work
Distributing health education materials (including having these available on the intranet)
Providing a subsidy for participation in sports teams or health clubs (e.g. gym, tennis club etc)
Encouraging the use of stairs (e.g. through signage)
Flexi-time - allowing employees to take a longer lunch break in order to exercise (Pricewaterhouse Coopers, 2008)
Sponsored participation in local sporting events (e.g. fun runs) (Pricewaterhouse Coopers, 2008).
Heinen (2004 in Grossman, 2004) notes that by offering a number of relatively minor things, keeping what works and investing in interventions that provide the biggest return on investment, positive effects will be seen. Whilst the overall goal of WHP is to reverse negative health trends, Grossman (2004) points out that "just to flatten the trend line for obesity would be a victory".
4.3 Creation of a Support System
Developing a true culture of health can significantly increase participation in WHP programmes (Huckabee 2005 in Partnership for Prevention, 2005). The World Economic Forum (2007) notes the execution steps in the creation of a support system for WHP programme are having active leadership and a healthy environment.
Active Leadership
Senior leadership must lead the wellness changes in order to create the desired healthy workplace culture (Shamian and El-Jardali, 2007; Abbot et al, 2007). Active leadership to support the implementation of WHP initiatives includes demonstrating the organisation's commitment to achieving optimal health and emphasising the value of wellness as a key organisation-wide strategy (World Economic Forum, 2007). Securing the support of the senior leadership is also vital for gaining buy-in from more junior management (World Economic Forum, 2008c), this is important as it may be the more junior managers who make the decisions as to whether employees are able to take part in WHP interventions. Leaders influence culture change in a number of formal ways (e.g. company memos, presentations, provision of resources etc) but also in informal conversations (Abbot et al, 2007) and in unspoken ways (e.g. behaviour). The implication of this is that leaders need to be provided with the tools, education, support, and resources to effectively create positive culture change (Abbot et al, 2007).
Healthy Environment - A Wellness Culture
An important part of creating a support system for a WHP programme is to modify the physical work environment to reflect the organisation's wellness goals (e.g. provide healthy options for vending machines and cafeteria menus, healthy food in meetings, have ergonomic furniture, signs supporting use of the stairs, showers, bicycle racks, quiet rooms, fitness facilities etc) (Huckabee 2005 in Partnership for Prevention, 2005; World Economic Forum, 2007). As well as the physical environment it is important to consider other aspects of an organisation (e.g. workplace culture, workplace relationships, workloads, policies etc).
Barriers to Creating a Support System
The barriers to active senior leadership support include the long term time horizons (e.g. asking for long term commitment without long term supporting evidence in the first instance), and the fact that WHP programmes can be resource intensive (e.g. undertaking a needs assessment, formative research, programme design and ongoing monitoring) (World Economic Forum, 2007). Lack of leadership skills, lack of understanding of the importance of wellness and apathy can also be an issue.
The barriers and challenges to having a healthy environment include employee skepticism, limited resources, and the fact that culture change may take time (World Economic Forum, 2007).
Overcome Barriers to Creating a Support System
Ways to overcome the barriers to active senior leadership support include:
Pilot programme with management - undertaking a pilot wellness programme with senior staff before rolling out a broader wellness programme to all other employees (World Economic Forum, 2007). Coaching and informing senior staff about their own health risk status and wellbeing may increase their understanding and support of the WHP programme - resulting in a positive cascade effect for the organisation (World Economic Forum, 2007).
Education - train supervisors and front line managers in leadership and stress management (Huckabee 2005 in Partnership for Prevention, 2005). Educate management in how to apply the factors needed to cultivate change (Abbot et al, 2007) and provide leadership training (Shamian and El-Jardali, 2007).
Accountability - making aspects of WHP (e.g. employee participation in programmes) a performance measure that management is assessed on will highlight the importance of supporting wellness in the workplace. Make leaders accountable for healthy environment; inform leaders of their responsibility to avoid creating a stressful or toxic work environment (Huckabee 2005 in Partnership for Prevention, 2005).
Information - provide managers with information on the costs of poor health and chronic disease, and the values and benefits of wellness to the organisation so they understand its importance (Ryan et al, 2008).
Ways to overcome the barriers and challenges to having a healthy environment include:
Consult with employees - to come up with priority wellness areas (and ideas to overcome any barriers), also make consultation with employees about any WHP interventions a routine occurrence (Abbot et al, 2007).
Develop a health mission statement - stating that wellness is an important value and objective of the organisation, align the health mission statement with the organisation's overall mission (Huckabee 2005 in Partnership for Prevention, 2005; World Economic Forum, 2007).
Communicate the new culture - using ongoing awareness and reinforcement campaigns via common and popular communication channels (Huckabee 2005 in Partnership for Prevention, 2005; World Economic Forum, 2007) (e.g. staff newspaper, intranet, staff meetings, notice boards etc). Explain the steps being taken to mitigate risk (Huckabee 2005 in Partnership for Prevention, 2005). Ensure the messages about the healthy culture/environment are consistent, honest and achievable (World Economic Forum, 2007). Overcoming skepticism and creating trust is important - employees who believe their workplace will do the right thing for them are more likely to participate in wellness initiative (Huckabee 2005 in Partnership for Prevention, 2005).
Policy development - workplace policy is required to ensure the sustainability of healthy environments (Shamian and El-Jardali, 2007). New collective agreements should contain arrangements for self-scheduling, flexible scheduling (e.g. flexible hours/working from home etc), overtime, time-in-lieu, and job sharing (Shamian and El-Jardali, 2007).
Create employee support teams - (Huckabee 2005 in Partnership for Prevention, 2005) (e.g. walking teams, weight loss groups etc) competition between these groups can foster both team building and motivate individuals to participate in interventions.
4.4. Implementation
The World Economic Forum (2007) notes the execution steps in the implementation stage of a WHP programme are employee engagement, a communication strategy and the use of incentives/rewards. These three components of the implementation stage are discussed below and overleaf.
4.4.1 Employee Engagement
In order to engage employees in a WHP programme, it is important to listen to their opinions (formative research will assist with this) and translate these opinions into a targeted programme. Generating high levels of engagement and participation is essential to the success of all prevention programmes (Chapman, 2006, Goetzel and Ozminkowski, 2008).
Participation Rate
The WHP programme participation rate that is purportedly required in order to have 70 percent of employees with a low health risk status is as follows:
80 percent employee participation in a health risk assessment (or other WHP initiative) at least once over three years
60 percent employee participation at least two times over a three to five year period, and
40 percent employee participation at least three times over a three to five year period (Serxner et al 2003 and Musich et al 2001 in Partnership for Prevention, 2005).
(N.B. Participation may involve preventive screenings [e.g. blood pressure, cholesterol], targeted risk reduction [e.g. weight management, smoking cessation, stress management], one-on-one wellness coaching [online, telephone or face to face] [Serxner et al, 2003 and Musich et al 2001, in Partnership for Prevention, 2005]).
The reported average employee participation rate among exemplary WHP programmes is 60 percent (Goetzel et al 2001, in Goetzel and Ozminkowski, 2008). In the first instance of WHP programme implementation, 60 percent participation could be the figure to aim for in programme goal setting.
Health as a Shared Responsibility
It should be noted that health is a shared responsibility; whilst employers are primarily responsible for the health of an organisation (e.g. policies, physical environment etc) employees also need to assume personal responsibility (Highsmith, 2005 in Partnership for Prevention, 2005). Making positive lifestyle choices such as eating healthy food, moderating alcohol consumption, being physically active, managing stress, being smoke free, and losing weight are all examples of personal responsibility, which is the foundation of primary prevention of chronic illnesses (Highsmith, 2005 in Partnership for Prevention, 2005).
WHP needs to take a holistic approach to programme delivery, whereby employers and employees have a mutually beneficial partnership that allows both parties to take and accept responsibility for wellness in the workplace (Hillier et al, 2005).
Challenges and Barriers to Employee Engagement
The following can be barriers to participation:
Interventions (e.g. educational sessions) being held offsite during work hours take up more time to attend (Moy et al, 2006)
Lack of time before, after or during work hours (Kruger, 2007)
A gap between formal policies and informal practices (Abbot et al, 2007) (for example there may be a workplace policy about offering time-in-lieu for overtime worked but managers may discourage employees from accessing this time owed)
Working shifts or overtime (Moy et al, 2006)
Influence of peers (e.g. employee trying to give up smoking may be encouraged to join colleagues for cigarette breaks) (Moy et al, 2006)
Employee scepticism - all change initiatives are potentially threatening and a company's motives may be called into question by some employees (World Economic Forum, 2008c)
Intervention not being seen as relevant to certain employees (e.g. more for females than males, more for employees without disability than those with disability, not culturally appropriate etc)
Trade union/staff side mistrust around confidentiality/employer motivations (World Economic Forum, 2008c).
Overcoming Challenges and Barriers to Employee Engagement
The following can assist in overcoming barriers to employee engagement:
Participatory approach to development and implementation - involve employees early on in planning stages, listen to employees' opinions and suggestions, include employees from across all services/divisions of organisation on wellness committees, and appoint key employees as workplace wellness champions (Taft, 2005 in Partnership for Prevention, 2005; World Economic Forum, 2007; World Economic Forum, 2008c).
Increase programme relevance and plan for diversity - The World Economic Forum (2008c) notes the importance of planning WHP programmes with diversity in mind at the design stage. The needs assessment and formative research can assist in planning for diversity, in addition relevant experts should be consulted (e.g., cultural advisors and associations representing differently able people [e.g. Deaf Association, Blind Association etc]).
British Telecom (BT) implemented a WHP programme, learnings from their programme included (World Economic Forum, 2008c):
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The need for different strategies and messaging for males and females
There are geographical differences for some health issues and attitudes that need to be reflected in the programme design
Ethnic communities may require special attention, materials must be available in local languages
Planning for diversity at the outset saves time, trouble and money later.
Goal setting - motivate employees through individual goal setting. For example, having employees choose the health specific goal they would like to work on (e.g. weight loss, improved fitness, smoking cessation, reduced cholesterol etc), allowing the participants to work on a topic that is highly relevant to them (NB it is important that goals are measureable) (World Economic Forum, 2008d).
Non-financial incentives - interventions held at a convenient time and at a convenient location (Kruger, 2007) such as onsite at the workplace (Moy et al, 2006). Having a healthy workplace environment that makes healthy behaviours convenient (e.g. showering facilities, ready availability of healthy food and water etc) (World Economic Forum, 2008d).
Offer financial incentives and rewards - (Pricewaterhouse Coopers, 2008) such as paid time off (Kruger, 2007).
Wellness screenings paid for by employer - research has found that participation in health screenings (e.g. cholesterol, blood pressure, weight, stress, fitness, health risks) is highest when employer pays for the screening rather than when employees have had to contribute to costs (e.g. pay half) (Erfurt and Holtyn, 1991).
Use appropriate communications - (Pricewaterhouse Coopers, 2008) inform employees of win-win strategy - enhanced employee wellbeing benefits both employee and employer (Highsmith, 2005 Partnership for Prevention, 2005). (N.B more on communication strategies to follow in the next section [Section 4.4.2])
Union involvement and support for WHP programme - running a WHP programme in partnership with the trade union can overcome employees' suspicion and increase participation (World Economic Forum, 2008c). In New Zealand The PSA (Public Service Association - Te Pukenga Here Tikanga Mahi) is New Zealand's largest union with 57,000 members working in central and local government, state- funded agencies, health and community services. The PSA could potentially be involved in promoting the benefits of both offering and participating in workplace wellness initiatives.
A study of over 800 worksites in US found that greater union representations at workplaces was associated with more support for WHP activity, involving local unions in WHP (equipping them with the knowledge of health (and other) benefits) may play a useful role in communicating with organisations that employ their members (Brisette et al, 2008). Developing partnership relationships with trade unions was important in securing occupational safety improvements and it would make sense to take the same approach with health (World Economic Forum 2008c).
GO involvement and support for WHP programme - working with or partnering with NGOs to implement individual campaigns not only provides valuable expertise and resources it also can reinforce employees' perception that the programme is worthwhile (and can enhance an organisation's corporate social responsibility credentials) (Taft, 2005 in Partnership for Prevention, 2005; World Economic Forum, 2008c)
Case Study - Hot Steppers (Melbourne, Australia) (Shaw et al, 2007)
The following WHP programme "Hot steppers" provides an example of some of the barriers to engagement that can occur, and suggests ways to overcome those barriers.
"Hot steppers" was a three month walking challenge, participants were issued with a free pedometer and encouraged to walk 10,000 (or more) steps per day, the number of which they recorded in a log book. Initially the pedometers were a novelty but that wore off to the end of the three months (Shaw et al, 2007). Barriers to participation included the novelty wearing off, losing motivation (for both wearing the pedometer and for walking), losing pedometer, pedometer stopping working/flat battery, sedentary nature of work not providing any opportunity for walking, disliking wearing the pedometer (because it drew attention to individuals), and poor weather (Shaw et al, 2007). Another issue mentioned was the fact that the pedometer does not measure other forms of activity such as swimming (Shaw et al, 2007).
Participants in the pedometer intervention were asked for ideas to keep people interested, suggestions included: organised walks for participants, providing for competition between participants, providing more incentives to use log book, providing more prizes for achieving good results, use of good quality pedometers, and anonymously graphing achievements of others relative to participant (to encourage peer competition) (Shaw et al, 2007). Additional ideas for overcoming loss of interest and motivation to participate in pedometer based interventions includes making the pedometer exercise an individual challenge (e.g. converting steps taken into kilometers walked and having prizes for 'walking' between major cities or 'walking the distance of the country') or a team challenge for charity (e.g. employer prize donation to charity of choice for the team that walked the most number of steps).
4.4.2 Communication Strategy - Promoting Workplace Wellness
The purpose of the communication strategy is to foster and maintain employees' interest and participation in the WHP programme. Communication is a critical enabler during the WHP execution stage for overcoming employee skepticism and apathy (Pricewaterhouse Coopers 2008).
It is important that organisations communicate at all stages of the WHP programme implementation cycle, including during the planning process to let employees know that planning is underway, what to expect, timing and so forth (Ryan et al, 2008). Planned and purposeful "grapevine" communications (e.g. informal conversations with senior management) are also a valid and powerful approach (Ryan et al, 2008).
Creating a brand or programme identity for the WHP programme helps establish credibility and appeal (Ryan et al, 2008). A programme launch should be included in the communications plan as a way of introducing the programme and generating employee interest (Ryan et al, 2008). Before and after the launch, marketing and promoting the programme is an ongoing activity.
Communication methods may include websites, pay stub messages, newsletters, bulletin boards, pamphlets, fliers, posters and signage, e-mail guest speakers, e-learning courses or programmes, executive addresses, mission statements, and elevator or stairwell messages (Partnership for Prevention, 2005; Pratt et al, 2007; World Economic Forum, 2008d). The Switch2well WHP programme at Southern Cross had a pre-launch (advertising the upcoming programme using posters, fliers, emails etc), a launch, follow-up evaluation forms, and sharing success stories as part of its communication strategy (Broadhead, 2008).
Communication Challenges
The main challenge for WHP is overcoming employee disinterest/apathy (World Economic Forum, 2007). Another challenge is communicating relevant messages in a professional way and avoiding communicating bland general messages, which can be difficult given health is a broad topic (World Economic Forum, 2008c).
Overcoming Challenges
The following are useful for overcoming the communication challenges mentioned above:
Use of personalized and tailored communication (Rees and Finch, 2004 in World Economic Forum, 2007). Messages can be tailored according to need as determined by stage of change23 (e.g. awareness raising for 'pre-contemplators' and encouraging commitment and confidence for 'contemplators'). Research has shown that individualised behavioural e-counselling is more effective than basic internet interventions (Tate et al, 2003 in Lewis, 2005).
Stay focused - develop a 'brand identity' that ties together and communicates all the programme initiatives (Anderson, 2002 in World Economic Forum, 2007). Keep messages clear, simple, and avoid additional messages even if they are relevant (World Economic Forum, 2008c). Include an appropriate fun element in communications (World Economic Forum, 2008c), humour can makes messages more appealing.
Gates (et al, 2006) undertook qualitative research (focus groups) with employees and also with managers (using separate groups) to explore effective communication strategies - both employees and managers agreed signs should be simple, use humour, involve storytelling, provide facts (e.g. nutrition facts such as fat content), feature large pictures and words, and frequently change (to avoid 'viewer fatigue'). Employees said signs should be colourful and positive, and located in places such as employee break rooms and worksite café; managers said signs should be where employees make choices (this includes worksite café, but also includes walking path, lifts etc) (Gates et al, 2006).
Promote small steps - encourage employees to make small but sustained changes that won't be overwhelming or act as a deterrent to change (World Economic Forum, 2008c).
Bolster participation - use general awareness strategies (Partnership for Prevention, 2005), encourage competition and links to charitable work in order to boost participation and maintain interest (World Economic Forum, 2008c).
Use varied delivery methods - the delivery of the WHP programme should consider the different ways people learn (e.g. visual, auditory, or kinesthetic) and a variety of media should be used to support these different learning styles (print, telephone, e- technology, and in-person). Ideas for delivering educational strategies include interactive sessions (such as quizzes, games, puzzles), handouts for healthy recipes, employee authored healthy cook book, programme launches (with 'draw-cards' e.g. offering free healthy food), health spots at work where employees can access healthy messages, and regularly changing the healthy messages used (either online or on a notice board at work) (Gates et al, 2006). Educational material should include the following; humour, stories, statistics, trivia, weekly health tips, quotes and simple messages (Gates et al, 2006).
Registration - if possible use a registration tool so that information is being captured about participating employees at the outset (World Economic Forum, 2008c).
Communications expertise - a core requirement for any programme. A comprehensive and professional communications plan is essential, if they appear amateurish or disorganised they will most likely fail (World Economic Forum, 2008c).
Case Study - "Take it off 83!" (United States) (Seidman et al, 1984)
The following WHP programme "Take it off 83!" provides an example of how communication strategies can foster engagement, participation and success. "Take it off 83!" was a successful WHP programme aimed at reducing weight in a cost effective manner, it was based on concepts of competition and self responsibility (Seidman et al, 1984). The programme had an intensive one week public relations campaign (posters, flyers etc) pre launch, articles in the companies' two weekly newspaper, and contests to guess the company's combined weight at the initial weigh-in (Seidman et al, 1984).
Communication was constant throughout the 12 week programme - all employees were exposed to motivating and education material and events, including:
an intensive one week Nutrition Fair with representatives from organisations such as the American Heart Association and the American Cancer Society providing materials on nutrition
a behaviour modification techniques seminar
weekly weigh-ins
cook books (with low fat, low calorie recipes) were available
employees were shown a film called 'weighing the choices' (a series of short vignettes on food facts)
personalised certificates were handed out to those who met their weight loss goals (around a third of the males and 17% of the females) and congratulatory 'keep up the good' work certificates for those who had lost weight but not achieved their goals (Seidman et al, 1984)
programme results and photos of winners were included in the company's newspaper.
Seventy percent (out of the initial 2,500) of employees took part and 90% of them lost weight (Seidman et al, 1984). The average weight loss for men over the 12 wks was around 5kgs for males and 3kg for females (Seidman et al, 1984). The cost worked out to be around $2 for every kilo lost (Seidman et al, 1984).
4.4.3 Incentives and Rewards
Once the novelty of a WHP programme has worn off, employee participation tends to decrease this has led to an almost universal use of incentives for WHP programme participation to counter attrition and maintain engagement (Chapman, 2006). In order for WHP programmes to be beneficial at the organisational level (i.e. provide return on investment) employers need to generate high levels of participation (Chapman, 2006).
Examples of incentives include: financial incentives for participation, time off for participation, token gifts and merchandise, internal competitions between divisions, organisation sponsored donations to social and sports clubs, team building away days, organisation sponsored donations to employee charities, free use of onsite gym facilities, and prizes (Hoekman, 1999; Pricewaterhouse Coopers, 2008; Broadhead, 2008). Participation is influenced by the rewards/incentives on offer, the higher the average monetary value of the rewards the greater the participation or impact (Chapman 2006; Finklestein et al, 2007).
There are typically three levels (or phases) of incentives that employers use (Chapman, 2006):
Level one: token incentives to mark participation in programmes. Generally limited to inexpensive items such as pens, t-shirts, water bottles etc (Chapman, 2006).
Level two: moderately priced gifts ($20 to $50) such as gift vouchers. Level two incentives typically involve employees accumulating points which are redeemable for 'gifts' (Chapman, 2006). For example, in the US a WHP programme (marketed as a 'lifestyle change' as opposed to a 'weight loss' programme) used the following points system - points were awarded for wise food choices, aerobic activity, other types of physical activity, and participation in healthy stress busting activities, once employees got to 1000 points they got a t-shirt, at 2000 points a cook book, then at 3000 points employees received a gift certificate for sporting goods (Garofalo, 2004). (In addition to the points system there was also a major prize of a four day Caribbean cruise for two [Garofalo, 2004]).
Level three: typically involves incentives with larger dollar values that are easily redeemed such as cash or reductions in health care payments (Chapman, 2006).
Challenges of Incentives/Rewards
The challenges to overcome with incentives/rewards include ensuring the cost of the reward does not outweigh the cost savings of the changed behaviour (Chapman 2006), and having incentives that are appealing and motivating (formative research can assist with determining this). Also, there is the challenge that the use of incentives may only achieve short-term participation as opposed to long term behaviour change (World Economic Forum, 2007).
Behaviour modification for changes like smoking cessation and weight loss require personal ownership (i.e. internal motivation and commitment), a WHP programme can provide tools, advice and encouragement but the employee also needs personal responsibility for sustained change (World Economic Forum, 2007).
Case Study - A Reward Scheme that Caters to Diverse Workforce
The Southern Cross WHP programme "Switch2well" incorporates a rewards scheme that aims to reinforce wellbeing while catering to the individual preferences of a diverse workforce (Broadhead, 2008a). So far, 94 percent of Southern Cross employees have participated in at least one activity (Broadhead, 2008b). The reward scheme includes (Broadhead, 2008a):
health related financial incentives (employer contributions via a corporate health management account - employees have a card and they can use it to purchase from over 3,600 health-related retailers)
paid wellness leave (e.g. employees can take part in a 'wellness challenge' and win a day of wellness leave)
a points reward system - employees accumulate points when they work through each stage of the programme (three stages per annum), available rewards that can be 'purchased' with points include onsite massage therapist voucher, financial top-up in health management account, or half wellness day leave etc)
there are also spot prizes in order to recognise the positive achievements of employees who are not competitive participants.
4.5 Evaluation and Monitoring
Research and evaluation is integral to successful programmes. It is important that programmes have clear goals and systematically document their results relative to their goals. New information reinforces and expands on previous material (e.g. characteristics of successful interventions) and provides data necessary for a WHP programme to evolve. As well as shaping programmes, research can assess a programme's success by measuring its outcomes (short to long-term).
As organisations spend money on WHP programmes, they must be sure they are effective (World Economic Forum, 2007) this requires evaluation of employee participation, and the short term and long term strategic aims of the intervention (Pricewaterhouse Coopers 2008). It is also necessary to identify and collect cost and benefit data in order to undertake financial impact modeling (Pricewaterhouse Coopers, 2008). The World Economic Forum (2008b) recommends that data collection use online assessments where possible, be employee-centric (e.g. respectful of privacy/confidentiality and easy to participate in), proactive (with WHP programmes having measurement built into their framework), and importantly provide accurate information which allows organisations to understand the efficacy of any interventions.
4.5.1 Baseline Measures
At the beginning of a WHP programme, organisations need to establish a set of measures that will allow evaluation of financial and health outcomes (World Economic Forum, 2007). Along with these measureable metrics, key indicators of success (or performance) need to be established including critical aspects of participation rates (e.g. programme registration, health risk assessments completed, attendance at seminars, weigh-ins, healthy food sales in worksite cafeteria, attrition rates, completion rates etc).
In addition to participation, indicators for outcome measures need to be identified for both the short and long term strategic goals of the WHP programme (e.g. increase employees' awareness of the programme and knowledge of particular risk factors, increase staff morale and retention, reduce absenteeism, aim to increase the percentage of low risk employees to more than 70% of the organisation [Meads, 2005 in Partnership for Prevention, 2005]) (World Economic Forum, 2007). These indicators will be used to measure the WHP programme activities impact (Abbot et al, 2007).
A systematic approach to data collection (baseline and ongoing) should be undertaken to ensure both consistent data practices and the effective tracking of data (Institute of Medicine 2005, in World Economic Forum, 2008b). Furthermore, a long term view to data collection is required for WHP programmes because certain outcomes may improve before others (e.g. reduced absenteeism may occur before cost savings or reduced incidence of chronic disease in the wider community) (Pricewaterhouse Coopers, 2008).
Challenges of Obtaining Baseline Data
Some of the main challenges when developing the list of key performance indicators are a lack of organisational clarity as to what the strategic aims of the WHP programme are (e.g. what success looks like), no consistent definitions for indicators in the workforce (internally and externally), plus some desired outcomes can be difficult to measure (e.g. soft metrics like 'performance' in roles that have no production or traditional output component) (World Economic Forum, 2007).
Other challenges discussed earlier (refer Section 4.1 Needs Assessment) relate to employees concern about the confidentiality of health measures and tracking data, and the associated reluctance to participate in measurement activities (World Economic Forum, 2007).
Overcoming Challenges of Obtaining Baseline Data
These challenges relating to key indicators can be overcome by defining the WHP programmes strategic goals before developing an evaluation plan, having simple and consistent key performance indicators and providing a standard definition for those indicators the company aims to measure (World Economic Forum, 2007).
Concepts like productivity for white collar workers can be measured usefully and reliably with self reported survey instruments (e.g. WHO's Health and Work Performance Questionnaire [HRQ]) (Kessler et al, 2001 and Kessler et al, 2005 in Rowe, 2005 in Partnership for Prevention, 2005). Riedel (2001) notes that in the absence of 'widgets' that absence data can be used as a proxy for productivity; overall absenteeism is often the primary measure used to evaluate the effect of behaviour change programmes on employee performance.
4.5.2 Data Management
It is necessary to have a system of data management. Technology provides a new and consistent means for monitoring (World Economic Forum, 2007). In order to be effective (i.e. readily accessed in a meaningful format) data management needs to be technologically advanced (e.g. use an online assessment methodology and 'dashboard24' reporting tools to track changes and show the effectiveness of interventions) (World Economic Forum, 2008c). Data collected (e.g. participation rates, costs of intervention, outcomes etc) should be linked to other metrics such as employee absences, costs, productivity, staff retention etc) (World Economic Forum, 2008c).
Data Management Challenges and Possible Solutions
There are three main challenges with data management (World Economic Forum, 2007):
firstly, the use of technology (e.g. internet survey) creates new privacy issues (this can be overcome by using aggregated de-identified data [i.e. no identifying details])
secondly, there needs to be a system in place that allows for ready access of data that is meaningful (this can be overcome by making the system easy to use for all people who have a role inputting or accessing monitoring information)
hirdly, there are often limited available resources for data management (this can be overcome by outsourcing data to specialist third party)
4.5.3 Ongoing Measurement
Having research and evaluation measures in place facilitates evidence-based decision making (Abbot et al, 2007). Ongoing measurement contributes to planning and allows for refinements to be made as required to ensure the WHP programme remains effective and relevant (i.e. meets changing concerns) (World Economic Forum, 2007; Pricewaterhouse Coopers 2008).
The usual challenge of continuous monitoring is that limited resources are available; this can be overcome by leadership support and commitment to resources (World Economic Forum, 2007). Reporting of WHP programme results at the board level is evidence of leadership support and commitment to both the programme and measurement (accordingly it is important that the data collection is seen to be of organisational significance [National Business Group on Health, Improving Health in World Economic Forum, 2008b]).
5 A Workplace Wellness Framework
This section details the World Economic Forum's workplace strategy for prevention of chronic disease and includes the identified gold standards for structuring (and measuring) WHP interventions in the four areas of leadership, workplace culture, people and processes (e.g. research).
There are considerable variations in the types of wellness programmes employers offer, and how these programmes are implemented and received by employees.
The challenge for organisations today is no longer whether or not WHP programmes should be implemented but rather how they should be designed, implemented and evaluated to achieve optimal benefits (health and cost-effectiveness) (Pelletier, 2005).
The World Economic Forum have developed a workplace strategy for preventing chronic disease, referred to here as a workplace wellness framework, within this framework there are eight key gold standards for structuring (and measuring) success, these are captured within four areas as follows25:
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Source: World Economic Forum, 2007. Page 19.
Each of the four areas listed above are explored in more detail overleaf. Examples for each of the eight gold standards above have been supplied, these examples of wellness initiatives/strategies are organised (as per the World Economic Forum, 2007) as being either common practice, best practice or leading edge practice (N.B Section 6.0 of this report also provides examples of effective WHP interventions, based on research and data collection).
Note 'common practice' does not imply that the wellness initiatives/strategies are not successful or valid, just as 'leading edge' practice does not necessarily imply those initiatives/strategies are better than common or best practice (rather 'leading edge' reflects newer innovations and more recent ways of thinking around workplace wellness).
5.1 Leadership
Gold standard: "Promote active leadership of senior management in wellness initiatives" (World Economic Forum, 2007).
It is widely recognised that leadership involvement and support is vital to successful WHP programmes and a powerful influence on an organisation's culture (Hillier et al 2005; Abbot et al, 2007; World Economic Forum, 2007; Dellve et al, 2007; Williams et al 2007; Downey and Sharp, 2007; Goetzel and Ozminkowski, 2008).
Leadership qualities such as goal clarity (e.g. employers having realistic expectations and employees knowing what is expected of them) as well as the use of rewards are important for increasing workplace attendance, and potentially for increasing participation in WHP programmes (Dellve et al, 2007).
The table below lists the common, best and leading edge practices for Leadership associated with WHP programmes (World Economic Forum, 2007).
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Source: World Economic Forum, 2007 (unless otherwise specified)
5.2 Culture
A culture of health is one where an organisation includes wellness in the organisations' mission, business objectives and employment polices (World Economic Forum, 2007).
5.2.1 Align Wellness and Business Goals
Gold standard: Align wellness goals with business strategy (World Economic Forum, 2007).
There is agreement in the literature that WHP programmes should have goals that align with business strategy (Cuthell, 2006; World Economic Forum, 2007; Pricewaterhouse Coopers 2008; Ryan et al, 2008). The effectiveness of WHP programmes is greatly influenced by the successful alignment between the programme goals and the organisation's objectives (Goetzel and Ozminkowski, 2008); alignment increases the likelihood of sustained management support (financial and non-financial).
Human Resource personnel are typically charged with the challenge of convincing organisational leaders of the importance of investing in human capital (e.g. employees) (Cuthell, 2006). Reviewing an organisations strategic values can assist in understanding where a WHP programme fits within the organisation, for example, if an organisation has a strategy to be seen as an 'employer of choice' then having healthy, productive and satisfied employees are necessary to accomplish this goal, thus the organisation considers healthy employees as significantly contributing towards its strategic goals (Ryan et al, 2008).
WHP programmes should be driven by clear objectives around achieving workplace wellness, and these should be reported to key stakeholders - reflecting WHP programmes core role in an organisations business strategy (Cuthell, 2006). WHP programmes need to be seen as integral to the operation of business, as opposed to a series of ad hoc one off initiatives (Cuthell, 2006). The ultimate goal is to fully integrate comprehensive WHP programmes26 within an organisation and to ensure they are not seen as a luxury or an optional add-on only to be maintained times are good and cut in lean times (Goetzel and Orminkowski, 2000 in Plotnikoff, et al, 2005).
Hillier (et al, 2005) notes that in order for wellness to manifest itself as a critical business strategy then there needs to be a clear demonstration of a positive relationship to the organisations bottom line (e.g. reduced absenteeism, improved efficiency and productivity). The following quote illustrates how wellness goals and business goals line up; "Staff have to be 'happy, healthy and here' (i.e. at work) in order to deliver efficiency gains and first rate services. That is the best way to position our organisations to better deliver core functions." Lord Hunt of Kings Heath, Ministerial Task Force on Health, Safety and Productivity. 27
The table below and overleaf lists the common, best and leading edge practices for aligning goals with business strategy (World Economic Forum, 2007).
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Source: World Economic Forum, 2007 (unless otherwise specified)
5.2.2 Environment and Culture
Gold standard: Create a supportive environment and culture focused on wellness (World Economic Forum, 2007)
To create a supportive environment and culture, it is necessary that workplace wellness is seen as an integral part of human resources planning and processes (Abbot et al, 2007). A supportive, enabling culture is very important for positive behaviour change (Hillier et al 2005). People are more likely to make healthy choices more frequently if their surrounding environment is supportive (WHO, 2006).
In order for behaviour change to be sustainable then the culture of wellness created by effective WHP programmes must extend beyond the worksite and include partners and family (World Economic Forum, 2007). For example, the effective WHP weight loss programme "Take it off 83!". included spouses and dependents as participants both individually and in employees' 'teams' (for competitions etc) (Seidman et al, 1984). The design of "Take it off 83!" recognised the simple truth that for weight loss to occur, a healthy eating environment needed to be supported in both the workplace and home.
The table overleaf lists the common, best and leading edge practices for creating a supportive environment and culture that focuses on and enables wellness (World Economic Forum, 2007).
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Source: World Economic Forum, 2007 (unless otherwise specified)
5.3 People
It has been noted that employers often find employees are hesitant to participate in new WHP programmes meaning organisations must take an innovative approach to persuade employees to participate (e.g. using targeted communication and interventions, along with incentives) (World Economic Forum, 2007).
5.3.1 Targeted Interventions
Gold standard: Target interventions based on unique characteristics of employee population (World Economic Forum, 2007).
Well planned and comprehensive WHP programmes are cost effective when the programme is matched to the specific health issues of the specific employee population of interest (Patton, 1991 in Makrides, 2004). Well matched programmes are likely to have greater uptake and less attrition because they are more relevant than generic 'one size fits all' approaches. Programmes can be matched to individuals (e.g. based on their health risk assessment and/or stage of change) or matched to an organisation's workforce based on the most common health issues faced by employees (as determined by collated health risk assessment data or self report surveys).
Focus groups are another effective method for obtaining important data needed for planning a targeted WHP programme; qualitative research such as focus groups with employees provides an opportunity to discuss WHP ideas, preferences, barriers, and possible solutions to any challenges etc (Gates et al, 2006). Having a participatory approach to the development of programmes not only assists with targeting interventions it is also likely to increase employee buy-in.
The table below lists the common, best and leading edge practices for targeting interventions based on employees' profile (World Economic Forum, 2007).
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Source: World Economic Forum, 2007 (unless otherwise specified)
5.3.2 Incentives for Participation and Achievement
Gold standard: Offer incentives to encourage participation and better outcomes. (World Economic Forum, 2007).
To encourage participation it takes more than just using alarming statistics about chronic diseases such as heart disease, diabetes and cancer, thus organisations offer employees rewards for participation in WHP initiatives (World Economic Forum, 2007). Increased participation has been linked to initiatives such as offering incentives (Hillier et al, 2005; World Economic Forum, 2007).
The table below lists some examples of the common, best and leading edge practices for incentivising WHP programmes (World Economic Forum, 2007).
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Source: World Economic Forum, 2007 (unless otherwise specified)
5.3.3 Communication
Gold standard: Use targeted and ongoing mass communication (World Economic Forum, 2007).
The World Economic Forum (2007) states employers should use every method of communication possible to promote health and raise awareness of risk factors for chronic disease, including newsletters, internet, 24-hour help lines, management led initiatives (formal communications31 and informal conversations) and wellness champions (i.e. employees who encourage and inspire colleagues to wellness). Pratt (et al, 2007) also agrees with saturating employees with key health messages.
The table below lists some of the common, best, and leading edge practices for communication of WHP interventions and programmes (World Economic Forum, 2007).
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Source: World Economic Forum, 2007 (unless otherwise specified)
5.4 Processes
Processes involving collaboration, measurement and monitoring of the WHP wellness initiatives strengthen the motivations of both companies and employees (World Economic Forum, 2007).
5.4.1 Collaborative Partnerships
Collaborate with external parties through public-private partnerships (World Economic Forum, 2007).
Shamian and El-Jardali (2007) note the need for collaboration between researchers, policy makers, stakeholders and practitioners (i.e. human resource managers, clinicians etc) to establish comprehensive WHP programmes.
A multi-stakeholder approach is required in order to successfully undertake the following tasks:
comprehensively address the issues of nutrition/diet and physical activity (World Economic Forum, 2008d)
develop and implement WHP policies and programmes (World Economic Forum, 2008d). Implementation includes the roll-out of policies and programmes, along with employee engagement and participation.
educate employees about how to prevent chronic disease (World Economic Forum, 2007)
measure, monitor and evaluate WHP programmes (overall and on a single intervention basis).
Potential collaborators (or stakeholders) include (WHO/ World Economic Forum, 2008; World Economic Forum, 2008d):
international organisations
governments (local and national) including ministries concerned specifically with health, labour and safety
non-governmental organisations (NGOs) (e.g. the Heart Foundation)
employers and employees
trade unions
private sector (e.g. insurance companies, expert consultants [i.e. in research, communications, marketing/promotion, specialty fields such as nutrition etc], food producers, catering and food distributors, and the sports industry e.g. trainers/advisors).
Non-governmental organisations can play an important role in both the advocacy (encouraging acceptance of workplace as a setting for health promotion) and development (establishing and disseminating information about best practice) of WHP programmes (WHO/ World Economic Forum, 2008). Trade unions can raise awareness of benefits of good nutrition and exercise and be advocates of positive behaviour change (e.g. working with employers to improve the workplace culture and environment to make it supportive of wellness) (WHO/ World Economic Forum, 2008).
The table overleaf lists some of the common, best and leading edge practices for collaboration to support WHP efforts (World Economic Forum, 2007).
Collaborative Partnerships (continued).
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Source: World Economic Forum, 2007 (unless otherwise specified)
5.4.2 Establishing Evaluation and Monitoring Programmes
Gold Standard: Establish evaluation and monitoring programmes to measure change, outcomes and financial impact (World Economic Forum, 2007).
Evaluation and monitoring is critical for informing decision making (e.g. on programme design and modification), and for contributing to the collection of evidence on WHP to provide accountability for resources and further development of effective WHP programmes (World Economic Forum, 2008d).
Evaluation and monitoring of WHP programmes are considered the most difficult area of the gold standards (World Economic Forum, 2007).
The table below and overleaf lists some of the common, best and leading edge practices for evaluation and monitoring of WHP programmes (World Economic Forum, 2007).
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Source: World Economic Forum, 2007 (unless otherwise specified)
6 Effective WHP Interventions/Programmes
This section includes the following:
Successful components of wellness interventions (i.e. factors that contribute to the success of interventions)
WHP focused on physical activity
WHP focused on healthy eating (nutrition and weight loss)
WHP focused on supporting breastfeeding mothers.
6.1. Successful Components of WHP Interventions/Programmes
The components seen to be part of successful WHP interventions or programmes (the framework under which a number of interventions may sit) are detailed below and overleaf. In general, successful WHP programmes:
Are based on theory (Editors of Wellness Program Management Advisor, 2006; Glanz et al, 1998; Goetzel and Ozminkowski, 2008). Examples of theory that WHP programmes may be based on include; social cognitive theory - self efficacy (i.e. improving individuals' sense of control and outcome expectancies); Trans Theoretical Model (TTM - Stages of change) (Prochaska et al, 1992 in Bernaards et al, 2006); Precaution Adoption Process Model (PAPM - which is the same as the Stages of Change model but introduces two new stages. These new stages distinguish between people who are unaware of an issue (Stage 1) and those who know something about an issue but never actively thought about it (Stage 2) [Weinstein, 1998 in Bernaards et al, 2006]).
Have clear goals and objectives - goals and objectives are linked to business objectives and are seen as integral to an organisation's culture (Marshall, 2004; World Economic Forum, 2008d). (NB an exploratory study into physical activity commented on participants not being entirely outcomes focused; it also important to be process centred [i.e. to have a satisfying experience from the programme itself as opposed to only being concerned with the achievement of the goals of fitness and weight reduction]34 (Rice and Saunders, 2001).
Foster networks and partnerships - (World Economic Forum, 2007) strategic partnerships offer a coordinated, collaborative approach to producing better outcomes. Potential partners include trade unions, nongovernmental organisations (e.g. the Heart Foundation) and private sector organisations (e.g. caterers).
Participatory Approach to Development and Implementation - research has shown employee involvement in the design and implementation of WHP is beneficial (Harden et al, 1999 in Addley et al, 2001; Voit, 2001; Sorensen et al, 2004 in Story et al, 2008; Hunt, 2007; Abbot et al, 2007; World Economic Forum, 2008d; Hersey, 2008). Two examples follow:
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The 'Wellworks' study was a randomised controlled intervention study targeting behaviour change by having joint manager-employee participation in WHP planning and implementation, and included consultation with management on workplace environmental changes and health education programmes (Sorensen et al, 1998b). The 'Wellworks' interventions resulted in reduced fat consumption, increased dietary fibre intake, and increased fruit and vegetable consumption, no change for smoking was recorded (Sorensen et al, 1998b). Sorensen (et al, 1998b) note that the size of effects was modest but at the wider population level could have a large effect on cancer-related and coronary heart disease.
The 'Healthy-Directions Small-Business' (HD-SB) study (Hunt, 2007) aims to reduce employees' cancer risk by increasing their fruit and vegetable consumption, their physical activity and daily multivitamin intake, whilst decreasing their red meat consumption. For this WHP programme, employee advisory boards (EABs) were established at different worksites, these boards included workers and managers. The role of the EABs was to meet with management representation in order to plan and implement educational strategies and policies that would contribute to creating a workplace environment that supported healthy eating and physical activity patterns, along with tobacco control. The EABs meet with HD-SB health educators monthly during work time (Hunt, 2007).
The HD-SB intervention included; providing health promoting activities/materials for employees' friends and family (in recognition of their role as influencers of employees), providing one-to-one, small group (e.g. lunchtime walking groups) and worksite level activities (e.g. of worksite level WHP activity included large displays of actual employees engaged in healthy behaviours such as using the stairs instead of the lift), there were also changes in company policies to support healthful behaviours (e.g. catering policies etc) (Hunt, 2007).
Recommendations from the EABs included having easy-to-do low cost physical activities for employees and education about healthful convenient meals (especially for employees with limited resources and multiple family responsibilities). The worksites that enjoyed high rates of participation in the programmes (e.g. three quarters of employees) had well functioning EABs, strong management support, and a healthy culture whereby managers and employees were respectful of each other and an existing culture of getting together for social activities (Hunt, 2007).
Use of Peers - peers are an effective means to promote health in the workplace (and are in keeping with having a participatory approach) (Hersey, 2008). Two examples follow:
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The 'natural helper' programme - a study by Tessaro (et al, 2000) found that existing social networks in the workplace can be successfully utilized. The 'natural helper' programme is a WHP intervention focusing on changing the health behaviours associated with major causes of morbidity and mortality in women (smoking, high fat intake, low fruit and vegetable consumption, and lack of physical activity) (Tessaro et al, 2000). 'Natural helpers' (a number of selected female employees) were provided with education sessions and information to undertake health promoting conversations and activities. The study found that 'natural helpers' organised more group activities over time (e.g. walking groups), and expanded the health promotion messages from close network members (e.g. colleagues in immediate area) to other co- 64 workers, and also started getting approached by co-workers for this information (Tessaro et al, 2000).
Peer educators - peer education appears to be an effective means of achieving an increase in fruit and vegetable intake (Buller et al, 1999). Buller (et al, 1999) undertook a peer education WHP intervention study with lower socio-economic multicultural workers (predominantly males). Peer educators were chosen on the basis of their ability to be good communicators, their existing strong relationships with colleagues, and ability to be 'opinion leaders' (Buller et al, 1999).
The selected peer educators attended a 16 hour educational programme over eight weeks that included discussion on the health benefits of eating fruit and vegetables, cultural trends in dietary practices, methods of incorporating the topic of fruit and vegetables into conversations at work, how to motivate individuals, and were also taught persuasive communication techniques (Buller et al, 1999). Peer educators were tasked with having two hours of conversations per week on fruit and vegetables (e.g. the 5-a-day message), they also attended a two hour session each month to review their activities and solve any problems (Buller et al, 1999). Peer educators were paid for participating in training and associated activities (Buller et al, 1999). The positive changes produced by the peer education programme were larger than those achieved by a community campaign in Australia (Dixon, 1998 in Buller et al, 1999).
Tailored/targeted Interventions - tailoring interventions (and moving away from the one-size-fits-all approach) is an important strategy for increasing the efficacy of WHP programmes; tailoring wellness approaches takes into consideration the differences (e.g. information needs) and varying challenges (e.g. health issues, ability) of employees (Harden et al, 1999 in Addley et al, 2001; Marshall, 2004; Goetzel and Ozminkowski, 2008; WHO/World Economic Forum, 2008).
Kreuter and Skinner (Kreuter and Skinner, 2000 in Irvine, 2004) suggest the term `tailoring' be used to describe interventions (e.g. communications) designed for individuals and `targeting' be used to describe interventions aimed at groups (e.g. on the basis of gender, race/ethnicity etc).
Tailoring can be based on an individual's demographics (e.g. age, gender), attitudes (perceived barriers, stage of change, self-identified areas of concern), or personal health issues (based on the results of individual health risk assessments). Targeting can be based on organisational health issues (based on the aggregated results of individual health risk assessments or aggregated employee feedback) or at a group demographic level (Irvine, 2004) in terms of workplace interventions designed for females. Tailoring may be done on multiple factors (e.g. health risk assessment results and stage of change [Cowdery et al, 2007]). Multiple studies show tailored print communications are more likely to be noticed, read and influential than non- tailored print messages (Campbell et al, 1994, Campbell et al, 1998, Strecher et al, 1994 Brug et al, 1996, Brug et al, 1999, all in Irvine, 2004). Examples of tailored interventions follow:
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Tailored feedback - research into Health Risk Assessment feedback found employees receiving tailored messages were 18 percent more likely to change at least one risk factor (e.g. physical inactivity) (Kreuter and Strecher, 1996 in Goetzel and Ozminkowski, 2008).
Tailored communication (based on stage of change) - a randomised study of physical activity found employees who received written messages tailored to their 'stage of change' (e.g. contemplation, preparation) demonstrated a 13 percent increase in physical activity, compared to a one percent increase for those employees who received generic messages (Peterson and Aldana, 1999 in Goetzel and Ozminkowski, 2008).
Tailored Communication (based on health risk assessment) - a wellness study by Mills (et al, 2007) included (for the intervention group) access to a password protected personalised wellness and lifestyle web portal that included articles, assessments, and interactive online behaviour change programmes. Members of the intervention group were also sent tailored emails fortnightly - these individualised emails were on relevant personal topics based on known health risks according to each person's health risk assessment), the emails included practical tips for self-improvement and also promoted use of the personalised web portal (Mills et al, 2007). In addition, the intervention group received four paper-based information packs (on the four most prevalent health risks identified by the health risk assessment across the employee population); topics included stress management, sleep improvement, nutritional balance and physical activity (Mills et al, 2007).
This study showed improvements in the intervention group relative to the control group in reduced health risk factors and increased work performance, along with reduced absenteeism (Mills et al, 2007)35.
Variety of Communication/Education Strategies - offer a variety of employee engagement methods to best suit different working/learning styles (and schedule constraints); some employees like to work on their own, whereas others prefer teams, some prefer printed versus electronic (i.e. web-based materials), others may prefer visual materials as opposed to audio etc (Anderson and Dusenbury, 1999; Goetzel and Ozminkowski, 2008). Offering a 'menu' of WHP choices (e.g. attend a seminar, read information in own time, have a one-on-one session etc) (Anderson and Dusenbury, 1999; Goetzel and Ozminkowski, 2008) is likely to increase employee participation and engagement.
Effective communication (i.e. communication that is well received and engages the target audience) is a key component of successful WHP programmes (World Economic Forum, 2008d).
Promotes the Inclusion of Existing Social Support Systems - (Seidman et al, 1994; Sorensen et al, 1998c; Marshall, 2004; Goetzel and Ozminkowski, 2008; World Economic Forum, 2008d). Health education programmes are more likely to be effective when they take into account social support systems, such as the influence of colleagues and household members (spouse, family, significant others) (Sorensen et al, 1998c; Goetzel and Ozminkowski, 2008).
Promotes the Creation of New Social Support Systems - As well as taking existing social support networks into consideration, successful programmes build social support (e.g. foster coworker norms that build support for behaviour change) (World Economic Forum, 2008d). Social support in turn improves the effectiveness of behaviour change programmes (Anderson, et al 1993). For example, Seidman (et al, 1994) found encouraging the formation of supportive and/or competitive teams was an effective means of promoting weight loss.
Includes Environmental Support - (World Economic Forum, 2008d) WHP programmes that incorporate environmental modifications (e.g. make stairwells more attractive, have WHP signage, have chill-out or relaxation rooms, mark out walking tracks, onsite gym or gym equipment etc) are more effective (Renaud et al, 2008).
Comprehensive - (Makrides, 2004; Renaud et al, 2008). The most recent National Worksite Health Promotion (NWHP) survey lists the following five factors considered to be key components of a comprehensive wellness programme (Linnan, 2008 in Goetzel and Ozminkowski, 2008):
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Health education (e.g. awareness raising and risk reduction)
Links to related employee services (e.g. EAP)
Supportive physical and social environments for health improvement
Integration of health promotion into the organisation's culture
Employee health screenings with regular follow-up (Linnan, 2008 in Goetzel and Ozminkowski, 2008).
The NWHP survey found that only seven percent of employers have all five factors (Linnan, 2008 in Goetzel and Ozminkowski, 2008). Based on the findings of this literature review, a comprehensive intervention is also one that:
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Addresses a broad range of determinants of health including personal health practices, coping skills, working conditions, social support, and physical conditions (Makrides, 2004).
Is holistic - focusing not only on the physical aspects of an individuals' health but also on psychological wellbeing and social/spiritual needs (SEED, 2008).
Includes education but provides more than just education of the health benefits of certain behaviours; successful programmes also include health assessments, goal setting, ongoing opportunities to acquire knowledge, skill building and feedback, and creation of supportive environments (O'Donnell, 2004).
Has an ecological approach - does not focus exclusively on employees instead also considers the relationships between colleagues and management and other factors (such as organisational and policy factors, and physical environmental elements) and their influence on wellness (Plotnikoff, et al, 2005; Linnan et al, 2007).
Has structure - structured interventions have a greater likelihood of success. For example, a structured workplace smoking cessation intervention which included medical counselling and the provision of nicotine patches achieved better results than sporadic unstructured advice in the workplace (Rodriguez- Artalejo et al, 2003).
Has multiple components - a review by Heany and Goetzel (1998 in Goetzel and Ozminkowski, 2008) found 'indicative to acceptable' evidence supporting the effectiveness of multi-component WHP in achieving long-term behaviour change and risk reduction among employees. Research has found that effective WHP programmes are those which offer multiple risk factor interventions combined with group participation, and individualised risk reduction counseling to high risk employees (Pelletier, 2001 in Moy et al, 2006).
An example of an effective multi-component WHP pilot programme designed to reduce cardiovascular risk is White's (2007) 12 week pilot employee wellness programme. The intervention focused on dietary changes, increasing physical activity and education via workshops (topics included such things as 'quick and healthy meals', 'stress and eating', 'healthy snack foods', 'surviving special occasions', 'the food and mood connection' etc) (White, 2007). Pre-intervention measures (health metrics) were undertaken.
The intervention included employees' participating in a minimum of four workshops in three months, an 'exercise prescription' (an individualised exercise plan), a meal plan, a week of sample menus, healthy recipes, information about available resources related to physical activity, and discounted fitness classes. The post-intervention measures found significant results (e.g. cholesterol reduction) (White, 2007). Whilst this study was a pilot (N=25) and had no control group it still shows promising results using a multi- component study.
Remove barriers to participation - it is important that employees have easy access to WHP programmes including holding onsite activities or other easily accessible location, making modifications to the workplace environment, scheduling intervention in work hours, flexibility to undertake exercise during work hours (e.g. longer lunch breaks), and taking employees individual work schedules into account (Anderson and Dusenbury, 1999; Voit, 2001; Renaud et al, 2008; Goetzel and Ozminkowski, 2008).
Are flexible - successful WHP programme delivery requires a flexible programme design (for example, being able to shorten sessions [Williams et al 2007] or modify aspects of the programme based on employee feedback) and also a flexible workplace.
Grzywacz (et al, 2007) states that workplace flexibility may contribute to positive lifestyle behaviours for employees and as such may play an important role in effective WHP programmes. Grzywacz (et al, 2007) cites cross-sectional and longitudinal data that showed greater perceived workplace flexibility was associated with employees who had better sleep habits, who undertook advocated stress management practices, who reported having healthier lifestyles, and undertook more physical activity36.
Includes the Use of Incentives - maximising employee participation is critical in order to maximise health benefits and return on investment (Voit, 2001; World Economic Forum, 2008d; Goetzel and Ozminkowski, 2008; Hersey, 2008).
Has a long term focus - interventions need a longer term focus (Renaud et al, 2008) to allow for implementation and embedding of wellness into the culture of the organisation. There is consensus that WHP programmes need to place for three years to in order measure health and financial outcomes (NB annual assessments of interventions are still necessary to track progress and undertake any fine tuning required.) (Goetzel and Ozminkowski, 2008).
Improves Self Efficacy - improving the self-efficacy of the participants (World Economic Forum, 2008d). Self efficacy is people's belief in their ability to undertake the behaviour necessary to succeed in certain situations (e.g. to become physically fit); enhancement of self efficacy is typically a direct or indirect goal of educational sessions within WHP programmes (WHO/World Economic Forum, 2008).
Includes Research and Evaluation - Research and evaluation is integral to successful programmes. It is important that programmes have clear goals and systematically document their results relative to their goals. As well as shaping programmes, research can assess a programme's success by measuring its outcomes (short to long-term).
An important part of research and evaluation is the dissemination of results as this assists future programme design (via contributing to the development of a blue-print for successful WHP programmes) and ultimately supports health promotion and the prevention of chronic disease.
Formative research is critical for informing the development and successful implementation of WHP intervention strategies (Devine et al, 2007). Formative data can provide information such as employees preferred communication/learning styles, types of incentives they would find most appealing, barriers to taking part in WHP programmes and potential ways to overcome these barriers.
Has Strong Management Support - (Hillier et al 2005; Abbot et al, 2007; World Economic Forum, 2007; World Economic Forum, 2008d; Dellve et al, 2007; Williams et al 2007; Downey and Sharp, 2007; Goetzel and Ozminkowski, 2008).
A review of over 100 WHP interventions revealed one of the factors identified as important for the success of wellness interventions was senior management support (Harden et al, 1999 in Addley et al, 2001). Management support includes providing resourcing, participating in interventions, and sign-off on wellness policies.
Focuses on Modifiable Risk Factors - effective interventions focus on modifiable risk factors (Harden et al, 1999 in Addley et al, 2001) (such as changing diet, increasing physical activity, moderating alcohol consumption etc).
Include Health Risk Assessments/Screenings - (Anderson and Dusenbury, 1999; Schilling et al, 2005; Cowdery et al, 2007; Hersey, 2008). The health risk assessment (HRA) is one of the most widely used strategies for promoting individual health behaviour change (Becker and Janz, 1987 in Cowdery et al, 2007). Health risk assessments/screenings may contribute to early detection as well as motivate change (Schilling et al, 2005). Two examples are listed below.
Schilling (et al, 2005) undertook research on the "Check bus campaign" - a WHP intervention consisting of a well trained medical team in a bus that was well-equipped to undertake various physical examinations of employees in work time at no cost to employees (a range of tests were available e.g. eye examination, blood pressure checks, mole checks, bone density measures etc) (Schilling et al, 2005). Employees were sent their individual exam results to their private address, along with a recommendation for any further action required to be taken (e.g. follow-up visit to general practitioner, diet modification etc); two-fifths of employees (39%) said they changed their lifestyle as a result of the "Check bus campaign" (Schilling et al, 2005).
A healthy lifestyle and physical activity intervention that was carried out amongst Northern Ireland public servants found that brief assessment programmes were effective in getting employees to modify their lifestyles; after six months almost two- thirds of employees were maintaining an improved diet and increased physical activity, around one-half were moderating their alcohol intake, and one-half were achieving weight reduction (Addley et al, 2001).
In summary, successful WHP programmes:
Are based on theory
Have clear goals and objectives
Foster networks and partnerships
Include a participatory approach to development and implementation (i.e. involve employees)
Use of peers (for promotion and delivery)
Include tailored/targeted interventions
Use a variety of communication/education strategies
Promote the inclusion of existing social support systems
Promote the creation of new social support systems
Include environmental support
Are comprehensive
Remove barriers to participation
Are flexible
Include the use of incentives
Have a long term focus
Improve employees' self efficacy
Include research and evaluation
Have strong management support
Focus on modifiable risk factors
Include health risk assessments/screenings.
Example of a Successful WHP Programme in New Zealand
In New Zealand, the Southern Cross 'Switch2well' is an example of a WHP programme that has many components of successful WHP programmes. It has a range of initiatives including; individual health checks, team walking challenge, influenza vaccinations, subsidised smoking cessation programme, dietary management and support (including subsidised Weight Watchers or Jenny Craig fees), establishing of an employee sports committee, and subsidised participation in sports events (Broadhead, 2008a, Broadhead, 2008b).
In addition, the Southern Cross 'Switch2well' includes research and evaluation, has an incentives programme, a systematic communication strategy, focuses on modifiable risk factors, has a long-term focus, and strong leadership support (Broadhead, 2008a, Broadhead, 2008b).
Southern Cross 'Switch2well' WHP programme results are very positive. Participation in the programme is high with 94 percent of employees having done some activity (e.g. 80% have had a health check and 70% signed up for the team walking challenge) (Broadhead, 2008a, Broadhead, 2008b).
Six months into the Southern Cross 'Switch2well' WHP programme and positive outcomes include37:
33 employees have given up smoking
there has been a combined weight loss of 375kg by 76 employees who participated in Weight Watchers
there is a strong level of staff satisfaction with 'Switch2well', and staff satisfaction and motivation have improved substantially (as measured through staff [self-report] surveys)
lastly, there have been improvements in the key business metrics of absenteeism and turnover - Southern Cross forecasts that 'Switch2well' will go onto be self- funding via savings in these areas (Broadhead, 2008a, Broadhead, 2008b).
6.2 Specific WHP Interventions
The next section provides WHP examples of effective wellness interventions concerned with physical activity, healthy eating and breastfeeding specifically.
6.2.1 WHP - Physical Activity
Physical activity has a significant and critical role to play in achieving and maintaining a healthy weight; few individuals are successful at long term weight management unless they are committed to undertaking regular physical activity (Biddle and Fox, 1998).
It has been suggested physical activity interventions should be focused on encouraging employees to improve fitness, rather than concentrating on weight loss (this focus will also help target all employees - including the 'lean, unfit' ones) (Grossman, 2004).
It should be noted that physical activity interventions are not always about increasing fitness or weight loss, particular types of physical activities (e.g. yoga, stretching) have shown promise in reducing workplace stress and pain reduction in the neck, shoulders, arms and back (including lower back pain) (Gura, 2002; Tveito et al, 2004). A review by Tveito (et al, 2004) found exercise and multidisciplinary interventions (addressing beliefs and attitudes) also have an effect on the prevention of lower back pain (Tveito et al, 200438).
There are different types of WHP physical activity interventions including exercise interventions (e.g. exercise breaks, 'fitness prescriptions' etc) and lifestyle physical activity interventions. Lifestyle physical activity interventions are different to exercise programmes in that their goal is to 'integrate moderate intensity physical activities into daily life' (Dunn et al, 1998 in Bernaards et al, 2006). A key feature of lifestyle physical activity interventions is that physical activities are not 'prescribed' but are chosen by the participating employees (e.g. whether to take the lift or the stairs; whether or not to walk to work; whether to take part in walking challenges or not) (Bernaards et al, 2006).
Amount of Physical Activity Required - Physical Activity 'Dosage'
Health gains can be achieved by undertaking thirty minutes of moderate physical activity on all or most days; 10,000 steps is the estimated reasonable number of steps a healthy adult should be walking each day (Shaw et al, 2007). Achieving 10,000 steps a day is associated with health benefits including (but not limited to) lowered blood pressure (Moreau et al, 2001 in Burton et al, 2008) and reduced body fat (Tudor-Locke et al, 2001 in Burton et al, 2008).
Research shows the majority of health benefits occur when inactive adults become moderately active (Pate et al, 1995 in Eyler, 1997) (e.g. 30 minutes of physical activity each day). When sedentary people take up moderate activity such as brisk walking they can experience a risk reduction of 25 percent to 50 percent in major diseases (e.g. diabetes and heart disease) (Gaesser in Gurze, 2000 in Grossman, 2004).
Thøgersen-Ntoumani (et al, 2005) notes that moderate levels of physical activity may also be enough for employees to feel more enthusiastic in the workplace, have increased levels of life satisfaction, and feel better about their physical selves. As such organisations should aim to implement programmes which support lifestyle physical activity (e.g. active commuting to work, stair usage etc), as well as exercise, thereby making WHP programmes aimed at increasing physical activity more attractive to a wider range of employees (Thøgersen-Ntoumani et al, 2005).
Research by Atlantis et al, 2006 reported that the most effective and feasible option available for targeting overweight and obese employees in a time-constrained worksite setting may be a moderate dose (150 minutes per week) of moderate-to-high intensity supervised exercise (aerobic and weight-training) plus dietary intervention. Atlantis (et al, 2006) intervention prescribed 150 min/week exercise; this level of exercise is lower than the recommended dose for weight loss treatment (Jakicic et al, 2001 in Atlantis et al, 2006) but still resulted in improved fitness and reduced waist circumference in a sedentary employee group.
It has been noted that it requires much less exercise to reduce pathogenic factors than that required to increase physical fitness and maintain it at a higher level (Herbert et al, 1984 and Duncan et al, 1991 both in Fukahori et al, 1999). Dunn (et al, 1998 in Bernaards et al, 2006) reports that lifestyle physical activity interventions that seek to increase physical activity up to at least 30 minutes per day seem to be promising with regard to the ongoing maintenance of physical activity.
Examples of Workplace Interventions to Increase Physical Activity
WHP interventions to increase physical activity include such things as the provision of onsite gym facilities, walking challenges (e.g. using pedometers, stair usage), exercise breaks, facilities such as bicycle storage racks, showers and lockers, and subsidised sports team participation or sports club membership.
Eyler (1997) noted some examples of useful WHP interventions aimed at increasing physical activity in women, these include: flexible schedules which provide opportunities to be physically active, job sharing (rotating to less sedentary jobs), buddy programmes or group exercise, incentives to adopt/maintain physical activity and offering non-traditional forms of exercise such as cultural dance in programmes of physical activity.
Walking for Health
Individuals appear more likely to continue to undertake simple exercise such as walking than other forms of aerobic activity (e.g. aerobic exercise classes) (Pollock, 1998 in Brox and Frøystein, 2005).
Some examples of WHP interventions aimed at increasing the amount of walking employees undertake include:
A brief tailored counselling intervention with sedentary female employees was effective in increasing the amount of walking (as both exercise activity and incidental activity) in the intervention group as compared to controls (Purath, et al, 2004). The randomised intervention group participated in a health screening, a brief counselling intervention (3-5 minute discussion), and a fortnight later a booster telephone call from a nurse (to discuss progress, answer questions, discuss any problems, and if required information was posted to them) (Purath, et al, 2004). The brief counselling intervention was based on their stage of change (e.g. those in the pre-contemplation stage discussed their views of the benefits of physical activity and were encouraged to increase their activity; those employees in the contemplation and preparation stages were set a physical activity goal and given a prescription style note with the physical activity goal on it (such as to undertake 30 minutes of walking most days a week) and they signed a contract committing to achieve their goal) (Purath, et al, 2004).
Six weeks post the intervention, the intervention group when compared to baseline had significantly improved their physical activity relative to the controls (Purath, et al, 2004). (Whether this short term improvement was sustained overtime is not known).
'Hot stepper' programme - this intervention includes an educational session upfront on the benefits of being active, provision of pedometers and log books to record daily steps taken (Shaw et al, 2007). The intervention has shown promise; a pilot of the 'Hot Stepper' programme reported that half of the participants felt motivated to increase activity on basis of taking part in programme and the majority (87%) felt that wearing the pedometer encouraged them to take more steps (Shaw et al, 2007).
Ten week pedometer walking programme (Faghri et al, 2008) - this low cost intervention aimed at increasing physical activity involved participants being given a pedometer, the use of e-technology (i.e. motivational emails and a website with motivational messages and information such as weekly steps taken logs, calendar of events, monthly newsletter, maps of walking routes, and healthy living seminars), and a buddy system (as this has been shown to be effective for exercise programmes in motivating and retaining participants). The intervention recorded a significant reduction in participants' blood pressure and a significant increase in the amount of physical activity reported by participants (Faghri et al, 2008).
Another pedometer based health promotion intervention (at the community rather than workplace level39) is the "10,000 Steps Rockhampton programme" (Burton et al, 2008). This was a multi-strategy (including social marketing, health professionals and environmental change) intervention aimed at increasing adults physical activity in Rockhampton (Australia), the intervention theme was to convey the specific dose of physical activity required and to promote the accumulation of small bouts of physical activity throughout the day (Burton et al, 2008).
Burton (et al, 2008) undertook qualitative research (five focus groups) with Australian males aged 45-65 years to understand how they viewed the programme. Most participants were familiar with the 10,000 steps message but did not like it, preferring time-based recommendations (e.g. 30 minutes per day). The participants thought that whilst pedometers may be useful in the short-term to assess levels of physical activity they were not for ongoing use (Burton et al, 2008).
Walking was regarded as a good physical activity for this age group, however there was mixed interest in this activity - other suggested activities were swimming, cycling and tennis (Burton et al, 2008). Barriers to physical activity included a lack of time and motivation/interest, health and weight restrictions, and prohibitive cost (Burton et al, 2008).
Suggestions of how to engage males of this age group included workplace initiatives, making physical activity 'fun' and creating opportunities for men to do physical activity with their family or same-aged peers (Burton et al, 2008). Creating opportunities for social physical activity (in particular with same-aged peers), was seen as a useful promotional strategy (Burton et al, 2008). The researchers also noted that physical activity promotion could be also opportunistically incorporated with other information sessions for mid aged men (e.g. seminars on retirement and financial planning could identify the benefits of physical activity, such as reduced health care costs and improved physical functional capacity for independent living in retirement) (Burton et al, 2008).
Stair usage - Incidental Walking
WHP physical activity interventions that promote stair use have been shown to have mixed degrees of success in increasing stair usage.
A study to test the efficacy of an intervention which used signs alone to prompt stair usage versus an intervention which used signs, and had artwork and music in the stairwell found that signs alone made no difference but artwork and music increased stair usage (N.B the study did not distinguish between stair climbing and stair descent, however any stair usage is better than none) (Boutelle et al, 2001 in Eves, et al. 2006).
To increase stair usage, Marshall (et al, 2002 in Eves et al, 2006) used motivational signs targeted at reducing heart disease (these were placed as a 'point of choice' prompt e.g. between lift and stairs), they found the signs increased stair usage (modest improvement only). The intervention had a greater effect (although still modest) in overweight people compared to normal weight people, this may be because the message (regarding heart disease) was more relevant to overweight people who may have greater awareness of their personal risks from heart disease, also it may be because stair climbing is a brief duration activity, not a team sport, can be done in privacy, and requires no additional facilities or equipment (Marshall et al, 2002 in Eves et al, 2006; Eves et al, 2006).
A study by (Kwak et al, 2007) found that stair use by employees (in at least the short- term) can be positively influenced in both blue and white collar workplaces. The stair usage intervention was a short term low-cost initiative that involved using prompts on posters; stair usage returned to baseline measures once posters were removed (Kwak et al, 2007). The authors noted that the effect of the posters also is dependent on the level of difficulty the intervention is trying to change behaviour to, for example, if only one flight of stairs a poster might be enough to encourage stair usage but if five flights or more, employees might need additional motivation to be persuaded to use the stairs (Kwak et al, 2007).
Another study investigated the effectiveness of using negative (i.e. to cause guilt or regret) and positive (i.e. 'take the challenge') themed messages placed between elevators and staircases to increase the odds of people taking the stairs (Cooley, et al, 2008). There was no (statistically significant) increase in stair usage; the negative message was somewhat better than the positive message but it was still no better than having no message (Cooley, et al, 2008).
Authors postulated that the negative message they used may not have been strong enough in the face of increasingly more negative public health promotion (e.g. smoking campaigns) and in the instance of the positive message it may not have been enough of a challenge; they advise considering the strength of the messages being used (Cooley, et al, 2008).
Other studies have shown that other factors (e.g. the attractiveness of the amenities, loads to be carried, and the number of stairs) influence pedestrian choices (Russel and Hutchinson, 2000, Kerr et al, 2001, and Webb, 2005 all in Cooley et al, 2008).
A WHP intervention undertaken by Engbers (et al, 2006) found modest reductions in cardiovascular risk with a 12 month WHP intervention that included both a 'food' aspect and a 'steps' aspect. The 'steps' aspect involved:
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using motivational prompts in staircases and on elevator doors
cut-out footsteps leading from the elevator doors to the stairs to encourage stair use
making the stairs more attractive/interesting through the use of motivational texts (including poetry) and exercise related facts on the windows between floors. Also, a large 'slim making' mirror was placed on every other floor in the staircases (Engbers et al, 2006).
The intervention group had lowered total cholesterol levels and increased stair usage (at least in the short-term) (Engbers et al, 2006).
One idea organisations could use to motivate employees is an incremental reward system like frequent flier points (e.g. 'stair miles') that rewards employees for each flight of stairs taken (with more points awarded for going up as opposed to going down).
Levine and Miller (2007) note a couple of potential issues with strategies to promote incidental workplace activity (e.g. stair climbing and walking to deliver messages) including that they necessitate employees leaving their work station and the activity is only for short amounts of time.
Exercise Breaks
The following are two examples of enforced exercise breaks to encourage physical activity:
'Lift off!' - this was a WHP intervention in minority-serving LA health and social service agencies that targeted a largely unmotivated captured audience and involved 10 minute exercise breaks in meetings, events, and other functions that were longer than one hour (Yancey et al, 2004). The exercise breaks were composed of a series of simple aerobic/dance movements with catchy names (e.g. the 'hulk', the 'Hallelujah', the 'knee high' etc), the dance movements were designed by physical activity promotion experts and intentionally designed to be appropriate for the unfit and overweight in ordinary clothes (i.e. not exercise gear) (Yancey et al, 2004). The 'Lift off!' programme had the following characteristics:
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Materials tailored to different groups through use of different music e.g. Latino music, African American music.
Inclusiveness in images used on videotape of the exercises (e.g. broad range of ages, fitness levels, sizes and ethnic groups).
Senior management participation in these exercise breaks (Yancey et al, 2004).
Social support - integrating physical activity into group settings requires social support. This approach had cultural congruence for ethnic minority communities, in which social participation in spontaneous group physical activity is more common than in mainstream European settings (Yancey et al, 2004 in Lara et al, 2008).
The intervention achieved 90 percent participation showing considerable organisational and individual receptiveness to the program. (Yancey et al, 2004).
"Pausa para tu Salud" (For your health, move) - this WHP intervention involved brief periods of physical activity being incorporated into employees day (during paid work time) (Lara et al, 2008). At a set time of day (following two reminders over a loudspeaker), music would come on and employees would do exercise, initially the exercise started off as gentle stretching and dance movements for 10 minutes and then got more intense over time as employee's fitness levels improved (Lara et al, 2008).. The type of music played was employee's choices (Lara et al, 2008). The intervention was associated with improvements in BMI and waist circumference (Lara et al, 2008).
This early evidence from the "Pausa para tu Salud" (For your health, move) intervention is practice based and there are limitations to the study design (e.g. not controlled, missing certain baseline measures etc). However, it does provide useful information for addressing gaps in understanding how to increase the impact of WHP (e.g. through use of exercise breaks); sedentary workers have not typically been involved in traditional workplace fitness efforts limiting return on investment for employers thus success in engaging them in everyday moderate physical activity is important (Lara et al, 2008).
Innovative Approaches to Encourage Physical Activity
The following are two examples of innovation to encourage physical activity:
Vertical workstation - this is a workstation that allows an office worker to use a normal personal computer while walking on a treadmill at a self-selected speed. (Levine and Miller, 2007). Levine and Miller (2007) undertook a pilot of the vertical workstation (with treadmill) with 15 obese and sedentary individuals. The pilot study concluded if for obese people 'sitting computer-time' was replaced by 'walking-and-working' at the vertical workstation for two to three hours per day, then the resultant increased energy expenditure means (if other components of energy balance were constant i.e. food intake) a weight loss of 20-30 kg/year could occur.
Use of technology - 'HealthMiles' is a programme used by a South African and United States insurance company, this programme provides incentives of gift cards to employees who exercise regularly (World Economic Forum, 2007). The programme is based on using USB-enabled pedometers and the results of every exercise session are transferred to a personalised webpage so that each employee can anonymously compare their performance to others of the same age and same sex (World Economic Forum, 2007).
The 'HealthMiles' programme found within six months of implementation around a third (30%) of employees who had participated in the programme had improved their fitness and 16 percent of employees with hypertension (high blood pressure) had normalised their blood pressure (World Economic Forum, 2007).
WHP Physical Activity Interventions - Successful or Not?
Whilst many studies report positive effects of physical activity interventions in the workplace not all studies have showed a positive effect of undertaking an exercise programme in the workplace (e.g. Brox and Frøystein, 2005). This may be due to the type of exercise, the intensity of the intervention or other factors.
Plotnikoff (et al, 2005) notes there is much evidence in the literature that indicates workplace physical activity programmes have significant limitations. There is a lack of scientific consensus with regards to the efficacy of workplace physical activity programmes; this may be because in the past the intervention focus has typically been on individual employees with not enough attention on changing other factors that may influence the physical activity of individuals (e.g. social support, organisational factors, policy factors and physical environmental elements) (Gauvin et al, 2001 in Plotnikoff, et al, 2005). More recently, interventions have begun to consider these other things, including all these things is known as a multilevel intervention and considered an ecological approach (Plotnikoff, et al, 2005).
Marshall (2004) undertook a review of successful PA programmes (those which included tailoring, multiple components, varied and mass reaching communication [electronic and media], social support strategies, were embedded in organisational culture and had leadership support). Marshall (2004) noted in his review that there was little evidence to support the long term effectiveness of workplace PA programmes (this lack of evidence was due to a number of reasons, including attrition (i.e. participants dropping out of programmes), a lack of studies (meaning a lack of evidence), modest participation in interventions, and short-term interventions as opposed to genuine organisational culture change).
Marshall (2004) notes that promising WHP physical activity interventions appear to be those that promote 'incidental activity' (e.g. stair use, increasing active transport to/from work, encouraging alternatives to passive email communications at work [i.e. walking]). A study by Heirich (1993) found that counselling, supplemented by peer support (i.e. a buddy system), and simple exercise activities (e.g. walking competitions) produced better health improvements than the equipping and staffing of a gym.
6.2.2 WHP - Healthy Eating
This section looks at WHP examples of wellness interventions concerned primarily with promoting healthy eating and weight loss.
Prevalence of obesity in New Zealand has increased in the last few decades (9% of males and 11% of females were classified as obese in 1977 this increased to 20% for males and 22% for females in 200340). Data from the 2006/07 New Zealand Health Survey states one in three adults are overweight (36.3%) and one in four obese (26.5%41). Overweight adults are more likely to experience health problems (includingHypertension [high blood pressure], certain cancers, heart disease, Type 2 diabetes, stroke and respiratory problems)42. Successful weight loss requires education to obtain knowledge of appropriate weight loss behaviours (e.g. food choices, portion sizes and strategies to avoid overeating [i.e. at social occasions), and also performance of those behaviours (Anderson, et al 1993). The workplace has been found to be a more supportive environment than a community setting for behaviour change (Brownell et al, 1984 in Anderson, et al 1993).
WHP nutrition interventions in the workplace have been shown to have a positive influence (albeit modest) on employees' dietary intake, for example: studies have shown small increases in fibre, fruit and vegetable consumption and decreased fat consumption (Story et al, 2008). Modest changes may be meaningful from the greater population perspective (Story et al, 2008).
Some examples of WHP nutrition and weight loss interventions in the worksite include:
Increasing the availability and variety of healthful foods (Jeffery et al, 1994, and Engbers et al, 2005 both in Story et al, 2008) (e.g. what is on offer in vending machines, at cafeterias or supplied in meetings and at work functions).
Reducing the price of healthy food options in workplace cafes and vending machines (i.e. providing preferential pricing for healthful foods) (Jeffery et al, 1994, French et al, 2001 both in Story et al, 2008; Pratt et al, 2007).
Sending employees tailored nutrition messages by email (Block et al, 2004 in Story et al, 2008).
Having point of purchase labeling on foods (i.e. fat content, calories etc) and targeted food placement (i.e. healthy foods at eye level and less healthy food choices not so visible) (Schmitz and Fielding, 1986 in Steenhuis et al, 2004; Engbers et al, 2005 in Story et al, 2008).
Eliminating unhealthy foods from the workplace and substitute with attractive healthy food options which are low fat and low salt, modifying cafeteria recipes to lower their fat content and reducing portion sizes (Pratt et al, 2007; Williams, 2008).
Providing health promotion education so employees can learn about making healthy choices for themselves e.g. information and education about food selection and portion control (Williams, 2008).
Subsidising attendance at weight loss groups (Broadhead, 2008a, Broadhead, 2008b).
Offering financial incentives for weight loss.
Providing handouts for healthy recipes, and encouraging the creation of an employee authored healthy cook book (Gates et al, 2006).
When designing WHP nutrition interventions it is necessary to be take into consideration the complexity of dietary behaviour; dietary practices are not all or nothing, and no modern health guidelines recommend the total abstinence of any one food group (rather food groups are typically classified as 'everyday' or 'occasional') (Glanz et al, 1998). Also, WHP nutrition interventions that seek to add something (e.g. increase fruit or fibre intake) may require different strategies from those interventions that seek to reduce something (e.g. reduce fat) (Glanz et al, 1998).
Examples of WHP Nutrition and Obesity Prevention/Reduction Interventions
The following are examples of WHP interventions promoting healthy eating or seeking to assist employees to lose weight or prevent weight gain.
A WHP intervention pilot for police department employees focused on nutrition education and included the following; nutrition counselling with a registered dietician, seminars during work time on nutrition and eating behaviours delivered to both employees and their spouses (as potential influencers and 'food providers'), and monitoring of weight and blood lipid levels (Briley and Montgomery, 1992). This pilot found a significant group trend for decreased weight and lower total cholesterol levels (Briley and Montgomery, 1992).
A longer term (two year) WHP intervention aimed at reducing cardiovascular disease included nutrition, physical activity and other risk factors (for cardiovascular diseases such as smoking) focused on the dietary aspects of reducing cholesterol levels and weight management for the at risk group; those employees who were low risk/no risk were encouraged to maintain healthy diet and physical activity (Moy, 2006).
The multi-component intervention consisted of twice yearly one-to-one counselling, (additional group counselling was also provided for smoking cessation, stress management and ways to increase physical activity), three to four group education sessions per annum based on feedback from health checks, environmental modifications such as provision of a microwave oven, water cooler, and scales, employer support in terms of modifying work practices and social norms of employees, activities and incentives were provided (e.g. quiz with small gifts for winners), and also employees anthropometric and biomedical measurements were collected (and self monitored by employees) (Moy et al 2006).
The work place was shown to be an effective channel for health promotion to reduce cardiovascular disease risk (Moy et al 2006). The intervention results showed a statistically significant reduction in employees' mean total cholesterol levels as compared with the comparison group (also reduced HDL-cholesterol which is protective against heart disease this was most likely due to the overall reduction in cholesterol as a result of dietary changes but without a large increase in physical activity or exercise - other studies that combined dietary and physical fitness interventions saw an improvement in ratios of total serum cholesterol to HDL- cholesterol [Angotti and Levine, 1994, Lalonde et al, 2002 both in Moy et al 2006]). The intervention was also effective in reducing the number of cigarettes smoked (Moy et al 2006).
A WHP intervention on worksite cholesterol and nutrition included health screening, counselling and education with an emphasis on skill building - sessions canvassed risk factors, food issues (fat, fibre, sodium, dietary/nutrition guidelines), blood cholesterol, and also provided information on smoking cessation, increasing exercise, and reducing blood pressure (Anderson and Dusenbury, 1999). Employees were given a choice of having an individual programme or group education sessions. The intervention results (within 12 months) included positive change in employees' attitudes, decreased weight, declined smoking incidence, and increase in exercise frequency (Anderson and Dusenbury, 1999).
The 'Heartbeat Award (HBA)' is a national nutrition labeling scheme in UK, evolved from the Heartbeat Wales project (NB Heartbeat New Zealand also modeled itself on the Heartbeat Wales project) (Peach et al, 1996 in Holdsworth, 2004). A longitudinal study of the 'Heartbeat Award (HBA)' found a modest impact on dietary intake; there was significant positive change in intervention worksites for only four of the 20 food items tested (resulting in increased fruit consumption, reduced consumption of fried foods and sweet puddings, and a change to lower fat milks) (Holdsworth, 2004). Holdsworth (2004) concluded that the effectiveness of the HBA scheme might increase if the scheme was part of a wider multi-component nutrition intervention.
The 'Working Well Trial' - a five year cancer control WHP intervention trial using a randomised matched-pair design in four work sites (Glanz et al, 1998). This intervention is based on a theoretical model derived from individual, organisational and community activation theories (Abrams et al, 1994 in Glanz et al, 1998) and was designed to approach behaviour change in a stepwise fashion initially focusing on raising awareness, followed by skills training and action, and lastly behaviour maintenance. The intervention included a comprehensive communication/education strategy (e.g. event launch, educational materials, and seminars), environmental modifications (e.g. changing food offerings, vending machines and catering policies) and an employee advisory board. The 'Working Well Trial' found that intervention participants were more likely than the control group to be at a later stage of dietary change and that those who were at a later stage of change used or took advantage of more programme components than did those in earlier stages (Glanz et al, 1998).
The Heartbeat Catering Programme is not a WHP intervention per se rather it aims to provide a supportive environment within the food service industry where caterers make decisions about food by providing nutrition information and education opportunities to encourage caterers to develop their skills in providing healthy food choices (Young et al 2004). The programme is reportedly making a difference in New Zealand by improving the nutritional value of foods being served by caterers (Young et al 2004) (NB quantification of this difference was not provided). This programme may provide opportunities for increased healthy food provision by ensuring that only caterers who adhere to the Heartbeat Catering programme are used in the workplace.
Innovative Ways to Encourage Nutrition and Prevent Obesity
The following are two examples of innovation to encourage healthy eating:
The use of an interactive multimedia (IMM) programme. Interactive multimedia (IMM) programming combines audio, video, graphics and printout, and is a useful substitute for an individualised counselling programmes as it is:
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cost effective
appealing e.g. like a personalised television programme
able to assess user characteristics and interests and make user specific recommendations (Irvine, 2004).
An IMM programme to encourage individuals to decrease their dietary fat consumption and to increase consumption of fruits and vegetables was developed and evaluated at two worksites (Irvine, 2004). The intervention programme used a host who was a known television personality (Irvine, 2004). Programme users (referred hereafter as users) answered a series of mandatory questions which allowed the programme to provide a narrator/guide matched to the user on gender and ethnicity. The programme's menu included a number of strategies with several pathways e.g. one strategy might be 'increasing fruit and vegetables' with three pathways such as 'at work', 'at home' and 'dining out' (Irvine, 2004). Most on-screen graphics were narrated to assist poor readers (Irvine, 2004).
In each content area users were asked to identify the behaviours they currently do, and to commit to behaviours for the week, they were also asked to identify barriers (Irvine, 2004). For each barrier identified (e.g. dealing with cravings' or 'lack of time') up to a possible 24 barriers, video models delivered short vignettes about how they had overcome these barriers (three vignettes were available for each barrier) (Irvine, 2004). Each model used in the first vignette was matched to the user on at least three demographic characteristics (e.g. age, gender and ethnicity), for the second vignette the model was matched to the user on two characteristics and on the third vignette the model was matched on one characteristic (Irvine, 2004).
Users were supplied with passwords which allowed them to access previous data entries as required (Irvine, 2004).
After 30 days significant intervention effects were noted including self reported changes such as:
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increased consumption of fruit and vegetables
positive changes with regards to stage of change to adopt a low-fat diet
perceived self-efficacy to reduce dietary fat
positive changes regarding attitudes about the importance of diet (Irvine, 2004).
These changes were maintained at the 60-day follow-up. These results demonstrate the potential for short exposure IMM programmes to positively impact eating habits of employee populations (Irvine, 2004).
"Working on My Health: Nutrition" [WOH-N] - an online nutrition programme that included consultation with employees to determine their nutrition priorities (thus assisting in making sure the content of the programme would be relevant and interesting) (Cousineau et al, 2007). Cousineau (et al, 2007) state employees are more likely to use a nutrition website if it is linked to their work environment (e.g. through incentives, contests, and community message boards). This online nutrition programme and other computer mediated interventions are potentially efficient ways to target employees as they are can be tailored to particular employees, have vast reach, and are cost-efficient (Cousineau et al, 2007). (NB Outcome measures for this intervention were not available).
WHP Nutrition and Obesity Prevention/Reduction Interventions - Successful or Not?
The literature indicates that many WHP nutrition interventions are successful to some degree (as mentioned previously even modest changes can have a considerable and positive impact at the population level).
Some WHP programmes are more successful than others, reflecting variations in content and delivery. A systematic review of the literature (Katz et al, 2005 in Williams et al 2007) found that multi-component WHP interventions were the only population based obesity prevention programmes with sufficient evidence of effectiveness to warrant recommendation. A similar statement, that multifaceted dietary change programs are the most effective, was suggested by Glanz (1999 in Kristal et al, 2000 in Irvine, 2004). Another review of the literature (Benedict and Arterburn, 2007) found that high intensity programmes resulted in significant weight loss as compared to low intensity programmes (intensity was defined by the amount of face-to-face contact participants had e.g. a high intensity programme was one that had at least twice monthly counselling).
Engbers (et al, 2005) undertook a review of WHP strategies that involve environmental changes to assess their efficacy. Engbers (et al, 2005) notes that it was difficult to assess the effects of environmental changes as they are often part of a multi-component WHP programme. Evidence (e.g. increased sales of healthier products) exists that trials of simple environmental modifications can influence dietary intake (e.g. point of purchase signs in vending machines, pricing strategies, expanding healthy product selection etc) (Engbers et al, 2005). However, as noted by Holdsworth (2004) environmental modifications will likely have a more positive impact if part of a comprehensive multi-faceted programme.
Dalziel and Segal (2007) evaluated ten nutrition interventions, of these eight were able to be reviewed in order to assess their economic performance (expressed as cost per QALY [quality adjusted life year] gained). All eight interventions reviewed were estimated to be highly cost effective (Dalziel and Segal, 2007). The Mediterranean Diet and Intensive Lifestyle Change (nutrition and physical activity) to Prevent Diabetes were found to be the most cost-effective interventions (Dalziel and Segal, 2007)43. Performance of the Mediterranean Diet and Intensive Lifestyle Change to Prevent Diabetes interventions could be estimated with the most certainty (based on good quality trials) and both were highly cost- effective interventions, at AU$1,020 (US$760) and AU$1,880 (US$1,410) per QALY gained, respectively (Dalziel and Segal, 2007).
6.2.3 Supporting Breastfeeding in the Workplace
Guidelines from the European Commission (EC) urge employers to enable infants to be breastfed at or near the workplace and to provide appropriate facilities for pumping and storage of breast milk. The EC notes breastfeeding can protect the mother against cancer and the baby from infant diseases (Godfrey, 2001). Almost twice as many bottle-fed babies are ill, compared to breast-fed babies; therefore breast feeding mothers take less time off work to look after sick babies (Godfrey, 2001).
No randomised controlled research has been undertaken to assess the efficacy of WHP interventions. However, research has been undertaken to identify the barriers to breastfeeding and to establish what the requirements are to support breastfeeding.
Research has shown that maternal employment is one of the greatest barriers to breastfeeding (Ortiz et al, 2004). Initiation of breastfeeding occurs at the same rate for mothers who work outside the home as those who stay at home, however the breastfeeding continuation rate decreases amongst mothers who return to work (Bai, 2008).
Around twenty-five years ago breastfeeding rates in Sweden and the United States were both low; now breastfeeding rates are higher in Sweden even though it has more maternal employment (Greiner, 1999 in Libbus and Bullock, 2002). National averages for Sweden reveal breastfeeding rates of 75 percent for two months, 57 percent for four months and 34 percent for six months (Silfverdal, et al, 1999 in Libbus and Bullock, 2002).
The significant increase in breastfeeding rates in Sweden is thought to be due to Government-based activities which supported improving nationwide maternity benefits (such as paid leave and provision of suitable facilities to allow breastfeeding and expressing milk in the workplace) (Hofvander and Sjolin, 1979, Rea et al, 1999 both in Libbus and Bullock, 2002).
Libbus and Bullock (2002) note, as with mandated parental leave, the establishment of sustainable change in employer policies with regards to supporting breastfeeding may have to come from government legislation.
Challenges Breastfeeding Mothers face in the Workplace
The known challenges that mothers face trying to maintain breastfeeding once returning back to the paid workforce that result in stopping breastfeeding include lack of preparation (e.g. nothing organised to support returning mother), lack of support from employer/colleagues, non supportive work environment (e.g. inadequate facilities to pump/store milk), difficulties expressing milk, and insufficient break times (Bai, 2008).
A web-based survey of n=296 female employees (based in the United Kingdom) experiences with regards to breastfeeding support after returning to work found that positive experiences regarding breastfeeding were associated with particular managers' attitudes rather than with the organisation's policy (Wallace et al, 2008). The worst experiences were attributed to a lack of support and understanding by immediate managers (Wallace et al, 2008). Wallace (et al, 2008) note that interventions should include organisations having a publicised breastfeeding policy (as well as appropriate facilities and flexi time).
Needs of Breastfeeding Mothers in the Workplace
The following list details what is required of a workplace wishing to have a WHP programme that is supportive of breastfeeding.
Minimum requirements include:
Hygienic facilities for expressing milk - ideally a private, lockable room (Thompson, 1997 in Wyatt, 2002; Bar-Yam, 1998; Libbus and Bullock, 2002; Ortiz et al, 2004; Abdulwadud and Snow, 2008)
Electrical outlet (if using electric breast pump) (Bar-Yam, 1998)
A chair (Bar-Yam, 1998)
Refrigerator to safely store expressed milk (ideally not a shared refrigerator) (Thompson, 1997 in Wyatt, 2002; Abdulwadud and Snow, 2008)
Time to either express milk or to breastfeed44 (Bar-Yam, 1998; Abdulwadud and Snow, 2008)
Employers understand breastfeeding employee's needs (Dodgson et al, 2004). As well as employers, supervisors/managers need to be educated to understand the needs of lactating women (Ortiz et al, 2004)
Support (e.g. to take breaks to express milk or breastfeed) via employee policies, and also from staff in contact with the breastfeeding mother45 (Thompson, 1997 in Wyatt, 2002; Bar-Yam, 1998).
A comprehensive WHP programme that is supportive of breastfeeding would potentially also include:
Employer providing electronic breast pumps and other accessories such as an insulated tote bag with ice packs to take milk home (Ortiz et al, 2004)
Pre-natal classes (Ortiz et al, 2004; Bai, 2008)
Daycare available on site (Bar-Yam, 1998; Bai, 2008)
Lactation professionals available to consult with mothers (either onsite or able to come to workplace) (Bar-Yam, 1998; Bai, 2008)
Flexible work schedules (Bai, 2008; Abdulwadud and Snow, 2008), ability to job- share, and telecommute (Libbus and Bullock, 2002)
Establishing a support system - e.g. putting breastfeeding mothers in touch with other breastfeeding mothers in the workplace (Bar-Yam, 1998)
Maternity leave (Abdulwadud and Snow, 2008)
Breastfeeding committee - to ensure support available to breastfeeding employees (Dodgson et al, 2004)
Policy at the level of the employer and government is also a critical factor for creating a supportive environment (Dodgson et al, 2004)
Paid breastfeeding breaks (Payne and James, 2008)
Societal support (e.g. educational campaigns concerning breastfeeding) (Meek, 2001)
Legislative protection (longer paid maternity leave) (Meek, 2001)
Tax incentives for employers (e.g. tax credits to employers who create private rooms for breastfeeding/expressing milk, hire or purchase pumps, hire a lactation consultant etc) (Meek, 2001).
Findings from Research about Breastfeeding/Expressing Milk in Workplace
Positive results from interventions to support breastfeeding include:
An employer sponsored lactation programme in the United States reported that breastfeeding was initiated by 98 percent of the women enrolled in the programme (Ortiz, 2004 in Abdulwadud and Snow, 2008).
A United States study of some employer sponsored lactation programmes (e.g. involving at a minimum, access to a breast pump room in the workplace, and counselling from a lactation consultant) found that of the women who returned to work (n=435), the majority (79%) attempted to express milk, and of those nearly all (98%) were successful. The study found that working mothers continued to express milk in the workplace for a mean of six months; the mean age of infants when mothers stopped expressing milk was nine months (the mean postnatal maternity leave was 3 months) (Ortiz et al, 2004).
Workplace Support
Supporting breastfeeding may be one of the easiest family friendly WHP interventions for an organisation to put into place because of minimal monetary costs (Prince, 2002 in Seijts, 2004). A potential challenge for employers is managing the perceptions of coworkers (i.e. to design supportive policies that work to protect mothers' rights while avoiding negative reactions from coworkers). Female employees supported by colleagues to continue breastfeeding (e.g. take lactation breaks at work) may in turn be more open to accommodating the needs of other staff, resulting in a more co-operative and tolerant workplace culture46.
A New Zealand qualitative study found that workplace support was important to continuation of breastfeeding (Payne and James, 2008). Breastfeeding support was made visible in several ways including allowing the infant to be brought into work, allocating worksite spaces to be used for breastfeeding and expressing, and allowing breastfeeding mothers time to breastfeed/express milk (Payne and James, 2008).
When employers supported the mothers they felt valued as employees, and when they did not offer such support, the mothers felt discouraged from returning to work or continuing to breastfeed when they started work (Payne and James, 2008). Given that economic necessity was cited as the main reason for returning to work it is probable that mothers would cease breastfeeding as opposed to delaying returning to work (Payne and James, 2008).
For workplaces to be routinely supportive, structural strategies need to be implemented (e.g. paid breastfeeding breaks as in Sweden and parental leave allowances [Galtry, 1998 in Payne and James, 2008] and the Australian Breastfeeding Accreditation scheme47 (Eldridge and Croker, 2005 in Payne and James, 2008). Norms around breastfeeding need to change, instead of the focus being on mothers to be resourceful and individually responsible, breastfeeding support within the workplace needs to be seen to be in the public's interests (e.g. something that reduces the incidence of disease in the short and long term which has benefits for the wider community) and thus recognised as a social responsibility to support breastfeeding occurring (Payne and James, 2008).
7 Challenges and Gaps
This section summarises the challenges and gaps associated with WHP interventions and programmes including:
Topic related challenges
Getting organisational buy-in
Embedding a culture of health in employees social context
Wellness needs of employees from different ethnic groups
Wellness needs of employees with a disability
Research related gaps and challenges.
There are a number of challenges and gaps associated with WHP interventions and programmes, some examples are outlined below and overleaf.
7.1 Topic Related Challenges
Personal health matters can be a sensitive topic to canvas with employees. Employees may not want to take part in health risk assessments if they do want to disclose known health issues or certain behaviours (e.g. drug use).
Another example of a WHP topic that presents challenges is weight; an individual's weight is generally considered a sensitive issue, the implication of this for WHP is that employers often must take an indirect and general wellness approach targeting all staff as opposed to individuals (McAlear in Ghent, 2004).
Another related challenge is that WHP obesity prevention programmes have a high rate of attrition and participants can find it very difficult to maintain the decreased weight (Hagihara, 2002). Hagihara (2002) notes the need to develop effective programmes that tackle issues of programme attrition and weight maintenance; this may involve exploring higher order interactions of the causal factors of obesity such as smoking cessation, issues related to working conditions or to other factors such as alcohol consumption.
Another topic challenge relates to the inclusion of mental health topics in WHP programmes. WHP programmes have reportedly come a long way from focusing solely on individuals and now tend to have multiple components (e.g. include environmental and psychosocial interventions, policy changes etc), however mental health issues are still not at the forefront of workplace health promotion and in some instances are notably absent from WHP programmes (Pelletier, 2005).
7.2 Getting Organisational Buy-in
Seed's New Zealand survey of 200 human resources staff found 81 percent say workplace wellness is a priority of their organisation (Seed, 2006), leaving one fifth who do not regard it as a priority. The World Economic Forum (World Economic Forum, 2008b) believes that wellness is not a boardroom priority in most organisations and that this is mainly because of the inadequate and inconsistent definitions, approach and measurement used. In order for sustainable and consistent buy-in to wellness as a key strategic objective, organisations need to have a WHP wellness strategy that is simple, embedded within the organisation's culture (e.g. part of its strategic objectives), has measureable outcomes that are as easy to understand as profit and loss, consistent delivery, is evidence based (e.g. clinically and commercially validated) and supports positive sustainable, measurable change within the organisation (World Economic Forum, 2008b).
It is a challenge to make wellness a priority in organisations, and to get organisations to appreciate the need for a comprehensive WHP programme to establish a culture of wellness as opposed to offering ad hoc one-off activities. Pricewaterhouse Coopers (2008) state that whilst employers [in the United Kingdom] may believe that a healthy workforce is the key to their ongoing success they have been slow to implement comprehensive WHP programmes addressing wellness.
Pricewaterhouse Coopers (2008) cite a number of factors as to why it is difficult to get organisational buy-in including:
a lack of a clear definition of workplace wellness and core wellness service offering
a lack of understanding about incentives to increase employee buy-in
no clear business case and evaluation of the direct financial return of supporting WHP programmes' impact on tangible business benefits.
7.3 Embedding a Culture of Health in Employees Social Context
Once organisations have established a culture of health in the workplace they face the challenge of also embedding it in the larger social context of employees' health behaviours including the family (Sorensen et al, 1999). Changes brought about by WHP can only be maintained if they become part of the culture not only of the organisation but also of the wider community (World Economic Forum, 2007).
Partners, family and close friends are all potential influencers in terms of health behaviours such as dietary intake. Research has found that worksite plus family interventions are more successful in increasing fruit and vegetable consumption than the worksite interventions alone (Sorensen et al, 1999). McAlear (cited in Ghent, 2004) states WHP interventions should include everyone in the mix in particular spouses and family who may be instrumental in helping establish healthy lifestyle choices in the home.
7.4 Wellness Needs of Employees from Different Ethnic Groups
There is a gap in terms of data available about what works for WHP programmes for different ethnic groups. Sorensen (et al, 1998) notes that WHP programmes need to respond to the increasing ethnic diversity of the workforce and the varying cultural patterns likely to influence dietary habits. It is recognised that different cultures have different views about the importance and sanctity of food, yet research on WHP interventions re nutrition and diet for different ethnic groups is not readily available.
Yancey (et al, 2004 in Williams et al 2007) points out that despite ethnic differences in prevalence figures for obesity and obesity related morbidity, the best available data do not answer the question of how best to create and sustain weight loss, or improve physical activity or diet in at-risk groups.
Exploratory research needs to be undertaken in New Zealand to understand how WHP programmes can best meet the needs of different ethnic groups, in particular for M_ori and Pacific peoples.
7.5 Wellness Needs of Employees with a Disability
As with ethnicity there is also a paucity of literature or studies that take into consideration the workplace wellness needs of people with a disability (e.g. formative research that includes people with a disability to inform programme design and implementation) or discusses valid alternatives to existing physical activity programmes. Typically, any mention of people with a disability appears to be about getting them either to start work or return to work (which has health benefits from improving income, reducing social exclusion48 etc) but nothing specifically about getting people with a disability to take part in workplace wellness programmes.)
Exploratory research needs to be undertaken to understand how WHP programmes can best meet the needs of individuals with a disability.
7.6 Research Related Gaps and Challenges
There are a number of research related gaps regarded WHP programmes and also a number of challenges. The specific information gaps (in addition to a lack of data on WHP interventions for different ethnic groups and for people with a disability) are listed below.
7.6.1 WHP - Research Gaps
The most obvious initial gap is that there is no common definition of the term "wellness" World Economic Forum (2008b). Other gaps include:
Gaps Relating to Research Tools
Inconsistent tools are used to measure "wellness" along with different methods of gathering the information (World Economic Forum, 2008b) meaning there is no baseline measures to consistently compare WHP interventions to.
There are also very few evaluation instruments to measure ecological approaches (Plotnikoff, et al, 200549). Another gap in terms of research instruments is resources for measuring management support (Williams et al 2007).
Gaps Relating to Measuring Healthy 'Well' Employees (Direct and Indirect Measures)
There is a scarcity of data or measurement of "wellness" in workplace (i.e. how many workers are well as opposed to stressed or unhealthy) (Hillier, et al, 2005). Little research has been conducted into the relationship between a healthy workforce and productivity (tend to measure sickness and the impact of that on productivity) (Economic and Social Research Council [ESRC], 2006). The ESRC also notes that sickness absence is used as an indicator of occupational health, and postulates that organisations need to measure health by how many employees are healthy not how many are sick (Economic and Social Research Council [ESRC], 2006). However, measuring ill health is easier than measuring good health. More reliable, sensitive and cost efficient methods of measuring good health and well being (i.e. 'wellness') are needed (Economic and Social Research Council [ESRC], 2006).
A gap also exists in terms of being able to reliably and consistently measure the value of healthy employees in terms of the indirect benefits of good health (aside from reduced absenteeism) for example, improved quality of outputs, greater creativity and innovation, enhanced resilience, and increased intellectual capacity (Hillier et al 2005).
Gaps Regarding the Factors that Promote Wellness
Little research has been directed towards factors that may promote positive well- being in the workplace (Thøgersen-Ntoumani and Fox, 2005). There is a need to learn more about the mechanisms and processes that facilitate positive behaviour change amongst employees, as well as those that are ineffective (Goetzel and Ozminkowski, 2008). Also, need to investigate the amount of time needed to develop new health habits (Goetzel and Ozminkowski, 2008).
A Lack of Rigorous/Controlled Studies
A lack of controlled studies (Simpson et al, 2000; Makrides, 2004). Whilst many pre/post studies provide evidence of changes within organisations they tend to have problems with attribution (e.g. can report associations between interventions and outcomes but cannot determine causal relationships).
No random controlled trials or quasi-random controlled trials have evaluated the effectiveness of workplace interventions in promoting breastfeeding (e.g. initiation, continuation, duration or exclusiveness) among women returning to paid work after childbirth (Abdulwadud and Snow, 2008).
There is insufficient evaluation of WHP programme outcomes (especially financial outcomes as noted above) using rigorous study methods (Goetzel and Ozminkowski, 2008). For example, it is known that WHP weight loss programmes can result in modest short-term improvements in body weight; however, long term data on the health and economic outcomes is lacking (Benedict and Arterburn, 2007). Study design weaknesses (e.g. non-experimental design [i.e. no control group], low participation and high attrition rates) make it difficult to draw sound inferences about the effectiveness of WHP programmes (Simpson et al, 2000; Goetzel and Ozminkowski, 2008).
As a result of the critical gaps in evidence and associated lack of dissemination of evidence-based guidance, there are inconsistent recommendations regarding best practice (Simpson et al, 2000; Makrides, 2004; Goetzel and Ozminkowski, 2008; Department for Work and Pensions and the Department of Health, 200850).
A Lack of Financial Analysis and Data
There is a lack of cost-benefit or return on investment (ROI) studies. Or if there are studies, they are poorly designed (Brand 2006) producing results which are difficult to interpret (e.g. no baseline measures, no measures of [or controlling for] concurrent interventions [within or outside of the workplace] and no control groups - i.e. groups without the intervention with whom to make comparison with).
This means there is a lack of useful financial data The ROI due to avoided costs resulting from interventions for an employed population is often unknown, as are the impact of long term weight loss and associated economic outcomes (Benedict and Arterburn, 2007; World Economic Forum, 2008d). Without this information [financial data] it is difficult to assess the most effective WHP programmes (Benedict and Arterburn, 2007). Limited evidence about the economic viability of investing in WHP programmes also means many business organisations are skeptical about such investing (Brand, 2006). WHP programmes need to collect data on their cost effectiveness and benefit (Goetzel and Ozminkowski, 2008).
7.6.2 WHP - Research Challenges
Measurement Challenges
Some particular measurement challenges are noted below:
Double blinding (i.e. when researcher and participant do not know who is taking part in the intervention) - blinding the intervention from either the participant or researcher is impossible in WHP research; this can be overcome to some extent by assigning controls to 'usual care' and participants to 'usual care' plus intervention (O'Donnell, 2004). Although the difficulty with this is that it masks the interaction effect of combining the two interventions (the interaction effect may be negative [i.e. competing or destructive], or positive [i.e. enabling or complementary in effectiveness]) (O'Donnell, 2004).
Measuring Productivity - it is a challenge to measure productivity in today's 'widget' sparse economy (Hemp, 2004). Self reported survey data from employees on productivity may be received with skepticism by managers (Hemp, 2004). However, research linking employees self reported presenteeism with actual productivity lost have been conducted and shown that self reports did correlate with actual measures (NB with self report data the consistency of measures overtime is important given the accuracy of self report data is not likely to be 100% [i.e. because they often require estimates or 'best guesses']) (Kessler cited in Hemp, 2004).
Difficulty Benchmarking 'Wellness' - because no consistent definitions exist (World Economic Forum, 2008b).
Lack of Validated Research Tools - the development of simple and easy-to-use validated instruments for diet and physical activity evaluation is encouraged (World Economic Forum, 2008d) and would allow for comparison of findings.
Difficulty Measuring WHP effects - (Downey and Sharp, 2007) the intangible benefits of WHP programmes can be difficult to measure.
HR Measurement Challenges (e.g. ROI) - Human Resource professionals face the challenge of evaluating return on investment of WHP and demonstrating the bottom line value of WHP programmes (Cuthell, 2006).
Promising Interventions - No Effect on Behaviour Change
One challenge is about understanding why promising interventions remain unproven or are classified as ineffective WHP interventions.
Some promising interventions show no significant differences between intervention and control group. This may in some instances be due to the control (comparison) group being 'contaminated' for example, providing health checks with feedback for members of the comparison group may succeed in raising people's awareness and this may motivate them to make healthy changes even without the WHP intervention (Pine et al, 1997 and Ammerman, 2003 both in Moy et al, 2006). In other instances it may be because the intervention, whilst having potential, does not have a strong enough 'dose' for example, may offer only low intensity counselling (i.e. short duration of actual sessions or limited frequency [Aittasalo et al, 2004]) or health promotion messages that lack intensity (e.g. use of negative themed messages to increase stair usage that were too mild [Cooley et al, 2008]).
Widespread Dissemination
An important challenge is the widespread dissemination of information regarding WHP success factors (WHO, 2006; Goetzel and Ozminkowski, 2008). This requires expanding the evidence base (e.g. by designing and implementing pilot projects) (WHO, 2006). (N.B Goetzel and Ozminkowski [2008] note that several large publicly funded studies are currently underway to test alternative WHP programmes and the [UK] Government plans to disseminate the findings and potentially may also legislate to support financial incentives to encourage the implementation of effective programmes [e.g. tax cuts]).
Shamian and El-Jardali (2007) state monitoring, evaluation, documentation and effective dissemination is essential and that more public reporting of measurable results from WHP programmes should be encouraged (to increase accountability and share learnings about successes and barriers).
It is important to highlight that the lack of results from randomised control trials should not prevent the development and implementation of WHP programmes (WHO/World Economic Forum, 2008). Pelletier (2005) states that despite limitations many WHP studies show favourable trends. Identifying and publishing (through non- traditional means if necessary [e.g. HR magazines as opposed to academic journals etc]) case reports and examples of international WHP programmes can also build supportive evidence and can help better understand how to develop WHP programmes that will suit different workplace contexts (WHO/World Economic Forum, 2008).
8 Planning for Success - Some Considerations
This section summarises the key factors for successfully designing and implementing an organisational health and wellness policy (including measuring success and sustaining positive culture change).
8.1 Making a Business Case for Wellness
There are some considerations to be made before presenting a business case to senior managers (Hillier et al, 2005). Specifically before approaching senior managers three questions need to be answered:
Firstly, what are the organisations short-term and long term priorities? (Hillier et al, 2005). (This information can be used to develop wellness objectives that align with business strategy.)
Secondly, what benefits can be expected from the proposed wellness programme and what are the potential benefits of health promotion per se to the organisation? (Hillier et al, 2005). (Consideration could also be given on how to measure these benefits e.g. how they might become KPIs.)
Thirdly, what are the leadership styles, pressures, strengths, and weaknesses of the senior level executives? (Hillier et al, 2005). (Given the critical importance of leadership support and participation in WHP interventions it is essential to understand their perspective and any assistance they might require).
The business case for a wellness programme should include the creation of a 'wellness team' (including reference to any external partnerships), planned collection of data to drive health efforts (e.g. baseline measures), an operational implementation plan (e.g. communications, marketing, and use of incentives), choice of appropriate interventions, creation of a supportive environment (e.g. physical and cultural environment), and a research and evaluation plan (Hillier et al, 2005).
8.2 Considerations for WHP Programme Design
Below and overleaf are some factors to take into consideration when planning and designing WHP interventions.
Diversity - the workforce is becoming more diverse (in terms of ethnicity, gender, religion, language, and work patterns [i.e. telecommuting, job sharing, part time employment]) this increasing diversity requires programme development that provides personalised tailoring (Ryan et al, 2008). Tailoring requires an organised programme planning process (Ryan et al, 2008) for example, undertaking formative research with the different subgroups within an organisation. When planning for diversity such as ethnic and cultural diversity, HR practitioners can use the 'Healthy-Directions Small-Business' HD-SB intervention51 contextual guidelines to increase the likelihood that employees from various cultural groups will participate in their organisations WHP programmes (Goldman, et al, 2003 in Hunt, 2007). These guidelines include:
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examining any assumptions about culture/ethnicity held by project staff
designing and using inclusive health messages/materials (e.g. inclusive imagery)
using an asset-based approach (e.g. EABs - Employee Advisory Boards)
supporting employees' values and customs
acknowledging and addressing contextual issues in employees' lives that affect their efforts to modify their health behaviours (e.g. family or other commitments) (Goldman, et al, 2003 in Hunt, 2007).
This approach does not exclude specific race/ethnic specific strategies but, rather, incorporates them into a broad-based, holistic intervention (Goldman, et al, 2003 in Hunt, 2007).
Consideration of gender differences is also necessary when thinking about the health education needs of males and females as they tend to have different health risks, different health knowledge and behaviours, and different motivations (Teufel, 1992). For example, motivations for weight loss, females are more likely to change their diet in order to lose weight for appearances and males more likely to change diet in order to control a health problem [Jeffrey et al 1991 in Teufel, 1992).
Physical environment - need to think about the organisation's physical environment (and supporting policies) not just target individual employees' health risks (Abbot et al, 2007).
Size of organisation - in smaller organisations it is easier to share information and there may be a greater sense of community (Lassen 2007). For employers with a large number of employees it may be beneficial to target employees in existing work groups or set up employee advisory boards (Lassen 2007).
External collaborators - collaborators should be chosen wisely. The workplace is a location where people will access programmes that they might not elsewhere (e.g. smoking cessation programmes); reaching at-risk populations with health promotion has long been a goal of public health professionals (Crump et al, 2001), thus it is important to use external collaborators with a proven track record or a known, trusted brand (e.g. the Quit programme, the Heart Foundation).
Address barriers to participation - interventions need to make it easy to make healthy choices, and make it harder to make unhealthy choices; it is also important to offer a range of options to increase the likelihood of engagement with the intervention (Williams, 2008).
Research has found gender differences with regards to barriers for participation. For example, there are specific barriers to getting women to participate in physical activity programmes such as a lack of time due to work and family commitments (females are more likely than males to have social pressures to care for others and put others needs first) (Tavares and Plotnikoff, 2008).
Consider behavioural intentions - research looking at the intention-behaviour relationship for physical activity shows intention is a moderate predictor of behaviour and that the gap between intention and behaviour is caused by high intenders not taking action (Goddin, 2008) (e.g. intending to do thirty minutes of exercise each day and then not actually doing it). Consideration in the design of WHP programmes needs to be given to targeting the factors that moderate the intention-behaviour relationship (e.g. overcoming barriers and addressing the reasons why people intend to have healthy behaviours but do not actually follow through) (Godin and Conner, 2008).
Be aware that risk is not static - WHP programme designers need to be conscious of the fact that risk is not static; design of programmes needs to include low risk employees to ensure they do not become high risk employees (Hanway, 2005 in Partnership for Prevention, 2005). Hanway (2005 in Partnership for Prevention, 2005) notes that maintaining employees' low risk status is at least as effective as addressing high risk (e.g. risk reduction costs on average US$153 per person per annum compared to savings of US$350 per person per annum from risk avoidance [i.e. prevention]).
Address one or more risk factors at once? - a decision needs to be made whether WHP programmes will address multiple risk factors at once or one at a time. There are pros and cons for each approach. Addressing multiple risk factors can increase the impact of the programme (Goetzel and Ozminkowski, 2008). However, several studies suggest there may be a need to break one bad habit at a time (e.g. establish a pattern of exercise before starting a healthy eating plan) and that people with multiple risk factors may be overwhelmed if they have to address multiple things at once (cited by Strecher et al, 2002 in Goetzel and Ozminkowski, 2008). In the first instance it might be best to address the risk factor that the employee is most ready to change (as determined by assessing their stage of change); success in tackling one area may provide motivation to address additional habits (Goetzel and Ozminkowski, 2008).
More research is needed in this area to understand whether addressing single or multiple risk factors at once is the most effective approach for WHP programme implementation.
Consideration of depression - in the past WHP programmes have not addressed the issue of depression. It is important to consider depression given its common prevalence and serious impact (WHO predicts depression will be the second highest cause of death and disability in the world by the year 2020)52.
Harvey (2008b) notes there are a number of ways that depression can be addressed in WHP programmes, including:
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routinely including depression as part of Human Resources information and education on work life balance and stress management
educating employees to understand that depression is an illness and not a character weakness and to recognise the signs and symptoms of depression53, education also needs to inform staff that in most instances it is unlikely depression will permanently affect an employee's capacity to be an able member of the workforce
teaching managers about minimising stress, conflict resolution and team building can play a positive role in minimising the risks of their employees suffering from depression
support and promote use of employee assistance programmes (EAP) if available
have policies in place around having breaks during the working day and also do not allow annual leave allowances to build up beyond a certain point (breaks from work are vital in protecting an individual's mental health)
be vigilant in spotting and dealing with stressors such as overwork, unreasonable deadlines and poor quality supervision (Harvey, 2008b).
8.3 Principles of Change Management
The principles of change management can usefully be applied to WHP programme implementation (which makes sense, given that WHP programmes often aim to change employees' behaviours).
The principles of change management as detailed by the Harvard Business School (2002 in Abbot et al, 2007) consist of eight steps, as listed below:
Firstly, create sense of urgency - this is important to avoid complacency and failure to achieve goals.
Secondly, create a 'guiding coalition' - a wellness group with formal titles, relationships with collaborators and commitment to the WHP goals.
Thirdly, develop a vision and strategy - aim to be able to describe the change initiative in 5 minutes or less (this is important in that it encourages goal clarity).
Fourthly, communicate the 'change vision' - need credible and appealing communications that will make people believe change is attractive and transformation possible.
Fifthly, empower broad based action - remove obstacles (such as lack of communication, employee disengagement, and environmental issues) to success in order to create a supportive environment.
The sixth principle involves generating short terms wins and rewards for people involved (e.g. provide incentives for registration into WHP interventions; share the number of people who have 'successfully' signed-up to participate etc).
The seventh principle involves consolidating gains and producing more change - need to celebrate wins (e.g. publicise improved health metrics, reward achievement with incentives). This principle also cautions that true culture change can take 3-10 years.
Lastly, anchor the new approaches to culture (i.e. the new way of things) to become social norms, shared values, and communicate how the new behaviours and attitudes have made a difference in the workplace (e.g. improved staff morale, reduced sickness and increased staff retention). As part of embedding the new healthy way of things it is important to management personifies the new approach.
8.4 Considerations regarding Management
Much responsibility for the successful implementation of WHP programmes and positive culture change within organisations is attributed to management. It is important when considering implementation of WHP programmes that the support and skills of managers be taken into account, as well as the programme offering, for example:
Education of managers - it is critical that managers have the necessary competencies and skills to be effective given the influence and impact they have on other employees; good management skills and practices will promote healthy behaviours and healthy workplaces (Department for Work and Pensions and the Department of Health, 2008).
The UK Department for Work and Pensions and the Department of Health, (2008) recommends partnering with relevant organisations in order to disseminate the basic principles of good line management (e.g. encouraging employee participation and engagement, motivating employees, addressing short and long-term sickness absences, and managing employees who have long-term health conditions or impairments).
Managers may also require topic specific information (e.g. on nutrition practices, chronic conditions etc).
Address concerns of managers - in order to gain managers support for WHP programmes it is first necessary that any concerns they may have are identified and addressed. Managers at different levels have been shown to have different concerns (e.g. a study by Linnan (et al, 2007) found that middle managers more than senior managers were likely to see 'getting the job done' as conflicting with offering WHP interventions (e.g. attending seminars); costs and space were also seen as more of a barrier to frontline managers.
Have a quality WHP offering - Linnan (et al, 2007) study showed a clear risk to managers support if the WHP programmes offered are poor quality (e.g. not evidence-based or comprehensive) and notes badly designed WHP programmes lead to the corrosion of support from managers, which may be difficult to rebuild.
8.5 Considerations regarding Successful Teamwork
It is not enough to have EABs/wellness teams/champions in place and collaboration with external parties, if these relationships do not function well. Functional collaboration (internal and external to organisations) requires successful teamwork.
Clements (et al 2007) collated information about the success factors required for working as a team within the health system (these can be modified for any setting whereby effective teamwork is necessary). The factors that make a team that is required to implement collaborative practice successful are (Clements et al, 2007):
leadership and having champions who can steer change management processes
clear understanding of the roles on the part of all team members
modelling of positive behaviours such as trust, respect, value (i.e. others opinions and time) and being valued
cultural readiness within the workplace (e.g. a supportive culture), or significant efforts to try to create a culture of acceptance.
Clements (et al, 2007) also note the things that undermine teamwork, as follows:
a lack of time to bring people together (for reflection, planning and action)
insufficient inter-professional education
systems of reward (including payment) do not promote collaboration
few links between collaborative practice and individual goals (NB as a counter to this, an organisation could make being a being a wellness champion or on an employee advisory board and attending meetings [along with other related measurable] a KPI)
not attempting to collect evidence of success or communicate this to key stakeholders (e.g. what has been achieved to date and how well the team is doing).
8.6 Considerations around Policy Development
More research and discussion needs to be undertaken about policy development with regards to WHP. Public and private policies for WHP (e.g. aimed at obesity prevention or breastfeeding support) can take a number of forms, including regulation and incentives (Fuemmeler et al, 2007).
Policy related actions in the workplace include flexible working hours, offering reduced rates for gym membership, incentives for cycling or walking to work, access to facilities (e.g. showers, changing rooms, lactation rooms), health promotion education (e.g. on nutrition), and optimising the offering in workplace cafes (WHO, 2006). When designing a WHP programme existing policies should be considered through a 'wellness lens'.
Not all employers share a commitment to health goals of employees, thus proposals to legislate or regulate rather than relying on voluntary participation alone can be effective (WHO, 2006). For example, in Norway, a new 'Working Environment Act' obliges employers to view physical activity as a part of their responsibility [WHO, 2006]).
WHO (2006) suggest that fiscal measures such as tax breaks for employers should also be considered for improving physical activity. There is little information available about public views with regards to legislating aspects of WHP. A US telephone survey of over 1,000 respondents canvassed public opinion about the degree of public support for policy-level interventions to prevent obesity (Fuemmeler et al, 2007). Strong support for healthcare and employment policies in obesity prevention and treatment was found, for example, 85 percent of respondents support offering employers tax breaks if they provided adequate exercise facilities in the workplace (Fuemmeler et al, 2007).
8.7 Considerations around Sustaining Momentum
It is important that the momentum of WHP programmes is sustained, in order to have an impact on chronic disease (World Economic Forum 2008c) and provide a return on investment. This means considering ways to keep WHP programme offerings fresh and appealing, and supported by both employees and employers. Overleaf is a case study from British Telecom (BT) about how they maintain the momentum for their Work Fit programme.
Case Study of the BT 'Work Fit' Programme
The BT 'Work Fit' Programme is a rolling WHP programme that consists of a standing resource for BT employees with regular new interventions addressing different aspects of chronic disease prevention and management added as required (World Economic Forum 2008c).
Within the 'Work Fit' Programme individual interventions are designed to excite general interest at the outset (e.g. via a programme launch or other promotion); employee engagement is refreshed through events (e.g. road shows), and activities (e.g. such as competitions/quizzes that are linked to modest incentives) (World Economic Forum 2008c). All interventions are run under the 'Work Fit' "brand" using consistent imagery, but each intervention takes a slightly different approach in terms of packaging and content (World Economic Forum 2008c). The key messages of 'Work Fit' (i.e. that small behavioural changes lead to benefits for the individual and the business) are repeated continuously (World Economic Forum 2008c).
In addition to adding new initiatives, the momentum of 'Work Fit' is sustained by refresher initiatives linked to everyday life (e.g. get in shape for summer), encouraging family participation, and also ensuring senior leadership support through the regular provision of the business benefits of 'Work Fit' in terms of increased employee motivation, corporate responsibility, and performance metrics (World Economic Forum 2008c).
In summary, the World Economic Forum (2008c) state that in order to sustain the momentum for long-running WHP programmes the following is required:
a rolling programme of health promotion (e.g. one main programme with new interventions added)
interventions need to be refreshed throughout their lives to avoid decay (e.g. through the use of activities and events)
use of different communication methods to aid refreshment (e.g. road show, intranet etc)
consistent branding and imagery helps reinforce key messages and avoids 'clutter' which can dilute an interventions effectiveness
links to everyday life (e.g. preparation for summer, dealing with stress at Christmas time etc)
family engagement to promote ongoing involvement by employees
regularly reminding senior managers of the benefits of WHP (World Economic Forum, 2008c).
8.8 Considerations regarding Research
Research Planning
Research and evaluation (including measures of cost effectiveness) needs to be built into the WHP programme design from its inception. When planning measures of cost- effectiveness, consideration should be given to the measurement of partial change (i.e. not just viewing fail/succeed outcomes) (Wagner and Goldstein, 2004). Adopting positive healthy behaviours may be the main outcome of a WHP intervention, however given the process of changing can be lengthy and complex it is useful to measure partial change (Wagner and Goldstein, 2004). For example, consider a WHP smoking cessation intervention that runs for 6 months, if the intervention made some one seriously think about quitting then that is partial success (moving from one stage to the next) and if they actually quit that is success (Wagner and Goldstein, 2004).
Research - Practical Considerations
One identified gap in the literature is the lack of randomised controlled trials (RCTs). RCTs are recognised as the gold standard for scientifically evaluating an intervention's efficacy as RCTs are best able to identify whether or not outcomes are attributable to the intervention or to other factors. Proof that an intervention is efficacious typically requires at least one definitive RCT or several convincing ones (Hoffer, 2003). RCTs require complex study design, and typically are expensive and difficult to undertake (Hoffer, 2003).
Hoffer (2003) notes that it is not always appreciated that such high-cost, definitive RCTs come near the end, not the beginning, of the process of evaluating new interventions. Prior to RCTs there is usually a lengthy process of information gathering; only sufficiently promising interventions merit the effort and expense of final confirmation (or refutation) with large, definitive RCTs (Hoffer, 2003). This preliminary research is termed "plausibility building" (NB usually in medical research this refers to biological or clinical plausibility) (Hoffer, 2003).
Expense and time aside, RCTs are not necessarily a good fit for workplace intervention studies for example; randomisation of individuals in one worksite may not be appropriate since staff work closely together, leading to contamination or spill over of the intervention. (Moy et al 2006). Similarly, RCTs are not possible if the WHP intervention is an environmental intervention such as signage in the workplace to increase stair use, or changes to the food on offer in workplace cafeteria (Engbers et al, 2007).
According to health promotion experts the research design best able to provide the strongest evidence for a causal relationship between the intervention and any change in outcome measures is a non-randomised experimental design with a comparable 'control' group (e.g. from a similar workplace) (WHO, 1998; Green and Tones, 1999; Rimer et al, 2001 all in Moy et al, 2006). The design needs to include pre and post test measures on intervention data for each group (intervention group and control group), and report on all outcomes targeted at individuals in the intervention (WHO, 1998; Green and Tones, 1999; Rimer et al, 2001 all in Moy et al, 2006).
Bauman (2002), a professor of epidemiology, notes there needs to be broader approaches than just public health approaches to WHP research. Instead of lamenting a lack of evidence from RCTs, WHP programme designers can draw from promising or indicative workplace findings (such research could also be considered "plausibility building"). Clinical intervention measures have a narrow focus that fails to address the real world relationships between health, work performance and work places (World Economic Forum, 2008b).
Goetzel and Ozminkowski (2008) also state there is a need for more and better science when evaluating programme outcomes. In this instance, better science does not refer to RCTs but rather research that will competently be able to assess workplace interventions. New methods for evaluating evidence and assessing cost-effectiveness need to be developed to support the selection of WHP interventions (WHO, 2006).
Alternative Approach to WHP
Thinking about the available data and the limitations of traditional approaches to evidence collection means acknowledging that WHP interventions will involve some risk (uncertainty of outcome) and different levels of return (effects of intervention) (WHO, 2006). The implication of this absence of conclusive evidence is that WHP interventions should be subject to prospective, ongoing evaluation and that other approaches to data collection beyond the classical medical paradigm that depends on controlled trials should be considered (WHO, 2006).
One alternative approach is the investment approach (e.g. the 'investment portfolio') to WHP (WHO, 2006). In the 'investment portfolio' (derived from banking and financial risk management) interventions are considered investments, and the 'investment portfolio' should carry a mixture of safe, low-return interventions and risky but potentially high-return interventions (WHO, 2006). Return on investment can be measured in terms of expected health gains and other desired outcomes (e.g. reduced absenteeism). Risks can be measured by the consistency of the intervention impact, its penetration within a given population (e.g. participation rate), indications of its likely effectiveness and resources likely to be used (e.g. time, space and facilities required) (WHO, 2006).
For example, high intensity weight loss interventions with small groups might be classified as low-risk (e.g. produce consistent weight loss behaviour changes) and low-return (because they only have a small effect on the occurrence of obesity in the population) (Hawe and Shiell, 1995; Swinburn et al, 2005 in WHO, 2006). This model can be used to select interventions to include in a WHP programme.
Practice-Based Data
In the absence of well designed studies, the best available data (such as practice-based data from the worksite as opposed to evidence-based data from scientific studies) can still be useful in making progress toward public health goals (Koplan et al, 2005 in Dunet et al, 2008) and should not be dismissed as being not useful. The gathering of practice-based data for WHP interventions (e.g. on activities best received by employees) can shape future research areas, by identifying the areas that appear the most promising (Dunet et al, 2008). Thus practice-based and evidence-based approaches can work together to broaden the knowledge base on WHP.
The usefulness of practice-based data can be improved by collecting data about employee participation, the representativeness of the employees taking part in a programme, any long term effects (Bull et al, 2003 in Williams et al 2007), measuring return on investment (Ozminkowski and Goetzel, 2001 in Williams et al 2007), and recording any factors that affect adoption of behaviours or participation (Lusk and Kerr, 1994, Linnan et al, 2001 both in Williams et al 2007).
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