Managers’ Support for Employee Wellness Programs: An Integrative Review

Abstract

Objective:

The aim of this integrative literature review is to synthesize the existing evidence regarding managers’ support for employee wellness programs.

Data Source:

The search utilized multiple electronic databases and libraries.

Study Inclusion and Exclusion Criteria:

Inclusion criteria comprised peer-reviewed research published in English, between 1990 and 2016, and examining managers’ support in the context of a worksite intervention. The final sample included 21 articles for analysis.

Data Extraction:

Two researchers extracted and described results from each of the included articles using a content analysis.

Data Synthesis:

Two researchers independently rated the quality of the included articles. Researchers synthesized data into a summary table by study design, sample, data collected, key findings, and quality rating.

Results:

Factors that may influence managers’ support include their organization’s management structure, senior leadership support, their expected roles, training on health topics, and their beliefs and attitudes toward wellness programs and employee health. Managers’ support may influence the organizational culture, employees’ perception of support, and employees’ behaviors.

Conclusions:

When designing interventions, health promotion practitioners and researchers should consider strategies that target senior, middle, and line managers’ support. Interventions need to include explicit measures of managers’ support as part of the evaluation plan.

Keywords

managers’ support leadership support workplace worksite health promotion wellness programs

Objective

Wellness programs are initiatives and policies directed at chronic disease prevention and supporting healthy behaviors for employees.¹ Comprehensive wellness programs have the following 5 key elements that are outlined in Healthy People 2010: (1) health education, (2) a supportive social and physical work environment, (3) integration of the wellness program into the organization’s structure, (4) linkage to related programs such as employee assistance programs, and (5) workplace screening and education.² Participation in comprehensive wellness programs can decrease employees’ burnout and turnover and increase job satisfaction, productivity, and mental well-being.³ In addition to promoting health, employees view the access to and provision of wellness programs as a sign of employer commitment to health and well-being.⁴ These potential benefits, however, are diminished by the lack of employee participation in wellness programs.⁵ Practitioners and researchers in the field of health promotion are interested in strategies to facilitate employee participation and reduce potential barriers to wellness programs.

Managers are important stakeholders when an organization adopts a wellness program because they make decisions that can influence employee participation.⁶ For instance, managers are responsible for establishing wellness programs and policies and allocating resources to support their implementation.⁷ Managers, by directly endorsing wellness programs and showing visible support for employees’ health, can create an organizational culture that encourages wellness.⁵ Prior research suggests employees are more likely to participate if the organizational culture is supportive of individual health and well-being.⁵

The commitment to wellness programs from all levels of management (senior, middle, and line) is thought to be essential for employee participation.⁷ Senior managers are in executive positions, for example, chief operating officer, and are responsible for managing all of, or major parts of, the organization.⁸ Senior managers develop the long-term strategies, objectives, and plans of an organization, but the middle managers are responsible for implementing senior managers’ strategies.⁸ Middle managers are in charge of departments or units and they supervise line managers and report to senior managers. Line managers are concerned with the day-to-day operations of the organization and supervising employees who do not hold management positions.⁸ The evidence for the extent to which senior, middle, and line managers support or impede their direct reports’ participation in wellness programs is limited. Furthermore, it is not clear how best to engage all levels of management to support wellness programs.

The aim of this integrative literature review is to synthesize the existing evidence regarding managers’ support for wellness programs. Examining the current body of literature will assist in understanding how to engage managers to support employee participation and identify future areas for research.

Methods

Increasing managers’ support for wellness programs is an emerging topic with relatively few experimental studies available in the literature. Thus, we used an integrative approach, which is a type of review that systematically describes the existing literature while imposing fewer exclusion criteria than a traditional systematic review.⁹ The goal of an integrative review is to synthesize the available knowledge on a given topic. This is a distinct difference from a systematic review, where the goal is to answer a specific research question.¹⁰ The integrative review allows for the inclusion of experimental and nonexperimental studies with different methodologies and outcomes.^9,10

Data Sources

We conducted a systematic search using electronic databases and consultations with academic colleagues. We also searched references and citations found in other publications, commonly referred to as “snowballing,” which has been shown to be an effective way to identify pertinent literature.¹¹ The search included several electronic databases: PubMed, Google Scholar, and the University of Washington libraries, which allowed access to WorldCat, PsycArticles, EBSCO, CINAHL, MEDLINE, and ScienceDirect. We searched the Medical Subject Headings in PubMed and EBSCO subject headings for search terms. The key search terms we included are: (1) worksite health promotion and wellness programs, (2) managers’ support and supervisor support, and (3) employee participation. We used broad search terms to capture all relevant research articles. We discovered and included additional search terms during our electronic database search: “leadership support”, “management support”, and “health promotion intervention.”

Inclusion and Exclusion Criteria

The inclusion criteria included peer-reviewed research articles published between January 1, 1990, and January 31, 2016, in English, and study samples of working adults aged 18 to 65 years. See Table 1 for a detailed description of the inclusion and exclusion criteria. The initial search yielded 361 article abstracts that we saved and reviewed for topic area and key search terms. We eliminated 309 abstracts that addressed different topics that had similar keywords. These included abstracts about organizational support, leader-member exchange, and social support. We saved and assessed in detail the full-text articles of the remaining 52 abstracts. We reviewed the first pages of each article to identify whether a study was relevant to the topic and scope of the integrative literature review. We excluded 31 articles for not meeting the inclusion criteria. The most common reason for article exclusion was that the study topic did not relate to manager or leadership support. We summarized the remaining 21 articles and evaluated them for quality. Table 2 provides the search process and a summary of the data sources.

Table 1.

Criteria for Included Articles.

	Inclusion	Exclusion
Published	January 1, 1990, to January 31, 2016	Before 1990
Target population	Working adults aged 18 to 65 years	Nonworking/unemployed populations
Setting	Worksite/occupational	Outside worksite or occupational settings
Methodology	Quantitative, qualitative, mixed	Practice guidelines, consultant surveys
Study design	Experimental, quasi-experimental, nonexperimental	Confirmatory or exploratory factor analysis, reviews, meta-analyses
Topic area	Manager support, leadership support	Topics not related to manager or leadership support
Language	English	Languages other than English

Table 2.

The Search Results, Number of Citations Retrieved From the Database Search, and Data Sources of the Full-Text Articles Saved, Excluded, and Included.

Search Results
	PubMed		Google Scholar	UW Libraries	Total
Total citations retrieved^a	502		2194	663	3359
Abstracts pulled to review	114		206	41	361
Data Sources
	Peer-Reviewed Journal Article	Book Chapter	Evaluation Report or Executive Summary	Dissertation and Thesis Papers	Total
Full-text saved	30	4	11	7	52
Exclusion criteria applied	11	4	11	5	31
Included	19	0	0	2	21

Abbreviations: UW, University of Washington.

^aFor all searches using keywords.

Data Extraction

The articles selected for analysis include qualitative, quantitative, and mixed-methods studies. The inclusion of studies with varying research methodology is consistent with the approach of an integrative review.^9,10 We analyzed the included articles for common themes and patterns using a content analysis approach, which is a subjective interpretation of the content of text data.¹² This method is useful for integrative reviews that have studies with different methodologies and outcomes, for example, by noting common themes among the research findings.¹² The unit of analysis being an entire study article, we used an inductive approach, in which concepts are derived directly from the text in the articles.¹² For this process, the article texts are read and open-coded, then the codes are grouped into main categories and then extracted into major categories.¹² Two authors independently analyzed the content of the included studies and then came together to find consensus on the codes and categories. After developing and extracting the codes and categories, one author described the data in a narrative synthesis and a second author checked the accuracy and consistency of the narrative synthesis. The entire research team presented the final data extraction to check the plausibility of findings. The results of the analysis are given in Table 3.

Table 3.

Results From the Content Analysis of the Included 21 Articles.

Codes	Main Categories	Major Categories
Perceived responsibility for their employees’ health: 1 study	Beliefs and attitudes	Factors associated with managers’ support
Perceived control over wellness program spending: 1 study
Employee buy-in, employee value: 2 studies
Workplace training on health-related topics: 2 studies	Training
Strategies to increase knowledge: 2 studies
Strategies to increase awareness: 2 studies
Leadership style: 1 study	Senior leadership
Leadership support for managers: 1 study	Senior leadership
Workload demands: 1 study	Work roles
Role expectations: 1 study
Limited time in the workday: 1 study
Perceived responsibility for supporting wellness programs: 1 study
Incentives to support wellness programs and activities: 1 study
Senior managers’ support for middle managers: 2 studies	Management structure
Interactions between levels of management: 2 studies
Middle managers’ influence on implementation: 1 study
Ownership over implementation: 1 study
Middle and line manager involvement in decisions: 2 studies
Creating the workplace culture: 2 studies	Organizational culture	The influence of managers’ support
Promoting the workplace culture: 2 studies
Employee health as an organizational priority: 1 study
Leadership endorsement of programs and activities: 2 studies	Employees’ perception of support
Managers’ visible actions to support the wellness program: 1 study
Positive physical changes to the work environment: 1 study
Employees’ health behaviors at work: 3 studies	Employee behaviors
Support for making healthy choices: 3 studies	Employee behaviors

Data Synthesis

The included articles were evaluated for quality using a rating system developed for this study that has specific criteria for qualitative,¹³ quantitative,¹⁴ and mixed-methods research studies.¹⁵ The quality rating rubric has 6 criteria that each have 4 areas related to research quality (6 criteria × 4 areas = 24 areas total). The areas within each criterion are worth 0.25 and must be adequately described in the article to receive points. The total quality rating score ranges from 0 to 6 in 0.25 increments (24 areas × 0.25 = 6 points possible). The scores are categorized by: 0 to 3.24 = low, 3.25 to 4.9 = moderate, and 5.0 to 6.0 = high. Studies were considered low quality if they did not meet more than half the quality criteria, and high-quality studies met 80% or more of the quality criteria. A low-scoring study, for example, received points for less than half the areas. The description of the quality rating criteria and scoring is given in Table 4.

Table 4.

Quality Rating Criteria.^a

	Qualitative¹³	Quantitative¹⁴	Mixed¹⁵
(1) Writing style, abstract, and authors	Concise, grammatically correct, avoids jargon: 0.25; researcher’s expertise in the field: 0.25; title is accurate and unambiguous: 0.25; abstract provides a clear overview: 0.25; subtotal: 1.0	Concise, grammatically correct, avoids jargon: 0.25; researcher’s expertise in the field: 0.25; title is accurate and unambiguous: 0.25; abstract provides a clear overview: 0.25; subtotal: 1.0	Concise, grammatically correct, avoids jargon: 0.25; researcher’s expertise in the field: 0.25; title is accurate and unambiguous: 0.25; abstract provides a clear overview: 0.25; subtotal: 1.0
(2) Purpose, literature review, and conceptual framework	Purpose and research questions: 0.25; literature review meets philosophical underpinnings: 0.25; phenomenon to be studied: 0.25; conceptual or theoretical framework: 0.25; subtotal: 1.0	Purpose and research questions: 0.25; literature review offers critical analysis: 0.25; follows logical process: 0.25; conceptual or theoretical framework: 0.25; subtotal: 1.0	Purpose and research questions: 0.25; literature review provides appropriate background: 0.25; role of each method: 0.25; conceptual or theoretical framework: 0.25; subtotal: 1.0
(3) Study sample and ethical considerations	Informed consent and ethical permission: 0.25; philosophical approach: 0.25; sampling method and sample size: 0.25; data collection and saturation: 0.25; subtotal: 1.0	Informed consent and ethical permissions: 0.25; research questions related to theoretical framework: 0.25; study sample selection: 0.25; sample size: 0.25; subtotal: 1.0	Informed consent and ethical permission: 0.25; research design and sequence: 0.25; sample selection and definition: 0.25; insights gained from mixed methods: 0.25; subtotal: 1.0
(4) Rigor	Credibility, dependability, and transferability of findings: 0.25; findings presented appropriately 0.25; placed in context of what was known: 0.25; purpose is adequately addressed: 0.25; subtotal: 1.0	Data description and statistical analyses: 0.25; terms and concepts defined: 0.25; study design adequately described: 0.25; instrument reliability and validity: 0.25; subtotal: 1.0	Data collection and analysis for each method: 0.25; terms and concepts defined for each method: 0.25; integration of methods: 0.25; threats to validity for each method: 0.25; subtotal: 1.0
(5) Discussion and conclusions	Recommendations to develop findings: 0.25; implications match the study scope and depth: 0.25; strengths and limitations are discussed: 0.25; citations and references accurate: 0.25; subtotal: 1.0	Findings link back to literature review: 0.25; implications for future research: 0.25; strengths and limitations are discussed: 0.25; citations and references accurate: 0.25; subtotal: 1.0	Each method sufficiently developed: 0.25; findings link back to literature review: 0.25; strengths and limitations of each method: 0.25; citations and references accurate: 0.25; subtotal: 1.0
(6) Scientific relevance	Provides important implications: 0.25; contributes substantial evidence: 0.25; generates generalizable knowledge: 0.25; directly addresses review topic: 0.25; subtotal: 1.0	Provides important implications: 0.25; contributes substantial evidence: 0.25; generates generalizable knowledge: 0.25; directly addresses review topic: 0.25; subtotal: 1.0	Provides important implications: 0.25; contributes substantial evidence: 0.25; generates generalizable knowledge: 0.25; directly addresses review topic: 0.25; subtotal: 1.0
Total points	6.0	6.0	6.0

^aQuality rating category: 0 to 3.24 = low; 3.25 to 4.9 = moderate; 5.0 to 6.0 = high. Conversion to 3-point scale: 0 to 3.24 = 1 (low quality); 3.25 to 4.9 = 2 (moderate quality); 5.0 to 6.0 = 3 (high quality).

Two authors independently rated the quality of the included articles. The inter-rater reliability, or percent agreement, is the number of quality ratings in agreement divided by the total number of quality ratings. The percent agreement in rating scores between the 2 raters was 71% (15/21). We decided the quality rating for studies with disagreements by consensus. For ease of interpretation in the summary table, the quality ratings are converted to a 3-point scale: 1 = low quality, 2 = moderate quality, and 3 = high quality. We synthesized data into a summary table sorted by study design, study sample, data collected, key findings, and quality rating (Table 5).

Table 5.

Summary Table of Included Studies.

Author, Year	Design	Sample	Data Collected	Key Findings	Quality Rating^a
Kawakami et al, 2005²²	Randomized trial testing web-based supervisor training on mental health	16 Section chiefs and 167 subordinates at an engineering company in Japan	Change in supervisor attitude and knowledge, supervisor support, coworker support, and subordinate psychological distress	Supervisors who received training improved knowledge and attitude toward worksite mental health Trained supervisors had a positive effect on subordinates’ perception of supervisor support	1/3
Goetzel et al, 2009³⁸	Quasi-experimental study testing an organizational intervention with environmental and leadership support	3152 Dow Chemical Company employees at 12 worksites	Employee health risk assessment with biometric data and environmental assessment	The first-year results from an intervention designed to target organizational culture and leadership support had an incremental effect on employee health risks	2/3
Goetzel et al, 2010³⁹	Quasi-experimental study testing an organizational intervention with environmental and leadership support	1521 Dow Chemical Company employees at 12 worksites	Employee health risk assessment with biometric data and environmental assessment	The second-year results provide evidence that an intervention can boost the perception of a supportive workplace environment by targeting the organizational culture and leadership support	2/3
DeJoy et al., 2011³⁵	Quasi-experimental study testing an organizational intervention with environmental and leadership support	1859 Dow Chemical Company employees at 12 worksites	Employee health risk assessment with biometric data and environmental assessment	The results suggest manager support can impact front-line employees’ health if it is effectively communicated and there are visible actions with tangible changes to environment	2/3
DeJoy et al, 2009³⁷	Quasi-experimental study testing intervention with senior management endorsement and environmental supports and prompts	1442 Employees at 16 worksites of a national retailer in the United States	Perception of management support, employee involvement, and physical activity level	The increase in perception of management support resulted from positive changes to the work and organizational environment The perception of management support was related to increased physical activity among employees	2/3
Stoltzfus and Benson, 1994²³	Quasi-experimental study testing an intervention with management training, educational workshops, and policy changes	639 Employees participating in a worksite Alcohol and Drug Prevention Program at 3M	Employee health behaviors, employee empowerment, supervisor skill development, and morale	Success of intervention attributed to strong management support, employee involvement, placing emphasis on caring about coworkers, and linking the program with existing safety and productivity initiatives	2/3
Milner et al, 2013³⁶	Cross-sectional survey from the largest health insurer in South Africa	11 472 Employees from 71 companies in South Africa participating in the Healthy Company Index	Provision of health promotion policies and programs, leadership support, company commitment, employee well-being, and organizational health assessment	Company commitment and leadership support for health promotion mediated the relationship between provision of programs and employee well-being	2/3
Linnan et al, 2007¹⁶	Cross-sectional survey from the Working Healthy Project 2	1047 Senior, middle, and line managers from 24 manufacturing sites in the United States	Managers beliefs and attitudes toward offering wellness programs, management level, age, and experience working at a company offering health promotion	Senior and middle managers believed that employers were responsible for employee health Middle and line managers perceived lack of management interest and production conflicts as barriers	3/3
Robbins and Wansink, 2016²⁹	Cross-sectional online survey of worksite managers	270 Managers from several industries in the United States	Manager attitudes and preferences regarding role in workplace wellness	Managers had favorable attitude and high intentions toward partially linking salary increases and promotions to supporting workplace wellness efforts	2/3
Downey and Sharp, 2007¹⁷	Cross-sectional survey of managers in the automotive industry	113 Senior and human resource managers at 213 automotive parts manufacturing plants in Canada	Managers attitudes toward increasing discretionary spending on wellness programs	General managers’ moral responsibility was predictive of intention to increase spending on wellness programs Human resource managers’ perceived control over discretionary spending was predictive of intention to increase spending	2/3
Bäckström et al, 2014²⁵	Observational study of health promotion activities targeting leadership	102 School leaders and teachers at 8 elementary schools in Sweden	Perception of leadership qualities and perception of coworker health	Health promotion interventions had different outcomes, this was attributed to the quality of leadership provided by school leaders	1/3
Dellve et al, 2007²⁰	Prospective study using interviews and quantitative data on employee work attendance	23 Health promotion leaders and 3275 employees at worksites in Goteborg, Sweden	Health promotion strategies, program platform, and attitudes related to influencing employee health	Leadership qualities and attitudes toward employee work-related health were important for health promotion implementation and long-term work attendance	2/3
Baird and Carroll, 2011³³	Case study using qualitative interviews and focus groups	26 Managers and employees at 2 different call centers implementing health promotion programs in Canada	Perception of senior leaders’ role in health promotion implementation	The level of involvement in health promotion from senior leaders was central to creating a culture of health	1/3
Renton et al, 2011¹⁸	Case study using qualitative interviews and quantitative surveys of managers at 10 call centers	15 Managers from call centers in Canada	Current practices used to promote physical activity and organizational barriers/facilitators to promoting physical activity to employees	Managers perceived that employees did not value physical activity and would rather smoke than exercise Physical activity was not considered a priority for the call center managers	1/3
Hasson et al, 2014³⁰	Qualitative interviews conducted as part of a longitudinal occupational health intervention	29 Senior, human resource and line managers at 9 worksites in Stockholm, Sweden	Managers’ views of occupational health, the current intervention being implemented, and barriers/facilitators for working with the intervention	Findings suggested the need for clear role descriptions and strategies and aligning intervention to existing organizational structures before implementation	2/3
Gillen at al, 2004³⁴	Qualitative focus groups	22 Safety managers, risk managers, general contractors, and senior managers from construction firms in California	Important aspects of the safety program, unsuccessful practices they had implemented, and obstacles to optimum safety management	Managers identified the workplace safety culture as the most important for implementation Managers identified supervisors as the most important influence for promoting a workplace safety culture	1/3
Gates et al, 2006¹⁹	Qualitative focus groups conducted as part of a larger community-based participatory study	33 Managers at 4 manufacturing companies in Ohio planning to implement a health promotion program	Identifying workplace strategies to reduce barriers to wellness programs	Managers who believed the workplace culture would be receptive to health promotion strategies were supportive of the proposed environmental changes	1/3
Chuang et al, 2011³²	Qualitative interviews and focus groups conducted as part of an implementation study of a work-based learning program for front-line employees	92 Middle managers at 17 health-care organizations in the United States	Middle managers’ facilitators and barriers to the implementation process and systems change needed for implementation	Middle managers’ commitment to implementation was dependent on senior managers making it an organizational priority and showing visible support	3/3
Makala, 2011²⁸	Mixed methods study using qualitative interviews and quantitative surveys with managers	Interviews with 12 managers and surveys with 52 managers at a government agency in South Africa	Employees awareness about health and perception of wellness program, leadership support, health conducive work atmosphere, and wellness improvements	Managers did not see promoting wellness programs as part of their managerial role Managers reported not feeling responsible for raising employee awareness about wellness programs	1/3
Wilson et al, 2007²⁷	Mixed-methods study to develop environmental and ecological worksite interventions targeted at overweight and obese employees	Surveys with 134 leaders at Dow Chemical Company	Employee health and job factors, physical environment, social organization, leadership support, and current health programs	Employees and leaders reported barriers to health initiatives, such as time constraints and workload, and low perception of relevance to employee health	2/3
Birken et al, 2015³¹	Mixed-methods study examining the influence of managers when implementing an innovation	Surveys with 120 middle managers and 103 CEOs and interviews with 16 middle managers at 120 health centers in the United States	Middles managers’ moral obligation, perceived costs, and affective attachment to the innovation and senior management support	There was a direct effect of senior managers’ support on middle managers’ commitment Middle managers who had open communication to senior managers could specify the support needed	3/3

^aQuality rating: 1 = low quality, 2 = moderate quality, and 3= high quality.

Results

The narrative summary follows the 2 major categories identified from the analysis. The first major category, factors associated with managers’ support, is divided into 5 main categories: beliefs and attitudes, training, senior leadership, roles, and management structure. The second major category, the influence of managers’ support, is divided into 3 main categories: organizational culture, employees’ perception of support, and employee behaviors.

Factors Associated With Managers’ Support

Managers’ beliefs and attitudes

Several studies in our sample examined managers’ beliefs and attitudes with respect to workplace wellness programs. These studies defined beliefs as the internal feeling that something is true and attitudes as the application or expression of beliefs.¹⁶ Among these studies, we found 3 types of beliefs held by managers: perceived responsibility for employees’ health, perceived control, and the perceived value employees place on wellness programs. One study in our sample found that managers’ beliefs about wellness programs differ by age, previous experience with wellness programs, and management level (senior, middle, and line).¹⁶ Specifically, this study found that middle and line managers believed production conflicts are a barrier to wellness programs, whereas senior managers are supportive of wellness programs because they felt responsible for employees’ health. One study at a manufacturing worksite in Canada found that senior managers are more likely to allocate resources to wellness programs if they perceive a moral responsibility for employee health.¹⁷ The same study found that human resource managers are more likely to allocate resources to wellness programs if they have perceived control over discretionary spending.¹⁷ Two studies conducted at call centers in Canada found that the perception of employee buy-in is important for managers’ support. Senior managers who believe employees do not value healthy living are less likely to promote wellness programs.¹⁸ Similarly, one study from several factories in Ohio found that senior managers are supportive of implementing low-cost environmental changes when they believe employees are receptive to strategies promoting healthy behaviors in the workplace.¹⁹ Finally, one study among government employees in Sweden found that positive attitudes from senior leadership toward employees’ work-related health is associated with successful program implementation.²⁰

Managers’ training

Two studies examined workplace training, which is defined as an initiation by organizations to foster learning among employees and broaden skills needed for future responsibilities.²¹ One study from an engineering company in Japan found that educational web-based training on relevant health topics can improve middle managers’ knowledge and attitudes toward employee health issues as well as increase employees’ perceptions of managers’ support.²² One study on a worksite substance abuse prevention program at 3M manufacturing company demonstrated that management trainings aimed at supporting employee health are successfully implemented by being linked with existing safety and productivity initiatives.²³

Senior leadership

Senior leadership is defined as the ability to influence and guide individuals and groups within an organization.²⁴ Only one study in our sample examined the role of senior leadership in worksite wellness programs. This study found that school leaders and teachers in Sweden linked supportive senior leadership with successful wellness program implementation.²⁵

Manager roles

Three studies in our sample examined managers’ roles, which are defined as the descriptions of what an individual is expected to do. Role conflict arises when managers are expected to perform a task that interferes with another expected role.²⁶ One study that examined manager roles and role conflict among Dow Chemical worksites found that senior managers perceived time constraints due to workload and demands as barriers to their role in supporting wellness programs and initiatives.²⁷ One study among government employees in South Africa found that managers do not view promoting wellness programs as part of their role and as such did not feel responsible for raising employee awareness about wellness programs.²⁸ One study found that managers viewed annual salary increases and promotions partially linked to workplace wellness efforts as an incentive to take an active role in promoting employee health.²⁹ The managers in this study felt that an incentive would improve their role in supporting wellness programs at their worksite.²⁹

Management structure

Three studies from the fields of organizational management and occupational psychology provide evidence as to how management structure influences worksite program implementation. The management structure was defined as the roles, power and responsibilities, and information flow among different levels of management.⁸ One study from several Swedish worksites found that the level of endorsement and communication from senior managers influenced middle and line managers to support their occupational health programs.³⁰ Middle managers are important for allowing employees time to participate, and line managers, having the most direct contact, serve as positive role models for encouraging employee participation.³⁰ One study from a health-care setting found a direct effect of senior managers’ support (ie, allocation of resources and visible endorsement) on middle managers’ commitment to the implementation of an innovation.³¹ Middle managers are more committed when they are able to specify the types of support they need to facilitate implementation.³¹ One study found that when middle and line managers in health-care organizations are involved in the planning and implementation process, it provides them with a sense of ownership over worksite programs.³²

The Influence of Managers’ Support

Organizational culture

Two studies examined how managers influence the organizational culture, that is, the norms, attitudes, and shared values of an organization.⁷ These studies found that managers at each level (senior, middle, and line) are important for creating and promoting an organizational culture that supports wellness programs. One study conducted at 2 call centers in Canada found that managers’ visible support of and engagement with employees is central to creating an organizational culture that supports health.³³ One study among construction managers in California found that senior managers felt responsible for setting the organizational safety culture by making employee health and safety an organizational priority, and middle and line managers felt that they promote the safety culture by role modeling desired behaviors and engaging with employees.³⁴

Employees’ perception of support

Two studies in our sample examined how the perception of support is influenced by the practices and behaviors of managers toward employees’ health.²⁶ One study found that the amount of tangible evidence of senior leader endorsement influenced employees’ perception of company commitment to health and, ultimately, employees’ well-being.³⁵ One study from South Africa found that changing the work and organizational environment to be consistent with management support (eg, visible company commitment and policies) is associated with employees’ perception of management support for wellness programs.³⁶

Employee behaviors

Three studies in our sample examined how managers’ support influences employees’ behaviors in the workplace.⁸ These studies defined management support as senior managers’ visible actions to make tangible improvements to the work environment. These studies found that the alignment of health and productivity goals, management training on health topics, and reporting program feedback and progress to senior leaders positively impacted front-line employees’ healthy food choices and engagement in physical activity.^37
-39

Conclusions

This integrative review synthesized the existing evidence regarding managers’ support for employee wellness programs. We found that several factors may affect managers’ support: managers’ beliefs and attitudes toward wellness programs and employee health, training on health-related topics, senior leadership, expected roles within the organization, and the workplace’s management structure. We found that the amount of visible and tangible support from managers may influence the organizational culture, employees’ perception of managers’ support, and employees’ behaviors.

To our knowledge, this is the first literature review about managers’ support for workplace wellness programs. The results point to several gaps in the literature regarding managers’ support for wellness programs. First, we found few experimental studies testing middle and line managers’ support. About half the articles included in this review focus on senior managers’ support, 8 include middle managers, and 4 include line managers. Three of the studies included in this review specifically target managers to encourage employee participation in wellness programs. However, these were from the same quasi-experimental intervention at different time points.^37
-39 Second, the literature we found on managers’ support has come from identifying components of “what works” for successful interventions versus identifying how it worked. For example, several of the included observational studies measure managers’ support indirectly through employee surveys and do not directly measure support from managers. This highlights the lack of definition and conceptual clarity regarding managers’ support for wellness programs. Third, the diversity of disciplines and research areas included in this review suggest managers’ support is a complex organizational issue that may require an interdisciplinary approach, for example, adopting strategies from organizational psychology and occupational safety. This is consistent with previous research that recommends interdisciplinary approaches to implementing health promotion interventions.⁴⁰

Limitations

The present review has 3 limitations. First, the concept of managers’ support lacks a standard definition and measurement (ie, conceptual clarity). Consequently, we used broad search terms and inclusion criteria. This uncovered literature from the field of health promotion as well as the fields of occupational health psychology and organizational management. Although the studies from the latter 2 fields are not traditional worksite health promotion, they provide valuable insights into the role of managers and the management structure in worksite program implementation. Second, there may be unpublished studies or studies published in languages other than English that are not included in this sample. Third, the quality rating criteria follow previously published guides, but we developed the quality-rating rubric solely for the purposes of this study.

Recommendations and Implications

Future research on managers’ support for wellness programs should test the strategies provided in this review. The results of this review suggest that the literature regarding managers’ support for wellness programs lacks experimental evidence as well as consensus on how to define and measure the concept. Some categories had very few studies. For example, despite the perceived importance of senior leadership support for wellness programs, we only discovered one study examining how senior leadership influences managers’ support for wellness programs. Future research will need to develop experimental studies that examine how managers’ support affects implementation of wellness programs. Workplace wellness practitioners and researchers should identify factors that hinder or promote managers’ support at all levels of the organization, devise strategies that target those factors, and measure managers’ support as part of the intervention evaluation.

SO WHAT?

What is already known on this topic?

It is widely held that managers’ support is an important driver of employee participation in, and success of, wellness programs. Yet, there is limited evidence on the specific factors influencing managers’ support for wellness programs.

What does this article add?

Several factors may influence managers’ support, including their beliefs and attitudes toward wellness programs and employee health, training on health topics, senior leadership, expected roles within the organization, and the management structure. The amount of visible and tangible support from managers may influence organizational culture, employees’ perception of support, and employee behaviors.

What are the implications for health promotion practice or research?

When designing future wellness program interventions, health promotion practitioners and researchers should consider strategies that target senior, middle, and line managers’ support.

Footnotes

Acknowledgments

Deborah Passey and Meagan Brown gratefully acknowledge funding received from the National Institute for Occupational Safety and Health (T42OH008433) while working on this review.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by a contract from the State of Washington Health Care Authority. Additional research support was by the University of Washington Health Promotion Research Center (HPRC), one of the Centers for Disease Control and Prevention’s Prevention Research Centers Program (HPRC cooperative agreement U48DP005013). Funding was received from the National Institute for Occupational Safety and Health (T42OH008433).

ORCID iD

Deborah G. Passey, MS, PhD

References

Goetzel

Ozminkowski

. The health and cost benefits of work site health-promotion programs. Annu Rev Public Health. 2008;29:303–323.

US Department of Health and Human Services. Healthy People 2010. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC; US Department of Health and Human Services; 2000.

Parks

Steelman

. Organizational wellness programs: a meta-analysis. J Occup Health Psychol. 2008;13(1):58–68.

Hammerback

Hannon

Harris

Clegg-Thorp

Kohn

Parrish

. Perspectives on workplace health promotion among employees in low-wage industries. Am J Health Promot. 2015;29(6):384–392.

Goetzel

Henke

Tabrizi

. Do workplace health promotion (wellness) programs work? J Occup Environ Med. 2014;56(9):927–934.

Mujtaba

Cavico

. A review of employee health and wellness programs in the United States. Public Policy and Administration Research. 2013;3(4):1–5.

Golaszewski

Allen

Edington

. Working together to create supportive environments in worksite health promotion. Am J Health Promot. 2008;22(4):1.

Lussier

. Management fundamentals: concepts, applications, skill development. 5th ed. Mason, OH: South-Western Cengage Learning; 2011.

Torraco

. Writing integrative literature reviews: guidelines and examples. Hum Resour Dev Rev. 2005;4(3):356–367.

10.

Whittemore

Knafl

. The integrative review: updated methodology. J Adv Nurs. 2005;52(5):546–553.

11.

Greenhalgh

Peacock

. Effectiveness and efficiency of search methods in systematic reviews of complex evidence: audit of primary sources. BMJ. 2005;331(7524):1064–1065.

12.

Krippendorff

. Content Analysis: An Introduction to its Methodology. 2nd ed. Thousand Oaks, CA: Sage Publications; 2003.

13.

Ryan

Coughlan

Cronin

. Step-by-step guide to critiquing research. Part 2: qualitative research. Br J Nurs. 2007;16(12):738–745.

14.

Coughlan

Cronin

Ryan

. Step-by-step guide to critiquing research. Part 1: quantitative research. Br J Nurs. 2007;16(11):658–663.

15.

O’Cathain

Murphy

Nicholl

. The quality of mixed methods studies in health services research. J Health Serv Res Policy. 2008;13(2):92–98.

16.

Linnan

Weiner

Graham

Emmons

. Manager beliefs regarding worksite health promotion: findings from the Working Healthy Project 2. Am J Health Promot. 2007;21(6):521–528.

17.

Downey

Sharp

. Why do managers allocate resources to workplace health promotion programmes in countries with national health coverage? Health Promot Int. 2007;22(2):102–111.

18.

Renton

Lightfoot

Maar

. Physical activity promotion in call centres: employers’ perspectives. Health Educ Res. 2011;26(6):1050–1059.

19.

Gates

Brehm

Hutton

Singler

Poeppelman

. Changing the work environment to promote wellness: a focus group study. AAOHN J. 2006;54(12):515–520.

20.

Dellve

Skagert

Vilhelmsson

. Leadership in workplace health promotion projects: 1-and 2-year effects on long-term work attendance. Eur J Public Health. 2007;17(5):471–476.

21.

Snell

Morris

Bohlander

. Managing Human Resources. 17th ed. Boston, MA: Nelson Education; 2015.

22.

Kawakami

Kobayashi

Takao

Tsutsumi

. Effects of web-based supervisor training on supervisor support and psychological distress among workers: a randomized controlled trial. Prev Med. 2005;41(2):471–478.

23.

Stoltzfus

Benson

. The 3M alcohol and other drug prevention program: description and evaluation. J Prim Prev. 1994;15(2):147–159.

24.

Yukl

. How leaders influence organizational effectiveness. Leadersh Q 2008;19(6):708–722.

25.

Bäckström

Lagrosen

Eriksson

. Change of the quality management culture through health-promotion activities? Total Qual Manage Bus Excell. 2014;25(11-12):1236–1246.

26.

Clegg

Kornberger

Pitsis

. Managing and Organizations: An Introduction to Theory and Practice. Thousand Oaks, CA:Sage; 2015.

27.

Wilson

Goetzel

Ozminkowski

. Using formative research to develop environmental and ecological interventions to address overweight and obesity. Obesity. 2007;15(S1):37S–47S.

28.

Makala

. Perceptions of Employees and the Level of Awareness About Employee Health and Wellness [master’s thesis]. Johannesburg, South Africa: University of Witwatersrand; 2011.

29.

Robbins

Wansink

. The 10% solution: tying managerial salary increases to workplace wellness actions (and not results). J Occup Health Psychol. 2016;21(4):494–503.

30.

Hasson

Villaume

von Thiele Schwarz

Palm

. Managing implementation: roles of line managers, senior managers, and human resource professionals in an occupational health intervention. J Occup Environ Med. 2014;56(1):58–65.

31.

Birken

Lee

Weiner

Chin

Chiu

Schaefer

. From strategy to action: how top managers’ support increases middle managers’ commitment to innovation implementation in healthcare organizations. Health Care Manage Rev. 2015;40(2):159.

32.

Chuang

Jason

Morgan

. Implementing complex innovations: factors influencing middle manager support. Health Care Manage Rev. 2011;36(4):369–379.

33.

Baird

Carroll

. The role of senior leaders in the development of healthy workplace programs: a case study in call centres. 2011. https://library2.smu.ca/handle/01/25654#.VpRQa5MrLVo. Accessed January 5, 2016.

34.

Gillen

Kools

McCall

Sum

Moulden

. Construction managers’ perceptions of construction safety practices in small and large firms: a qualitative investigation. Work. 2004;23(3):233–243.

35.

DeJoy

Parker

Padilla

Wilson

Roemer

Goetzel

. Combining environmental and individual weight management interventions in a work setting: results from the Dow Chemical Study. J Occup Environ Med. 2011;53(3):245–252.

36.

Milner

Greyling

Goetzel

. The relationship between leadership support, workplace health promotion and employee wellbeing in South Africa. Health Promot Int. 2013;30(3):514–522.

37.

DeJoy

Bowen

Baker

. Management support and worksite health promotion program effectiveness. Ergonomics and Health Aspects of Work with Computers. 2009; 5624:13–22.

38.

Goetzel

Baker

Short

. First-year results of an obesity prevention program at the Dow Chemical Company. J Occup Environ Med. 2009;51(2):125.

39.

Goetzel

Roemer

Pei

. Second-year results of an obesity prevention program at the Dow Chemical Company. J Occup Environ Med. 2010;52(3):291–302.

40.

Newton

. Interdisciplinary health promotion: a call for theory-based interventions drawing on the skills of multiple disciplines. Community Dent Oral Epidemiol. 2012;40(suppl 2):49–54.