Implementation Outcomes Following Participation in a Large-Scale Healthy Workplace Program Conducted Across Multiple Worksites

Abstract

Purpose:

To measure implementation outcomes of a freely available workplace health promotion program (Healthier Workplace Western Australia [HWWA]) that provides employees with services and supports to make changes in their workplaces.

Setting:

Western Australian workplaces.

Subjects:

Employees accessing HWWA services.

Intervention:

A range of services (training sessions, tailored advice, grant schemes, online resources) were offered relating to nutrition, physical activity, smoking, alcohol consumption, and mental health.

Design/Measures:

Of the 1627 individuals e-mailed 6 months after participation in HWWA, 345 (21%) individuals who recalled accessing one or more services completed a survey assessing the number and type of changes they had implemented and the perceived barriers to doing so.

Analysis:

Negative binomial regressions and one-way analysis of variances assessed whether respondent characteristics or number of services used was associated with the number and types of changes made. A qualitative analysis of the perceived barriers was also conducted.

Results:

The majority of respondents (86%) reported implementing one or more changes. Greater perceived responsibility/authority to make change (β = .56, P < .01), perceived support from coworkers (β = .23, P < .05), and number of HWWA services used (β = .04, P < .05) were positive predictors of the number of changes made. Frequently reported barriers included cost/budget restrictions, lack of management support, and resistance from staff.

Conclusion:

The HWWA program facilitated implementation of various healthy workplace initiatives across the organizations represented in the evaluation.

Keywords

behavior change capacity building workplaces nutrition obesity

Purpose

There is an increasing appreciation of the role an individual’s environment has on their health and well-being.¹ A number of studies have shown that an individual’s behaviors can be influenced by altering the environment through what is called “choice architecture.”^2
-4 When applied to health, the aim of this approach is to make the healthy behaviors the “default,” easier and/or more appealing option.⁵ Given the number of hours people spend at work, the workplace is an important environment for implementing health and well-being initiatives.⁶ The World Health Organization recognizes the workplace as a priority setting for health promotion and has emphasized the need for organizations to commit to implementing appropriate initiatives.⁷ A large synthesis of 103 reviews carried out between 1995 and 2008 found that public health interventions delivered within the workplace are highly effective at creating behavior change.⁸ Such initiatives can minimize sick leave, disability, medical costs, and reduce costs incurred by high turnover, low productivity, and reduced quality of products and services offered.^7,9,10

Numerous risk factors can increase an employee’s level of absenteeism and/or presenteeism (working while ill)¹¹ in the workplace. Unhealthy weight (influenced by poor nutrition and physical inactivity), drug use (most commonly smoking and alcohol consumption), and poor mental health are some of the most costly and preventable health risk factors.^8,9,12 A large study with 70 000 employees from 58 companies in Australia (the location of the present study) found that drug and alcohol problems, psychological distress, and obesity were significant risk factors for absenteeism.¹³ Presenteeism has also been found to occur more frequently among workers who are obese,^14,15 depressed,¹⁶ or suffering from drug and alcohol use disorders¹³ compared to employees without these conditions. Furthermore, research shows a negative relationship between severity and number of individual risk factors and an individual’s productivity.¹⁷

Organizations can reduce the health risks described above by implementing workplace health and well-being policies and programs. These programs typically aim to increase awareness of, encourage, and/or facilitate physical activity, better nutrition, enhanced mental health, reductions in alcohol consumption, and smoking cessation. Numerous reviews have found that such programs can have positive effects on employees’ health outcomes.^{18

-27} For example, research looking at physical activity and nutrition programs promoting healthy weight and exercise among employees found modest improvements in weight,¹⁸ diet,¹⁹ and mental health.²⁰ Additionally, workplace interventions targeting stress and mental health literacy have been found to have a small but significant beneficial impact on depression and anxiety.²⁰ Workplace smoking cessation policies and programs are effective at reducing rates of smoking,^21
-23 increasing productivity, and reducing absenteeism,²⁴ while interventions targeting alcohol can help reduce consumption and/or alcohol-related problems.^25
-27

Workplace-based behavior change interventions can take many forms. These range from those that aim to increase awareness (eg, workshops) to those that enable or prevent certain behaviors (such as through the implementation of organizational policies), encourage healthy behaviors (eg, by providing incentives for participation in healthy activities), or facilitate a healthier lifestyle (eg, through environmental modifications). Although these forms of implementation are not mutually exclusive, few studies have examined the effectiveness of comprehensive approaches that target multiple behaviors using multiple forms of workplace interventions.^8,28 Given the interlinked nature of health behaviors and their outcomes, greater impact is expected from an integrated approach.¹⁶ Comprehensive programs can also contribute to creating an organizational culture that recognizes the importance of health and well-being.¹⁶ Such a culture can contribute to long-term changes in employee health and well-being and ultimately improve business performance.²⁹

Although the benefits of workplace health and well-being programs are now well recognized,^10,16 not all workplaces have the necessary in-house expertise or can afford external consultants to deliver programs. The Healthier Workplace Western Australia (HWWA) program aims to overcome these barriers. It is a free, comprehensive workplace health promotion program that is funded by the Health Department of Western Australia and administered through the National Heart Foundation Western Australia Division and Cancer Council Western Australia. The development of HWWA was informed by a search of relevant literature and new formative research to identify attitudes, barriers, and enablers to creating healthier workplaces.³⁰ HWWA aims to support and build capacity within workplaces to make cultural, environmental, and policy changes that encourage positive behavior changes among employees by offering a range of services including training sessions, tailored support, and advice from HWWA advisors (through face-to-face, telephone, or online consultations), grant schemes, online tools and resources, newsletters, and social media channels. A range of health areas (nutrition, physical activity, smoking, alcohol consumption, and mental health) are targeted by providing staff members with the knowledge and skills to create or improve organizational policies, run educational workshops, conduct participation initiatives, and change the physical environment within the workplace. The program is complemented by a comprehensive web site (www.healthierworkplacewa.com.au) and has been in operation since 2012. It has been used in over 2000 workplaces across Western Australia.

The HWWA program applies principles from social cognitive theory by providing employees who participate in the program with knowledge of the benefits of health behavior change and the personal efficacy to create this change.³¹ Employees who participate can be both the agent of change and the subject of change.³² The program differs from typical organizational health and well-being programs in several ways. First, the focus is on empowering workplace managers and staff to enable changes led by staff from any level within the company (rather than an external consulting organization), which can be beneficial because internal staff may be more aware of the specific needs of the organization and therefore well placed to determine which areas most require attention. This can also help create a sense of ownership over the interventions, which can result in better outcomes.^16,33,34 Second, the program builds internal capacity within organizations, which is especially important for small businesses.^35,36 Third, due to its scale and the fact that resources can be used by many organizations at once, HWWA is an efficient way to simultaneously facilitate health and well-being initiatives across a large number of organizations. Fourth, comprehensive workplace programs are supported, addressing multiple risk factors by targeting both individuals and their environments. Given the lack of prior research assessing the impacts of comprehensive workplace health programs that are implemented at scale, the aim of this study was to assess the implementation outcomes of HWWA in terms of the number and type of changes implemented in organizations postparticipation in the program and the factors influencing the extent to which the various program components were implemented.

Methods

Sample

Data for the present study were collected between June 2016 and December 2017. Survey respondents were employees from various organizations across Western Australia who accessed training or support services through HWWA. Approximately 6 months after initially engaging with the program, 1627 respondents were contacted and asked to complete an online survey relating to the program (detailed subsequently). Of these, 461 elected to respond to the survey invitation. Only those who reported using at least one service were included in analyses, leaving a final sample of 345 respondents (response rate: 21%). According to the data provided, respondents came from 203 different organizations (representing 218 different worksites) across the state of Western Australia. The sample was comprised of managers (18%), individuals working within a Human Resources/Occupational Health and Safety department (HR/OHS; 52%), and employees acting as “champions” for workplace health and well-being (30%). Respondents were also classified as working in a small (less than 19 employees: 11%), medium (20-199 employees: 45%), or large (more than 199 employees: 44%) organization.

Design

Individuals accessing training or support services through HWWA provide their e-mail address and consent to being sent surveys about the program. Approximately 6 months after their initial engagement with the program, they are invited to complete an online survey. To optimize the response rate, program participants can enter a draw to win a $100 voucher. Two reminder e-mails are sent to each participant over a 2-week period following the initial invitation. The study protocol received approval from a University Human Research Ethics Committee.

Measures

The survey commenced with background questions about the individual and their organization (eg, their role within the organization and the total number of people employed). Respondents were presented with a list of services offered by HWWA and asked to select the services they had used. Using a 5-point scale, they then rated the degree to which they felt supported by management (“I have support from management to initiate change in my workplace to support employee healthy lifestyle behaviors”) and their coworkers (“I have support from my co-workers [workplace champions/health and well-being committee] to implement and promote healthy lifestyle initiatives in my workplace”). Respondents rated their motivation and commitment (“I am motivated and committed to make changes in my workplace to promote healthy lifestyle behaviors to staff”) and their current level of responsibility/authority (“Have you been given more responsibility/authority to influence change in your workplace to support employee health since your engagement with Healthier Workplace WA?”). They were then presented with a list of potential policies, workshops, participation initiatives, and aspects of the physical environment (shown in Table 1) and asked to indicate which had been implemented or were in the process of being implemented “as a result of [their] engagement with Healthier Workplace WA.” They could also indicate whether the initiative was already present within their organization prior to their engagement in the program. Finally, respondents were given the opportunity to answer to an open-ended question, “Have you experienced any barriers when making changes in your workplace to improve employee health?”

Table 1.

Average Number of Changes Made by Respondents (According to Role) and the Effect of Personal and Organizational Variables (Assessed Through Regression) on the Number of Initiatives Implemented (According to Type of Change).^a

	Policies β	Workshops β	Participation Initiatives β	Physical Environment β	All Changes β
Average
All respondents (n = 345)	1.7	1.5	1.5	2.8	7.6
Manager (n = 63)	2.0^b,c	1.6^b	1.9^b	3.4^b	9.0^b
HR/OHS (n = 178)	1.9^b	1.8^b	1.7^b	2.8^b	8.3^b
Champion (n = 104)	1.2^c	0.8^c	1.0^c	2.5^b	5.6^c
Regression predictors
Role—Manager					-
Role—HR/OHS	−0.04	0.03	−0.13	−0.37^d	−0.18
Role—Champion	−0.24	−0.57^d	−0.42	−0.37	−0.40^d
Organization size—small
Organization size—medium	0.00	0.25	0.35	−0.11	0.08
Organization size—large	0.24	0.27	0.27	0.09	0.22
Given more responsibility/authority	0.62^e	0.41^e	0.47^e	0.65^e	0.56^e
Perceived support from management	0.23^d	0.02	0.07	−0.13	0.02
Perceived support from coworkers	0.36^e	0.20	0.28^d	0.18	0.23^d
Motivation/commitment to implement changes	0.31^d	0.03	−0.03	0.16	0.14
Number of services used	0.01	0.05^d	0.05^d	0.04	0.04^d
R ²	0.11	0.15	0.18	0.11	0.21

Abbreviation: HR/OHS, Human Resources/Occupational Health and Safety department.

^a Different superscript letters (b and c) across the same row indicate there was a significant difference (P < .05) between average number of changes made by those working in different roles.

^d P < .05.

^e P < .01.

Analysis

Quantitative and qualitative data were analyzed using SPSS and NVivo, respectively. Negative binomial regression analyses were conducted to determine whether factors relating to respondent characteristics or the number of HWWA services used were associated with the number and types of changes made. To explore how staff members’ roles within their organizations impacted on whether they implemented changes, one-way analysis of variances (ANOVAs; with post hoc Sidak adjusted comparisons) were conducted, with role as the independent variable and the standardized number of changes implemented in each area (ie, policies, workshops, participation initiatives, and the physical environment) as the dependent variable. Since the survey instrument assessed a different number of changes across each area, the number of changes was standardized to facilitate comparison. Finally, to identify factors that may prevent HWWA program participants from implementing changes, qualitative responses to the question of perceived barriers were analyzed by one of the authors (ZT) using an inductive approach. No specific theoretical framework was used. Rather, emergent themes were identified and quantified using frequencies.

Results

In total, 2616 changes were reported across the sample of 345 respondents. The average number of changes reported by respondents was 7.6 out of a possible 34 changes assessed. Across the sample, 14% reported making no changes in the last 6 months. A substantial minority (35%) reported making between 1 and 5 changes. A further 18% reported making between 6 and 10 changes and 21% reported making 11 to 15 changes. Table 2 shows the percentage of respondents who reported implementing different types of initiatives within their organizations. An important factor to consider when interpreting implementation rates is whether specific initiatives were already in place within the respondents’ organizations prior to taking part in HWWA (also shown in Table 2).

Table 2.

Workplace Changes Implemented Prior to and After Taking Part in the HWWA Program.

	Percentage of Respondents Reporting Initiatives Already in Place in their Organization prior to HWWA	Percentage of Respondents Implementing Initiatives in their Organization After HWWA	Total of Respondents With Initiative in Place at their Organization After HWWA
Policies
• Sedentary behavior	14	31	45
• Healthy eating	13	30	43
• Physical activity	14	28	42
• Alcohol consumption	32	28	60
• Smoking	37	28	65
• Mental health and well-being	22	28	50
Average	22	29	51
Workshops
• Mental health	22	42	64
• Healthy eating	18	35	53
• Physical activity	21	34	55
• Alcohol consumption	18	20	38
• Smoking cessation	20	20	40
Average	20	30	50
Participation initiatives
• Initiating workplace challenges	16	30	46
• Healthy morning teas/lunches	18	29	47
• Incentives to participate in workplace health promotion activities	14	27	41
• Workplace sporting teams	24	26	50
• Providing pedometers	14	19	33
• Support for workplace teams in community events	15	16	31
• Subsidized public transport fares	8	6	14
Average	16	22	37
Physical environment
• Putting up posters promoting healthy lifestyle	29	43	72
• Providing standing work stations/meeting rooms	23	30	53
• Provision of healthy alternatives in workplace canteens	21	21	42
• Provision of healthy alternatives to vending machines	19	20	39
• Providing a designated lunch area	59	20	79
• Removing fundraising chocolate and lolly boxes	12	19	31
• Providing kitchen facilities	61	18	79
• Removing vending machines and lolly and biscuit jars	18	17	35
• Providing fruit and vegetable boxes	22	16	38
• Installation of bike racks, rails, cages, lockers	41	13	54
• Providing showers	58	13	71
• Providing change rooms	56	12	68
• Providing lockers	43	12	55
• Providing shelter for bike racks	34	10	44
• Providing on-site gym equipment	20	9	29
• Providing shared bikes and associated equipment	19	7	26
Average	33	18	51

Abbreviation: HWWA, Healthier Workplace Western Australia.

Table 1 shows the results of the one-way ANOVAs looking at the impact of role on the number and types of changes made. Overall, champions implemented fewer changes than managers and those working in HR/OHS. This difference was significant for workshops and participation initiatives. For policies, there was only a significant difference between employees working in HR/OHS and champions. There were no significant differences for physical environment changes, which had the lowest uptake across all roles.

Results of the regression analyses (also shown in Table 1) revealed that champions were less likely to implement changes than managers. However, being given more responsibility and/or authority to make change, perceived support from coworkers, and the number of services used were positive predictors of the overall number of changes made. Organizational size was not a significant predictor of change. Within the specific change areas, the number of services used was only a significant positive predictor of implementation for participation initiatives and workshops. Perceived support from management and motivation/commitment to implement changes were significant predictors of policy changes, while perceived support from coworkers was a significant predictor of the number of policy and participation initiative changes made. Employees identifying as champions were less likely to implement workshops compared to managers, while those working in HR/OHS were less likely to make physical environment changes compared to managers.

The qualitative analysis revealed that resistance from staff was the most frequently reported barrier to making changes in the workplace, closely followed by cost and budget restrictions and lack of management support. Figure 1 shows the extent to which respondents in different roles identified certain barriers (calculated as a percentage of the total respondents within each role). In comparison to those in other roles, a higher percentage of HR/OHS respondents reported cost/budget restrictions. For champions, the most frequently reported barrier was lack of management support. For managers, there was a greater perceived difficulty creating cultural change.

Figure 1.

Reported barriers to implementing change by role type.

Discussion

The present study assessed the implementation outcomes of a free, comprehensive workplace health promotion program available to organizations within the state of Western Australia. The results revealed which initiatives were most commonly adopted after engagement with the program and which were most likely to already be in place. On average, respondents were more likely to report implementing policies and workshops (31% and 29% of respondents respectively), while participation initiatives and changes to the physical environment were less frequently reported (by 22% and 18% of the sample respectively). Specifically, changes to organizational infrastructure (such as facilities for bike users) were the least implemented, which appeared to be due to the fact that much of this infrastructure was already present within participating organizations. This suggests that comprehensive health and well-being programs have the potential to produce larger gains through workplace participation initiatives (which were least likely to be adopted prior) and policies and workshops (which were most likely to be adopted after), compared to improvements to the physical environment. The finding that participation initiatives were less likely to already exist within organizations suggests that this is one area in which organizations may need additional help for successful implementation. Initiatives such as these are likely to be important components of a comprehensive workplace health program because they can be effective at changing behavior, at least in the short term.^37,38

The results also illustrate the factors influencing whether changes were implemented in the workplace. Overall, the number of HWWA services accessed was significantly and positively associated with the number of changes implemented. This was more so the case for workshops and participation initiatives than policies and physical environment initiatives. Those who perceived that they had been provided with the responsibility and/or authority to make changes after taking part in HWWA were more likely to implement initiatives. This appeared to be more important than stated commitment/motivation to making changes (which was only a significant predictor of policy changes). Finally, perceived support from coworkers was also a significant predictor of overall change and specifically for policy and participation initiative changes.

The finding that perceived support from coworkers was a significant predictor of overall change while perceived support from management was not runs somewhat contrary to past research showing that management support is important when it comes to implementing workplace health and well-being programs.³⁹ The current findings may have been influenced by the fact that 52% of the sample comprised HR/OHS employees, and management support is potentially less important for them given that making these kinds of changes may be considered part of their role. Rather, the present results suggest that management support is more important for champions since lack of management support was the most frequently reported barrier to making change among this subgroup. While for HR/OHS employees, the cost of making changes was reported as a leading barrier. Among the managers subgroup, resistance from staff and difficulties creating cultural change were reported as the major barriers to implementing changes.

Managers and those working in HR/OHS reported implementing significantly more changes on average in terms of policies, workshops, and participation initiatives than respondents who did not hold these roles within their organizations. There were no differences in the roles of those making changes to aspects of the physical environment. The implication of this finding is that some changes may require a certain level of authority to be successfully implemented in an organization. Thus a potential strategy to increase the effectiveness of health and well-being programs may be to primarily target staff members in management or HR/OHS roles.

Limitations

A major limitation of this study was the absence of a baseline measure or control group. Thus, it is not possible to know whether the changes implemented were a direct result of participation in the program. However, the survey specifically asked about changes that were made as a result of engagement with HWWA, providing some assurance of the validity of the results. Furthermore, the number of services used was a significant predictor of the number of changes implemented, suggesting the program was at least partly responsible for the reported changes. Another limitation is that the results provide a cross-sectional view of changes made after 6 months, but not the resulting changes to employee well-being. It is crucial that programs such as this create sustained change. Longer-term measurement of outcomes (including assessment of the effectiveness of the implementation) would have provided more information on the true impact of this program. However, a substantial research base has established the effectiveness of similar health and well-being initiatives,^{18

-27} indicating that the reported changes will assist in improving health and well-being in the organizations represented within the sample.

So What?

What is already known on this topic?

Workplace health promotion programs are highly effective at creating behavior change and producing positive health outcomes in employees. However, not all workplaces have the necessary in-house expertise or can afford external consultants to deliver such programs.

What does this article add?

This study measured implementation outcomes of a freely available workplace health promotion program that provides employees with services and support to make changes in their workplaces across various content areas (nutrition, physical activity, smoking, alcohol, and mental health).

What are the implications for health promotion practice or research?

Capacity building programs like the one under study can support employees to make changes to workplace policies, workshops, participation initiatives, and modifications to the physical environment. Greater perceived responsibility/authority to make change, perceived support from coworkers, and number of program services used were positive predictors of the number of changes made.

Footnotes

Declaration of Conflicting Interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: ED and TS were employed by the National Heart Foundation and CG was employed by Cancer Council WA. ZT and SP were commissioned by the National Heart Foundation to conduct the evaluation.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Implementation and evaluation of the Healthier Workplaces WA program is funded by the Department of Health, Western Australia. The program is administered by the National Heart Foundation (WA Branch) and Cancer Council WA. Financial support (for ZT and SP) was provided by the Department of Health WA.

ORCID iD

Zenobia Talati, B.Sc, MPsych, PhD

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