Unique Barriers to Workplace Health Promotion Programs by Wage Category: A Qualitative Assessment of Secondary Data

Analysis Strategies

Descriptive analyses were conducted to describe the participants’ demographic characteristics and determine the general representativeness of the sample compared to the broader university workforce. Analysis of the open-ended responses was performed using a grounded theory approach.^20,21 Two of the co-authors read, re-read and coded responses to each open-ended question. Some responses contained multiple codes. Codes were then grouped into recurring themes and subthemes around barriers and facilitators to participation in WHPP. Next, these themes and subthemes were separated out by wage category, to explore similarities and differences. Definitions of themes, codes, and sample quotes were then reviewed by the rest of the research team. The research group used NVivo™ 12 Plus ²² to organize the codes and quotes.

Survey Participants

The qualitative analysis was limited to those who responded (yes or no) to a question about whether they had participated in a program or activity sponsored by U-WHPP in the last 12 months (which routed them to the open-ended questions described above). Of the 3,212 who responded to the general survey, 2,997 (93%) noted whether or not they had participated in the U-WHPP and 1,420 (44%) responded to one of the three open-ended questions. 66% of respondents were lower-wage employees (annual income <$45,000 per year (n = 334) and $45,000–$75,000 (n = 609)) and 34% were higher-wage employees (annual income $75,001–$95,000 (n = 199) and ≥ $95,001 (n = 278)). Women comprised 82% of the lower-wage respondents and 73% of higher-wage respondents. In comparison, 83% of all University employees were lower-wage earners at the time of analysis. Across the university, women were similarly overrepresented among lower-wage earners (71% of lower-wage employees vs 42% of higher-wage employees). Lower-wage employees, on average, were younger than higher-wage employees (40 vs 46 years old; P <.001). Aside from women being overrepresented in the survey, the survey sample is fairly representative of the university employee population. Sample sizes by wage category are shown in Appendix Table A1 (University Office of Budget and Planning, 2014). Demographic data is shown in Appendix Table A2.

Among those who responded to the question, “In the last 12 months have you participated in a program or activity sponsored by U-WHPP?” individuals receiving less than $45,000/year reported the lowest participation rates (see Figure 1).OPEN IN VIEWER

Those who selected “Yes,” that they have participated in a program or activity sponsored by [U-WHPP], were asked to rate the accessibility of programs (see Figure 2). Most respondents either “Strongly agree” or “Agree” that programs were easily accessible. Those who selected “Strongly disagree” or “Disagree” were offered a text box to comment on their choice.OPEN IN VIEWER

During the coding, we identified several broad themes describing barriers to WHP program participation that workers face. Responses were organized around these general themes and then grouped by wage category. We then examined the themes to identify potential differences between wage categories.

General Themes

Five key themes emerged from our analysis, reflecting barriers that were described by participants in each wage group. Although some of the themes were discussed across wage groups, their frequency and/or content differed.

Time

The time theme emerged to describe barriers to accessing or using health promotion programs because of a general lack of time and/or the scheduling of the program. Survey participants across all wage groups described time-based barriers, including how programs occurred during work hours and took time to complete, making it difficult to participate.

Although all groups reported time barriers, employees in the two lower-wage categories reported them more frequently (<$45,000, n = 84 total codes for time; $45,000–$75,000, n = 159; $75,001–$95,000, n = 38; ≥ $95,001, n = 64). In addition, a greater percentage of participating respondents in the lowest-wage group (23/37, 62%) mentioned time barriers than in the highest wage group (14/41, 34%). Lower-wage employees were more likely to describe irregular work schedules (versus 9a-5p schedules) and shift work as significant work-related time barriers to participation in WHP programs. Those who worked night or weekend shifts noted that there were few programs they could attend around their work time, or before or after their shifts. Other lower-wage employees described how their schedules could change at the last minute, with variable availability limiting attendance at some program sessions. It was difficult to participate consistently.

Requests to use lunchtime for health promotion activities also varied by wage group—and generally increased with wage. Lower-wage participants found it difficult to travel to the program location, participate in the activity, and get back to their worksite in the time allotted for their lunch break. In contrast, higher-wage participants cited lunchtime as one of the few times they had available for physical activity and/or health promotion participation.

Finally, relative to higher-wage workers, lower-wage employees cited a general lack of control in their daily work schedule as another reason for time barriers. They were not allowed to take time in the middle of the day for health promotion. In contrast, higher-wage workers appeared to have more control over their work schedule, even if it was still difficult for them to find time to participate. Respondents noted that they thought they could find time to participate in a program during their workday if they wanted to, though the process of doing so might not be straightforward.

Financial Costs and Incentives

The second theme, financial costs and incentives, emerged to describe barriers around program and/or equipment costs and a lack of incentives. First, employees from all wage groups expressed interest in incentives to promote health (<less than $45,000, n = 48; $45,000–$75,000, n = 85; $75,001–$95,000, n = 30; ≥ $95,001+, n = 30). Employees noted that incentives motivate busy employees to find time to participate and that more incentives would increase participation across the organization.

However, there were differences across the wage groups about whether those incentives were an added perk for participation or necessary to participate in the first place. Many of the comments from lower-wage employees about how to improve the program asked for free or reduced-price exercise and relaxation classes so that all employees could afford them (other classes were already being offered for free). Lower-wage workers were happy that there was some reimbursement for gym membership costs. However, they suggested that more people might participate if the amount of the reimbursement were increased.

In contrast, higher-wage workers expressed interest in financial discounts or reimbursement to supplement unique physical activities in which they were already engaged, such as digital exercise programs or pool memberships. These activities often required special equipment or ongoing subscription fees to participate. At the time of the survey, organizational incentives offset the cost of some facility memberships and did not include reimbursement for equipment. Higher-wage workers expressed interest in expanding the criteria for reimbursement as a perk to offset expenses for which they were already paying. Further demonstrating the challenge of developing health promotion programs for all employees, a small number of higher-wage employees emphasized a desire for tailored programs dealing with maintaining an already good level of health as opposed to managing chronic disease and modifiable risk factors.

Commute

The commute theme included the costs and convenience of parking and/or transportation to programs. All wage groups complained that parking was a barrier to accessing programs; however, lower-wage workers more frequently expressed issues related to the use of public transportation. They said that it was difficult to access classes before or after work because of bus schedules or vanpools.

Workload/Job Demands

The workload theme emerged to describe factors associated with the responsibilities and demands of the job itself that impacted the employee’s ability to participate in healthy activities. These included demands related to staffing coverage (e.g., ensuring that someone is available to cover a desk, phone line, or other tasks between certain hours), number and types of tasks to be completed, and role flexibility. Some employees noted that participating in the health promotion activities often conflicted with their job responsibilities so that either they could not participate or they could participate, but would have to make up the job responsibilities they neglected by participating.

While all wage groups noted heavy workloads, lower-wage employees often focused on external demands related to staff coverage and lack of role flexibility. They described how the nature of customer service roles made it difficult to leave their desk, even to go for a walk. Their supervisors also strongly emphasized the importance of maintaining coverage, with some lower-wage employees describing pressure to stay at the desk to avoid a lack of coverage.

In contrast, higher-wage employee responses reflected more self-generated, internal considerations. This group was less impacted by considerations about staff coverage or role flexibility. Instead, they noted that given their busy schedules, prioritizing health activities often “fell to the wayside” as the demands of their work took priority. Some of the individuals in this group described about how they felt it was up to them to set aside time for health promotion activities, despite the work demands on their time.

Organizational Policies/Practices

This section refers to organizational factors that can support (or hinder) employee health, including organizational policies, structures, and/or actions (e.g., designated time for healthy activities, break time, or relationships with outside vendors), organizational units (e.g., departments, units, and colleague preferences), and or supervisor/peer support that relate to health. Individuals in all wage groups noted a desire to create a culture of health and to make it an organizational priority. They wanted to see it become as important a part of their role as other parts of their job, including attending work meetings or finishing projects.

Lower-wage workers highlighted the need for WHP policies that allow employees time and space to address health concerns. In the extreme, lower-wage employees argued that a lack of flexibility in taking time-off when sick results in an environment with many sick employees.

Supervisor support. All wage groups commented about the important role of supervisor support in promoting U-WHPP and a culture of health. Lower-wage workers described supervisors as gatekeepers to participation in health promotion programs. They described how their supervisors did not encourage involvement or were not supportive of staff participating in health promotion activities. As a result, lower-wage employees were reluctant to participate in U-WHPP.

Higher-wage employees responded more generally about the role of supervisor support in promoting health in the workplace rather than the role of their direct supervisor. They suggested that supervisors could demonstrate support for work-life balance and excitement for health promotion through their actions and attitudes. Respondents suggested that supervisors could encourage employees to attend sessions and then ask them about what they learned and how it could be applied to their unit.

In addition to the supervisor, leadership in an employee’s unit can also impact support for health promotion activities. Lower-wage employees suggested that department leadership would not let employees use worktime to participate in U-WHPP. In contrast, higher-wage employees saw the unit as an opportune location in which to emphasize health. They gave examples about how department leaders could support employees through daily activities to promote physical health and weight management.

Mental health. As an important part of workplace culture, all four wage groups noted the need for enhanced emotional and mental health support. However, the higher-wage groups were more assertive about the importance of mental health, asking for enhanced support from leadership for employees who were dealing with work-related stress.

Preferences for Group/Individual Programs

Representatives from all four wage groups described their desire for individualized or team-based programming. Lower-wage employee responses focused more on group participation and team approaches. They noted how it is sometimes easier going through a health promotion program with a group to provide additional accountability. In contrast, higher-wage employees again emphasized tailored, individualized offerings that met their specific needs. They described the importance of setting aside time in order to pursue these programs.

Discussion (All)

Our findings suggest that one-size-fits-all health promotion programs may not be appropriate for the diverse set of employees that exist in most mid- to large-sized organizations. Lower-wage employees are often the ones who could benefit the most from wellness initiatives, but are the least likely to participate. Research suggests that individuals with lower socioeconomic status have a higher prevalence of unhealthy lifestyle behaviors such as smoking, ¹¹ being sedentary, ¹⁰ and excessive alcohol consumption,^23,24 and consequently, are generally less healthy. A comprehensive study of wellness program participation revealed that lower-earning employees were less likely to complete a health risk assessment. ⁷ Similarly, a recent analysis of a commercially insured population demonstrated a direct association between employee wage and wellness program participation in the health risk assessment and biometric screening, such that workers in the lowest-wage category were 30% less likely to participate in these programs. ²⁵ Our study provides some initial explanations for the participation barriers experienced by employees in different wage groups.

Our findings indicate that most employees were generally pleased with the WHP offerings provided by their organization. Employees highlighted the diversity of program offerings and the perquisites that made it fun to participate. At the same time, however, our results suggest that even in organizations committed to equitable access to comprehensive WHP offerings, employees reported differential access to and use of WHP programs. First, lower-wage employees reported participation barriers more frequently than higher-wage workers. This is consistent with previous research showing that lower-wage employees have a more difficult time participating. ²⁶ An important factor seems to be support from immediate supervisors, who often act as gatekeepers to program participation. Organizations could develop cultural supports to encourage employee participation, including support for supervisors who want to give their employees an opportunity to participate, but are unsure how to balance employee health with organizational initiatives and priorities. This might be done through policies that outline how employees can use worktime for participation or through better training for middle-managers about how to better support their employees’ well-being. ²⁷ Second, the nature and prevalence of the identified participation barriers differed between workers based on wage category. In general, all employees reported barriers regarding time constraints (e.g., to participate and/or because programs were only available at times when they were not), financial concerns (e.g., requesting free or reduced-price exercise and relaxation classes so that they could participate), commuting (e.g., parking expenses or timing with public transportation), and job demands (e.g., not being able to leave their post to participate in WHP programs). However, differences in perceived barriers emerged by wage category. For example, in relation to financial concerns, lower-wage employees expressed interest in free or reduced-cost classes so that they could afford to participate, while higher-wage employees shared a desire for reimbursements to help offset the cost of specialized equipment or subscription services necessary for home exercise or pool memberships. These differences highlight the distinction between health promotion programs as a way to increase or enable access to WHP programs vs a way to reward existing healthy behaviors. With respect to job demands, lower-wage employees emphasized external forces that prevented participation, including rules preventing a lack of flexibility, while higher-wage workers emphasized internal forces, including their own inability to carve out the necessary time. There was also a distinction between people who could participate, but did not choose to, and those who felt that they could not participate, even if they wanted to; effectively differentiating between the perception of WHP programs as addressing a need vs a perquisite. In either case, efforts to engage employees in healthy activities are beneficial for employee health, but the range of survey responses likely signals a need for more thoughtful program planning to promote equitable access and value of WHP offerings.

It is worth noting that physical activity does not have to be costly—people can achieve physical activity through walking, which does not require expensive equipment, classes, or memberships. However, it is important to note that walking still requires time and space. Many lower-wage workers described how challenging it was for them to leave their workstations and how they felt they did not have time for lunch, much less other activities.

Finally, we note that while organizational senior leadership has adopted a strong culture of health, some employees noted that their supervisors did not prioritize WHP programs, indicating that effective dissemination and practical implementation of organizational philosophy could be improved. In some cases, the need for coverage, where employees are expected to staff customer-facing desks or phone lines to ensure uninterrupted customer access, means that employees cannot leave to participate in available programs. This seems to be the case even if employees want to use break or lunch time to do so. Additionally, lower-wage workers noted that increased supervisor support could enhance their ability and willingness to participate in WHP programs. They recommended that organizational leadership emphasize to supervisors the importance of WHP, increasing the likelihood that supervisors would encourage employees to participate. As a result of this feedback, the organization has since implemented such trainings to help leaders build and support a healthy workplace culture In contrast, higher-wage employees were less likely to discuss the impact of their direct supervisor, but instead acknowledged the general importance for supervisors to support WHP participation.

Our paper contributes to the literature by focusing on qualitative descriptions across wage groups highlighting barriers that employees experience in relation to participation in WHP programs. Understanding the unique concerns of participants in each wage group is a first step towards designing tailored or adaptive WHP programs that can address health inequity concerns. Future research should investigate these concerns across wage groups.

It may also be useful to explore the impact of organizational diversity, equity, and inclusion initiatives in relation to employees in different wage categories. Some survey responses acknowledged a lack of diversity in WHP programs. Since certain racial or ethnic groups are overrepresented among low-wage workers, increasing the diversity of program offerings and representation among WHP program staff may increase interest and participation rates. This consideration may have business impact, in light of the increased risk of turnover and absenteeism among employees who have poor health and/or do not feel that their employer cares about their well-being.

To address some of these concerns, the organization has already begun to increase the number and types of available WHP offerings. Online content is now available, so that employees can participate from their desks or on their own time at home, if they are unable to attend classes in specific locations or at specific times. In fact, the organization has already received survey feedback from new participants who report first-time engagement with program offerings because of increased virtual options in response to the COVID-19 pandemic. The U-WHPP is also addressing SDH among underserved employee populations with food-sharing cupboards, meal planning/food budgeting, and launching a Resource Coach Pilot program that offers community resource referrals and 1:1 budget counseling. ²⁵

Future efforts are planned to consider how best to engage different stakeholders. We note that higher-wage groups tended to discuss food options and food culture, while lower-wage groups were focused on weight loss and smoking cessation programs. Different groups may have different preferences or priorities that would motivate their participation. It is worth acknowledging the valuable insight gained from subpopulation analyses, particularly in relation to the unique issues or concerns expressed by lower-wage workers as a historically underserved group. Employers should ensure available programs meet identified priorities and participation needs for the entire workforce. Specifically, they should work to ensure that WHP programs do not inadvertently discriminate against lower-wage workers who may not have the flexibility to participate due to time or resource constraints, organizational policies/practices, or job demands.

Limitations

One key limitation of this study is that we used wide groupings of less than and greater than $75,000 annual income to distinguish lower and higher-wage workers, respectively. The literature on low-wage work focuses primarily on households within 200% of the poverty level ($52,493 for a family of 4). Although our bands are wider than this, we were still struck by the way the two groups characterized different barriers and facilitators to WHPP access and participation. Another limitation is that the analyses are limited to employees from a large mid-western university who participated in a voluntary and non-incentivized survey. Given the voluntary nature of the survey and relatively low response rate, it is likely that there are characteristics unique to survey participants compared to non-participants. Thus, selection bias may make it challenging to generalize to larger populations. Also, other social determinants beyond wage were not evaluated and may confound results.

What is already known on this topic?

Research has demonstrated that low-wage workers experience different access to and utilization of WHPP than higher-wage workers. Yet, more work is needed to understand the specific barriers to participation across employees.

What does this article add?

This paper begins to address that gap by looking at the barriers described by employees at different wage levels. While the broad themes categorizing barriers are relatively consistent across the two groups—time, cost, commute, workload/job demands, and organizational policies/practices—the specific rationales differ across groups.

What are the implications for health promotion practice or research?

To reduce or eliminate wellness initiatives’ barriers to participation, managers may want to emphasize the whole employee (i.e., how work and home demands could impact program participation), take an active role in tailoring programs for employees, and implement new aspects of the program that allow for greater program flexibility and participation.