Facilitating and limiting factors of workplace health promotion at Rhodes University,South Africa

Abstract

BACKGROUND:

Workplace health promotion programs, when well designed and implemented are beneficial to both employees and their employers.

OBJECTIVE:

To investigate the factors that affect workplace health promotion initiatives intended for support staff at Rhodes University. To explore ways in which future initiatives that aim to reduce the prevalence of non-communicable diseases in the workplace may be improved.

METHODS:

A qualitative study, using semi-structured interviews and focus group discussions with key stakeholders and support staff. All interviews and focus group discussions were voice recorded and then transcribed verbatim. Transcripts were uploaded into NVivo^® 10 for coding and thematic analysis.

RESULTS:

Key stakeholders reported that health promotion initiatives have been attempted and were advertised, however the turnout was poor. The support staff in turn, stated that past initiatives were not tailored to their health needs and they lacked context-specificity and cultural sensitivity. They also suggested improvements for future initiatives such as convenient venues and using films and short plays as a means of delivering health information.

CONCLUSIONS:

Based on inputs from key stakeholders and support staff, there are several factors that affect the success of health promotion initiatives in the workplace. Employees, who are the recipients of the planned initiatives, need to be involved in all stages of the planning and implementation.

Keywords

Worksite employee health non-communicable diseases health promotion programs

1 Introduction

As highlighted by the World Health Organisation (WHO), non-communicable diseases (NCDs) account for 63% of all annual deaths [1] and currently contribute to 44% of all annual deaths in South Africa [2]. The increase of NCDs such as hypertension, diabetes, cancers and chronic respiratory disorders has resulted in a multitude of complications, including increased health issues resulting in greater financial burdens on individuals, families and organisations [3]. However, the main risk factors causing these diseases are largely preventable. People may learn from advice and health campaigns that they should eat and live healthily, eliminate alcohol and tobacco from their daily lives as well as participate in physical activity, but knowledge does not automatically translate into action [4].

NCDs are not only a health burden, but these disorders force many people into poverty as a result of catastrophic expenditures for treatment, compounded by a loss of productivity [1, 5]. Behaviours associated with health are based on choice, and these choices are shaped by the opportunities and constraints that people are exposed to in the environments where they live and work [6]. The WHO has recognised the workplace as a priority setting for health promotion. Workplaces directly influence the physical, mental, economic and social well-being of employees, which in turn, affects the health of employees’ families, communities and societies. They offer an ideal setting and infrastructure to support the promotion of health of large groups of people [7]. It is unfortunate that the concept of workplace health promotion, especially focusing on the awareness of and reduction of NCDs has not yet been very well established and accepted in most developing countries [8 –10]. Although some organisations have worked hard to safeguard their employees’ health, their programs have not been guided by any specific policy or workplace health promotion framework, therefore making it difficult to evaluate the program outcomes or duplicate these programs in other workplaces [11, 12].

Most staff spend more of their time at the workplace than any other setting outside the home; therefore policies, protocols and practices that exist in the workplace tend to influence their health behaviours more than those in a clinical or any other settings [7]. It becomes necessary to redesign the workplace in such a way that health is promoted by both employers and employees [13]. Paying attention to employee health may result in extensive benefits for both an organisation and its employees [13 –18]. Evidence shows that initiatives in which employees actively participate and adopt healthy lifestyles have resulted in increased productivity, and, therefore, in increased efficiency at the workplace [19].

This article focuses on the results obtained from an investigation into the facilitating and limiting factors of past health promotion initiatives intended for the support staff at Rhodes University. It also explores improvements that were suggested by the staff members to increase participation in health promoting initiatives, and considers ways to successfully deliver health-related messages to this target population as an attempt to reduce the prevalence of NCDs in the workplace.

2 Method

2.1 Research design, setting and sample

2.1.1 Design

Owing to the exploratory and flexible nature of this study, as well as an emphasis on context-specific and dynamic interactions, a case study approach [20, 21] was used in this qualitative research study.

Prior to commencing data collection, the research proposal was presented to the Faculty of Pharmacy Higher Degrees Committee at Rhodes University and ethical clearance was obtained (Pharm 2015-5) from the Rhodes University Faculty of Pharmacy Ethics Committee on the 24th of June 2015.

2.1.2 Participants

The first two participants were purposively selected. Thereafter, a snowball sampling technique was used to gather the rest of the sample which was comprised of key stakeholders 1 and support staff 2 . Out of a total pool of 1500 support staff, 100 were approached and 78 agreed to participate. All participants were above the age of 18 and were current Rhodes University staff, who had worked at the university for at least a year. Rhodes University is an academic institution located in Grahamstown, Eastern Cape, South Africa. Potential participants were informed of the purpose of these semi-structured interviews and focus group discussions, which was to explore the facilitating and limiting factors of workplace health promotion initiatives, as well as to seek suggestions on how to improve such initiatives in the future. All communication with key stakeholders with regards to agreements to meet, times, and venues was made via personal e-mails, while that with the support staff was liaised by the heads of departments, who then communicated the details to the researcher. All participants provided their informed written consent to take part in the study prior to the commencement of data collection and recording. Participation was voluntary and no remuneration was offered.

2.2 Semi-structured interviews

Eleven semi-structured interviews (SSIs) were conducted with key stakeholders, and these included representatives from the Human Resources department at Rhodes University, personnel from the Health Care Centre (sanatorium) and various managers, to whom the bulk of the support staff report. Their inputs from a policy and practice perspective were gathered. A question guide was used to guide the interview. All SSIs were conducted in English and werevoice-recorded.

2.3 Focus groups

Exploratory research was conducted through 10 voice-recorded focus group discussions (FGDs). Each group consisted of 5 to 8 participants, who are support staff at Rhodes University, resulting in a total participant sample size of 78. FGDs were conducted with groups of support staff from departments such as Food Services, Housekeeping, Grounds and Gardens, Electrical workshop, Building and Maintenance workshop, the Campus Protection Unit as well as a group of peer educators. A question guide was used to guide the discussions. Each FGD ran for 45 minutes to an hour. All discussions were voice-recorded. FGDs were conducted until data saturation was reached.

2.4 Data analysis

All voice-recordings of the FGDs and SSIs were transcribed verbatim. Participant anonymity was preserved by assigning each participant a unique identifying code, instead of using names. All transcripts were uploaded into NVivo^® 10 for coding and thematic analysis. Coding and analysis was done by the researcher. Analysis of the SSI and FGD data followed a simple version of the general steps of qualitative data analysis as outlined by Creswell and Plano Clark [22]. Following content analysis member checking [23] was done during the FGDs and SSIs, and peer debriefing [21, 24] was done with a fellow research student. Data saturation was reached when information became repetitive and no new insights were revealed.

3 Results

3.1 Demographics

The demographic details were gathered prior to the commencement of the SSIs and FGDs. Of the 11 key stakeholders, three were female and 8 were male. All except two were second language English speakers. Key stakeholders held either a diploma, bachelor’s degree, or higher qualification.

There were 78 support staff members who participated in the 10 FGDs, over half (56%) were female, more than three quarters spoke IsiXhosa as their primary language, and more than half had completed grade 8 or higher (Table 1).

Table 1
Demographic profile of participants (n = 78)

Demographic Parameter Participants, n (%)

Gender

Male 34 (44)

Female 44 (56)

First language

English 2 (2)

Afrikaans 16 (21)

IsiXhosa 60 (77)

Highest Level of Education

Grade 1–7 10 (13)

Grade 8–12 54 (69)

Additional/formal courses attended^* 14 (18)

Demographic Parameter	Participants, n (%)
Gender
Male	34 (44)
Female	44 (56)
First language
English	2 (2)
Afrikaans	16 (21)
IsiXhosa	60 (77)
Highest Level of Education
Grade 1–7	10 (13)
Grade 8–12	54 (69)
Additional/formal courses attended^*	14 (18)

^*Additional/formal courses- refer to further qualifications e.g. diplomas or certificates in the participants’ field of work.

3.2 Themes arising from the semi-structured interviews and focus group discussions

Five main themes emerged from the content analysis of data from the interviews and discussions: (1) views on workplace health promotion, (2) the benefits of workplace health promotion, (3) the facilitating factors that led to the success of past initiatives at Rhodes University, (4) the limiting factors that contributed to the failure of past initiatives at Rhodes University, and (5) improvements that the staff wished to see implemented that might increase their willingness to participate in future initiatives.

3.2.1 Views on workplace health promotion

Since there are many views of what workplace health promotion entails, it was essential to understand the participants’ views of what it meant to them and what it should entail. Prior to commencement of the FGDs and SSIs around past initiatives, views on what workplace health promotion were discussed.

“A holistic approach. Health promotion would include telling people about possible diseases that [are] out there and then teaching people about lifestyle changes. That is very important because people think that if they take a pill they are going to get better but there’s preventative measures. You don’t need to take the medication. Medications have a lot of side effects, so if we can promote a culture whereby people can avoid the illness then they will never have to get to the medications that have so many side effects. So that is where we should end up so that people don’t end up being diagnosed in the first place.”–R2 FGD 5

“Having programs at the workplace that educate the staff about healthy behaviours and encouraging them to live healthily.”- R4 FGD 8

“I suppose it’s the initiative to try and coach the staff to live healthy lives.”- SSI 5

“It’s about promoting healthy lifestyles in order to have a healthy workforce.”- SSI 11

3.2.2 Benefits of workplace health promotion

Most SSI and FGD participants reported that a healthy workforce was key within the workplace. Reasons provided included increased productivity, more positive attitudes, and greater levels of job security. Productivity was the most frequently mentioned outcome in relation to having healthy staff. Greater productivity was believed to translate into higher efficiency in the workplace. Unhealthy staff were perceived to be more likely to take sick days or to carry out their duties more slowly due to fatigue, thus costing the institution money, as other personnel may have be hired or trained to cover their duties.

“Some of my staff, maybe myself included, are heavily overweight, probably morbidly obese. Regularly, my staff are absent, with medical certificates. I have a lot of absenteeism due to sick leave. A lot of them with chronic issues. It impacts on our operations significantly. We are a small department as it is. Very often I have 2 [support staff members present]. One week I had 4 staff, an entire week. An entire week! And that week I had less than 50% of my staff [present] for the entire week on sick leave. So that’s how bad it gets here sometimes and it really impacts ouroperations.”- SSI 4

“I’m sure we will generate savings as there will be less people calling in sick, therefore we don’t have to get other people to fill in for them.”- SSI 3

“We will work better and achieve our work goals if we know how to prevent and manage our chronic diseases.”- R1 FGD 3

“If people are educated about healthy behaviours, they will know how to act and be more productive at work.”- R6 FGD 1

3.2.3 Success factors of past workplace health promotion initiatives

Participants reported on a few desirable factors that led to the success of some of the previous initiatives. Most were motivated to participate when they were offered incentives. Incentives were a major driving factor that led to good turn outs and participation in some previous projects.

“If you say there’s going to be incentives, the turnout is good.”- R1 FGD 5

“A little gift - a t-shirt, a pen, a mug - always does the trick. Staff appreciate these incentives and are more willing to participate if there’s something in it for them.”- SSI 2

3.2.4 Limitations of past workplace health promotion initiatives

Although some aspects of past initiatives were successful, the limitations seemed to outweigh them. Participants emphasised that projects and events on health promotion were not well-communicated, information provided at some events was largely cliché and boring, and none were context-specific or culturally sensitive. The staff also indicated that a needs assessment was not carried out, and that this lack of engagement resulted in poor turn out and low participation rates. Ultimately, the intended health messages were not delivered, as staff did not engage in the planned projects and/or events.

“... sometimes we don’t get time to go there [to participate in health-related initiatives] because we are busy and it’s far.”- R5 FGD 4

“It is good that gym subscriptions are subsidised but it’s not culturally correct for me to wear skimpy gym attire. I can’t go there in a dress either.”- R4 FGD 10

“The other thing is that guys come here to do presentations, some of your presentations, people don’t get the chance to ask questions. Some people would have wanted to ask but didn’t get the chance.”- R6 FGD 6

“Some of the staff here are old. They don’t understand English very well. We need activities that they can understand and are comfortable to participate in.”- R7 FGD 9

Managers also outlined the reasons behind their lack of interest in initiating health awarenessprograms, events or activities in the workplace.

“It’s difficult to communicate with the staff about health promotion events because they don’t always have email access.” - SSI 5

“The staff do not show any interest.”- SSI 11

“I think we are not including staff. We just assume what’s good for them.”- SSI 2

“We do not have a set framework or clear outcomes for these health promotion activities.”- SSI 9

“We need health information on diseases that are common to our target population like hypertension and diabetes. This is not the case most of the time. Most health talks are on HIV/AIDS; the focus needs to shift”- SSI 5

3.2.5 Suggested improvements for future initiatives

Participants were keen to suggest improvements that they wished to see implemented in future workplace health promotion initiatives.

“If it could be put in a film where everybody will see.”- R1 FGD 12

“I would like you guys to involve us more, if we can go [work] together in these projects.”- R2 FGD 12

“We would like to have posters in our changing rooms... . most of the time you give us a small paper which we fold and put in the pocket and then into the rubbish bin.”- R2 FGD 6

“If a Sister [nurse] or Doctor could come test us here at work for cholesterol, sugar and things like that.”- R2 FGD 4

“I want Human Resources to also be involved in issues of the staff. There should be more programs on health awareness.”- R1 FGD 4

“You can also use pamphlets that have all this information you presented to us or put it on boards because we also like to read.”- R2 FGD 6

“Giving plain and simple information.”- R4 FGD 5

“It’s very rare that you find each and every month you have not been invited to attend a memorial service, one of our staff members has passed on. And it really make me to think of this thing of not only concentrating on HIV but on the wellness at large. We need to educate our staff on how to prevent risk factors that contribute to the increase of non-communicable diseases.”- SSI 1

“Take culture into consideration.”- R1 FGD 1

4 Discussion

Several researchers have investigated the positive outcomes that result from the implementation of workplace health promotion [15 , 28].However, very few have explored the factors that influence participation from an employee’s point of view [29]. In the current study, possible barriers to participation were investigated. Several factors influenced staff participation in health promotion initiatives including: lack of interest, the need to align information on the potential benefits of workplace health promotion with perceptions relating to healthy behaviours so that employees can contextualise the information provided, and the need to develop initiatives targeting specific employee needs. These results are similar to those of Nöhammer et al. [29].

The present findings support the concept that to improve employee participation in designed initiatives, engaging with them during the development of an initiative is key to the success of health promotion projects. Conducting a needs assessment is a key part of the development of health promotion initiatives in the workplace. Finding out the health needs of the employees, and involving employees early in the design and development of initiatives is critical. Although none of the participants expressed that they would appreciate being part of the teams that deliberate and decide on which health promotion initiatives would be conducted, involvement of representatives from the intended target recipients of these initiatives is necessary [30 –35].

Although the findings of this study are most applicable in a South African setting, they may be relevant in international contexts, given the universal applicability of workplace health promotion and the growing need for the implementation of wellness programs in the workplace. Gathering context-specific data for a particular organisation allows for the identification of limiting factors of past health promotion attempts. This in turn aids in the design of tailor-made health promotion initiatives in the future. Reluctance to engage with employees with regards to health issues has been noted in several organisations, even though the need to tailor health promotion initiatives according to the needs of employees has been reported [36 –39].

Some of the most common reasons why workplaces implement health promotion initiatives are to raise awareness of health related issues, to reduce the rates of absenteeism, and to increase productivity at the workplace [40, 41]. The findings from the present study also supported the concept that programs designed to improve well-being within a workforce may be used to significantly and positively impact employee health and productivity, which in turn may result in reduced health care costs and absenteeism, improved employee productivity, and increased overall profitability of the organisation. The positive impact of programs designed to improve employee health has also been reported elsewhere in the literature [13 , 43].

Finally, cultural sensitivity is imperative when designing initiatives and interventions, as participants expressed their unwillingness to participate in culturally inappropriate activities. Cultural sensitivity refers to the tailoring of materials or a program such that it is suitable, acceptable, sensitive and respectful towards the culture of the people to whom it will be delivered [44]. Identifying cultural beliefs, values, and norms within a target group may be useful as these may be used as a foundation for designing targeted health promotion programs to reinforce the intended behaviour [45 –47]. Evidence from other research also supports the need to eliminate deterrents such as cultural insensitivity to attract employees to and/or to maintain their commitment to these initiatives [12 , 49].

5 Strengths and limitations of the study

The findings presented are qualitative in nature. Snowball sampling was employed, which may have introduced possible bias by excluding or underrepresenting some staff categories. The results of this study therefore may not be generalised beyond the population that was sampled. Views expressed in the SSIs and FGDs may not be representative of staff from other institutions within the country or internationally. Free responses given by the participants during FGDs and SSIs posed another limitation, as participants may have wanted to impress the researcher. During FGDs, social desirability bias may have also occurred as participant responses may have been influenced by the presence of their peers. The data generated may provide important information that could aid health promoting organisations and researchers in creating context-specific and culturally sensitive workplace health promotion initiatives. Findings may also guide future health promotion projects to effectively generate interest and action from both employers and employees, by engaging both organisers and their target populations early in the design of interventions. Another strength in the research process was the separation of key stakeholders from the support staff during data collection. By excluding their superiors from the FGDs, the support staff were better able to voice their opinions and beliefs, especially those that were negative.

6 Conclusion

Based on inputs from the key stakeholders and support staff, health promotion initiatives that address non-communicable diseases have been attempted at Rhodes University by management over the years. However, these initiatives were not well-received due to deficiencies such as their lack of cultural sensitivity and context specificity. These initiatives were also not as successful as anticipated, because they were not tailored for the intended recipients. A ‘top down’ approach, where the support staff were passive recipients of set initiatives, was employed rather than a ‘bottom up’ approach, where the staff would have been engaged in the planning of such initiatives. On the other hand, some of the factors that contributed to increased participation in these initiatives included the introduction of incentives and fun interactive activities.

Conflict of interest

None declared.

Funding

This work was supported by the Rhodes University Research Development Grant awarded to Professor Sunitha Srinivas.

Footnotes

Key stakeholders - non-academic Rhodes University staff who work as managers of the support staff.

Support staff- non-academic Rhodes University staff who work in various departments such as: catering, gardening, cleaning and laundry.

Acknowledgments

The authors wish to thank the participants for their participation in this research.

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