Identifying opportunities and barriers for introducing a workplace nutrition and health program for employees: Findings from formative research

1 Introduction

Around 4.14 million Indians are employed in the largest private employment sector of India—the Information Technology (IT) and Business Process Outsourcing (BPO) industries—across 17,000 firms of different sizes located in 50 delivery locations. This industry constitutes 8% of India’s Gross Domestic Product (GDP) [1] and contributes significantly to the economic progress of the country. However, the work style of the employees in this sector is dominantly sedentary and exposes them to detrimental obesogenic environment with unhealthy diet [2–4] work stress [5] unhealthy lifestyle contributing to the growing rate of non-communicable diseases (NCDs). Studies have shown higher prevalence of central obesity, diabetes, insulin resistance, dyslipidemia (hypertriglyceridemia), hypertension among the shift workers [6, 7] of this industry. Consequently, the economic costs of obesity and chronic diseases are high for the employers in terms of absenteeism, lack of productivity and health care claims [8, 9]. In India, the total loss in productive life years due to NCD related deaths among the working population of 25–64 years is expected to rise to 17.9 million years by 2030 from 9.2 million in 2000 [10, 11]. This would be a major barrier to economic growth of the country and a large proportion of this estimated loss is likely to be contributed by this most rapidly developing work sector. The convergence of health and economic factors highlights the importance of the workplace as an important intervention site for prevention of chronic diseases. Workplaces can be the priority settings for health promotion, as workplace impacts the physical, mental, economic and social wellbeing of not just the employees but also their families, communities and the society as a whole [12]. Workplace Health Programmes (WHPs) have been recognised internationally as one of the best ways of promoting health and reducing NCD risk factors [10] since such programmes can influence health behaviour of a large proportion of the population. This is in accordance with the 2017 National Health Policy of India that emphasizes a preventive and promotive approach to healthcare. As a result, there is an emphasis on designing employee friendly health policies and WHPs. Unfortunately, the concept WHPs as an important part of occupational health is not yet widely accepted in India. According to a survey by a global consultancy firm Watson Wyatt the main objective of providing health care plans among most Indian companies is to use it as a talent management tool to attract and retain more employees. Such health care plans are generally confined to providing insurance or annual health check-ups which yield limited benefit. A report by the Associated Chambers of Commerce and Industry of India [13] states that 43% of the top 500 companies in India do not pay much attention to employee health, while it is projected that well implemented WHPs can potentially save up to $20 billion by reducing the cost of absenteeism.

Using the Communication for Behavioural Impact (COMBI) approach as the theoretical framework for this research, a multi-component model of WHP with interventions at individual, interpersonal and organisation levels for awareness generation among the employees along with provision of an enabling environment (that includes cultural and social environment along with policies that promote, encourage and enable physical activity) [14] was proposed [15]. However, to implement the proposed model as a workplace wellness initiative, understanding the NCD risk factors of individual workplace environments and discussion with stakeholders forms a critical step of formative research [16]. This article covers the formative research carried out to identify the opportunities and barriers for developing and implementing the flexible model of strategic interventions according to the needs of the workplace.

The main aims of this study are:

(i) Assessing the opportunities and barriers of initiating a workplace health and nutrition programme by understanding the perspectives of employers and employees; (ii) Developing research tools to (a) capture the food and physical activity environment of a workplace and (b) understand the knowledge, attitude and practices (KAP) of health, nutrition and physical activities of the employees.

2 Materials and method

3 Results

I. Focus group discussions: In all 55 employees of 3 study sites participated in 7 FGDs. There were 38 male and 17 female employees with a mean age of 32.1±10.0 years (range 23–61 years). On the basis of designation, the employees holding posts of ‘Managers’ or ‘Consultants’ and categorised as senior employees were above 40 years (31%) and employees holding the position of ‘Engineers’ or ‘Associate Engineers’, categorised as junior employees were below 39 years (68.4%). Based on the content analysis of the FGDs some differences of opinion between the senior and junior employees were noted. The key findings are illustrated using the most appropriate quotes of the participants (Table 2).

II. (a) Ground truthing: Onsite observations and ground truthing indicated the presence of a large cafeteria set up in worksite ‘A’, managed by an outsourced food service management company. The cafeteria maintained the food safety norms and provided a wide range of menu but there were no strategies in place for promoting healthy food choices. It was found to be most crowded during the evening breaks. Though an enabling physical activity environment was provided, in terms of presence of all facilities like gymnasium, walking track, sports grounds, there was very low foot fall within the working hours on the observation days. Active entertainment events like dance and Zumba sessions were organised for employees on monthly basis, however employee participation remained low. The office campus had posters and danglers of health messages at different places.

The medium sized worksite ‘B’ shared a cafeteria with other business entities in the premises. There were stalls managed by different restaurant brands providing different cuisines. No special efforts to promote healthier food choices were observed. Most employees were observed to opt for ‘Indian Combo’ meals consisting of cereals, vegetarian or non-vegetarian curries during lunch time. Although there were no facilities of physical activity at worksite ‘B’, the management was reported to encourage employee participation in physical activity events such as 5-K runs and marathons.

In worksite ‘C’, there was no cafeteria but a small common dining space with options of coffee vending machine and packaged cookies, biscuits and packed sweetened drinks. No facility for enabling physical activity was found but there was a designated smoking area within the premises.

Although there were designated wellness coordinators in all the companies, they were not trained wellness workers but were regular employees with an additional responsibility assigned to them. The ground truth observations on the food and physical activity environment of the worksites according to the pointers of the checklist is presented in Table 3.

Based on the above discussed results, the following opportunities for development and implementation of a WHP were identified:

The focus group discussion with the employees revealed that most employees possessed basic nutrition knowledge and were keen on knowing about certain health and nutrition areas. This indeed is an opportunity to identify the relevant areas of interest to the employees for designing nutrition and health education materials for the nutrition and health program at the worksites.

However, the probable barriers identified that could hinder the implementation of the WHP are:

The junior (younger) employees considered themselves as non-susceptible to NCDs. This positive bias can hamper their interest and participation in the WHP and also impact the effectivity of such programs.

(b) Development of questionnaire: An item pool of 92 questions was generated for the closed-ended Health, Lifestyle and Food Questionnaire (HLFQ). After content validity, irrelevant, repetitive or confusing questions were removed and a few necessary questions were added. In the section on general health status, questions on self-reported NCDs and perception of risk of developing NCDs were added. The questionnaire thus finalized had 60 items under five broad sections. In addition to these the sixth section consisted of a food frequency questionnaire to assess the frequency on consumption of fruits, vegetables, cereals, lentils, egg, chicken, meat, fish, milk, sweets, savouries, fats and oil in the past one month.

As a result, 10 items were included in personal profile section, 6 items on general health status (after removing 2 items which were marked as irrelevant and merging of two questions regarding usage of sugar or artificial sweeteners into one question), 20 on dietary practices, 8 on lifestyle and physical activity and 16 items were on stress and sleep pattern.

There are limited mandating policies towards implementation of preventive health programs in the workplace in most work sectors in India [28] and the importance of such policies have been highlighted in earlier studies [29]. The aim of this study was to look at the feasibility of a WHP from two different perspectives: the employees’ perspective about susceptibility to NCDs and willingness to participate in a WHP; and perceived need and support for initiation of such programmes from the senior management of the worksites.

In the current study, it was observed that although the knowledge about healthy and unhealthy foods was good, the attitudes and practices of the junior employees towards healthy eating were not in tandem with their knowledge. Among most of them, food choices were only taste driven and they cared a little for the wholesomeness or healthfulness of the food. Such self-reported traits have been reported in another study among corporate employees in India where the behavioural, lifestyle and dietary risk factors for NCDs were found to be higher among the younger age group (26–32 years). The study also stressed the need to take early preventive measures to control the loss of productive days among this population [30].

In general, most nutrition and wellness programmes aim to address the behaviours of the priority groups, but it is necessary to understand that the people are likely to be at different stages of behaviour adoption. Thus, they usually need different messages and sometimes different approaches of communication [31]. Different stages of behaviour adoption can generally be described as precontemplation, contemplation, preparation, action and maintenance [32]. Many studies conducted across the globe report that over 50% of adults, in general, are in precontemplation stage. They have a poor understanding of the association between healthy diets and the prevention of chronic disease and do not acknowledge the need for any change in their eating habits and are more concerned about palatability of the food than health [33–35]. These attitudes are driven by ‘optimistic bias’. In the current study, such attitudes were observed among the junior employees who believed that they were not at risk of developing NCDs and were rather careless about their dietary habits and lifestyles. However, some studies report that adults with health risks like prediabetes, hypertension or familial history are likely to be in the ‘preparation stage’ making conscious food choices as they recognize the importance of healthy eating but often do not remain committed to it [36]. Similarly, in the current study, the senior employees who had some prevalent health issues or NCDs were likely in the ‘preparation stage’ making conscious food choices. Hence a workplace is a unit where the population is in different stages of behaviour change that must be addressed through custom-made workplace intervention programmes. The above findings clearly indicate that nutrition knowledge, though important, is not the only determinant of eating behaviour [37]. There is a need of schema building and proactive role of educators to develop nutrition and knowledge intervention framework that could result in behaviour modification.

An earlier study has stressed on the importance of focusing on issues relevant to employees of a particular service industry while designing components of employer delivered health program [16]. For the development of such a framework, different factors at organisational as well as at individual level should be the determinants for designing a WHP.

In this study, the ground truthing data revealed that despite the availability of facilities for an active workstyle, the utilisation by the employees was very limited. The participants in the FGDs mentioned work pressure, inability to manage time, impact on appraisals, lack of energy as the barriers for complete utilisation of the facilities. Genin et al. pointed out that such facilities can be put to better use by employees if they are already inclined towards physical activity while the inactive ones are likely to show lesser interest in getting involved citing a host of work-related pressures [38]. For promoting better utilisation of the existing facilities, it is essential to go beyond mere provision of the facilities and create an “active culture” at the workplace by involving the managers.

For bettering the food environment and promoting healthy food choices among the employees, strategies such as ‘priming’ of healthier food options can be utilised as a part of the workplace wellness programmes. Priming is a psychological effect in which exposure to a stimulus through visual/auditory/olfactory cues is found to influence a person’s choice [39]. Studies have reported effectiveness of health goal driven incidental cues in promoting healthier food choices [39, 40].

Considering that the food and physical activity environment, enabling facilities may differ from one organization to the other based on their scale and extent of operation, the most important determinants for building a safe, healthy and nutritious workplace need to be assessed. The checklist developed as part of this study and the ground truthing approach used can be useful tools to adopt and assess the organizational factors for designing a context specific WHP.

The successful implementation and utilisation of a WHP depends on the knowledge framework of the employees. The success of any WHP depends on employee engagement³⁷. The lifestyle, knowledge, perception and practices of the employees at the individual level would impact their engagement and utilisation of facilities if provided. The HLFQ developed for this study can help in collecting such data and thereby designing the education component for the WHP with a focus on practical strategies to improve nutrition knowledge, self-efficacy of making healthy lifestyle choices.

As reported by Justesen et al. [41], the middle managers play a vital role in successful implementation of WHP but often face difficulty in engaging employees or show reluctance in taking actions. Similar obstacles were faced in this study, as mostly the role of wellness coordinator is an added responsibility to an employee apart from his usual job role hence the role is often neglected resulting in lack of coordination of the health educators and employees. Proactive personal initiatives by the managers and their competence in decisiveness, risk taking, flexibility, persistence and pragmatism can change the work environment and is a major driver of success of workplace health initiatives [42]. Mattke et al. reported that consideration of wellness as an organizational priority by senior managers is a key facilitator of successful WHPs [43]. In this study at all the study sites the senior managers agreed on the importance of implementation of WHP but believed that health depends on individuals’ priority and not on worksite policies. On the other hand, employees felt until worksite policies are made for participation in such programmes it might affect their appraisals. Similar employee and employer related barriers are reported in another study [29]. The regional guidelines for the development of healthy workplace WHO suggests changes at both the organizational level in terms of improved working conditions, support for healthy lifestyles and provision of health information and education at the employee level must go on simultaneously [44]. Our proposed model of WHP is in tune with that [15]. Unless the workplace itself is healthy and safe, education will not be effective in improving the overall health status of the workforce. The promotion of lifestyles conducive to health and the development of personal health skills are keys for building a healthy workplace.

The strength of this study is in examining all the possible determinants for successful implementation of a WHP, which included the dynamic interrelations between perspectives of employees and employers as well as the work environment. However, the small sample size, specific industry and workplace location are the limitations of the study due to which the generalizability of observations may be limited. However, the methods and corresponding research tools used in this study can be useful for mapping the opportunities and barriers for evolving customised WHPs elsewhere.

5 Conclusion

This formative study paved the way for development of targeted WHPs for the organizations by addressing the issues of optimistic bias, unhealthy food choices, gap between nutrition awareness and practices. The WHPs also encompass food environment modifications and physical activity promotion through individual and group level education/counselling sessions, demonstrations and by supporting the policy change at the management level.

Conflict of interest

The authors declare no conflict of interest.