The BELE program: The development of a holistic interdisciplinary health-promoting program enhancing work-life balance among female employees working in human service organizations in Sweden

1 Introduction

The workplace is one of the priority settings for health promotion in the 21st century [1] and to work towards a health-promoting workplace is becoming increasingly important as organizations are depending on a healthy and motivated workforce [2]. In the European countries the sickness absence has increased rapidly in human service organizations and it is critical to address the issue of workforce retention and recruitment [3, 4]. The COVID-19 pandemic exposes shortcomings that have existed in the elderly care and health care sectors for years and highlights the need for change [5, 6]. Furthermore, the COVID-19 pandemic increases the risk of sickness absence by direct infection and increasing stress and mental health disorders among the staff at the front line [7, 8]. To manage pandemics such as COVID-19 it is vital to have a mentally and physically healthy workforce [7].

Employees working in human service organizations, as social workers, elderly care staff and health care professionals, often work in environments where there are limited resources to meet client and patient needs [9, 3]. A report from the European Commission [3] stated that retention and recruitment of health workers must be everybody's business as everybody is dependent of high-quality care in one way or another throughout life. Therefore, the public health and health care sectors have to be among the most important social functions in the society [4]. In Sweden, sickness due to stressful work situations has, however, increased rapidly among women working in the areas of health care and social services in the public sector [4, 10]. Moreover, women working in health care professions have a three times higher risk of long-term sickness due to stress than men working in the same professions [4]. Women also report higher levels of work-life conflicts due to existing gender gap in the society and in the workplace, which have a negative impact on women's self-perceived health [11]. It seems crucial to provide female employees working in human service organizations with support, and appropriate health-promoting workplace interventions are needed.

Health promotion in the workplace is often a multidimensional concept, which includes both the individual and the organization. Moreover, to maintain an effective WHP, Work-Life Balance (WLB) seems to be a key issue [12]. A positive interaction between work and private life contributes to improved employee well-being [13], lower absenteeism and increased job performance [14], job satisfaction, and life satisfaction, as well as less anxiety and depression [15]. Recent research also shows that addressing the work- life interface by reducing work-life conflicts and enhancing work-life balance, improves work ability and continued workforce participation among nurses working in residential care for the elderly [16]. Moreover, a positive WLB is crucial for keeping social workers in the profession and can be used as one part of increased retention [17].

Despite an increase in WLB literature in recent decades, strategies for successful support to help employees manage their work and private life have developed slowly [18]. Interventions with a comprehensive approach in WHP, focusing on WLB, are scarcely seen. Hence, the development of a holistic health-promoting program aiming to enhance employees’ work-life balance seems crucial and adds to the WLB literature. So far, researchers and employers mainly focus on long work hours, schedules, flexible working, and family-friendly work policies [19, 20] to explain and reduce work-life conflicts and to enhance the WLB. These factors are all important, but research also shows the importance of focusing on supportive leadership, home environments, supporting networks in private life, recovery opportunities, as well as time management and reflection on life, to promote WLB [21, 22]. It is also important to focus on the individuals and their internal resources and strategies and to understand differences in the way people balance work and private life. By embracing employees as unique individuals, employee well-being can be improved and enhanced [23]. Moreover, WHP interventions focusing on female staff are scarce, even though women’s well-being and long-term sick leave differs from that of men throughout the work life [4, 24].

Thus, researchers, politicians, human resource managers and practitioners have a great task to find solutions for increased WLB among female employees working in human service organizations. One means for achieving this is appropriate health-promoting workplace interventions to ensure good health of the female workforce [25]. This paper presents the development and building blocks of the Balance of Everyday Life Empowerment program (the BELE program).

The BELE program is a result of an interdisciplinary collaboration to develop a health-promoting program that integrates parts of an occupational therapy program and health promotion strategies aimed at enhancing female employee health and well-being with a focus on WLB. In a previous study, the BELE program has shown that it promotes the female employees’ well-being and balance in everyday life [26].

We believe that it is curial for both researchers and practitioners to have access to the theoretical framework and the development of programs in this field in a more comprehensive way in order to foster collective learning. We also believe that it is crucial, not only to research factors that promote WLB, but also to study how to work with these promoting factors in the workplace. By sharing our ideas and the process of building the BELE program, this paper adds to the existing WLB literature as no program that we know of to date has used this dual theoretical framework.

2 Methods

The development and planning of the intervention program was guided by an intervention mapping approach [27] (see Table 1) and a research circle methodology [28].

3 Results

The planning- and development process of the BELE program resulted in a theoretical framework, a program structure and program content.

4 Discussion

The BELE program was developed in a WHP framework with a WLB focus to make a contribution to both WHP and WLB literature. The integration of health promotion and occupational therapy in the BELE program is new, even though the discussion of integrating health promotion and occupational therapy has been going on for decades [35]. Occupational therapy's contribution to health promotion is the focus on capabilities, skills, habits, roles, and routines from an everyday and action perspective [48], which has been seen as important to individuals in their striving to manage their WLB [21, 26]. WHP interventions at an individual level are mainly focusing on lifestyle, while the BELE program has a more holistic approach. Furthermore, the BELE program is a supplement to the dominating organizational focused WLB interventions. Combined, the strategies can be related to a more holistic approach based on comprehensive WHP.

The BELE program is developed in collaboration with female employees to improve the WLB and well-being of females working in human service organizations in the municipality. A systematic review on WHP interventions centered on women showed that WHP interventions directed at women are few and often have a focus on lifestyle elements such as physical activity [24]. There are biological, cultural and social differences between men and women, which affect the level of health [24], for instance that women working in health service professions have a three times higher risk of long-term sick leave due to stress than men working in the same profession [4]. It seems critical to develop interventions in WHP for the female population [24]. The European commission also highlights the need for interventions focusing on WLB to make the workplace more attractive for female healthcare professionals to be able to contribute to the sustainability of healthcare systems [3].

It seems thus crucial to invest in workplace health promotion, as for instance the BELE program, for improved sustainability of the workforce. Empowering female employees, through workplace health promotion including work life balance, can function as a preventive measure for coping with challenges throughout life in general [40] and thus as for instance the COVID-19 pandemic. It is vital to have a mentally and physically healthy workforce in the frontline to manage pandemics [7] and health workers retention and recruitment is important for high-quality care [3]. Hopefully the lessons learnt from the pandemic give incitement to politicians and managers in human service organizations to prioritize employees’ health to a greater extent and to acknowledge employee’s health as a resource.

Moreover, this research project is targeting a heterogeneous female working population and does not merely focus on work and family domains, which has been the main direction in WLB research [49]. To promote a positive WLB in WHP, the heterogeneity of the workforce must be considered and also include elderly, single and childless individuals [49]. Furthermore, it must be taken into consideration that “life” involves things other than childcare responsibilities, such as other caring activities, pursuing further education, hobbies or non-work-related training, in other words activities that are important to people [50]. In the BELE program, the participants were given tools to independently discover the changes they need to make in their everyday life without any “correct” directions to enhance health, well-being and WLB.

The development of the BELE program has both strengths and weaknesses. The strengths of the BELE program’s development process is the use of the intervention mapping approach, which enhances the possibility that the planned health promotion program will be effective in accomplishing its purpose [27]. The BELE program is based on theory and literature on the subject, and includes parts of and the main structure of the ReDO®-method which is an evaluated and scientifically proven profession-specific method [51]. Furthermore, the program was conducted with a participatory approach using collaboration between researchers, municipality representatives and participants in a “real world” setting. The contexts and settings were well known to the first author in the research project, as she has been working as a health promoter/planner in the municipality for several years. To know the context and the organizational culture is essential, as the information and knowledge can lead to a better tailoring of the intervention [52].

The research project and the development process of the BELE program spanned over four years and was built on the interest of the politicians, managers and employees in the municipality. There were several facilitating factors in the project. On the contextual level, the facilitating factors were political interest in the project and the willingness to provide sufficient resources over several years to ensure that the various stages of the project could be completed. On the organizational level, the managers provided great support for and interest in the project. They created possibilities for employees to participate in the various studies in the project and contributed to all employees having the opportunity to learn about the results of the project. Facilitating factors at participant level were their motivation and commitment to the research project and the development of interventions. Throughout the project, participation in the studies was high, for instance in the first study in the project [21] a majority of the target group declared their interest in participating. In the second study [22], the response rate was 76%. In the testing and development of the intervention, only four participants in the pilot groups opted out, even though the intervention lasted for six months with active participation and homework. Furthermore, the participants in the pilot groups informed their colleagues of their experience of the interventions in such a positive way that the interest in getting the opportunity to take part in the program was high among the female employees in the participating departments in the municipality. After the research project ended, the BELE program was incorporated as part of the WHP in the organization.

It is important to have knowledge of factors influencing WHP in order to appropriately plan, develop and implement interventions [53]. We believe that building a strong steering group with a mandate to make decisions and take action, starting from the need/interest that is expressed in the organization and building a good relationship and ownership between researchers and participants over several years, are important keys to success in the development and implementation of interventions. These facilitating factors have also been identified in the European commission report on recruitment and retention of the health workforce in Europe [54] where political support, pilot schemes and collaboration by stakeholders that builds trust and ownership has been highlighted to increase the probability of success in the development and implementation of interventions.

It took time, effort and persistence to keep the research project on track throughout ongoing organizational changes and political priorities. We also believe that the active participation of the HR manager played a vital role in the project, as the results of the studies in the project were continually used for the development of policies regarding workplace health promotion in the organization.

Moreover, the program content was evaluated, but one weakness is that the effect of the BELE program has not been assessed. Hence, a qualitative study that examines the participants’ perception of the BELE program shows that the program promotes both women’s well-being and balance in everyday life [26].

The ReDO®-method was evaluated, and its effect on return to work and a number of other outcome variables have been proven [31]. However, this evidence cannot be transferred to the BELE program. The evidence for the ReDO®-method takes the full program into consideration, and there is no research supporting similar effects when selecting parts of individual sessions as applied here.

Additionally, the BELE program has only been tested in a specific setting in the municipality, and the ability to make generalizations from the program must be discussed. Moreover, a cost effect and benefit evaluation should be made to further explore the effects of the BELE program.

5 Conclusions

The BELE program adds to the existing body of WLB knowledge, so far often based on a conflict approach. The development of the BELE program has been done consistently with a participatory approach, intervention mapping and innovative thinking in order to be able to meet the challenges of enhancing health and well-being among female employees working in human service organizations. The health of the employees is a resource for the individuals as well as the organization and has been identified as a key factor for management of the COVID-19 pandemic challenges.

Furthermore, an intervention focusing on a comprehensive approach to health and WLB with a salutogenic approach is new. Moreover, the integration with occupational therapy and health promotion in a WHP framework is innovative. The BELE program has shown that it enhances women’s well-being and balance in their everyday life, but it needs to be further tested and evaluated for example from a health economics perspective. It would also be interesting to explore the outcome of this innovative, theory-integrated program in comparison to other traditional, more one-sided interventions.