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

Abstract

BACKGROUND:

Despite an increase in work-life balance literature, the development of successful support to help employees manage their work -life balance is slow. Moreover, there are few interventions with a comprehensive approach to workplace health promotion focusing on work-life balance.

OBJECTIVE:

This paper aims to present the development and building blocks of a holistic interdisciplinary health-promoting program, the BELE program, to enhance female employees working in human service organizations health and well-being with a focus on work-life balance.

METHODS:

The planning and development of the program was done through an intervention mapping and research circles methodology.

RESULTS:

The planning- and development process of the program resulted in a theoretical framework, and a program structure with a program content. The intervention program was named “The Balance in Everyday Life Empowerment program” (BELE program).

CONCLUSIONS:

The BELE program adds to the existing body of work-life balance knowledge, so far often based on a conflict approach. Interventions focusing on a comprehensive approach to health and work-life balance with a salutogenic approach are rare. Furthermore, the integration with occupational therapy and health promotion in a workplace health promotion framework is innovative. In a previous study, the BELE program has shown that it enhances women’s well-being and balance in their everyday life.

Keywords

Program planning and development workplace health promotion work-life balance public health occupational therapy

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.

1.1 Aim

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].

Table 1
Activity and time period for the development of the BELE program; the steps of intervention mapping

Time Activity

Step 1 and 2 Needs assessment and objectives

January, 2010 Contact with the municipality, a steering group was created for the

June, 2010 research project. The objectives for the project were defined. A literature review was conducted.

August, 2010 New data of the WLB phenomena were collected in the municipality, one

June, 2012 qualitative and one quantitative study was conducted. Furthermore, there were constant discussions and collaboration with the steering group, managers and employees’ in the organization.

Step 3 Theoretical methods and practical strategies

August, 2012 Literature review - interventions including self-analysis and reflection of everyday life. The ReDO®-method was selected.

September, 2012 The ReDO®-method was discussed in the steering group for the research project. Contact was made with the researcher, in occupational therapy, developing the ReDO®-method. Collaboration was started.

November, 2012 Two occupational therapists from the municipality were trained in the ReDO®-method and the first author, representing public health science, participated as well.

Steps 4, 5, 6 and 7 Designing the program, adoption, implementation and evaluation

December, 2012 The “workgroup” in the research project constructed a pilot program.

February, 2013 The pilot program was discussed in the steering group and with all supervisors and managers in the social department and domestic service department. An invitation to participate in the research project was sent out to all employees inboth departments.

March, 2013 Four research circles with employees started testing and

August, 2013 discussing the pilot program. Focus group interviews were conducted with all four groups at the end of the program. Furthermore, a survey was conducted.

August, 2013 Revision of the program, and a few small changes were made. The program was named “TheBalance in Everyday Life Empowerment program” (The BELE program).

Time	Activity
Step 1 and 2	Needs assessment and objectives
January, 2010	Contact with the municipality, a steering group was created for the
June, 2010	research project. The objectives for the project were defined. A literature review was conducted.
August, 2010	New data of the WLB phenomena were collected in the municipality, one
June, 2012	qualitative and one quantitative study was conducted. Furthermore, there were constant discussions and collaboration with the steering group, managers and employees’ in the organization.
Step 3	Theoretical methods and practical strategies
August, 2012	Literature review - interventions including self-analysis and reflection of everyday life. The ReDO®-method was selected.
September, 2012	The ReDO®-method was discussed in the steering group for the research project. Contact was made with the researcher, in occupational therapy, developing the ReDO®-method. Collaboration was started.
November, 2012	Two occupational therapists from the municipality were trained in the ReDO®-method and the first author, representing public health science, participated as well.
Steps 4, 5, 6 and 7	Designing the program, adoption, implementation and evaluation
December, 2012	The “workgroup” in the research project constructed a pilot program.
February, 2013	The pilot program was discussed in the steering group and with all supervisors and managers in the social department and domestic service department. An invitation to participate in the research project was sent out to all employees inboth departments.
March, 2013	Four research circles with employees started testing and
August, 2013	discussing the pilot program. Focus group interviews were conducted with all four groups at the end of the program. Furthermore, a survey was conducted.
August, 2013	Revision of the program, and a few small changes were made. The program was named “TheBalance in Everyday Life Empowerment program” (The BELE program).

2.1 Program context

The main parts of the BELE program were developed as part of a larger participatory research project in a municipality in the south of Sweden. The research project was organized with a steering group and a work group with participants from the municipality, Kristianstad University and Lund University. The groups are described under the heading Participants.

Sweden is a welfare state, with parental, elderly and childcare benefits, mostly funded by taxes. The municipalities are self-governing local authorities, and they are large employers. In the current municipality, there were about 1,300 employees working in different areas such as education, caring, etc. The municipality introduced the “TimeCare” computer scheduling program in 2010, which enabled employees to influence their work schedules. Furthermore, the HR department in the municipality worked actively with prevention and promotion in the work environment, using policies and various activities. Before the research project started, the municipality worked with a sustainable work environment project with the first author as a health promoter/planner.

2.2 Participants

2.2.1 Steering group

The steering group consisted of four public health scientists from Kristianstad University and the Chairman of the Social Welfare Board (the Social Welfare Board consists of politicians who have responsibility and make decisions regarding the Social care department), the HR manager, five managers and five employees from the Social care department and the department for domestic services in the municipality. The steering group made decisions about the different steps to be taken in the project.

2.2.2 Work group

To design the intervention program for the current research project, a work group was created, consisting of two occupational therapists in the municipality, the occupational therapy researcher (last author), and the public health researcher (first author).

2.2.3 Pilot groups

All employees’ in the social care department and the department for domestic services in the municipality were invited to participate in pilot groups to test the intervention program developed in the research project. An information letter was sent out by email to all employees in the two departments. The employees also received oral information about the intervention from their manager at a workplace meeting. Participation included being a participant in a pilot group to test and discuss the intervention program and take part in an evaluation process. Employees who wanted to participate in the development process reported their interest to their manager. All employees who were interested in participating were included (n = 29).

The first version of the program was tested and discussed in four pilot groups of participants (n = 29). Each group consisted of 5–8 participants. The program lasted for a six-month period. In total, 25 employees finished the entire program. Reasons for dropout (n = 4) were quitting the job during the period or could not find the time to participate and therefore decided to opt out of the program.

The participants in the pilot groups were women aged 23 to 64. The women had different life situations, some were single parents with child/children, and others lived with child/children and partner, some lived alone or with a partner. The main professions were registered nurses and assistant nurses, personal assistants, social workers and cooking staff.

2.3 The planning and development of the program

The research project started with a dialog between the participating municipality and Kristianstad University with the purpose of finding research and/or methods aiming at enhancing female employees WLB in the municipality. The interest in enhancing employee WLB arose from a previous project for a sustainable work environment in the municipality. The overall aim of the project was to prevent sick leave and to promote health among employees in the social care department.

The first step in the research project was to create a steering group for the project. The participants in the steering group also communicated the research project throughout their networks in the municipality. For instance, the chairman of the social welfare board informed politicians on the social welfare board about the project. Furthermore, researchers and participants in the project were regularly invited to the social welfare board to present activities and results from the studies conducted in municipality.

2.3.1 Needs assessment and objectives

Initially, a literature review was conducted in the research field of WLB and discussed in the steering group for the project. The literature review gave few results, since our questions focused on factors that enhance balance, while the WLB field often has a conflict approach [29]. Therefore, to be able to answer our questions, two studies aiming to identify resources for WLB were conducted in the municipality [21, 22]. One study was qualitative [21] and one was quantitative [22]. Both studies were conducted in collaboration with the steering group, the HR department, as well as managers and employees in the included departments in the municipality.

The two studies [21, 22] highlighted the importance of including both the organization and the individual in order to enhance WLB. Resources associated with WLB were for instance to reflect on and discuss life, being healthy and taking care of yourself, recovery possibilities and a perception of a positive time experiences in both private life and work life [21, 22]. Unfortunately, the individual level in WLB literature is scarcely studied, as the research mainly focuses on the organization. However, individual WLB strategies play an important role in helping employees achieve better health [13]. In comprehensive health promotion, the importance of working with both the setting (organization) and the individual is highlighted as vital to accomplish conditions for health, well-being and empowerment [30].

As recommended by WLB research, the social care department and the department of domestic service in the municipality were already working with schedules, flexible work and family-friendly work policies [19, 20]. Therefore, the steering group decided that the research project should focus on methods/ programs that highlight the individual level with a comprehensive approach to WLB and health. With that as a background, the next step in the project was to find a method or program to use as an intervention in the municipality.

As a foundation for the intervention, the steering group discussed what could be expected to change as a result of the intervention, and how this would affect the health, well-being and WLB of employees. The main objective selected by the steering group for the intervention was to focus on reflections on and discussions of everyday life in relation to well-being, health and WLB.

2.3.2 Theoretical methods and practical strategies

When the objectives were set, another literature review was done searching for possible intervention methods/programs that matched the objectives of the project. No method or program that fully match our objectives was found. Therefore, the steering group decided to develop a new program/intervention that corresponded to the objectives of the research project.

In the literature review, the occupational therapy method ReDO® was found and discussed in the steering group, and it was decided to explore opportunities to develop contributions to the intervention. Collaboration with the researcher that developed the ReDO®-method was initiated.

Two occupational therapists working in the municipality were trained in the profession-specific ReDO®-method [31], and the first author participated. The ReDO®-method is a profession-specific method, and the occupational therapists were trained to become certified as group leaders. The advantage of educating and involving the two occupational therapists in the research project was that it enhanced and maintained the development process and the implementation of the intervention, both during the project and after the project was completed.

2.3.2.1.The redesigning daily occupations; ReDO®-method:The Redesigning Daily Occupations; ReDO®-method [31] was originally developed for women with stress-related disorders. The aim of the group-based intervention is to facilitate health and return to work, which is addressed by knowledge of the complexity and health impact of the repertoire of everyday occupations. In this context, the term occupation refers to all things people do in their everyday life; working but also taking care of themselves, their family and home, resting, as well as the things they do in their leisure time [32]. In the ReDO®-method, the participants are introduced to how they can analyze their own everyday activities themselves, in terms of e.g. occupational balance and patterns of everyday occupations, to find strategies for how to adjust their daily occupations and adapt their patterns to improve their health and work capacity. The ReDO®-method is based on occupational therapy and occupational science theories, and more specifically on previous research on the complexity of women’s everyday work [33, 34]. The intervention method, i.e. the ReDO®-method, is ™ed. For a more detailed description of the ReDO®-method, see Erlandsson [31].

2.3.3 Designing program and adoption

To design the intervention program for the current research project, a workgroup was created. The development of the program started with discussions in the workgroup regarding possibilities to use parts of single sessions in the ReDO®-method and how to fit them into a WHP intervention. Three specific sessions from the ReDO®-method were chosen: occupational balance, pattern of everyday occupation, and occupational value. In addition, the goal setting strategies were borrowed from the ReDO®-method. The original sessions were rearranged to fit the target group in this project, a ”healthy” working population. The main foci of the selected sessions were self-reflection for identifying resources and solutions in everyday life.

Furthermore, we discussed what subjects and parts of the previous WLB research on resources conducted in the municipality [21, 22], and other research in health promotion and WLB, should be included in the program.

The two occupational therapists and the occupational therapy researcher (last author) focused on the themes, including daily occupation and everyday repertoire, while the public health researcher (first author) was mainly responsible for the themes, including health competence, WLB and health promoting factors in the work environment. The remaining themes, which included lifestyle, stress, sleep and goal setting were developed together to include both an occupational therapy and a public health perspective. After deciding what to include in the themes, we started designing the program materials, including different tools for self-analysis and discussions. After the contents and themes of the program were finalized, we made a decision on the structure of the program. The structure of the program is presented in Table 2.

Table 2
Themes and contents of the BELE program

Session Theme Content

1 Program introduction Information about the program, themes and content, rules at the group meetings and presentation of participants and leaders. Homework: Vision board

2 Health / health competence Brief seminar: what is health, determinants of health and health competence and how can you promote it? Self- analysis: The health arrow, a scale from 1–10, on perception of one’s health. Homework: how to feel better? What needs to happen? etc.

3. Workplace health promotion/Work-life balance Brief seminar: what is workplace health promotion? The impact of the psychosocial and physical work environment on employees’ health and well-being. Discussions about work/private life interaction. Self- analysis: How do I feel about my work? My WLB? Homework: inventory of one's resources as a person in both private life and work life

4. Occupational balance^* B riefseminar: What is an occupation? What is occupational balance? Discussions about role theory and role balance/conflict. Self- analysis: a 24-hour circle with occupational categories to illustrate different amounts of time “today” and “how you would want it to be in the future” Homework: reflection on how to accomplish “future circles”

5. Occupational pattern^* Brief seminar; time perspectives, daily hassles and uplifting experiences, occupations in an unbroken set/mindfulness. Self- analysis: Identify hassles and uplifting experiences. Homework; The participants wrote a daily diary at home for session 6.

6. Occupational value^* B riefseminar: discussion about occupational values and self-rewarding occupations. Self -analysis: the daily diary is illustrated as a function of occupation and time. Homework; to do two self-rewarding occupations.

7. Stress / sleep Brief seminar: what stress means, how stress affects your body and mind, coping strategies. How sleep affects your body and mind, how to promote a good sleep. Self-analysis: a stress test and a relaxation exercise with discussions afterwards. Homework; to write a sleep diary during one week and to reflect on unwinding in everyday life.

8. Lifestyle Brief seminar; physical activities and diet habits in relation to health and well-being. Self-analysis; what my lifestyle pattern looks like. How I feel about it. Homework; to reflect on the course so far and set some goals to work on for improved well-being

9. Goal setting / action plan Brief seminar; what the goal and the action plan are and how to work with them. Self-analysis; to decide which goal to startwith, based on all self-analysis exercises in the program. Homework: continue with the action plan

10. Action plan / roundup Further discussions on action plans and a roundup of the program. An evaluation of the program.

11. Reunion / follow-up After three months, the group got together again and did a follow-up on goals and action plans.

Session	Theme	Content
1	Program introduction	Information about the program, themes and content, rules at the group meetings and presentation of participants and leaders. Homework: Vision board
2	Health / health competence	Brief seminar: what is health, determinants of health and health competence and how can you promote it? Self- analysis: The health arrow, a scale from 1–10, on perception of one’s health. Homework: how to feel better? What needs to happen? etc.
3.	Workplace health promotion/Work-life balance	Brief seminar: what is workplace health promotion? The impact of the psychosocial and physical work environment on employees’ health and well-being. Discussions about work/private life interaction. Self- analysis: How do I feel about my work? My WLB? Homework: inventory of one's resources as a person in both private life and work life
4.	Occupational balance^*	B riefseminar: What is an occupation? What is occupational balance? Discussions about role theory and role balance/conflict. Self- analysis: a 24-hour circle with occupational categories to illustrate different amounts of time “today” and “how you would want it to be in the future” Homework: reflection on how to accomplish “future circles”
5.	Occupational pattern^*	Brief seminar; time perspectives, daily hassles and uplifting experiences, occupations in an unbroken set/mindfulness. Self- analysis: Identify hassles and uplifting experiences. Homework; The participants wrote a daily diary at home for session 6.
6.	Occupational value^*	B riefseminar: discussion about occupational values and self-rewarding occupations. Self -analysis: the daily diary is illustrated as a function of occupation and time. Homework; to do two self-rewarding occupations.
7.	Stress / sleep	Brief seminar: what stress means, how stress affects your body and mind, coping strategies. How sleep affects your body and mind, how to promote a good sleep. Self-analysis: a stress test and a relaxation exercise with discussions afterwards. Homework; to write a sleep diary during one week and to reflect on unwinding in everyday life.
8.	Lifestyle	Brief seminar; physical activities and diet habits in relation to health and well-being. Self-analysis; what my lifestyle pattern looks like. How I feel about it. Homework; to reflect on the course so far and set some goals to work on for improved well-being
9.	Goal setting / action plan	Brief seminar; what the goal and the action plan are and how to work with them. Self-analysis; to decide which goal to startwith, based on all self-analysis exercises in the program. Homework: continue with the action plan
10.	Action plan / roundup	Further discussions on action plans and a roundup of the program. An evaluation of the program.
11.	Reunion / follow-up	After three months, the group got together again and did a follow-up on goals and action plans.

^*For details, see Erlandsson, 2013.

2.3.4 Implementation and evaluation

When a first version of the program was completed, the program was reported to and discussed in the steering group. Furthermore, it was discussed with all managers and supervisors in the social care department and domestic service department. The purpose to introduce the intervention program widely was two-fold, as it gave an opportunity for adoption and implementation in the organization as well as an education opportunity.

The occupational therapists and the public health researcher (first author) carried out the intervention as group leaders. The first author was group leader in all pilot groups and represented the public health perspective. The two occupational therapists were group leaders for two pilot groups each and represented the occupational therapy perspective.

The four pilot groups were guided by a research circle methodology [28]. Each session had its own topic for discussion, related to WLB and health. In the discussions and the exercises, new knowledge of the WLB phenomenon was enhanced and documented as field notes by the first author. The field notes were used both in the evaluation of each session in the program and for gaining new insights and ideas to be used in the research project as a whole. Each session was discussed and reflected on by the group leaders after each session was completed, and a summary was written. Examples of questions that the group leaders reflected on were “What happened in the group today?” “What was the motivation like?” “Was anything different than you expected?” Moreover, all sessions with the participants started with reflection on the previous session in the program.

After the program was completed, it was evaluated using a short questionnaire, and four focus group interviews where all participants were included. The questionnaire included questions about the content of the program, how they had experienced the program, how they had experienced the group leaders and the group, and whether the program had influenced motivation, knowledge and action to achieve goals, as well as whether the intervention had affected their everyday life, work-life balance and health. Furthermore, we asked for their ideas about improvements.

In the focus groups interviews, the overall questions were “What experience do you have of the program?” and “How has participating in the program affected you in relation to your well-being and work-life balance?” To read the results of the focus group interviews, please see Agosti [26].

After the data collected from field notes, questionnaires and focus group interviews had been compiled, some minor changes were made in the program. The changes made were adding diet and physical activity as a new theme, “lifestyle”, and the stress and sleep themes were united. The intervention program was named the “Balance in everyday life empowerment program” (the BELE program).

After the pilot testing of the intervention, the interest in taking part in the BELE program was high among the employees in the participating departments. Therefore, the municipality decided to offer all interested employees in the social care department and the department of domestic service to participate in the BELE program and to implement the program as a part of the WHP in the organization.

2.4 Ethical considerations

Participants in the pilot groups were informed that their participation was voluntary and that they had the right to withdraw from the study at any time. Before the program, the participants gave their informed consent to participate in writing. They were also informed that confidentiality would be preserved. If it was discovered in the pilot groups that any employee had a severe health problem or a problem arising from the intervention, they were referred to ordinary health care services. This study was part of a comprehensive PhD thesis work, ethically approved by the Local Ethical Review Board of Lund nr 2013/45.

3 Results

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

3.1 Theoretical framework

The theoretical framework for the BELE program has its underpinning in public health science, workplace health promotion, occupational therapy and occupational science. Occupational therapy and health promotion have similar conceptual and philosophical convictions: empowerment, autonomy and the value of the individuals. Thus, there seems to be benefits to integrating occupational therapy with a WPH model [35]. An interdisciplinary collaboration can also result in more effective outcomes in areas of health, well-being and balance of everyday life [36].

The “new public health” has a broader focus than just political and social interventions to improve people’s health. The new public health includes the determinants of health such as lifestyle and living conditions that should be maintained or improved [37]. Health promotion is defined by WHO as “. . . the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social wellbeing, an individual or group must be able to identify and realize aspirations, to satisfy needs, and to change or cope with the environment” (WHO, 1986, p.2) [38]. This definition is also in line with the goals of occupational therapy.

Moreover, the creation of the BELE program was also inspired by the EUHPID Health Development Model [39] which is based on general systems theory and explains health development as an ongoing process. Individuals’ self-regulation in a specific socio-ecological context is described as the core of a health development process, that is the reproduction of health as an integrated part of everyday life [39]. The EUHPID Health Development Model provides a theoretical foundation for various public health intervention strategies and methods related to both salutogenic and pathogenic approaches [39]. From this perspective, risk factors and salutogenic processes exist simultaneously in everyday life, with adherent positive as well as negative health-related experiences of the individual. In line with this model, the BELE program focuses on individual determinants of health as well as environmental determinants of health and considers health both an outcome of life and a resource for living [39].

The BELE program intended to create prerequisites for reflection, self-analysis, health literacy competence and power of action to improve the balance between work and private life and to promote the well-being and health of female employees. The program focuses on a combination of education and self-assessment. The BELE program is inspired by the ReDO®-method [31] and apart for using content from sessions of the ReDO®-method, the intention of the program is like that of ReDO®-method, to give the participants tools to independently discover the changes they need to make in their everyday life without any “correct” directions. Specific for the BELE program is, however, its focus on WHP with a salutogenic approach.

3.2 Program structure

The BELE program included eleven group sessions during a six-month period (see Table 2) which were led by the group leaders. There were ten program sessions, about one a week, and a follow-up session after three months. Each session lasted for two hours. The main structure of the BELE program mirrored that of the ReDO®-method [31] i.e. brief seminars, with different subjects each time. The participants were active in the seminars by making self-analyses and discussing each theme in relation to their concepts and experiences. Homework was handed out during each session and followed up at the next session. The participants defined individual goals and worked on their own action plans throughout the program. The sessions were held in a conference room near their workplace. The group sessions were held during work hours and the “homework” was done during the participants’ free time. The homework consisted of minor tasks, such as writing a sleep diary and creating a vision board.

3.3 Program content

3.3.1 Phase 1: The determinants of health, workplace health promotion and work-life balance

At the program’s first phase, which included sessions 1, 2 and 3, the concepts of health, WHP and WLB were introduced. The sessions contained research in the field, tools for self-analysis and discussions to raise awareness and give prerequisites for each participant to make changes if needed. An important feature of this phase was to enlighten the determinants of health in a wide sense to exclude “victim blaming”. To be able to discuss WHP, which includes both the social, psychological and the physical environment, linked with WLB, health and well-being, the sessions were based on the theory from the EUHPID Health Development Model [39], the Sense of coherence [40], the Job Demand Control Model [41], Role balance [42], Flow [43] and the broaden-and-build theory of positive emotions [44].

3.3.2 Phase 2: Occupational balance, occupational pattern and occupational value

At the second phase of the program, sessions 4, 5, and 6, the concept of occupation and tools for occupational self-analysis were adopted from the ReDO®-method [31]. We discussed how health is affected by the structure and experiences of daily occupations. We also explored, for example, the frequencies and characteristics of hassles as well as uplifts in the everyday life [34]. Furthermore, the concepts of time and energy were highlighted in relation to work-life balance [45].

3.3.3 Phase 3: Lifestyle, stress and sleep

The focus of phase 3, sessions 7 and 8, was to discuss and analyze lifestyle, stress and sleeping habits in relation to everyday patterns, health and WLB [45]. Interventions and information about health were highlighted as important key components that increase our knowledge and give an individual conditions and increased control to make his/her own decisions about his/her health [38]. To work with health literacy is strongly connected to empowerment, which is a key component for health promotion work [46].

3.3.4 Phase 4: Goal setting, action plans and roundup

The participants formulated their own goals during the entire program. Phase 4 focused on how to identify and describe goals and to create structured action plans. Goal setting has a statistically significant positive effect on behavior change in health promotion [47]. The importance of social support and motivation during a period of change [31] was also discussed in this phase.

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.

Footnotes

Acknowledgments

The authors wish to express their gratitude and thanks to the participants and the two occupational therapists, Helene Frejborn and Lena Strandberg, that took part and carried out the BELE program. Moreover, they would like to thank the managers and politicians in the municipality who opened up for the possibilities and resources for developing the program.

Author contributions

MTA performed this study with supervision of ÅB, IA and L-KE. All authors contributed to the concepts and design of the study. MTA and L-KE developed the BELE program in collaboration with two occupational therapists working in the municipality, the support group and participants. MTA was responsible for drafting the manuscript. All authors revised the manuscript critically and made contribution in revising the paper. All authors read and approved the final manuscript.

Conflict of interest

The authors declare that they have no competing interests.

Funding

This study was financed by Kristianstad University, Lund University and the participating municipality.

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