Lecture 3: Health promotion at the work-site

What is health promotion?

When talking about health promotion at the worksite, many things may pop up in your mind, like dealing with the (un)healthy food offered in the canteen, dealing with those who are smoking, bad sitting positions and offering fitness at the workplace.

There have been multiple generations of WHP programmes. The first programmes mainly focused on safety and quality of the products. For example, they wanted to make sure that the remains of cigarettes would not end up in the food, since some would smoke while producing food.

In the 60s/70s the focus of WHP programmes shifted to the top management. It became clear that top management experienced a lot of stress and that there was a higher prevalence of heart attacks and such among top management. Those WHP programmes focused on improving their health behaviour, by motivating them to quit smoking, exercise and eat healthy food.

The third generation of WHP programmes focused on improving medical risk factors. Now it was easier to assess things like glucose and blood pressure. Therefore, questions like Can we reduce high blood pressure/glucose/cholesterol? were asked, since risk factors like these were associated with things like strokes.

In the 80s, the fourth generation of WHP programmes shifted their focus to health improvement and health behaviour, by promoting healthy nutrition and exercising.

Nowadays, WHP programmes focus on health wellness and psychological well-being. This generation of WHP programmes will be discussed later on.

Why health promotion at the worksite?

It is important to promote health behaviour at the worksite, since life styles are connected with mortality and morbidity, but to other things as well, like absenteeism, health care costs (which are higher for those who show unhealthy behaviour) and productivity. In the USA the health insurance is based on the employer paying health care costs of employees. Therefore it is important for those employers to promote health behaviour for their employees. The more lifestyle risks/unhealthy behaviour, the lower the productivity. Each additional risk factor has been associated with a 2.4% excess productivity reduction, in medium risk employees 6.2% and in high risk employees are even 12.2% less productive.

Those with higher risks have higher rates of absenteeism. A graphic is shown on slide 11.

Smokers have a higher absence frequency (1.5x) and a higher number of absenteeism (14 days) than non-smokers). The estimated costs for a smoking employee are about 105 more euros than those for non-smokers. A risk of work disability is higher in those who are overweight and those have a higher absenteeism rate than employees with a healthy weight, about 14 more days. Employees who exercise are less often absent, but especially their absence spells are shorter.

Return investment means that when an employer invests in healthy nutrition, exercise in workplace and promoting employees to quit smoking gets less absenteeism and less additional costs in return.

Reasons to introduce WHP to the worksite are to keep employees healthy, it being a part of the business culture, reductions of indirect costs of heart failure, it being a moral responsibility towards employees, it being a desire to project a favourable corporate image, believing that WHP is an important benefit that improves employee recruitment and retention and as a means for improving employee morale and job satisfaction.

In the period of 1980-1992 there was an exponential growth of WHP prevalence in the US, and in 1992 WHP was present at about 81% of the workplaces. The most notable increases in interventions would focus on nutrition, weight control, physical fitness, high blood pressure and stress management. The most prevalent activities done were physical fitness and smoking control.

In the Netherlands, 75% of the larger companies (those with over 200 employees) have some sort of WHP activity. Their main focuses are on smoking, ergonomics/work posture and physical activity/exercise.

What are examples of WHP programmes?

Primary prevention has an orientation for prevention and promotion of health behaviour and focuses on all employees. Secondary prevention’s orientation is primarily prevention and focuses on employees who are at risk. Tertiary prevention’s orientation is to reduce the consequences of a certain condition or unhealthy behaviour. Their focus is on employees with ill health.

The Live for Life programme was designed by Johnson & Johnson to provide direction and resources to J&J employees and families that would result in healthier lifestyles. Their primary goal was cost containment. The programme consisted of health screening and health profile consultation by providing three hour lifestyle seminars, courses + (self-help) material, reward systems and regular feedback/follow-up results. The programme was supported by environmental measures, like smoking policies and healthy food in the canteen. The interventions were mixes between primary and secondary interventions, like weight control, exercise, stress management, yoga, assertiveness training and nutrition. 60% of the employees participated in at least one intervention. The results were that the favourable results after one year were still visible in the fields of weight, physical fitness, blood pressure, smoking and self-reported absenteeism. Favourable results after two years were only still visible in physical fitness and smoking.

The Staywell programme used socio-cultural processes by looking into how we can use the social context people are working in to promote health behaviour (in the workplace). An example of their method was that informal leaders and volunteers were put together in action teams and to change work environment into a healthy lifestyle and supportive environment.

The Working Well Trial, done by Sorensen et al. in 1996 was based on work-site based cancer prevention. It was a two year programme and it involved 111 worksites. Their target was dietary change and smoking cessation. There were significant but small effects on nutrition and positive, but non-significant effects on smoking.

Goetzel and Pronk did a review of the effects on assessment of health risks with feedback and found strong and sufficient evidence for a decrease in tobacco use, dietary fat consumptions, high blood pressure, total serum cholesterol levels, high-risk drinkers, number of days absenteeism due to illness or disability and health care use, and they found strong and sufficient evidence for an increase in seat belt use, physical activity and overall health and wellbeing. They found insufficient evidence for fruit and vegetable consumption, body composition and overall physical fitness.

There are two crucial elements to the effectiveness of WHP programmes. The first is the reach/participation rate. There should be a large group and high risk employees should also be included. This can be done by matching components to employees’ interests so they are interested in participating for example. The other element is the effectiveness in creating behaviour change. This can be done by individual goal setting, social support, low costs/barriers for health behaviour, activities with sufficient intensity and duration and by adjusting environmental cues.

What does the 5^th generation of WHP programmes look like?

Nowadays, the focus of the WHP programmes is on employee wellness next to health and absence of diseases. The programmes have now shifted towards targeting positive outcomes, rather than negative ones. For example work engagement, vitality and psychological capital. Now work is acknowledged as an important determinant of employee health and well-being.

Many stress management programmes focus on the individual employee. Examples of interventions like these are time management, mindfulness, relaxation training and cognitive-behavioural interventions. There is also some criticism towards these individual-focused interventions. This consists of often low participation, it often not attracting the target (stressed) population, the focus is often on those employees who do not cope adequately (‘victim blaming’) and they avoid employers having to modify any work-related causes of stress. According to Heaney and van Ryn, the first inclination may be to teach people to live with an obstacle rather than to remove or modify it.

The Job demand-control model indicates that he highest risks of psychological strain and physical illness is in the strain situation, where there are high demands and low control. An overview of this model is shown on slide 38. On slide 39 there is an overview of how job stressors can eventually influence health behaviour and therefore influence physical and mental health.

Maes et al. provided a project to promote healthier work at Brabantia, a Dutch company. Their goals were to increase health, wellness, safety and productivity and to decrease absenteeism, turnovers and accidents. They did this by creating an experimental group and a control group. Interventions on individual level (for the high risk population) consisted on referrals to physicians and dieticians, providing three group sessions of 30 minutes each and providing follow-up measurements with information regarding cholesterol and blood pressure. Interventions on individual level in the total population consisted of physical exercise during lunch break, 2-3 times a week, choice of activities, reward systems and providing professional instructors.

Examples of interventions on organisational and environmental level are interventions supporting lifestyle changes, like adjusting the canteen assortment and labelling healthy choices, on-site exercise facilities and smoking policies.

The characteristics of healthier at Brabantia were:

• • Support and active involvement management
  • Involvement of employees in planning and implementation
  • Use existing social networks
  • Multi-factorial
  • Targeting total group of employees and high risk groups
  • Interventions at individual, organisational and environmental level
  • Reward system
  • Emphasis on behaviour change
  • Continuity of interventions
  • Transferability

What is important in a job?

According to the Dutch Labour Act, the following factors are important in a job:

• Completeness of the job
• Complexity
  
  • Mix between difficult and easy tasks
• Involvement  in organizational tasks
• Autonomy
• Social contacts
• Cycle length
• Information
• Psychosocial arbeidsbelasting
  
  • Employer needs to define company policy concerting PSA
  • Focus on job strain and sexual intimidation/aggression and violence/bullying
  • Policy should be aimed at prevention, and if that’s not possible at limitation

Work conditions have changed over the year, examples are given in the table below.

The effectiveness of stress management programmes can be judged by checking the level of intervention (work environment or individual/group) and the level of prevention (primary or secondary/tertiary).