Health promotion that leads to change: what is the best approach?

Getting workplace health promotions right takes more than just a roadshow, says occupational health nurse practitioner Karen Coomer.

Picture the scene – employees attending a roadshow or lifestyle clinic and leaving with leaflets and measurements of weight, blood pressure, cholesterol and lifestyle advice. The information is provided by health professionals or sometimes machines that produce results that look similar to a till receipt.

Such initiatives could be part of an integrated wellness strategy or simply just a good idea by someone in the organisation who believes that informing employees on how to live more healthily is the way forward to reducing absence and increasing productivity. As occupational health (OH) professionals, we are used to providing advice on healthy eating, exercise, alcohol levels, managing stress, smoking and other unhealthy lifestyle habits that research tells us contribute to problems such as coronary heart disease.

Changing lifestyles

As the focus has changed from the management of traditional industrial diseases to the prevention of chronic disease, it is not surprising that employers have focused on the encouragement of healthy lifestyles for their employees. In recent years, wellness has become a business product that is now offered to companies in a variety of ways. It has also become part of health and wellness planning, with employees being offered various workplace initiatives to encourage behavioural change.

Society has shifted away from natural daily activity, where previous generations exercised more because of the absence of household appliances and a reduced use of cars. Exercise is now encouraged in the form of leisure activity. From the employee perspective, advice on healthy living does not just come from health and wellbeing professionals, it also comes in the form of multimedia information. Advice on what to do and how to live healthily are provided on a daily basis by television programmes, websites, magazines, celebrity DVDs and books. No longer are people ignorant of health advice, but this overload of information may present a confusing picture for many.

So what are the barriers to employees adopting healthy behaviours? Does the workplace and type of work have some influence on the ability to implement change? Do health professionals have a part to play in modelling a healthy lifestyle? What workplace intervention approach is effective in promoting and encouraging healthy lifestyles?

Workplace barriers

Addressing poor lifestyle choices and helping with change to healthy behaviours is often the focus of workplace health promotion and wellness initiatives. Throughout the history of work, there have always been physical and sedentary jobs – but the emphasis on knowledge workers and machinery to replace the human effort of the past has tipped the balance in favour of increased sedentary work. Over the past 50 years, it is estimated that occupation-related energy expenditure has decreased by more than 100 calories and has therefore resulted in an increase in the adult mean US body weight (Church, 2011).

Kirk et al (2011) reviewed research examining whether or not there was a correlation between adult participation in physical activity and occupational status. There was convincing evidence that supported the view that those employed in occupations demanding long work hours and low occupational physical activity often fail to achieve the recommended daily levels of activity. This may seem obvious, but there is little research examining the effect of work across health behaviours from an employee perspective. However, one such qualitative study (Payne et al, 2012) did identify four work-related themes that employees reported either promoted or were a barrier to healthy behaviour.

1. The work environment

Policies

The ban on smoking in UK workplaces reported a mixed view on its effects. A non-smoking policy reduced smoking during the working day, but increased smoking outside of work. However, a flexible working policy was seen to have a positive effect on the ability to exercise.

Convenience and temptation

The success of corporate gym memberships depended on the convenience and cost, and consequently on-site exercise facilities were seen as a more convenient option by some participants. Healthy eating appeared to be dependent on the choice available in the workplace, with unhealthy food a temptation at certain times of the day.

Workplace cultural norms

Eating, drinking and smoking were seen by some employees to be part of socialising with colleagues.

2. Business events

Lunches, dinners and travelling for business were viewed as a problem for healthy eating, drinking and exercise. Breaking the normal routine was seen as especially problematic for exercise. The temptation to overeat and overindulge was seen as an issue when away from home.

3. Being busy at work

The lack of time to exercise and eat healthily, because of working long or unsociable hours, was an issue raised by many employees. However, some also felt that this was often used as an excuse. Boredom and not being busy enough also led to eating junk food.

4. Work stress

In Payne et al’s study, “bad” and “good” days were identified. On bad days, smoking, drinking and comfort eating were reported as being used as a coping response. With regard to exercise, some employees reported that increasing their exercise had a positive effect on coping with work-related stress. On good days, some employees reported being more inclined to exercise or have a drink. For some employees, the behaviours were the same on both good and bad days.

To summarise, Payne et al’s study indicates that different interventions are necessary at both an individual and organisational level. The focus on design of work, workplace culture and appropriate organisational policies – for example, flexible working – all have a part to play alongside the traditional provision of lifestyle advice. The example set by the Investors in People framework for health and wellbeing is one such initiative that incorporates this concept of a broader strategy.

Practise what you preach

In 2012, a report from the NHS Future Forum stated: “A very strong message from our engagement is that, if we expect healthcare professionals to improve the health and wellbeing of the people they meet in the course of their work, the NHS must first ‘put its own house in order’. We further heard from patients and the public that it is harder to accept messages from the NHS if it is clear they do not follow these messages for their own health.”

So if healthcare professionals are called on to be role models, where is the evidence that they are unhealthy?

A study by Malik et al (2011) examined the health behaviour of 876 NHS new and registered nurses and found that: almost half of the sample failed to meet public health recommendations for levels of physical activity; almost two-thirds did not consume five daily portions of fruit and vegetables; and almost half ate food high in fat and sugar on a daily basis. It therefore seems that healthcare professionals do not necessarily practice what they preach – or are there other factors, similar to those identified in the Payne et al study, that prevent a healthy workplace in which to act as a role model?

Both the Boorman review (2009) and a more recent Royal College of Nursing report (2013) identified employment practices, job design and working hours as areas to focus on to promote healthy workplaces. It can therefore be argued that without this more strategic view, providing traditional individual health initiatives may well fall on deaf ears, even though they seem to be good ideas.

What should occupational health professionals do?

OH professionals are the ones that often lead on wellness initiatives, but a “light touch” is often what is requested from organisations. This is compared with a more thorough integrated strategy and policy-based initiative that risks interfering with the natural rhythm of the way businesses conduct themselves. The idea of holding a few wellness days and handing the personal responsibility of health to employees is seen as a much easier business option than examining work practices.

There is also the question of whether or not OH practice is a fit and healthy occupation. While OH professionals are seen to have the necessary education and awareness to adopt healthy lifestyles, does that translate into becoming a role model to the wider employee population?

Personal experiment

As an experiment, I conducted an unscientific case study. The practicalities of living the public health recommendations of physical activity (10,000 steps) and the daily intake of five portions of fruit and vegetables were measured using a pedometer and food diary. This took place over five different typical days of OH activity, between the hours of 8am and 6pm. My results are tabled below.

 

Activity	Steps (target 10,000)	Fruit and veg (target five a day)	Influencing factors
Working from home	765	Five	Able to plan meals throughout the day but minimal physical activity.
Full day of health surveillance (travel by car)	1,774	Four	Early start, late finish – needed to take food as the only catering facility was a “sausage bap” van.
Meeting in London (travel by train and tube)	5,839	Three	Long hours, temptation to snack on the run. Maximum physical activity due to walking.
A day at an OH conference (travel by train and taxi)	2,030	Three	Limited healthy snacks and a sandwich lunch were available.
Case management day (travel by car)	1,489	Three	Needed to plan to take own food as no catering facility on work premises. Worked through lunch.

As the results indicate, I had some control over the dietary factors during my working day but it required food planning and eating my shortfall from the five-a-day target after work. Exercise was my main problem because of the sedentary nature of my work, and the hours then available to fit in the required steps in between managing day-to-day family tasks. Practising what we preach is a harder concept when examined in practice.

So having discussed the barriers in the workplace and the difficulties in achieving public health recommendations, which workplace interventions are successful?

Successful health initiatives

The evidence for targeted workplace health interventions in those with unhealthy lifestyles is patchy. A Danish study examined whether or not workers with poor health status participated in workplace health programmes such as smoking cessation, weekly physical activity and healthy diet programmes (Jorgensen et al, 2013). The findings demonstrated that poor health behaviours were associated with reduced participation in work health programmes and that healthy workers used the programmes to support their already-established healthy behaviours. A different study concluded that there were no significant effects on weight, cardiovascular risk factors or quality of life when looking at the effectiveness of Dutch OH interventions (Verweij et al, 2013).

The use of pedometers is a popular workplace intervention and has been reviewed in relation to whether or not they increased physical activity and improved subsequent health outcomes. The conclusion was that there was insufficient evidence to assess their effectiveness because of limited and low-quality data (Freak-Poli et al, 2013).

Taking a psychological approach

In contrast to the emphasis on individuals to refrain from specific activities and habits, there is a growing body of psychological evidence that highlights the motivational theory of self-determination as a way of targeting health behaviour change. It is important to note that this theory was not formulated from clinical observations, but was formulated while studying the conditions under which people tend to thrive. It concentrates on our natural inclination to psychological growth, physical health and social wellbeing and by having three psychological needs met (Deci et al, 2000): autonomy; competence; and relatedness.

Autonomy

Autonomy refers to a need to feel as though we control our own behaviours and that there is some choice in this. Ways of doing this include: acknowledging an individual’s perspectives and feelings; exploring an individual’s values and how they relate to the behaviour being addressed; providing a clear rationale for advice given; providing effective options for change and acknowledge the option of not changing; supporting an individual’s self-initiation for change; and minimising pressure and control.

Competence

Competence is the feeling of being able to achieve our outcomes. Support for this includes: being positive that an individual can succeed; providing accurate and relevant feedback; identifying barriers to change; engaging an individual in skill building and problem solving; developing a plan that is appropriate for an individual’s abilities; and reframing failures as short successes.

Relatedness

Relatedness is the need to experience genuine support, care and trust from the community, including healthcare providers and family. Skills needed to promote this include: developing empathy; establishing a warm and positive interpersonal relationship with each individual; remaining non-judgmental; and the provision of unconditional positive regard.

Outside healthcare, video gaming is a good example of this theory in action, with games such as Minecraft providing freedom about how the game is played (autonomy), achievement rewards (competency) and the ability to play as a community on Xbox Live (relatedness). It is no wonder that such video games are so popular with children and have gained the attention of educational researchers.

Within the domain of health, examples can be seen in groups such as Weightwatchers that provide information, peer support, goals and positive feedback in a safe environment. Decision aids available from Patient.co.uk are also designed to promote patient-centred care, increase patient choice, and autonomy and involvement in clinical decision making.

Conclusion

From the evidence reviewed, the effectiveness of health promotion in the workplace is difficult to determine because of the lack of high-quality research in this area. Evidence shows that a one-size-fits-all approach to interventions is not effective, and most research recommends targeted efforts with an understanding of the views of employees. An appreciation of how difficult it is to achieve the public health targets we so readily quote, in the context of working life, may also aid the development of interventions to sustain long-term healthy behaviour.

OH practitioners are well placed to deliver motivational styles of interpersonal interaction in many different OH activities. The takeaway of this article is that the “good idea” of a lifestyle or wellbeing event should only provide measurements and leaflets if they can be interpreted into change-behaviour dialogue by using an approach that takes into account the physical, emotional and social wellbeing of people in the workplace.

References

Boorman S (2009). NHS health and well-being: final report. Department of Health.

RCN (2013). Beyond breaking point? A survey report of RCN members on health, wellbeing and stress.

Church TS, Thomas DM, Tudor-Locke C, Katzmarzyk PT, Conrad PE, Rodarte RQ, Martin CK, Blair SN, Bouchard C (2011). “Trends over five decades in US: Occupation-related physical activity and their associations with obesity”. PLoS One; vol.6, issue 5.

Deci EL, Ryan RM (2000). “The ‘what’ and ‘why’ of goal pursuits: Human needs and the self-determination of behaviour”. Psychological Inquiry; vol.11, issue 4, pp.227-268.

Freak-Poli RLA, Cumpston M, Peeters A, Clemes SA (2013). “Workplace pedometer interventions for increasing physical activity”. Cochrane Database of Systemic Reviews; issue 4.

Investors in People. Wellbeing tools.

Jorgensen MB, Villadsen E, Hermann B, Mortensen OT, Holtermann A (2013). “Does workplace health promotion in Denmark reach relevant target groups?” Health promotion International, first published online 15 June.

Kirk MA, Rhodes RE (2011). “Occupation correlates of adults’ participation in leisure-time physical activity: a systematic review”. American Journal of Preventative Medicine; vol.40, issue 4, pp.476-485.

Malik S, Blake H, Batt M (2011). “How healthy are our nurses? New and registered nurses compared”. British Journal of Nursing; vol.20, issue 8, pp489-496.

NHS Future Forum (2012). The NHS’s role in the public’s health.

Payne N, Jones F, Harris PR (2013). “Employees’ perceptions of the impact of work on health behaviours”. Journal of Health Psychology; vol.18, issue 7, pp.887-899.

Verweij LM, Proper KI, Weel ANH, Hulshof CTJ, van Mechelen W (2013). “Long-term effects of an occupational health guideline on employees’ body weight-related outcomes, cardiovascular disease risk factor, and quality of life: results from a randomized controlled trial”. Scandanavian Journal of Work, Environment & Health; vol.39, issue 3, pp.284-294.