How effective are health promotion programmes in improving employee health and what is their impact on reducing presenteeism and absenteeism? Debbie Davies offers a critical review of the available research.
Whitaker and Baranski (2002), Thornbory (2013) and Hutchinson and Wilson (2011) have all emphasised that one of the main functions of OH is health promotion. Many of the research projects and previous literature reviews on health promotion have suggested a causal effect, but there are limitations in the studies resulting from a combination of a variety of weaknesses within the research projects: small study groups; lack of consideration of all confounders such as gender, age, education and health status; and limitations with the quantitative data that can be drawn from the assessment tools employed (Cancelliere et al, 2011; Reidel et al, 2001).
Aims of the review
The aims of this systematic review were to:
- determine whether or not health promotion programmes reduce presenteeism and absenteeism;
- ascertain whether or not there is a causal relationship between health promotion and improvements in individual health; and
- identify which interventions have a positive, negative or nil effect on improving health.
Methods and study selection
The Cochrane Library, PubMed, Embase and other electronic databases were searched for research since 1984 and then reduced to those published between 1994 and 2014. The aim of the literature search was to locate studies where workplace health promotion interventions resulted in improvements in health behaviours, reductions in sickness absence and other factors on a range of health-related outcomes.
The articles were then narrowed down to those where at least one author was affiliated with an institution or organisation in the UK or Eire. A data extraction form was and a STROBE checklist was used to assess the robustness of the studies. STROBE is an international, collaborative initiative of epidemiologists, methodologists, statisticians, researchers and journal editors involved in the conduct and dissemination of observational studies, with the common aim of STrengthening the Reporting of OBservational studies in Epidemiology.
Of the research included in this review, five studies evaluated workplace health promotion programmes designed to improve the health and wellbeing of the employees and the occupational impact this has on productivity and absenteeism. Two studies reviewed the impact of national schemes designed to improve cardiovascular health when implemented in the workplace. One overall level of behavioural change after attending a workplace health check. Another study assessed the effects of two health risk appraisal interventions on lifestyle parameters, mental health and work ability, and one further study reviewed the effectiveness of a work-based smoking-cessations programme.
Whether or not workplace health promotion programmes are effective is reliant on the awareness and motivation of employers to provide such programmes. It is therefore important to collate evidence that will convince employers of the value of health promotion within their businesses. Companies should then implement programmes that are appropriate and satisfactory for employees to achieve the best outcomes for both the business and the individuals that participate in them.
It is important to consider whether or not these interventions have a positive effect on improving health and whether or not the research focus needs to be in areas that are important for businesses such as sickness absence rates, and performance and productivity. The interventions should therefore target those conditions, which account for the highest levels of absence and measure the outcomes for the business. Consideration needs to be given to the challenges posed to small and medium-sized companies and how these can be addressed. It is important that any initiatives support a business strategy and comprehensive OH service, which includes health promotion as an important aspect of that strategy, alongside the national focus on trying to improve public health.
When considering the methodological quality of the outcome evaluations in these reviews, four core criteria can be considered as affording consistent evidence of effectiveness. They are:
- of the 10 studies reviewed, six employed a control or comparison group with corresponding outcome measures and socio-demographic variables;
- nine out of 10 reported pre-intervention data;
- five reported post-intervention data, which was collected using the same measurements as pre intervention; and
- the majority (nine) of the studies evaluated all of the outcomes targeted in the aims of the evaluation.
Therefore, six studies met all of these criteria and can be considered as providing reliable evidence of effectiveness. The main shortcoming was the failure to utilise a corresponding control/comparison group. It is therefore not possible in nearly half of the reviews to make a strong case for workplace health promotion, as the evidence is not sufficiently rigorous for the benefits in relation to health and/or other outcomes.
In addition, most of the interventions were evaluated only in regard to short-term effects. Of the studies within this review, follow-up intervals ranged from immediately following the intervention to five years. Half only followed up for intervals of six months or less, four followed up for intervals up to 12 months and only one study followed up at intervals up to five years.
Consequently, there is a need to investigate the longer-term maintenance of these short-term effects. This fits with other studies (Mhurchu et al, 2010; Hutchinson and Wilson, 2011), which have shown that irrefutable evidence of the value of workplace health promotion programmes is not yet available.
In view of the very small number of studies with evaluation outcomes that can be considered to prove the effectiveness of the workplace health promotion programmes, it is difficult, based on this evidence, to make recommendations other than in relation to ensuring better engagement from employees.
Reducing absenteeism and presenteeism
One of the aims of this review wasto determine whether or not health promotion programmes reduce presenteeism and absenteeism. It is therefore disappointing that measuring the impact of health promotion interventions on employee absence and/or presenteeism is lacking in most of the studies reviewed.
Those studies that have commented on absenteeism, McEachan et al (2011) and Blake et al (2013), have not collected any quantitative objective data but relied on the self-report of the individuals participating in the studies.
Recent studies by Nagami et al (2010) and Krueger and Killham (2011) have indicated that a lack of physical wellbeing is a guide for reduced work productivity, plays a fundamental part in absenteeism and is also directly associated to performance in the workplace.
None of the studies within this review appear to have considered presenteeism when evaluating the outcome of the interventions that were instigated. This may, in part, be due to the difficulty measuring presenteeism as there is a lack of objective measurement tools.
The Center for Mental Health has highlighted that, in spite of the scale of the problem caused by presenteeism, there is a distinct lack of research into this significant element of employer productivity loss.
While several studies, (Zhang et al, 2010; Sogaard et al, 2010; and Schultz et al, 2007) have shown that chronic health conditions often contribute to presenteeism, a recent study by Merrill et al (2012) has recognised that the most frequently acknowledged factor contributing to presenteeism is “having too much to do and not enough time to do it”.
Lack of resources, financial stressors and personal issues were also major factors resulting in presenteeism, and this is once more consistent with previous research (Aronsson et al, 2000; Cocker et al, 2011). These factors were all more significant in relation to difficulty concentrating or performing at one’s optimum in the workplace than physical health restrictions or depression and/or anxiety.
These findings suggest that factors related to personal and perceived workplace pressure and stress have more of an adverse effect on presenteeism than physical ill health. Therefore, while health promotion interventions aimed at improving physical health and nutrition may have some positive impact on decreasing presenteeism, more benefit is likely to be achieved by targeting psychological issues and emotional resilience.
While the costs to business and the economy in general of dealing with poor mental health identified at work have been the focus of attention by policy makers in Europe and elsewhere in recent years (Dewa et al, 2007; McDaid and A-La Park, 2011), less attention has been given to evaluating the economic costs and benefits of promoting positive mental health at work.
There are many approaches that can be taken to mental health promotion in the workplace. These interventions can include: flexible working arrangements; career progression opportunities; ergonomics and environment; stress audits; improved recognition of risk factors for poor mental health by line managers; and emotional resilience training.
Musculoskeletal disorders include conditions such as low back pain and joint injuries and are the most common workplace illness in Great Britain, affecting 1.1 million people each year.
Beaglehole et al (2011) have highlighted the importance of physical activity as a public health priority. This is also supported by Das and Horton (2012) and Jarret et al (2010) who have reported the benefits of increased physical activity on the health of the population because individuals who exercise are healthier and less likely to be overweight than those that do not.
However, the evidence for a positive impact on productivity and sickness absence among individuals who have an active lifestyle is inconsistent. Bernaards et al (2009) and Alavinia et al (2009) did report an association, whereas Pronk et al (2004) and Jans et al (2007) have seen the opposite association between exercise, sickness absence and reduced workplace efficiency.
Financial and resource constraints
One of the main questions that needs to be answered when businesses implement a workplace health promotion is what they want to achieve from the intervention.
If the intention is to improve the overall health of their employees, with the expectation that this will also have a positive impact on attendance and productivity, then careful consideration needs to be given to how they intend to engage those employees that would benefit most from the intervention.
On the whole, health promotion programmes are voluntary and there is evidence from studies by Linnan (2001) and Goetzel (2008) that a common problem is a fairly low participation rate. It is therefore imperative that not only does the programme meet the needs of the business, but also what the employees want, otherwise they are unlikely to engage, and take up will be low.
A health needs assessment should be carried out specific to the population within the company before planning the intervention to achieve the needs that have been identified from the assessment.
The Rand Health review (Mattke et al, 2012) suggests that just 46% of employees undergo screenings or complete health risk assessments, 21% take up fitness programmes and only 10% participate in weight-loss initiatives. Very few employers evaluate the effectiveness of their health promotion and the Rand review found that while the 600 employers surveyed were extremely confident in the effectiveness of their programmes, only 2% reported actual cost-savings estimates.
Challenges for small and medium-sized businesses
With the majority of the UK workforce employed by a small company (less than 250 employees), it is imperative to understand the barriers and challenges to adopting workplace health promotion programmes in small businesses. Certain measures for managing risk, such as OH provision, are considered to be costly and therefore some small companies may take the decision to reassess the necessity for this approach to health management on financial grounds.
As a result, there have been a number of approaches devised in order to deliver OH advice within the SME market, including an NHS Plus SME helpline, the Constructing Better Health scheme, Scotland’s health at work SME toolkit and both the Welsh and English SME helplines.
The Faculty of Occupational Medicine (FOM) has suggested that SMEs do not necessarily require a traditional doctor-and-nurse-based service but could benefit from simple and sector-specific guidance on practical measures; the aim being to improve health and to prevent health risks at work and those issues that surround the effects of health at work. Alternative frameworks have been recommended to include the establishment and provision of OH helplines and websites for those needing help.
The Fit for Work initiative (2014) is intended to fill the gap for those SMEs that do not have access to OH services and has recently been implemented as a pilot, with a rollout to the rest of the UK to take place over the next few months.
Overall, the results from this review were not able to determine whether or not health promotion programmes reduce presenteeism and absenteeism. This is mainly because of the lack of specific objective measurement of these factors, which allow a causal link to be demonstrated.
More research is needed to prove empirically that there is a link between these programmes and improvements in health and work place productivity.
Although many workplace health promotion programmes are in progress in the UK, many programmes have either not been formally evaluated or much of the information is unpublished.
Interestingly, this review has highlighted that a more important and challenging factor than whether or not workplace health promotion programmes should be implemented is how they are actually planned, executed and their effectiveness assessed.
There needs to be a focus on developing a partnership between the employers and employees that involves the employee in the process. Higher management needs to be visible, show wholehearted support for, and get involved with, the workplace interventions. Employees from all levels of a company should be part of the design and implementation of the interventions and the programmes should be adapted for the specific needs and characteristics of the intended participants.
It is in the interest of employers to promote the health and wellbeing of their employees. Initiatives such as stress audits, healthy eating and physical activity programmes have, overall, a good return on investment. Benefits shown include: reducing staff turnover; reducing presenteeism and sickness absence; and improving morale.
More research needs to be done, but it is also worth considering whether those involved in the provision of health promotion want to spend valuable time carrying out meticulous research or if their time would be put to better use just getting on with the job at hand.
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