Questions raised about the quality of studies reporting return on investment from workplace health promotion initiatives make it worth examining what can be done. Dr Paul J Nicholson sifts through the evidence.
The Cochrane Collaboration is undertaking a review of the evidence for workplace activities directed toward the most prevalent lifestyle health risks – tobacco, alcohol, diet and physical inactivity (Wolfenden, 2016).
Meanwhile, we can draw some conclusions from existing systematic reviews and meta-analyses. These suggest that overall workplace health promotion programmes yield a small positive effect (Rongen, 2013) and that this evidence of small benefit contrasts with the widespread use of such programmes (Osilla, 2012).
As with any intervention or programme, the effectiveness will depend, in part, on “what, when, where, who and how”. Understanding and addressing the prevalent risks for the individual workforces is key; as is identifying individuals’ readiness to make changes. Both are sometimes assessed through the use of health risk appraisal (HRA) tools.
Early research based on few studies found weak evidence regarding the impact of HRA alone on health-related outcomes and suggestive evidence for the effectiveness of HRA when implemented as part of a comprehensive workplace health promotion programme (Anderson, 1996).
A more recent review adds to the evidence that assessment of health risks with feedback is useful as a gateway intervention to a broader workplace health promotion programme, especially when it includes health education lasting for an hour or more or repeated several times a year (Soler, 2010).
For health promotion programmes, there is some evidence of what does and does not work from systematic reviews and reviews thereof. It is important to note one caveat: while properly performed systematic reviews provide much higher-quality evidence than the many low-quality ROI studies, we need to consider aptness.
Systematic reviews place the randomised controlled trial (RCT) at the apex of the quality hierarchy; however, RCTs were designed to compare treatment with no treatment or one treatment against another. It may not be the most apt type of study for many public health interventions.
Nonetheless, systematic reviews do identify and rank studies for interference by bias, confounding, etc; problems that plague many ROI studies, and which consequently mean that we should take note of their findings. Additionally, systematic reviews published prior to mid-2007 have been reviewed and the findings synthesised by others (Hill, 2007; Sockoll, 2009).
Health promotion interventions designed to increase physical activity raise levels of physical activity among employees (Hill, 2007; Sockoll, 2009; Viullemin, 2011) and may also help to prevent musculoskeletal disorders (Soler, 2010).
However, a systematic review that included more RCTs than earlier reviews concluded that while there is some evidence of efficacy, overall the results are inconclusive (Commissaris, 2016).
It seems to be that while there is evidence that regular physical activity is associated with a decrease in risk factors for several chronic diseases, there is no, or only limited, evidence of positive effects on direct health outcomes, such as muscle flexibility, body weight, body composition, blood lipids, blood pressure and general health (Malik, 2013; Soler, 2010; Sockoll, 2009).
One review reported: limited evidence of effect for absenteeism; inconclusive evidence for other work outcomes (job satisfaction, job stress and employee turnover); and no effect on productivity (Sockoll, 2009). A subsequent systematic review reported inconsistent evidence of worker productivity and consistent evidence of no effect on sickness absence (Pereira, 2015).
Where studies showed some benefit, they involved occupations with higher physical loads, compliance and programme intensity (Pereira, 2015). Programme success may depend on taking a multi-faceted approach, including: elements of individual advice; health promotion; and environmental interventions – for example, access to fitness facilities (Soler, 2010; To, 2013).
This is likely to be more effective than single measures implemented in isolation – for example, while it is purported that programmes which include pedometer use are more likely to be effective (To, 2013), there is insufficient evidence for the effectiveness of pedometer interventions alone (Freak-Poli, 2013).
Diet and obesity
While there is limited to moderate evidence that workplace education and healthy food options at work improve diet (Feltner, 2016; Geaney, 2013, Maes, 2012; Mhurchu, 2010), it is not clear whether they are effective in influencing weight loss (Sockoll, 2009).
At best, there is only limited evidence that such interventions prevent weight gain (Gudzune, 2013).
Even when dietary interventions are combined with physical activity, there is only moderate-quality evidence for modest weight loss and only in the short-term – six to 12 months (Anderson, 2009; Lee, 2008; Verweij, 2011).
However, there is strong evidence of the effectiveness among those at risk of cardiovascular disease (Groeneveld, 2010); consequently, this is a group of employees who should be targeted for such interventions.
Those of us who have spent decades educating people to stop smoking are aware that the prevalence of smoking has fallen remarkably in that time; perhaps leaving a hardcore group of dedicated smokers.
Therefore, we should not be surprised that the evidence demonstrates that workplace smoking cessation interventions have some initial effectiveness, but the effect decreases over time (Rongen, 2013) and the absolute numbers who quit are low (Cahill, 2014).
Workplace health promotion interventions are only effective among those who are prepared to quit; so employers should use a range of interventions to meet the different needs of employees at various stages of readiness to change (Carroll, 2013).
There is evidence that cessation is more likely when interventions are directed towards individuals (Cahill, 2014). Smoke-free workplace policies reduce consumption considerably during working hours (Sockoll, 2009) and may be more effective than health promotion activities (Hill, 2007).
Initial findings suggest that workplace programmes on alcohol-related problems are worth doing. However, the lack of evaluation studies makes the evidence weak (Sockoll, 2009). Brief interventions, those contained within health and lifestyle checks, psychosocial skills training and peer referral have potential to produce beneficial results (Webb, 2009).
Another systematic review reported that health promotion programmes were associated with significant reductions in consumption, but the evidence for effects on absenteeism was insufficient (Osilla, 2012).
Brief interventions involving assessment of and feedback about individual lifestyle risks – including those delivered by web-based media – are accessible, acceptable and impact a broad range of employees (Nicholson, 2016). This includes staff who are drinking at risky levels and those dependent on alcohol (Cercarelli, 2012).
One RCT concluded that alcohol screening and brief intervention performed alongside health and lifestyle assessments in the workplace may be effective in reducing alcohol intake, and that alcohol screening may in itself lead to reduction in drinking (Hermansson, 2010). Web-based brief interventions are acceptable, they reach penetration target groups, and impact drinking behaviour (Cercarelli, 2012).
With the lack of access by UK workers to occupational health support, e-health initiatives should offer opportunities to use specialist staff time more cost-effectively.
As noted earlier, there is evidence for the effectiveness of assessment of health risks, with feedback as a gateway to a broader workplace health promotion programme.
A meta-analysis of RCTs that evaluated 82 different computer-delivered health promotion interventions concluded that such programmes can help individuals to make immediate improvements in health-related knowledge, attitudes and intentions; and modify health behaviours such as diet, tobacco use, substance use, safer sexual behaviour and general health. The evidence did not support their use to improve physical activity or weight loss (Portnoy, 2008).
Discussion and conclusions
The workplace can be an appropriate and effective setting for tackling health risks and improving the health of individual employees and working populations. Indeed, health promotion is not something new, although the reason for doing it in terms of being a caring employer may have shifted to being cost and productivity driven – albeit based on debatable evidence.
Workplace wellness programmes may reduce health risks, but employers should not take for granted that the lifestyle management component of such programmes reduces costs or leads to net savings (Caloyeras, 2014).
Whether or not individual workplace health promotion activities are effective and cost effective will depend on whether the health needs of the workforce have been properly assessed, and careful planning is needed for evidence-based programmes that respond to the identified needs. Clearly, OH professionals are well placed to lead such assessments and plan effective programmes.
It would be naive for a health needs assessment of a workforce to only look at personal health and lifestyle risks. Employee wellbeing is not just affected by individuals’ genes and lifestyle, but also by their job and workplace (Bryson, 2014).
Extensive literature identifies the characteristics of jobs that influence wellbeing at work. They are: job demands; opportunity for control; variety; environmental clarity; opportunity for skill use; supervision; interpersonal contact; fairness; pay; physical environment, career outlook; and significance (Bryson, 2014).
Attending to individual lifestyle risks without looking at organisational risk factors is unlikely to be productive – and possibly a case of choosing the easy wrong over the difficult right. At worst, health promotion might be perceived as being introduced as a smokescreen to detract attention from poor workplace conditions or a toxic culture.
Workplace health promotion activities should be supported by policies that promote healthy work and workers and environmental interventions, such as healthy food options in canteens or walking routes.
As well as assessing the diverse occupational and individual risk factors to determine the appropriate organisational interventions, success also depends on identifying each individual’s readiness to implement behavioural changes. Obviously, time spent trying to persuade someone to change their habits when they lack intentionality reduces the cost-effectiveness of the programme.
Likewise it seems the current interest in programmes to enhance employee resilience seems hypocritical if employers fail to pay as much attention to managing the sources of stress at work. The growing interest in employee wellbeing increases the risk that programmes will be implemented with an off-the-shelf approach.
However, it also presents the opportunity for OH practitioners to influence what programmes are delivered, to whom and how, and to ensure that employers recognise their wide responsibilities to ensure safe and healthy work and prioritise investment and interventions accordingly. This includes providing access to comprehensive OH services – and not just health promotion.
Just as there is heterogeneity in primary studies, systematic reviews also present their conclusions in varying styles, making it difficult to summarise the results in a consistent way.
Bearing in mind these limitations, one can rank health promotion activities according to the strength of evidence for effectiveness based on available scientific studies and which are worth considering.
Occupational health clinicians also have the opportunity to take a holistic approach and apply the evidence during consultations by offering tailored wellbeing advice to those who attend, such as for occupational health surveillance, and who might have lifestyle risks and are ready to change.
Dr Paul J Nicholson is an occupational physician.
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