Using organization theory to understand the determinants of effective implementation of worksite health promotion programs

The field of worksite health promotion has moved toward the development and testing of comprehensive programs that target health behaviors with interventions operating at multiple levels of influence. Yet, observational and process evaluation studies indicate that such programs are challenging for worksites to implement effectively. Research has identified several organizational factors that promote or inhibit effective implementation of comprehensive worksite health promotion programs. However, no integrated theory of implementation has emerged from this research. This article describes a theory of the organizational determinants of effective implementation of comprehensive worksite health promotion programs. The model is adapted from theory and research on the implementation of complex innovations in manufacturing, education and health care settings. The article uses the Working Well Trial to illustrate the model's theoretical constructs. Although the article focuses on comprehensive worksite health promotion programs, the conceptual model may also apply to other types of complex health promotion programs. An organization-level theory of the determinants of effective implementation of worksite health promotion programs.     

Factors influencing participation in worksite smoking cessation and weight loss programs: the Healthy Worker Project

Worksite intervention for health behavior change has attracted much recent interest as a potentially cost-effective way to promote healthier behaviors in the general population. In evaluating the impact of health promotion activities, it is essential to consider the entire work force rather than just self-selected participants. Overall, recruitment results reported to date have varied widely. There are a large number of factors pertaining to both employee and worksite characteristics that could contribute to variability in how well worksite health promotion programs attract employees. A critical issue that has received little research attention is the dynamics of participation in employee health promotion programs as they are offered repeatedly over time. The present study examined participation rates and contributing factors in worksite health promotion programs for weight loss and smoking cessation in the Healthy Worker Project, a randomized trial of worksite intervention conducted among 16 intervention and 16 control worksites in the Minneapolis/St. Paul metropolitan area between 1987 and 1990. Data analyses focused on characterizing individuals enrolling in worksite health promotion programs in comparison to those in the worksite population as a whole who would be considered in need of such programs.     

A review of health-related outcomes of multi-component worksite health promotion programs

PURPOSE: The purpose of this article is to critically review evaluation studies of the health-related effects (i.e., health risk modification and reduction in worker absenteeism) of multicomponent worksite health promotion programs. SEARCH METHOD: A comprehensive literature search conducted under the auspices of the Centers for Disease Control and Prevention identified 36 articles that examined health-related outcomes of multi-component programs. The authors identified 11 additional articles through manual searches of recent journal issues and through personal contacts with worksite health promotion researchers. Forty-seven studies describing the results of 35 worksite health promotion programs were reviewed. IMPORTANT FINDINGS: The worksite health promotion programs reviewed for this article varied tremendously in the comprehensiveness, intensity, and duration of the intervention activities. All of the programs provided health education to employees. In a majority of the programs, opportunities to learn and practice new skills were also offered. A smaller number of programs incorporated modifications in organizational policy or the physical work environment. Results from well-conducted randomized trials suggest that providing opportunities for individual risk reduction counseling for high risk employees within the context of comprehensive programming may be the critical component of an effective worksite health promotion program. Just offering low intensity, short duration programs aimed at increasing awareness of health issues for the entire employee population may not be sufficient to achieve desired outcomes. MAJOR CONCLUSIONS: The results of the studies reviewed provide both cautious optimism about the effectiveness of these worksite programs and some general guidance as to the critical components and characteristics of successful programs. Overall, the evidence suggests that a rating of indicative/acceptable may best characterize this literature.     

Mental health issues in the workplace: a case for a new managerial approach.

Anger, stress, and depression in the workplace are growing concerns among management. Traditionally, health outcomes have functioned under the realm of workplace health professionals. This study assessed whether a traditional worksite health promotion program had an impact on mental health factors. The results suggested that worksite health promotion programs play a limited role in ameliorating work-related mental health outcomes. Rather, management must play a greater role in addressing workplace stress, anger, and depression.     

Corporate characteristics and worksite health promotion programs: survey findings from Fortune 500 companies

A study was carried out to assess the nature and extent of worksite health promotion programs in Fortune 500 companies. Growth and interest in worksite health promotion continues at a remarkable rate. Fortune 500 firms are a good barometer of the state of the art of programs in work settings because these companies have large numbers of employees, an interest in cost savings, and expertise to invest in innovative efforts. Data collection consisted of questionnaires sent to the medical officer or Chief Executive Officer of all companies appearing on the 1984 Fortune 500 list. The following issues were addressed: whether companies offered worksite programs; what health promotion activities were provided in their programs; whether organizations had plans to start up or expand programs; what organizational support existed for programs (i.e. who pays, on whose time employees participate, when activities are offered, and what types of personnel are hired to staff programs); and whether these companies applied needs assessments, evaluation and cost analysis in their programs. Differences in these characteristics were examined in relation to the organizational variables of size (number of employees), Fortune 500 rank and type of industry (low-technology versus high-technology). The response rate for the survey was 49.4% (n = 247). Results of the study indicate a high level of health promotion activity in Fortune 500 firms. Out of the total group of respondents, two-thirds (n = 164) report having worksite programs and two-thirds of organizations with programs have plans to expand their health promotion offerings. One-third of responding organizations without programs planned to initiate them. The health promotion activities provided are numerous and varied, and within units that have programs rates of employee eligibility are reported to be high. However, the participation rates reported are appreciably lower. It is of special interest that, in general, the higher ranked, larger and high-technology companies are more likely to have programs; offer more activities in programs; have plans for program expansion; use a model of sharing costs of, and time to participate in program activities; make greater use of health professionals; and utilize more often needs assessment, evaluation and cost analysis techniques. The results of this study underscore the importance of examining a broad constellation of factors surrounding worksite programs. Given the organizational literature reviewed, it is likely that the characteristics of Fortune 500 programs documented here will serve as models for programs in midsize and smaller companies.     

Building program participation: strategies for recruitment and retention in worksite health promotion programs

Building program participation is vital for all health promotion programs. There are a large variety of strategies that have been used to enhance recruitment and retention in worksite health promotion programs. Many of these strategies are examined and their significance in the design and operation of health promotion programs in worksite settings is reviewed.     

Worksite health promotion programs in the U.S.: factors associated with availability and participation

PURPOSE: To examine how the availability of and participation in worksite health promotion programs varies as a function of individual (e.g., age), organizational (e.g., occupation), and health (e.g., high blood pressure) characteristics. Availability of worksite programs was also compared to that reported in two previous national surveys of private companies. DESIGN: Data analyzed were from the 1994 National Health Interview Survey (NHIS), a national cross-sectional probability sample of the U.S. civilian population. SUBJECTS: Five thousand two hundred nineteen NHIS respondents met the inclusion criteria of (1) being currently employed in a company of at least 50 employees, and (2) completing the NHIS section on worksite health promotion. MEASURES: Employees indicated the availability of, and their participation in, 33 different types of worksite programs. National Health Interview Survey data were also available regarding general health, blood pressure, body mass index, and medical conditions. RESULTS: Smoking cessation programs had the highest mean availability (43%), followed by health education programs (31%) and screening tests (31%). Overall, availability of worksite programs appeared comparable to that reported in a recent national survey. Participation ranged from 32% for health education programs to 5% for smoking cessation programs. Compared to availability, participation depended less on individual and organizational characteristics. Healthy employees were not consistently more likely to participate in worksite health promotion programs than nonhealthy employees. CONCLUSIONS: Although availability of worksite health promotion programs remains high, participation by employees in specific types of programs can vary widely. Attempts to increase participation should look beyond individual, health, and organizational variables, to specific features of the work environment that encourage involvement in health promotion activities.     

Assessing the effects of health promotion in worksites: a review of the stress program evaluations

In a recent issue of Health Education Quarterly, Chen(1) reviewed the evaluations of worksite health promotion programs published in health education journals from 1980 through June 1983. He found few evaluations in the literature that used either quasi-experimental or experimental designs. This paper reviews the evaluations of stress reduction programs in the worksite, most of which were either published outside of health education journals or unpublished. Over one-half of the studies used either experimental or quasi-experimental designs in the evaluations. This suggests that reviews of worksite health promotion program evaluations must encompass journals from a variety of disciplines. Recommendations for improving the evaluations of stress reduction programs in the worksite are included.     

A model for worksite cancer prevention: integration of health protection and health promotion in the WellWorks Project

OBJECTIVES. To describe a theoretic approach and rationale for the integration of health protection and health promotion in worksite cancer prevention programs and to describe an intervention study designed to implement this integration. METHODS. Twenty-four worksites were recruited to participate in this randomized, controlled study. The theoretically based intervention model integrates health promotion and health protection through (1) joint worker-management participation in program planning and implementation, (2) consultation on worksite changes, and (3) educational programs targeting health behavior change. RESULTS. Although the primary purpose of this paper is to describe a theoretic approach to the integration of health promotion and health protection, preliminary results are also noted. In these predominantly manufacturing worksites, many workers faced the double jeopardy of exposures to occupational carcinogens and personal risks such as smoking or poor dietary habits. Production workers' job responsibilities frequently limited their full participation. Barriers to participation were identified early in the project, and strategies were developed to facilitate maximal worker involvement and worksite changes. CONCLUSIONS. Lifestyle changes such as smoking cessation or dietary changes may be more effectively promoted among blue collar audiences when programs also encourage management actions to reduce occupational exposures. Public health professionals trained in health promotion and health protection must work together to effectively address the health concerns of this population.     

Health promotion and industry. Where interdisciplinary research meets reality.

Health promotion and disease prevention programs are now a common part of worksite life. Their acceptance has been based more on faith than scientific evidence of their effectiveness or benefit to either the companies or the participants. Evaluation research in worksite health promotion offers an opportunity to test the effectiveness of the programs and should be done using the methods of several disciplines: organizational psychology, industrial hygiene, and health education. Because of the inherent difficulties in planning, developing goals and objectives, and measuring outputs in worksite health promotion programs, any effective evaluation will have to combine methods and approaches from each of these perspectives.     

Using theory to understand the multiple determinants of low participation in worksite health promotion programs.

Low participation at the employee or worksite level limits the potential public health impact of worksite-based interventions. Ecological models suggest that multiple levels of influence operate to determine participation patterns in worksite health promotion programs. Most investigations into the determinants of low participation study the intrapersonal, interpersonal, and institutional influences on employee participation. Community- and policy-level influences have not received attention, nor has consideration been given to worksite-level participation issues. The purpose of this article is to discuss one macrosocial theoretical perspective--political economy of health--that may guide practitioners and researchers interested in addressing the community- and policy-level determinants of participation in worksite health promotion programs. The authors argue that using theory to investigate the full spectrum of determinants offers a more complete range of intervention and research options for maximizing employee and worksite levels of participation.     

Integrating occupational health, safety and worksite health promotion: opportunities for research and practice

BACKGROUND: There is emerging evidence that coordinating and integrating worksite health promotion and occupational health and safety enhances the effectiveness of efforts to promote and protect worker health, and growing attention internationally to the importance of integrating worksite health promotion and occupational health and safety. OBJECTIVES: (1) To present the rationale and scientific evidence for coordinating and integrating worksite health promotion and occupational health and safety as a means of enhancing the effectiveness of efforts to promote and protect worker health; and (2) to discuss recommendations for research priorities and future directions. METHODS: Review of the literature, drawing mainly on studies from the United States and Europe. RESULTS: The strongest evidence available supports the efficacy of this intervention model in promoting smoking cessation, particularly among blue-collar workers; some evidence additionally indicates significant effects for other health behaviors. Little evidence is available to date documenting the impact of these programs on occupational health and safety outcomes. Conclusions: Priority research directions include: social epidemiological research to identify key work-related factors associated with hazardous occupational exposures and risk-related behaviors, and to identify the underlying causes of social disparities in worker health; methods development research aimed at developing both appropriate measurement tools and new intervention approaches; efficacy and effectiveness studies to examine the effects of integrated interventions on both occupational health and safety outcomes as well as health behavior changes; assessments of the process of intervention implementation, including intervention implementation evaluation, cost assessments, and process-to-outcome assessments; and dissemination and durability studies, to identify strategies to promote the sustainability and dissemination of evidence-based programs.     

Results of the 2004 National Worksite Health Promotion Survey

Objectives. We examined worksite health promotion programs, policies, and services to monitor the achievement of the Healthy People 2010 worksite-related goal of 75% of worksites offering a comprehensive worksite health promotion program.Methods. We conducted a nationally representative, cross-sectional telephone survey of worksite health promotion programs stratified by worksite size and industry type. Techniques appropriate for analyzing complex surveys were used to compute point estimates, confidence intervals, and multivariate statistics.Results. Worksites with more than 750 employees consistently offered more programs, policies, and services than did smaller worksites. Only 6.9% of responding worksites offered a comprehensive worksite health promotion program. Sites with a staff person dedicated to and responsible for health promotion were significantly more likely to offer a comprehensive program, and sites in the agriculture and mining or financial services sector were significantly less likely than those in other industry sectors to offer such a program.Conclusions. Increasing the number, quality, and types of health promotion programs at worksites, especially smaller worksites, remains an important public health goal.Worksites are important public health settings because the majority of US adults spend considerable amounts of time at work, and the work environment exerts an independent influence on employee health. Addressing both the work environment and individual health behavior is essential to producing gains in employee health.1^–3 In addition, the “health” of a business depends on strategies that manage both business costs and employee health care costs. Thus, tracking employer efforts to promote health is warranted.In the United States, the first national worksite health promotion survey was conducted in 1985, and follow-up surveys were conducted in 1992, 1999, and 2004. These surveys serve as national benchmarks and as indicators of change over time. One major worksite health–related goal included in Healthy People 2010 is to increase to at least 75% the number of employers that offer a comprehensive health promotion program for employees.4^,5 We examined data form the 2004 National Worksite Health Promotion Survey to monitor the prevalence of worksite health promotion programs, policies, services, and supportive environments and to assess the implications of the survey’s results for public health practice and research.     

Betriebliche Gesundheitsförderung durch Arbeitsgestaltung und Unternehmenskultur

The article discusses worksite health promotion in the sight of work science and work design. Firstly, several conceptual factors of the health-oriented work science and work design are sketched, for example: an integral process-oriented definition of health, the health-oriented objectives of design, the extended stress-strain-concept, a psychological structure model of health-oriented actions, the strategy of participation-oriented design of work, the concept of differentiated and dynamic work design. Secondly, a few results of worksite health promotion by work design are described. Health circles are integrated into planning of a new production centre within the framework of a participation-oriented reorganization project. Another project is dealing with stress observation/evaluation and stress coping at computer-aided mental work.     

A short history of occupational fitness and health promotion

The suggestion of a linkage between adequate exercise and occupational health dates back to Ramazzini's classical observations on cobblers and tailors. However, excessive hours of work at too high an intensity were of greater concern than increase of fitness or health promotion in the early phases of the industrial revolution. Loss of physical condition is a more recent phenomenon, and it can be traced to automation in industry and the home, progressive urbanization, and widespread use of the automobile. The Canadian government has seen worksite fitness and health promotion programs as convenient tactics to reverse this trend. Exercise programs apparently yield a healthier and more effective labor force, and major corporations have thus followed the government's lead in developing fitness and health promotional facilities as a part of personnel or occupational health departments. Some health economists have suggested a substantial return upon such investment, but most corporations still regard the promotion of fitness and a healthy lifestyle as an expression of good citizenship. Currently, unifocal fitness programs are being replaced by modular health programs that address a wide range of lifestyle issues, including nutrition, stress relaxation, cigarette addiction, and drug abuse. The purpose of the present brief review is to trace from a personal perspective the development of an interest in employee fitness as an important component of occupational health programs over the past 300 years. The linkage of this phenomenon to the changing human demands of the worksite will also be explored.     

Threats to internal validity in worksite health promotion program research: common problems and possible solutions

Reviews of the research on worksite health promotion programs reveal that most studies are limited in their ability to draw clear inferences about program effects because the studies employed flawed research designs and/or analyses. Conclusions are often drawn about program effectiveness with little consideration given to alternative explanations for the findings. In an effort to promote improved research, this article uses the Cook and Campbell delineation of threats to valid causal inference to illustrate how the threats can operate in worksite health promotion program research as well as how they can be examined and controlled. Researchers, even those attempting to conduct true experiments, must consider the existence of all plausible threats to validity and control or rule them out before valid causal inferences can be drawn. The theoretical and design issues involved in worksite health promotion program research are presented, followed by a discussion of threats to internal validity.     

Worksite Health Promotion

Although the significant majority of employers offer health promotion programs, for most companies the size and impact of existing programs is minor. Recent research has yielded substantial data in support of worksite health promotion activities, from both medical and economic perspectives. Yet despite this compelling information, corporations have been slow to incorporate more substantial health promotion activities.Employers must come to see that an investment in employee health promotion programs is an investment in their workforce, likely their greatest asset. The impact of health promotion programs needs to be viewed not simply in the context of a business operations cost. In the face of rapidly escalating healthcare costs, successful health promotion programs have the potential to reduce those expenditures as well as enhance employee performance, resulting in improved business productivity.To be effective, worksite health promotion programs must be implemented in a systematic manner. To gain senior management support, education regarding the principles of health and productivity is critical. Program selection and implementation must be carefully planned, reflecting the health promotion interests, needs, culture and resources of the organization. Objective, easily measurable parameters of program quality and outcome must be identified prior to program implementation, in order to assess program effectiveness, from both employee health and business productivity perspectives. Collaborative data review through regular reporting can identify program strengths and weaknesses, leading to corrective modifications.