Overcoming barriers to employee participation in WHP programs.
Abstract: Studies have indentified many benefits of worksite health promotion programs such as decreased injuries, absenteeism, and increased productivity. However, employee participation rates remain low in many worksite health promotion programs. This article reviews barriers to participation in both comprehensive and selective programs, and suggests potential strategies to overcome these barriers.
Subject: Employers (Reports)
Medical care, Cost of (Reports)
Worker absenteeism (Reports)
Authors: Olson, Amy
Chaney, J. Don
Pub Date: 06/22/2009
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Summer, 2009 Source Volume: 24 Source Issue: 3
Topic: Canadian Subject Form: Absenteeism (Labour)
Product: Product Code: 9918630 Absenteeism; 9918660 Unauthorized Leave
Accession Number: 308743744
Full Text: INTRODUCTION

Worksite health promotion (WHP) programs began to develop over a century ago (Chenoweth, 2007). Since then, there have been numerous studies that report the benefits of WHP programs. WHP programs not only benefit the employer, but also benefit the employee and the community (National Association for Health and Fitness, 2009). According to the National Association of Health and Fitness (NAHF) (2009), some of the benefits employers receive from worksite health programs include reduced employee absenteeism, decreased rate of illness and injury, improved health care cost management, enhanced productivity, and development of employee leadership skills. NAHF (2009) describes some of the benefits for employees to include lower stress levels, increased self-esteem, increased well-being, increased stamina, and potential weight loss. The community of the worksite also benefits by being more competitive in the global market (NAHF, 2009). However, in order for these benefits to be evident, employees and their families need to participate in the WHP programs. Previous researchers such as Glasgow, McKaul, Fisher (2003) and Anspaugh, Hunter, and Savage (1996) have identified barriers to participation in both comprehensive and selective programs. These studies are reviewed and potential methods to overcome barriers are also discussed.

BARRIERS

Many WHP program administrators struggle with low participation rates. In fact, Glasgow, McKaul, and Fisher "reviewed available worksite studies that collected data on employee participation and found that only one-quarter to one-half of employees participated in health promotion programs offered in a given worksite, on average" (Linnan, Sorensen, Colditz, Klar, & Emmons, 2001, p. 592). This average is particularly low considering that more than 81% of private worksites with 50 employees or more offer WHP programs (Anspaugh, Hunter & Savage, 1996). There are various reasons why people do not participate in WHP programs. For some people, it may be the cost such as time and money (perceived barriers), and other people may not see the benefit (perceived benefits). In addition, some people may not feel susceptible to a disease or illness (perceived susceptibility). These are just a few of the many various reasons why people choose not to participate in WHP programs.

Glasgow, McKaul, and Fisher (1993) identified several factors that influenced employee participation in WHP programs. Individual perception of risk influences the decision to participate in disease prevention programs as well as how motivated and ready to change the individual is (Glasgow, McKaul, & Fisher, 1993). WHP programs need to assess employees' perception of risk and motivation level. Health risk appraisals (HRA) are tools that can be used for risk identification, risk assessment, and risk reduction (Chenoweth, 2007). A study conducted by Avis, Smith, & McKinlay (1989) assessed the use of HRAs to measure risk perception for heart attacks among employees. Nearly 56% of the respondents rated their risk as lower than average. The results showed that HRA feedback had increased awareness of perceived risk for heart attacks (Avis, Smith, & McKinlay, 1989). Employees need to be able to identify what their health risks are, so they can make an informed decision about participating in a WHP program. The employee will be less likely to participate if he or she feels the health issue is of no concern to them. As noted in Avis, Smith, & McKinlay's (1989) study, nearly half of the employees perceived themselves to be at low risk. Glasgow et al. (1993) also found that employees are more likely to participate in programs addressing multiple risk factors instead of a single risk factor especially when a health risk appraisal is conducted. For example, instead of a WHP program addressing smoking cessation only, it would be better to address several issues such as diabetes, high blood pressure, fitness, and safety. Edington, Sharp, Vreeken, Yen, & Edington (1997) stated "planning a variety of program-delivery methods such as screenings, referrals, classes, self-help materials, videos and one-on-one counseling" may assist in planning successful WHP programs. Thus, it is important that employees are aware of health risks, are ready and motivated to change, and the WHP program address a variety of health concerns.

Some other important factors that influence employee participation include managerial support, amount of time and resources required of the employee, and if any incentives are given (Glasgow, McKaul, & Fisher, 1993). Managers that actively participate in WHP programs will serve as a positive influence for employee participation (Glasgow, McKaul, & Fisher, 1993). Furthermore, activities are usually promoted more and have a larger impact when key leaders support the programs. Wellness Council of America (WELCOA) (1997) claims senior level support to be one of the most important factors in the success of a WHP program for several reasons including, but not limited to: senior management can approve budgets, can participate in the planning of the program, can communicate support of the program, and can serve as role models.

According to Anspaugh, Hunter & Savage (1996), the number one reason for not participating in WHP programs is "being too busy" (Anspaugh et al., 1996). However, Anspaugh et al. (1996) suggest that cultural influences and perceptions play a role in this concept. For example, among Hispanics, "individual health needs to be viewed in the context of the family because personal needs are often subordinated when viewed as directing energy away from the family" (Anspaugh et al., 1996). Therefore, educational and other marketing material should influence the potential benefits for the family also. For example, eating healthy will improve energy levels so more quality time can be spent with the family (Anspaugh et al., 1996). Cultural influences are not the only thing that influence's perceptions of involvement in WHP programs, but gender differences also play a role. Edington et al. (1997) found that gender affected program preferences. Men were more interested in topics such as cholesterol and blood pressure whereas women were more interested in topic such as nutrition, exercise and stress management (Edington, Sharp, Vreeken, Yen, & Edington, 1997). Edington et al. suggest investigating employees' interest for program topics and delivery methods to enhance participation (Edington et al., 1997). Thus, when marketing the WHP program it is beneficial to target the program to the individual.

Incentives also help to increase participation rates (Glasgow, McKaul, & Fisher, 1993). For example, time given off for employees to participate in the program, availability of flex time, financial incentives, and prizes can all serve as motivators to participate in WHP programs. Many WHP programs offer incentives to improve participation in programs. For example, Speedcall Corporation in Hayward, California offered a financial incentive of a $7 weekly bonus for not smoking at the worksite and within a year the number of smoking employees dropped from 24 to 5 (Chenoweth, 2007). Pepsi Bottling Group in Riviera Beach and Pompano Beach Florida allowed time for workers to participate in a mandatory pre-work stretching program which resulted in a decrease from 146 reported low back injuries to 13 within a two year period (Chenoweth, 2007). There are many different types of incentives a WHP program can use; however, it is imperative that these are incentives that the employees are interested in receiving.

In addition to the previous reasons mentioned for low participation rates in WHP programs, the following are examples of studies that were conducted that assessed barriers to participation and in some studies potential incentives to promote interest in participation. A study assessing physical activity participation among male factory workers conducted by Veitch, Clavisi, & Owen (1999) found participation barriers to include lack of awareness of potential benefits, reluctance to participate, cost, and adverse affects on productivity. In addition, Schwetschenau, O'Brien, Cunningham, & Jex (2008) assessed participation barriers at an on-site corporate fitness center and discovered that many employees were embarrassed to work out in front of other coworkers and inadequate facilities were some reasons given. Kruger, Yore, Bauer, & Kohl (2007) conducted a survey with over 4,000 respondents from various WHP programs and found the most commonly reported barrier to be lack of time. The respondents also suggested the following incentives would promote interest in participating in programs: free WHP program, convenient time, place, employer paid time off for participation during workday, healthy vending and cafeteria food choices, on-site exercise classes, weight loss programs, and fitness centers (Kruger, Yore, Bauer, & Kohl, 2007). Many of the examples given had similar barriers and others did not; however, barriers must be addressed in order to increase participation in WHP programs.

A WHP program administrator must consider all of these factors mentioned such as perceived risks, motivation, time, cost, gender differences and incentives before planning and implementing a worksite program. It is important to remember that every program is different. The WHP program administrator should also make sure that the program and incentives are tailored to meet the employees' needs and interest.

INCREASING PARTICIPATION

In order to increase participation rates it is important to indentify all of the potential barriers and minimize these barriers as much as possible. Many WHP programs in the past have lost large amounts of money by implementing WHP programs without assessing the needs and interest of employees only to find the program unsuccessful. It does not necessarily mean that the WHP program administrator did not have a good program, but the program did not meet the needs and interest of the employees or there were other barriers that prevented participation in the program. Therefore, it is crucial that WHP program administrators conduct a needs assessment before implementing a program.

NEEDS ASSESSMENT

A needs assessment will provide a better overview of the population at the worksite. Each worksite will have various needs and the program should be developed accordingly. Hodges and Videto (2005), provide several reasons why a needs assessment should be conducted before developing and implementing programs. These include "to provide a sense of connection and ownership of the program among the target population"; "to provide information needed to seek resources or funding"; "to identify barriers and limitations of a program you want to implement"; "to collect baseline data for evaluation"; "to identify programming goals and objectives"; and "to achieve the goals and objectives of our profession" (Hodges & Videto, 2005, p. 2-5). Furthermore, WELCOA (2007) present ten reasons, which coincide with Hodges and Videto, of why data collection is essential in building result-oriented wellness programs. Some of these reasons include providing a snapshot of the overall health status of employees; ensures an account of overall health status of the workforce; senior-level management are aware of the health and well-being of employees; ensures transparency for health management; provides accountability; allows measure of changes; and exhibits value to shareholders (WELCOA, 2007, p.5). Therefore, it is essential that data is collected before a WHP program is implemented. Hodges and Videto outlined some important steps to take in the needs assessment process that can be tailored to different programs. Table 1 can be used to assist WHP administrators in mapping needs assessment process (Hodges & Videto, 2005).

HEALTH BEHAVIOR THEORIES

Furthermore, WHP program administrators can apply health behavior theories, such as the Health Belief Model (HBM), Transtheoretical Model (Stages of Change), and a social ecological framework to further assess employees' needs, identify barriers and to determine effective methods to increase participation in the WHP programs. Health behavior theory provides program administrators with a blueprint for designing, implementing and evaluating successful WHP programs. In addition, theory is a mechanism for predicting and explaining health behaviors, and utilizing theoretical constructs in all phases of a WHP program is crucial for success (Glanz, Lewis & Rimer, 1997; National Institutes of Health, 1997). For example, constructs of the HBM include perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy (Sharma & Romas, 2008). A WHP program administrator that is considering a smoking cessation program may ask employees if they feel smoking is harmful to them and do they feel susceptible to the dangers of smoking, such as lung cancer (perceived severity)? What benefits are associated with participation in a smoking cessation program (perceived benefits)? Are there any barriers keeping them from quitting smoking (perceived barriers)? What programs or incentives would motivate them to stop smoking and/or participate in a smoking cessation program (cues to action)? Do they feel they have the ability to stop smoking (self-efficacy)? This information can be used to determine the intervention methods.

Furthermore, the program administrator can utilize the Transtheoretical Model in order to assess the employee's readiness to change or motivation. This allows the administrator to tailor the program to fit the employee's stage (Transtheoretical Model/ Stages of Change). For example, using the five stages in the model (precontemplation, contemplation, preparation, action, maintenance), program administrators can assess which level(s) best describe their employees motivation (or lack thereof) to engage in healthy behaviors. From this information, project administrators can provide activities, resources, and interventions on each level, to meet the needs of all employees. By addressing the different stages of readiness, the project administrator has increased the likelihood of participation of employees, because needs are being met at each level. It is important to note that individuals who are already engaging in healthy behaviors (i.e. in the maintenance stage) should not be omitted from programmatic efforts. Program administrators should provide resources, support, skills, activities, etc to prevent relapse of these employees.

According to Linnan, Sorensen, Colditz, Klar, and Emmons (2001), the social ecological model (McLeroy, Bibeau, Steckler & Glanz, 1988) suggests that "individual behavior (e.g., participation in a worksite health promotion program) is affected by multiple levels of influence: intra-personal, interpersonal, institutional, community/society, and policy" (Linnan et al., 2001, p. 592-593). For example, an employee that is interested in the smoking cessation program (interpersonal), has friends that encourage the employee to participate (intra-personal). If the company grants time off for participation (institutional), then employees will be more likely to participate in the smoking cessation program than individuals that experiences two or less of these positive influences (Linnan et al., 2001). Additionally, Eddy, Donahue, Webster and Bjornstad (2002) emphasize the use of an ecological

approach in WHP programs, and provide many examples of activities to be implemented on each level of the model (i.e. intrapersonal level--health communication activities; interpersonal level--inclusion of family members in programmatic efforts; institutional level--healthy food options in cafeterias and vending machines; community level--collaborate with community organizations to further healthy agendas; policy level--flextime policies to participate in WHP activities). In summary, health behavior theories can provide a better analysis in order to plan a more productive WHP program that is tailored to the employees needs and that will encourage greater participation.

Translation into Practice

There are many factors that may hinder participation in WHP programs such as time, culture, gender, and support. These barriers will vary among worksites. However, the authors have developed five practical guidelines to increase employee participation in WHP programming.

1. Conduct regular theory-based needs assessment.--It is a must to know the employees' needs, wants, level of readiness to change, and barriers to engaging in healthy behaviors. These items will be constantly evolving so a needs assessment should be administered on a regular basis.

2. Foster a corporate culture that supports positive health.--Research shows that healthy employees are more productive employees (Chenoweth, 2007). Employees are more likely to participate in WHP programs if positive health is woven into the mission of the company.

3. Have a menu of options available to employees.--In a time where consumers are prone to "one stop shopping," worksite health educators should adapt this notion. Worksite health promotion administrators should be able to design programs to meet the needs and interest of the employees.

4. Target your communication and interventions. --WHP programs should be framed within an ecological context, and have program components geared towards all employees regardless of the stage of readiness they may be in.

5. Conduct process evaluation to measure the key aspects of participation.--Evaluation should be a major part of any health promotion program. The WHP program administrators should be constantly evaluating program participation data including penetration, utilization, and adherence data.

REFERENCES

Anspaugh, D., Hunter, S., & Savage, P. (1996, May). Enhancing employee participation in corporate health promotion programs. American Journal of Health Behavior, 20(3), 112.

Avis, N., Smith, K., & McKinlay, J. (1989, December). Accuracy of Perceptions of Heart Attack Risk: What Influences Perceptions and Can They Be Changed?. American Journal of Public Health, 79(12), 16081612.

Chenoweth, D. H. (2007). Worksite Health Promotion (2nd ed.). New Bern, North Carolina: Human Kinetics.

Eddy, J. M., Donahue, R. E., Webster, R. D., & Bjornstad, E. D. (2002). Application of an ecological perspective of worksite health promotion: A review. American Journal of Health Studies, 17(4), 197-202.

Edington, M., Sharp, M., Vreeken, K., Yen, L., & Edington, D. (1997, May). Worksite Health Program Preferences by Gender and Health Risk. American Journal of Health Behavior, 21(3), 207.

Glanz, K., Lewis, M., & Rimer, B. K. (Eds.) (1997). Health behavior and health education: Theory, research, and practice. San Francisco: Jossey-Bass

Glasgow, R., McKaul, K., & Fisher, J. (1993). Participation in Worksite Health Promotion: A Critique of the Literature and Recommendations for Future Practice. Health education quarterly 20(3), 391-408.

Hodges, B., & Videto, D. (2005). Assessment and Planning in Health Programs. Sudbury, Massachusetts: Jones and Bartlett Publishers.

Kruger, J., Yore, M., Bauer, D., & Kohl, H. (2007, May). Selected Barriers and Incentives for Worksite Health Promotion Services and Policies. American Journal of Health Promotion, 21(5), 439-447.

Linnan, L., Sorensen, G., Colditz, G., Klar, N., & Emmons, K. (2001). Using theory to understand the multiple determinants of low participation in worksite health promotion programs. Health education & behavior, 28(5), 591-607.

McLeroy K.R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education Quarterly, 15(4), 351-377.

National Association for Health and Fitness (2009). National employee health & fitness. Retrieved January 29, 2009, from http://www.physicalfitness.org/nehf.html.

National Institutes of Health. (1997). Theory at a glance. Retrieved February 26, 2004, from http://cancer. gov/cancerinformation/theory-at-a-glance.

Sharma, M., & Romas, J.A. (2008). Theoretical Foundations of Health Education and Health Promotion. Boston: Jones and Bartlett.

Schwetschenau, H., O'Brien, W., Cunningham, C., & Jex, S. (2008, October). Barriers to physical activity in an on-site corporate fitness center. Journal of Occupational Health Psychology, 13(4), 371-380.

Veitch, J., Clavisi, O., Owen, N. (1999). Physical activity initiatives for male factory workers: Gatekeepers' perceptions of potential motivators and barriers. Australian and New Zealand Journal of Public Health, 23(5), 505-510.

Wellness Councils of America (WELCOA) (1997). A guide to developing your worksite wellness program. Retrieved April 25, 2009, from http://www.welcoa.org/pdf/well_workplace_wkbook1.pdf.

Wellness Councils of America (WELCOA) (2007). Why data collection is an essential step in building a results-oriented wellness program.

Amy Olson, BA, is currently a MA Student in Health Education and Promotion with East Carolina University. J. Don Chaney, PhD, CHES, is an Assistant Professor in College of Health and Human Performance at University of Florida. Please address all correspondence to: Amy Olson, BA, East Carolina University, 125 Rolling Cloud Dr., Louisburg, NC, 27549. Tel: (919)-729-1036. E-mail: ao1126@ecu.edu
Table 1. Needs Assessments Process

1. Determine who will assist in the needs assessment (Who will help
develop and/or administer the needs assessment process?)

2. Determine resources and readiness for the needs assessment (What
existing needs assessment resources are available? How will one
determine the employees' level of readiness to change? What
theory should the needs assessment be grounded in?)

3. Involve employees in the needs assessment process; seek
opinions, thoughts and perceptions. (Involve employees in the
needs assessment process. Use the human capital that you have
available to you in order to get employees participating from
the start.)

4. Find out as much information as possible about employees'
characteristics across various areas related to their health and
lives. (Make certain that the needs assessment is comprehensive
in nature.)

5. Examine health status of the employees to determine health
priorities. (Use the needs assessment to gather baseline data,
monitor on-going health behavior trends, and evaluate the success
of past programming if applicable.)

6. Find out what is contributing to employees' health risks and
what may assist in decreasing these risks. (What health related
conditions are of most importance to focus on. What can be done
to change the identified health risks?)

7. Find out why employees engage in risky health behaviors. (Why
are employees/dependents doing what they are/aren't doing? What
sort of programming can be done to increase the benefits and
decrease the barriers to program participation?)

8. Find out what non-behavioral factors contribute to health
problems and why they exist. (What physical and social
environmental factors may play a part in the employee
participation/behavior?)

9. Identify people and things associated with employees that may
act as agents of change. (What can be altered in order to
facilitate employee participation in WHP activities and health
behavior change/ maintenance?)

10. Research other WHP programs and determine if they were
effective. (What have others done to increase participation and
promote positive health among employees?)
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