Medicine, Faculty of
Population and Public Health (SPPH), School of
DSpace
UBCV
Leon Elizalde, Maria Angelica
Master of Science - MSc
University of British Columbia
Introduction: In recent years, the incidence of many non-communicable diseases, along with their risk factors, has increased in Canada. The workplace represents a convenient setting to reach a large segment of the Canadian adult population with prevention and health promotion programs. Given the central role that employers play in providing these programs, it is important to explore their perspectives on important aspects of programming. Objectives: This study explores employers’ perspectives on factors affecting the implementation of workplace health promotion programs, along with their motivations for implementing such programs. This study also compares factors affecting the implementation and motivations for implementing the program between participants whose programs were identified as following promising practices relative to those programs which have not achieved these standards. Methods: Participants were recruited from attendees at the 2017 Extra Mile Awards event sponsored by the Canadian Cancer Society. Employers who have previously worked with the Society and offered a workplace health promotion program to their staff were invited to participate in this event. Qualitative data were collected using semi-structured individual interviews on topics related to the history and design of programs. Data were analyzed following the template analysis approach, using an iterative process to categorize data into matching patterns. Results: A total of 15 participants agreed to take part on this study (15/46). The factors affecting the program implementation fell into two major categories: strategic and tactical. Motivations were related to improving the employees’ health and taking advantage of the associated benefits of this improvement to the business. There were no differences between programs that followed promising practices relative to those that did not in terms of factors affecting the implementation nor in the motivations for offering the program. Conclusions: The results of this study corroborated those found in previous literature on promising factors affecting workplace health promotion program implementation. Companies in BC are aware of the positive benefits that these programs have for both employees and businesses. However, there is a need for dissemination of information considered effective for workplace health promotion programs implementation and encouragement of the incorporation of this knowledge into practice.
EMPLOYERS’ PERSPECTIVE ON WORKPLACE HEALTH PROMOTION PROGRAMS IN BRITISH COLUMBIA, CANADA by Maria Angelica Leon Elizalde B.Sc., Universidad Nacional Autonoma de Mexico, 2009 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Population and Public Health) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) April 2018 © Maria Angelica Leon Elizalde, 2018 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, a thesis/dissertation entitled: Employers’ Perspective on Workplace Health Promotion Programs in British Columbia, Canada submitted by Maria Angelica Leon Elizalde in partial fulfillment of the requirements for the degree of Master of Science in Population and Public Health Examining Committee: Carolyn Gotay, PhD Supervisor Chris Lovato, PhD Supervisory Committee Member Barbara Kaminsky, MSc Supervisory Committee Member Arminee Kazanjian, PhD Additional Examiner iii Abstract Introduction: In recent years, the incidence of many non-communicable diseases, along with their risk factors, has increased in Canada. The workplace represents a convenient setting to reach a large segment of the Canadian adult population with prevention and health promotion programs. Given the central role that employers play in providing these programs, it is important to explore their perspectives on important aspects of programming. Objectives: This study explores employers’ perspectives on factors affecting the implementation of workplace health promotion programs, along with their motivations for implementing such programs. This study also compares factors affecting the implementation and motivations for implementing the program between participants whose programs were identified as following promising practices relative to those programs which have not achieved these standards. Methods: Participants were recruited from attendees at the 2017 Extra Mile Awards event sponsored by the Canadian Cancer Society. Employers who have previously worked with the Society and offered a workplace health promotion program to their staff were invited to participate in this event. Qualitative data were collected using semi-structured individual interviews on topics related to the history and design of programs. Data were analyzed following the template analysis approach, using an iterative process to categorize data into matching patterns. Results: A total of 15 participants agreed to take part on this study (15/46). The factors affecting the program implementation fell into two major categories: strategic and tactical. Motivations were related to improving the employees’ health and taking advantage of the associated benefits of this improvement to the business. There were no differences between programs that followed promising practices relative to those that did not in terms of factors affecting the implementation nor in the motivations for offering the program. Conclusions: The results of this study corroborated those found in iv previous literature on promising factors affecting workplace health promotion program implementation. Companies in BC are aware of the positive benefits that these programs have for both employees and businesses. However, there is a need for dissemination of information considered effective for workplace health promotion programs implementation and encouragement of the incorporation of this knowledge into practice. v Lay Summary As chronic conditions and risk factors associated with non-communicable diseases continue to increase in Canada, prevention strategies targeting a large proportion of the population are required. The workplace represents a suitable place to achieve this aim. While workplace health promotion programs have been implemented in Canada for a number of decades, little research has taken place on this topic. Existing literature suggests that the employer is a key stakeholder in the implementation of these programs. However, knowledge about the factors that affect the implementation of workplace health promotion programs, as well as the motivations for implementing these programs, from this important stakeholder perspective is limited. The results of this thesis will contribute to expanding our understanding of these aspects of workplace health promotion programs from the employer’s perspective and add to the body of literature on workplace health promotion programs in the Canadian context. vi Preface This thesis is an original intellectual product of the author, Maria Angelica Leon Elizalde under the supervision of the thesis supervisory committee: Carolyn Gotay, PhD, Chris Lovato, PhD, and Barbara Kaminsky, MSc. This research has not been partly or wholly published. This study was reviewed and approved by the University of British Columbia Behavioural Research Ethics Board (certificate H17-00726). vii Table of Contents Abstract ......................................................................................................................................... iii Lay Summary .................................................................................................................................v Preface ........................................................................................................................................... vi Table of Contents ........................................................................................................................ vii List of Tables ............................................................................................................................... xii List of Figures ............................................................................................................................. xiii List of Abbreviations ................................................................................................................. xiv Glossary ........................................................................................................................................xv Acknowledgements ................................................................................................................... xvii Dedication ................................................................................................................................. xviii Chapter 1: Introduction ................................................................................................................1 1.1 Burden of non-communicable diseases .......................................................................... 1 1.2 NCDs risk factors ............................................................................................................ 2 1.3 Literature review ............................................................................................................. 2 1.3.1 The workplace as a setting for health promotion ........................................................ 3 1.3.2 WHPP benefits ............................................................................................................ 4 1.3.2.1 Benefits to employee’s health and behaviour changes ....................................... 6 1.3.2.2 Benefits on employee’s productivity performance ............................................. 8 1.3.3 WHPPs promising practices ..................................................................................... 10 1.3.4 Employer’s role in WHPPs ....................................................................................... 12 1.3.4.1 Employer motivation for implementing WHPPs .............................................. 13 1.3.5 WHPPs in Canada ..................................................................................................... 14 viii 1.3.5.1 Outreach ............................................................................................................ 15 1.3.6 Limitations of current knowledge ............................................................................. 16 1.4 The purpose of the study ............................................................................................... 17 1.4.1 Importance of the study ............................................................................................ 18 Chapter 2: Methodology..............................................................................................................19 2.1 Study design .................................................................................................................. 19 2.2 Research population ...................................................................................................... 21 2.2.1 Extra Mile Awards .................................................................................................... 21 2.2.2 Sample....................................................................................................................... 23 2.3 Data collection .............................................................................................................. 23 2.4 Data analysis ................................................................................................................. 24 2.5 Potential strengths and limitations ................................................................................ 26 Chapter 3: Study findings ...........................................................................................................28 3.1 Participants .................................................................................................................... 28 3.2 Research question 1: What is the employer motivation to offer a WHPP? .................. 31 3.2.1 Theme 1: Improve employee health and wellbeing .................................................. 32 3.2.2 Theme 2: Benefits to the company ........................................................................... 34 3.2.2.1 Cost savings ...................................................................................................... 34 3.2.2.2 Employee work performance ............................................................................ 35 3.2.2.3 Sense of community .......................................................................................... 36 3.2.2.4 Reputation that the company cares about the employees ................................. 37 3.3 Research question 1: Are the activities of the program shaped by the motivations? ... 39 3.3.1 Theme 1: Promote healthier lifestyles ...................................................................... 39 ix 3.3.1.1 Increase awareness and education .................................................................... 39 3.3.1.2 Promote behaviour change ................................................................................ 40 3.3.2 Theme 2: Promote sense of community.................................................................... 43 3.3.2.1 Participate in community events ....................................................................... 43 3.3.2.2 Interdepartmental events ................................................................................... 44 3.4 Research question 1: Program evaluation ..................................................................... 44 3.4.1 Theme 1: Employees’ health and wellbeing ............................................................. 45 3.4.1.1 Change to healthier lifestyles ............................................................................ 45 3.4.2 Theme 2: Employees' work performance ................................................................. 49 3.4.2.1 Absenteeism, attendance and presenteeism ...................................................... 49 3.4.3 Theme 3: Engagement and usage ............................................................................. 50 3.5 Research question 2: What are the factors affecting implementation of WHPPs? ....... 51 3.5.1 Theme 1: Strategic factors ........................................................................................ 52 3.5.1.1 Defined budget .................................................................................................. 52 3.5.1.2 Employee health and wellness needs assessment ............................................. 54 3.5.1.3 Part of culture .................................................................................................... 57 3.5.1.4 Plans and objectives .......................................................................................... 57 3.5.1.5 Senior leadership buy-in ................................................................................... 61 3.5.2 Theme 2: Tactical factors.......................................................................................... 62 3.5.2.1 Characteristics of the activity............................................................................ 62 3.5.2.2 Communication and marketing ......................................................................... 65 3.5.2.3 Human resources dedicated to the program ...................................................... 68 3.5.2.4 Geographic outreach ......................................................................................... 70 x 3.5.2.5 Incentive use ..................................................................................................... 70 3.5.2.6 Learning from experience ................................................................................. 71 3.5.2.7 Leveraging existing resources........................................................................... 71 3.5.2.8 Management buy-in .......................................................................................... 72 3.5.2.9 Timing ............................................................................................................... 73 3.6 Research question 3: What are the commonalities and differences in factors and motivations in companies considered to have promising practices relative to those without this achievement?............................................................................................................................. 75 3.6.1 Motivations ............................................................................................................... 75 3.6.1.1 Improve employees’ health and wellbeing ....................................................... 75 3.6.1.2 Benefits to the company.................................................................................... 76 3.6.2 Factors affecting implementation ............................................................................. 77 3.6.2.1 Strategic factors ................................................................................................ 77 3.6.2.2 Tactical factors .................................................................................................. 78 3.7 Additional information.................................................................................................. 80 3.7.1 Future of the program ............................................................................................... 80 3.7.1.1 Theme 1: Keeping the program as it is ............................................................. 81 3.7.1.2 Theme 2: Improve or expand the program ....................................................... 81 3.7.1.2.1 Increasing or optimizing economic and human resources .......................... 81 3.7.1.2.2 Customize to current needs and interests .................................................... 82 3.7.1.2.3 Strategic approach ....................................................................................... 83 Chapter 4: Conclusion .................................................................................................................87 4.1 Summary of findings..................................................................................................... 87 xi 4.1.1 Motivations for implementing a WHPP ................................................................... 88 4.1.2 Factors affecting implementation ............................................................................. 89 4.2 Strengths and limitations............................................................................................... 95 4.3 Implications and recommendations .............................................................................. 97 4.3.1 Recommendations for future research ...................................................................... 97 4.3.2 Recommendations for future practice ....................................................................... 98 4.3.2.1 Resources .......................................................................................................... 99 4.3.2.2 Type of support ................................................................................................. 99 4.3.2.3 Advocacy and outreach ................................................................................... 101 4.4 Conclusions ................................................................................................................. 102 Bibliography ...............................................................................................................................104 Appendices ..................................................................................................................................113 Appendix A Literature review - search strategy ..................................................................... 113 Appendix B Interview ............................................................................................................. 114 xii List of Tables Table 3.1 Participants’ company characteristics ........................................................................... 30 Table 4.1 Summary of similarities on factors affecting the implementation WHPPs between study findings and existing literature ............................................................................................ 91 xiii List of Figures Figure 1.1 Articles selected for the literature review ...................................................................... 5 Figure 1.2 Example of a WHPPs in BC: WellnessFits ................................................................. 15 Figure 3.1 Participants’ recruitment ............................................................................................. 28 Figure 3.2 Motivations for offering WHPPs (final template) ....................................................... 32 Figure 3.3 Evaluation of WHPPs (final template) ........................................................................ 45 Figure 3.4 Factors affecting the implementation of WHPPs (final template) ............................. 52 Figure 3.5 Future plans for WHPPs (final template) .................................................................... 80 Figure 4.1 Recommendations for WHPPs advocates (final template) ......................................... 99 xiv List of Abbreviations BC British Columbia BCY British Columbia and Yukon CCOHS Canadian Centre for Occupational Health and Safety CCS Canadian Cancer Society EAP Employee Assistance Program EFAP Employee and Family Assistance Program HP Health Promotion HW Health and Wellness NCDs Non-communicable diseases PA Physical Activity PHAC Public Health Agency of Canada US United States WHP Workplace Health Promotion WHPP Workplace Health Promotion Program xv Glossary Absenteeism: a lack of physical presence at a behaviour setting when and where one is expected to be (Gosselin, Lemyre, & Corneil, 2013). Best practices: intervention, program, or initiative that has, through multiple implementations, demonstrated: high impact (positive changes related to the desired goals), high adaptability (successful adaptation and transferability to different settings), and high quality of evidence (excellent quality of research/evaluation methodology, confirming the intervention’s high impact and adaptability evidence) (PHAC, 2015). Emerging practices: intervention that incorporates the philosophy, values, characteristics, and indicators of other positive or effective public health interventions. It is based on guidelines, protocols, standards, or preferred practice patterns that lead to effective public health outcomes. It has an evaluation plan in place to measure intervention outcomes, but does not yet have evaluation data available to demonstrate the effectiveness of positive outcomes (Spencer et al., 2013). Presenteeism: the phenomenon of people who, despite complaints and ill health that should prompt rest and absence of work, are still turning up at their jobs (Gosselin et al., 2013). Promising practices: intervention, program, service or strategy that shows potential (or “promise”) for developing into a best practice. Promising practices are often in the earlier stages of implementation, and as such, do not show the high level of impact, adaptability, and quality of evidence as best practices. However, their potential is based on a strong theoretical underpinning to the intervention (PHAC, 2015). xvi Transferability: the degree to which the results of qualitative research can be transferred to other contexts or settings with other respondents. The researcher facilitates the transferability judgement by a potential user through thick description (Lincoln & Guba, 1985). Transferability judgement: in qualitative research, the reader assesses whether study findings are transferable to their own setting. (Korstjens & Moser, 2018). xvii Acknowledgements There are many people without whom this thesis would not have been possible. First of all, I will always be grateful to my supervisor, Dr. Carolyn Gotay for giving me the opportunity to pursue a new career path and for always pushing me to be a better researcher. I consider myself very lucky to had been one of your students. I’m also very thankful to my committee members, Dr. Chris Lovato and Ms. Barbara Kaminsky, for your kind guidance and for teaching me how to bring together practice and theory in a very supportive environment. I really enjoyed working with you both. I would also want to thank the Canadian Cancer Society for their invaluable support in the recruitment of participants, and for funding my studies through a graduate student fellowship from the Centre of Excellence in Cancer Prevention. A special thanks to the CoECP staff, Marliese and Melissa, for all the help and support provided throughout my studies and thesis work. I would like to extend my gratitude to the study participants for allocating time to be part of this study and for sharing their perspectives on WHPPs. Thanks to the School of Population and Public Health community, particularly to my fellow students: Candace, Molly and Narsis for all the personal and academic experiences shared. You made my graduate experience an enjoyable one. Finally, I want to thank my family and friends for giving me all the inspiration and support needed to achieve this important challenge. There are two persons without whom I would not be here: my sister Paty, who supported me in every way a person can supported; and my husband Eric, who showed me what unconditional love means. I’m truly blessed to have all of you in my life. xviii Dedication A mi familia y amigos quienes estuvieron presentes a pesar de la distancia. 1 Chapter 1: Introduction This chapter presents reasons why the workplace is a suitable place for health promotion within Canada. It begins by reviewing the current state of non-communicable diseases and risk factors as well as the demographic make-up of the population of interest. Additionally, it provides an overview of the current literature regarding WHPPs in Canada and highlights relevant gaps in this literature. Finally, it introduces the purpose of this study, outlines the research questions, and discusses the significance of the research objectives. 1.1 Burden of non-communicable diseases Non-communicable diseases (NCDs) are the leading cause of death globally. According to the World Health Organization (WHO), they accounted for 63% of deaths worldwide in 2008; this number is expected to grow 15% by 2020 (WHO, 2011b). The most common NCDs (also referred to as chronic diseases) are cardiovascular disease (CVD), cancer, chronic respiratory diseases, and diabetes (WHO, 2011b). In Canada, these NCDs accounted for 61% of all deaths in 2015 (Statistics Canada, 2018b). Approximately 60% of Canadians 20 years or older have at least one of these NCDs, and this rate is expected to increase by 14% each year (PHAC, 2011; PHAC & Elmslie, 2012). Population growth and increased longevity have contributed to an ageing population in many parts of the world. This ageing process, combined with the increased prevalence of NCDs, has resulted in more people suffering from these diseases for longer periods of time. This increased and prolonged demand for health care services to control and manage NCDs will put an increasing strain on public health resources in the coming years. Additionally, NCDs have resulted in increasing economic impacts through both direct and indirect costs. Healthcare systems face direct costs related to treatment: 67% of all direct 2 health care costs in Canada are related to NCDs, a total of approximately 21,630 million dollars (PHAC & Elmslie, 2012). Individuals also face indirect costs for out-of-pocket payments for services not covered by public or private healthcare insurance, particularly prescription drugs. At the corporate level, employers face indirect losses from lower productivity due to sick leaves (absenteeism) or reduced productivity while at work (presenteeism). These consequences demonstrate the broad distribution of the economic burden of NCDs (WHO, 2011b). This economic burden is anticipated to increase in the near future due to the combined impact of rising prevalence and treatment costs. 1.2 NCDs risk factors The WHO identifies several common modifiable risk factors for the main NCDs: having an unhealthy diet, physical inactivity, tobacco use, and harmful use of alcohol. Engaging in these behaviours leads to intermediate risk factors such as overweight/obesity, raised blood pressure, raised blood glucose and abnormal blood lipids; and ultimately an increased likelihood of the onset of NCDs (WHO, 2005). 1.3 Literature review In Canada, approximately 84% of the population 20 years or older reported having at least one intermediate health risk factor (PHAC, 2017). For example, only 17% of Canadians aged 18 years and older reported meeting physical activity (PA) guidelines; about 30% of Canadians aged 12 years and older reported consuming fruits and vegetables at least five times a day; nearly 15% of the population aged 15 years or older reported exceeding low-risk alcohol drinking guidelines; and despite the fact that the smoking prevalence has decreased in the past years, 13% of Canadians aged 15 years or older reported being current smokers (PHAC, 2017). 3 There is a wealth of evidence that the incidence of NCDs can be lowered by modifying these risk factors. It has been estimated that eating a healthy diet, being physically active and maintaining a healthy body weight could reduce all cancer cases by one third (CCS, 2018c). Similarly, it is estimated that 80% of premature heart disease, diabetes, and respiratory diseases cases could be prevented by eliminating tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol (PHAC & Elmslie, 2012). In 2011, the Moscow Declaration on NCDs and the UN Political Declaration on NCDs acknowledged the evidence of the effects of prevention on NCDs as well as the opportunities to control these diseases worldwide (WHO, 2011a). 1.3.1 The workplace as a setting for health promotion The increasing NCD burden and the evidence for the efficacy of health behaviours in reducing the risk of NCDs described above highlights the need for health promotion interventions to reduce modifiable risk factors and thus prevent the onset of disease and control the prevalent cases. In addition, it is important that these interventions target a large portion of the population, given the large proportion of society that is at risk of NCDs. The worksite is an ideal setting for achieving this goal as it allows for a broad segment of the population to be reached. In fact, the WHO has identified the worksite as a priority setting for health promotion (WHO, 2018). Approximately 30 million Canadians are aged 15 years or older (84% of total population), of whom 66% are part of the labor force (population aged 15 to 64). Of those defined as being able to work (workforce), 62% are employed (Statistics Canada, 2018a). A Canadian Cancer Society (CCS) survey reported that the main reason employees do not engage in healthier behaviours is a lack of time (CCS, 2015). This barrier could be removed 4 through workplace based health promotion programs. Employees spend a considerable portion of their waking hours at the workplace. According to the Organization for Economic Co-operation and Development (OECD), employees spend approximately 1703 hours/year at work, equating to a third of every day being spent there (OECD, 2016). The European Network for Workplace defines workplace health promotion programs (WHPPs) as “the combined efforts of employers, employees, and society to improve the health and wellbeing of people at work” (WHO, 2018). WHPPs have also been defined by Csiernik as “a combination of educational, organizational, economic, and environmental activities designed to support positive health maintenance behaviours conducive to the well-being of the employees and their families” (Csiernik, 2005). 1.3.2 WHPP benefits WHPPs can be divided into two types: individual and comprehensive. Individual programs offer single isolated activities targeting individuals to achieve desired change. An example would be offering individual nutrition consultations. Comprehensive programs offer a holistic approach, including supportive physical and social environments, and the integration of health promotion into the organization’s culture (Goetzel et al., 2007). In the previous example, a comprehensive program would include changes into the company’s policies to support healthier diets such as offering healthier options to the cafeteria, vending machines, and snacks offered in meetings. Regardless of the type of program, the benefits that WHPPs can provide to employees are considerable, with both direct benefits to their health and health behaviours, and indirect benefits to their productivity. The objective of the following literature review is to present an overview of the evidence for WHPPs in Canada and to identify any gaps in the literature. The database used as a source of 5 information was MEDLINE (through PubMed and Ovid). A literature review of English-language articles published between 2004-2017 evaluating WHPPs was conducted. The search strategy included the following: • Canada as the program setting • program carried out in the workplace • program aimed at enhancing physical activity, healthier diet, smoking cessation, weight loss, reduce absenteeism or reduce presenteeism • program tackling chronic disease, cancer, CVD, obesity, diabetes, metabolic disease or sedentary behaviour. The first search yielded peer-reviewed articles. This was supplemented with a grey literature search of unpublished articles and reports from companies and financial institutions that were publicly available on their websites. The complete list of search terms can be found in Appendix A. A total of 169 documents were found and 23 were included in this review. The process of article selection is presented in Figure 1.1. Figure 1.1 Articles selected for the literature review 169 Potential articles 163 Found in research databases 6 Found in grey literature 149 Excluded 106 Regarding Occupational Health and Safety 43 Opinions or notes to the editor 23 Articles selected 17 Peer reviewed 6 Grey literature 6 1.3.2.1 Benefits to employee’s health and behaviour changes Renaud and colleagues (Renaud et al., 2008) evaluated the outcomes of a comprehensive three-year WHPP aiming to reduce health risk factors. Employees from a branch of a financial organization in Quebec, Canada volunteered to participate in the program. The program consisted of providing employees with six modules of education and personalized support to reduce NCDs risk factors. The study followed an observational pre-post test design to assess health behaviour change in diet, PA and smoking. Data were collected using self-administered questionnaires. The study reported significant increases in the number of days participants engaged in PA, as well as in fruit, vegetable, and whole-grain consumption at the end of the program compared to baseline. There were also significant decreases in fat consumption, the number of smokers, and stress symptoms. The results of Renaud and colleagues are consistent with findings from similar studies evaluating WHPPs. A cross-sectional study found a positive association between PA and having a workplace that was supportive of PA (Watts & Masse, 2012). Another observational study evaluating a three-month program targeting CVD risk factors found significant increases in the number or hours per week of PA and a significant decrease in the number of smokers after the program relative to baseline (Lévesque, Vallières, Poirier, Després, & Alméras, 2015). Two randomized controlled trials found significant increases in minutes of weekly PA and healthier diet practices after the end of the intervention compared to baseline (Plotnikoff, McCargar, Wilson, & Loucaides, 2005; Plotnikoff, Pickering, McCargar, Loucaides, & Hugo, 2010). Similarly, a pilot study evaluating the effect of a men’s WHPP found significant increases in minutes of weekly PA after six months compared to baseline (Johnson et al., 2016). Other studies found significant increases in daily consumption of fruits and vegetable following 7 intervention implementation (Dawson, Dwyer, Evers, & Sheeshka, 2006; Gotay, Amick, Corbett, & Storoschuk, 2014). Important to note is that all studies discussed above relied on self-reported behavioural data gathered using questionnaires. This raises the possibility of biased results due to either over or under-reporting of actual behaviours due to social desirability bias. However, other studies have found similar results using objective indicators such as anthropometric and biological measurements. For instance, Chung and his team (Chung, Melnyk, Blue, Renaud, & Breton, 2009) evaluated the impact of an 18-month comprehensive WHPP to reduce CVD risk offered to employees working in DaimlerChrysler Canada Incorporated in Ontario. Employees who were considered to be of above-average CVD risk were invited to participate in the program. Using an observational pre-post test design, behavioural changes in diet, smoking, PA, body mass index (BMI), blood pressure, and blood cholesterol values were assessed. Behavioural results showed moderate positive changes from baseline to the end of the program, although none were statistically significant. In contrast, there were significant reductions in BMI, blood pressure and blood cholesterol measurements by the end of the program relative to baseline. Similar results were found in other studies using both objective and self-reported measures (Kabaroff, Eys, Schinke, & Eger, 2013; Makrides et al., 2011). One exception was the study by Lévesque and colleagues that reported all behavioural, anthropometric and biological measurements to have significantly improved (Lévesque et al., 2015). Most WHPPs were tailored to specific characteristics of the workforce, and took place in particular settings and contexts, thus limiting the generalizability of results and the potential for cross-comparison. Regardless, common characteristics were identified. First, all WHPPs were comprehensive, except for one (Plotnikoff et al., 2005, 2010). Second, the programs had short follow up times, varying from three months to three years, and the outcome assessments were 8 made immediately after the program ended or within one week of program end. These relatively short timelines for follow-up may not be sufficient to evaluate long-term benefits of WHPPs or to assess if observed behaviour change was maintained in the long-term. Third, most of the studies followed an observational pre-post design, and lacked a control or comparison group. Fourth, the participants volunteered to be part of the studies, the reasons why people decided to participate in these studies might be related to both WHPP (exposure) and behaviour change (outcome). For example, volunteers might have had better health seeking behaviours to make them more likely to participate in the study and more likely to change their health behaviours. Hence, there is potential for self-selection bias. While most of the literature reviewed reported positive results regarding employees’ health and behaviour changes, most of the changes were small. While these may have achieved statistical significance, the clinical significance of such changes may be limited. Additionally, it is important to stress that some studies showed moderate but non statistically significant changes (Chung et al., 2009; Kabaroff et al., 2013; Makrides et al., 2011; Plotnikoff et al., 2007; Tarride et al., 2011) and one study showed no change at all (Johnson et al., 2016). 1.3.2.2 Benefits on employee’s productivity performance Other research has studied WHPP effectiveness in relation to employee work-related outcomes. Most of this work reported positive results such as improvements in absenteeism, presenteeism, turnover, and health costs. These indicators have an appeal to employers because of their inherent connection to workforce productivity and cost savings to the company. One study was a randomized controlled trial to determine the cost-effectiveness of a 12-month worksite-based naturopathic approach to the primary prevention of CVD. Employees from three Canadian worksites in Edmonton, Toronto, and Vancouver, volunteered to be part of 9 the trial. Participants with a high risk of CVD agreed to be randomized to receive either a naturopathic component in addition to enhanced usual care (intervention arm) or enhanced usual care alone (control arm). The naturopathic component had a focus on healthier lifestyle and CVD prevention with the use of two approaches: counseling, and botanical and nutritional medicine. After one year, the results showed a significant reduction in CVD risk events and CVD mortality risk in the intervention arm compared to the control arm. Most of the costs in the intervention arm were lower than those in the control arm; however, these differences were not statistically significant. Likewise, there was a greater decrease in the rate of presenteeism in the intervention arm relative to the control arm, although it was not statistically significant. (Herman, Szczurko, Cooley, & Seely, 2014). These positive results in cost savings are similar to those reported by other short term studies (Chung et al., 2009; Makrides et al., 2011; Sun Life Financial & Harris/Decima, 2013; Tarride et al., 2011). However, a separate longitudinal cross-sectional study showed that the effect of WHPPs on the company’s return on assets (indicator of how profitable a company is in terms of its total assets) became non-significant after 4 years (Wilkin & Connelly, 2015). Important to notice is that the assessment in this last study did not include employees’ engagement with the WHPP, which has been identified as a key factor influencing program success (CCOHS, 2018; Renton, Lightfoot, & Maar, 2011). The non-statistically significant reduction of WHPPs in presenteeism discussed above found by Herman and colleagues in 2014 was consistent with other studies (Bustillos & Trigoso, 2013; Herman et al., 2014; Tarride et al., 2011). Similar to presenteeism, the available evidence shows no significant decreases in absenteeism rates following the implementation of WHPPs. (Makrides et al., 2011; Sun Life Financial & Harris/Decima, 2013; Tarride et al., 2011), with the 10 exception of one study (Renaud et al., 2008). However, despite WHPPs not resulting in statistically significant decreases in absenteeism and presenteeism in most studies, the reduction in the rates of these issues did constitute important cost savings for the businesses in question (Herman et al., 2014; Makrides et al., 2011). 1.3.3 WHPPs promising practices Best practices are interventions that have gone through a systematic process to consistently prove their effectiveness, starting as emerging practices that develop into promising practices, and ultimately become best practices (Spencer et al., 2013) . An emerging practice has been defined as an: “intervention that incorporates the philosophy, values, characteristics, and indicators of other positive or effective public health interventions. It is based on guidelines, protocols, standards, or preferred practice patterns that lead to effective public health outcomes. It has an evaluation plan in place to measure intervention outcomes, but does not yet have evaluation data available to demonstrate the effectiveness of positive outcomes” (Spencer et al., 2013). Once an emerging practice has gathered some evidence to prove its effectiveness, but not enough to be generalizable, it becomes a promising practice, which has been defined as: “intervention that shows potential (or “promise”) for developing into a best practice. Promising practices are often in the earlier stages of implementation, and as such, do not show the high level of impact, adaptability, and quality of evidence as best practices” (PHAC, 2015). Finally, when a promising practice has gathered high quality evidence to consistently prove its effectiveness so that it can be generalizable to other contexts, it reaches the status of best practice defined as: “intervention, program, or initiative that has, through multiple implementations, demonstrated: high impact (positive changes related to the desired goals), high adaptability (successful adaptation and transferability to different settings), and high quality of evidence 11 (excellent quality of research/evaluation methodology, confirming the intervention’s high impact and adaptability evidence)” (PHAC, 2015). Since evidence on WHPPs in Canada is limited, only promising practices can be identified in WHPPs implemented in Canadian companies. Only one study by Morrison and MacKinnon was identified addressing this issue (Morrison & MacKinnon, 2008). In 2008, Morrison and MacKinnon aimed to identify the critical issues of WHPPs in Canada. Since the Canadian literature on WHPPs was limited, they based their results on literature from Canada and the US. To account for the lack of Canadian studies, the authors included seven key informant interviews with experts on the field. The results were organized into seven major themes: 1. Stakeholder engagement: mainly from the employer, employees and unions but could also include health professionals, provincial and federal government, business, community and financial institutions. 2. Employee participation and involvement: employees should be involved in developing and implementing the program. The program should be flexible to address the particular needs of all the employees. 3. Organizational culture: wellness must be a core process in the organization. There should be a supporting culture for long term sustainability of the program. 4. Effect on direct medical economic outcomes: businesses must understand that wellness is a long-term investment. 5. Effect on indirect cost: the program should decrease absenteeism and presenteeism, in addition to increasing productivity. 12 6. Effect on clinical outcomes: there should be continuous support by health professionals to reinforce low-risk lifestyle choices and medication management. 7. Effect on humanistic resources: the program should increase the quality of life and job satisfaction among the workforce. 1.3.4 Employer’s role in WHPPs As mentioned, senior management involvement has been identified as a key factor influencing the effectiveness of WHPPs (BC Ministry of Health, 2006; CCOHS, 2018; Morrison & MacKinnon, 2008). Employers’ attitudes towards WHPPs are crucial because they have been found to directly influence decisions on factors crucial to WHPPs’ success. These factors include: • Integrating health within the organizational culture: nurturing a culture of health within the organization policies, mission, vision, values and goals in such a way that supports the WHPP objectives (Chung et al., 2009; Johnson et al., 2016; Kabaroff et al., 2013; Makrides et al., 2011; Morrison & MacKinnon, 2008; Renaud et al., 2008). • Long-term commitment: particularly for productivity benefits which have been shown to occur across longer timelines (Chung et al., 2009; Morrison & MacKinnon, 2008; Tarride et al., 2011). • Promoting employee engagement: advocacy from all leadership levels is needed to support employees to participate in the program (Alberta Health Services, 2012; Chung et al., 2009; Herman et al., 2014; Johnson et al., 2016; Lévesque et al., 2015; Makrides et al., 2011; Morrison & MacKinnon, 2008; Renaud et al., 2008; Renton et al., 2011; Tarride et al., 2011). 13 • Providing human and financial resources: designate personnel dedicated to WHPP activities as well as economic resources for materials and incentives to enhance engagement (Alberta Health Services, 2012; Chung et al., 2009; Herman et al., 2014; Johnson et al., 2016; Kabaroff et al., 2013; Lévesque et al., 2015; Renaud et al., 2008; Renton et al., 2011; Sun Life Financial & Harris/Decima, 2013). 1.3.4.1 Employer motivation for implementing WHPPs Evidence on the motivation for employers to implement WHPPs is limited. Two articles have explored this issue in specific industries (Downey & Sharp, 2007; Renton et al., 2011). Renton and colleagues focused on call centers. They found that the motivations to implement WHPPs included benefits to the employer (in terms of improved productivity, reduced health related costs and improved morale), to help employees improve their wellbeing, and the overall benefits of such a program to society. Downey & Sharp focused on the automotive parts manufacturing industry. They found that the most important drivers in implementing WHPPs were the perceived benefits the program would bring to morale and productivity, and decreased absenteeism and turnover. These motivations were also presented in the 2013 Sun Life-Buffett National Wellness Survey. Indirect benefits of WHPPs related to enhanced productivity, such as decreased absenteeism and improved employees’ engagement, are the most important incentives for employers to implement WHPPs (Downey & Sharp, 2007; Renton et al., 2011; Sun Life Financial & Harris/Decima, 2013). A better positioning of the company in terms of improved employee retention and morale (Renton et al., 2011; Sun Life Financial & Harris/Decima, 2013) was also cited as a motivating factor. Despite the Canadian health care system being publicly 14 funded, indirect benefits regarding health cost savings were another motive to implement WHPPs for companies offering extended healthcare benefits to their staff (Renton et al., 2011). It is important to mention that while employers did not commonly perceive employee health as their moral responsibility (Downey & Sharp, 2007; Renton et al., 2011), many companies were interested in improving employee physical and mental health (Sun Life Financial & Harris/Decima, 2013). 1.3.5 WHPPs in Canada In Canada, the Canadian Centre for Occupational Health and Safety (CCOHS) is a federal agency that promotes the health and well-being of Canadian workers. The CCOHS encourages WHPPs as a complement to the overall strategy for a healthy workplace. However, there is not an explicit mandate for companies to implement these programs. CCOHS works jointly with all province and territory occupational health and safety jurisdictions by offering extensive information on the development, implementation, and evaluation of WHPPs (CCOHS, 2018). In British Columbia (BC), the Ministry of Health encourages healthy work environments by promoting healthy behaviours in the workplace focused on disability and disease prevention. The Ministry regards a workplace to be healthy when employers integrate occupational, safety, health promotion, and organizational health in a comprehensive program (BC Ministry of Health, 2018). The Ministry has worked with other organizations in initiatives to inform and enable the creation of healthier workplaces in BC. One example was “WellnessFits”, an initiative in partnership with the CCS BC and Yukon Division (CCS BCY) and the Province of British Columbia Healthy Families BC Initiative that ran from 2012 to 2017. WellnessFits is described in figure 1.2. Currently, the CCS BCY promotes WHPPs on their website “Healthy 15 Workplaces”. This website provides free static resources on WHPPs similar to the ones provided by its predecessor WellnessFits, but no in-person consultations (CCS, 2018b). Figure 1.2 Example of a WHPPs in BC: WellnessFits 1.3.5.1 Outreach The implementation of WHPPs has increased in recent years. The large majority of businesses in Canada currently offer at least one type of WHPP to their staff (Macdonald, Csiernik, Durand, Rylett, & Wild, 2006; Sun Life Financial & Harris/Decima, 2013). In 2006, 29.4% of worksites with more than 100 employees offered WHPPs (Macdonald 2006). By 2013, 72% of companies offered at least one WHPP (Sun Life Financial & WellnessFits was a free comprehensive program directed to employers who wanted to implement a WHPP. This program aimed to change the health culture of companies through education and support techniques designed to create healthy workplaces and improve employee health. This program was divided into six modules including healthy eating, PA, healthy minds, tobacco free, sun and UV awareness, and early cancer detection and living with cancer. Each of these modules followed three main strategies: education (providing information and materials), action (putting information into practice), and support (modifications in policies and culture to maintain changes in the long term). The services provided by WellnessFits were free of charge for BC companies. These included one-on-one consultations for developing, implementing and evaluating WHPPs. Additionally, online resources were available with information about health promotion and workplace activities. The program worked with more than 500 business across BC seeking to provide WHPPs to their staff. A wide variety of business took part in the program including small (1-49 employees) and medium (50-499 employees) business as well as large corporations (500 and more employees). The program was implemented in a broad range of industries such as manufacturers, universities, and financial institutions. (CCS, 2018d) 16 Harris/Decima, 2013). The most common workplace programs offered were flexible work programs (49%), first aid/CPR courses (39%), and staff appreciation events (28%). One important criticism of these types of WHPPs is that they do not address the health risk factors for NCDs directly. For example, only 35% of large companies offered wellness needs assessment, and 19% offered smoking cessation programs. These numbers were considerably lower - 6% and 4% respectively - in small companies. 1.3.6 Limitations of current knowledge WHPPs have been implemented in Canada for more than thirty years, yet formal research on both the impact and the contribution of each stakeholder is limited (Morrison & MacKinnon, 2008). Most of the published literature on WHPPs comes from the United States. Although these studies provide valuable information, their applicability to the Canadian context is limited given the large differences between the US and Canadian health care systems. Although some Americans receive government-provided health insurance, the majority of the population (84%) is covered by private health insurance, individually purchased or offered collectively by their employers, and approximately 16% of the population is uninsured (Ridic, Gleason, & Ridic, 2012). Contrastingly, Canada has a national health insurance (NHI) program where healthcare coverage is universal and publicly funded (Ridic et al., 2012). With the implementation of the Affordable Care Act in 2010, financial incentives were provided to companies in the US offering WHPPs to their staff (Anderko, 2012). However, these policies are subject to change every time there is a change in the government. In contrast, in Canada there are no such financial incentives for businesses to provide WHPPs. Additionally, it has been demonstrated that there is no universal program that fits every company, but rather that WHPPs should be designed to meet each worksite’s particular social 17 and cultural context, as well as the constraints of the worksite. As a result, the components of WHPPs are likely to be different from one company to the next; thus, definitions and indicators of success will vary accordingly. However, it is still valuable to have general guidelines of effective strategies to achieve these differing goals. The important role of the employer in WHPPs has been highlighted in the existing literature but little has been written about their perspective on different aspects of WHPPs including motivations and factors considered to affect the success of implementation. It is an important area for investigation because evidence has shown there are important factors affecting the success of WHPPs on which the employer has a direct influence. Furthermore, our understanding of the motivations of employers to implement WHPPs would expand the limited knowledge from this important stakeholder perspective and would serve as a guide to design purposeful interventions. 1.4 The purpose of the study The purpose of this study is to explore WHPPs implemented in BC, Canada from the employer’s perspective. The study aims to identify the key components (“factors” hereafter) that affect the implementation of WHPPs from the employer’s point of view. Additionally, it will explore employer’s motivations to offer WHPPs in his/her company and whether these are predictors of program goals. Finally, this study aims to find the commonalities and differences in factors affecting the implementation of WHPPs as well as the motivations for implementing WHPPs, between companies considered to follow promising practices for WHPPs standards compared to those that do not. 18 Research Questions From the employer’s perspective: 1. What is the employer’s motivation to offer a WHPP? a. How do these motivations shape the goals and activities of the program? 2. What are the factors affecting the implementation of WHPPs? a. What are the primary facilitators that enhance implementation? b. What are the main barriers to implementation? 3. What are the commonalities and differences in factors affecting the implementation of WHPPs and motivations to offer WHPPs in companies considered to have promising practices compared to those that do not have promising practices? 1.4.1 Importance of the study This study seeks to address a gap in the literature on WHPPs in the Canadian context by focusing on the employer’s perspective. This research aims to situate these findings within the existing body of literature on WHPPs. From a practical point of view, although this study focuses on companies in BC, Canada, the results presented may be transferable to other companies implementing WHPPs in contexts similar to that of participating companies in the future, such as large (500 employees or more) (Statistics Canada, 2011) white collar Canadian companies. In particular, it may identify driving forces and barriers to implementation, essential knowledge in designing and implementing future programs. The results of this research may also be helpful for WHPP advocates to incorporate contemporary employer perspectives in future practice recommendations. Moreover, this research may encourage companies to implement WHPPs in Canada in line with promising practice standards since it will present a model of successful WHPP implementation. 19 Chapter 2: Methodology This section outlines the methodology used in this study. It starts by discussing the suitability of the study design, it then describes the research population, the recruitment process and data collection. This is followed by a brief explanation of the template analysis methodology. Finally, it discusses the potential strengths and limitations of the study methodology. 2.1 Study design The present study design was modelled on two previous studies in this area (Kent, Goetzel, Roemer, Prasad, & Freundlich, 2016; Renton et al., 2011). Similar to the present study, Kent and colleagues aimed to identify the key elements of successful WHPPs, but in the US context. The goal of the project was to provide further knowledge to companies interested in implementing effective WHPPs in the US. To identify successful WHPPs examples, they selected companies to participate from the winners and honorable mentions of the C. Evertt Koop Awards (corporate recognition for WHPPs). The present study used a similar methodology to that of Kent to select companies considered to follow best practices. Like the present study, Renton and her team were interested in exploring employer perspectives in call centres in the city of Greater Sudbury, Ontario regarding the provincial recommendations for workplaces to promote PA. Qualitative data were collected using semi-structured individual interviews, which was complemented by quantitative information regarding the workplace and participant characteristics gathered via self-report questionnaires. The present study used a similar approach to data collection as that of Renton. 20 The selection of the study design should be a function of matching the research question to the design that provides the most appropriate data. The present study aimed to be exploratory in nature, as such, a qualitative design was determined to be most appropriate. Participants were encouraged to express their perceptions freely, natural flowing dialogue was promoted, and there was minimal interference from the researcher. To help fulfill these aims, data were collected at the workplace - the participant’s natural setting - where the participant would feel most comfortable (Patton, 2002). In addition, this design was chosen because qualitative studies attempt to explore and interpret the phenomena under study in terms of “the meanings people bring to them” (Denzin & Lincoln, 2005). This approach yielded detailed and thick data (Patton, 2002), which allowed for achievement of a thorough understanding of the employer’s point of view regarding factors affecting WHPPs implementation, the motivation for implementing WHPPs, and the commonalities and differences among companies considered to follow promising practices standards relative to those that do not meet these standards. Finally, anticipating a broad variety of WHPPs because of the wide range of activities, designs and objectives for these programs, it was expected that the outcomes would be qualitatively different (Patton, 2002). In order to have multiple views of these highly-individualized programs, study participants were selected taking advantage of the broad scope of companies operating in BC, Canada (e.g., type of industry, company size, etc.). By consolidating the qualitative data from various programs and contexts, it was possible not only to capture the differences between them, but to also identify patterns and the critical elements affecting the success or failure of each program (Patton, 2002). 21 2.2 Research population The study population consisted of employers for BC companies that implemented a WHPP during 2016-2017. To tap into the employer’s perspective, the researcher aimed to speak with representatives of each company. The primary source for potential participants was representatives attending the 2017 Extra Mile Awards (EMA) from the CCS BCY. Employers who collaborated with the CCS BCY in 2016-2017 and who also offered a WHPP to their staff were invited to participate in the 2017 EMA. Additionally, the sample included a subset of companies considered to follow promising practice standards. To be selected based on this criterion, a company must have demonstrated that it had provided an effective program that followed promising practice standards. Any business in the list of winners and companies designated as ranked in second place (“runners-up” hereafter) of the 2017 EMA was considered to have achieved this target. As such, a convenience sample was drawn from the list of winners and runners-up of the 2017 EMA. The criteria for the 2017 EMA are outlined below. 2.2.1 Extra Mile Awards Starting in 2015, every March the CCS BCY has recognized the work of companies that have implemented a WHPP during the previous year. Based on the elements of the program, the awards are divided into four categories: special recognition for distinct achievements, and bronze, silver, gold and platinum awards for overall excellence (CCS, 2017b). Any business with at least five employees and with at least one branch in BC is eligible to apply for the EMAs. The criteria for a business to be considered a nominee include some of the former WellnessFits program elements: having implemented at least one of the WellnessFits modules as health strategies; having used at least two of WellnessFits strategies to implement the 22 health strategies; having management support; and having a designated wellness committee or an ambassador of the program (wellness champion). Additional points are earned on other organizational items used to support the program based on the essential components of a comprehensive WHPP listed by the CCS, such as using incentives to increase participation or having a designated budget for the program (CCS, 2017a). Businesses nominated themselves for the 2017 EMA using an online application form that required a description of the program elements and reasons that the applicant considered the company to be a good candidate to win an award. The decision of the finalists and winners was made by a committee including experts in health promotion, marketing and communications representatives from the CCS, and representatives from the Healthy Communities Service Department within the BC Ministry of Health. Finalists were chosen based on efficacy, creativity, employee feedback and contribution to overall workplace culture (CCS, 2017a). In March 2017, a total of 31 companies self-nominated for EMAs. From these applications, six companies received a special recognition award in distinct categories: health education, health innovation, small business, top senior management, top wellness champion and non-profit. There was one winner in each of the bronze, silver and platinum categories, and two winners in the gold category (CCS, 2017a). The activities offered by the WHPPs of companies nominated for the EMAs varied. For example, one program finalist for the health education special recognition included employee feedback in all aspects of the wellness activities and actively supported the creation of a healthy physical environment. Another program finalist for the health innovation special recognition offered salad bars and oatmeal buffets, stairs challenges and dance tournaments. Among the gold finalists, one program included complimentary meditation and fitness classes, lunch-and-learns, 23 and wellness fairs. Another gold medal finalist program included charity walks, screening checks, and behaviour change activities (CCS, 2018a). 2.2.2 Sample Participants were a convenience sample of company representatives that participated in the 2017 EMAs. Potential participants were recruited at the 2017 EMAs event and via email invitation sent on behalf of the CCS BCY. Based on the paper by Renton (Renton et al., 2011), the researcher sought to recruit 15 representatives as participants of this study. The sample included 5 participants representing companies considered to follow promising practices standards and 10 participants representing companies without this distinction. 2.3 Data collection After each of the potential participants showed an initial willingness to take part in the study by either providing their contact information at the EMAs event or responding the CCS BCY email invitation, the researcher approached them via email to explain the study in further detail and to set the interview appointment. The researcher conducted individual semi-structured interviews with all participants. The interview consisted of open-ended questions on topics related to the history and design of the company’s WHPP, factors affecting the success of the program and perceived benefits of offering this type of program to staff. Additionally, participants were asked questions about the general characteristics of their workplace including: a) Organization structure: size of the company (number of employees), type of industry, unionized status. 24 b) Nature of the workforce: demographic characteristics of employees such as sex, age, and language of preference distribution. These interviews lasted between 25 and 56 minutes and were electronically recorded. Along with the appointment details, the researcher emailed the participants the interview outline as well as the consent form. 2.4 Data analysis All interviews were recorded and transcribed verbatim. An alias was assigned to each participant to preserve his/her anonymity. The researcher used the qualitative analysis software called NVivo Pro 11 (QRS International, 2018) to organize and examine the data. Data were analyzed following a template analysis approach as follows: An initial template was developed using the first set of codes from the first three transcripts. To code each transcript, the researcher used an iterative approach categorizing data into matching patterns (Yin, 2009). The researcher read the transcripts several times to identify concepts or ideas before attaching relevant codes. After this process, the researcher sought to identify broader patterns or generalizations from the codes to form themes that addressed research questions 1) and 2) in a hierarchical way, from general to specific. For example, themes related to factors affecting the implementation of WHPPs were divided into two sub-categories: facilitators and barriers. This initial template also outlined the relationships between codes and themes (King, 2004). The researcher used this initial template to code the remainder of the 15 transcripts as follows: every time the idea reappeared, the code was attached again (Krueger, 1994). The initial template was adjusted to incorporate the appearance of new codes, adapt an existing code or 25 theme, or re-ordering the hierarchical order of a sub-category until a final template was reached (King, 2004). As outlined in the previous example on factors affecting the implementation of WHPPs, after analyzing the rest of the transcripts, it was found that the same factors were facilitators in their presence and barriers in their absence; therefore, the initial template was rearranged to group the factors by type instead of being considered separately as barriers and facilitators. Data repetition emerged on the third interview and from the 10th interview on, no new information was identified and data saturation was reached. To address third research question “What are commonalities and differences among employers in their perspectives?”, sources were classified according to whether the participant was a 2017 EMAs winner or runner-up, after all coding was complete. This classification facilitated a separate analysis between those companies identified as following promising practice standards and the remaining companies. Each source was reviewed again to find the differences and commonalities in motivations and factors. The report of the results was written in a narrative style following a thematic presentation of the findings (King, 2004). The themes were organized according to the research questions, and direct quotes from the participants’ individual interviews were added to exemplify the main themes identified (Krueger, 1994). Finally, at the beginning of each section, a visual representation of the final template was provided. These visual aids represented the themes found, their hierarchical order, and the relationships between them (King, 2004). Finally, the study results were compared to existing literature. To provide a Canadian context for comparison, the results were compared to the elements for successful Canadian WHPPs suggested by WellnessFits (CCS, 2018b), the CCOHS (CCOHS, 2018), and a study 26 from Morrison in 2008 (Morrison & MacKinnon, 2008). To compare the results of this study to other research within the Canadian context, the researcher used those presented by Renton in 2011 (Renton et al., 2011). Additionally, the results presented by Kent in 2016 (Kent et al., 2016) were used to enable a comparison of this study with research outside of Canada. The reasons for these comparisons were to confirm existing knowledge, identify new factors, and contrast them with what was previously known on selected aspects of WHPPs. 2.5 Potential strengths and limitations The evidence presented, from multiple perspectives and from various businesses and WHPPs, provided a broader understanding of the factors affecting WHPPs success. Participants of this study were a convenience sample of representatives from BC companies that currently have a WHPP. Therefore, the transferability of the results was limited to this particular context and to companies who are willing to have a representative speak about the company’s WHPP experience. This study included companies with programs that have been recognized as excellent, as well as others without this recognition. As such, important barriers and facilitators were found in companies with successful and less successful WHPPs, increasing the transferability of the findings. Moreover, the in-depth study of a relatively small sample of cases that are considered to be successful is a good source of “lessons learned” (Patton, 2002). In addition, detailed and rich data will allow readers to decide if the findings of this study are transferable to their own workplaces (Korstjens & Moser, 2018). Nevertheless, a convenience sample from the 2017 EMA winners and runners-up may be an indirect indicator of only companies that followed WHPPs promising practices; as such, companies that chose to participate in the study might be limited to organizations that have a WHPP of higher quality. 27 Secondly, template analysis is flexible enough to “examine the perspective of different groups within an organizational context” (King, 2004). Therefore, this analysis was suitable for the research population of companies across BC. In addition, this methodology enables a structured approach to analyzing data, and thus makes an accurate representation of the findings more achievable (King, 2004). Finally, the subjectivity of relying on one individual observer who collected, analyzed and interpreted the data could potentially biased the results. The researcher aimed to reduce this bias at different stages of the study. Before data collection, she wrote her a priori WHPP experiences and anticipated findings related to employer’s perspectives. This input helped prepare the researcher to ask for further clarification during data collection in cases where she considered a response to be unclear or vague. This helped ensure that each participant’s intentions were correctly captured, and avoided assumptions being made based on the researcher’s own perspective. By using open-ended questions, the interview allowed the participants to express freely their own perspectives without a predetermined point of view (Patton, 2002). The researcher reviewed emerging codes and themes with knowledgeable individuals including her thesis supervisor and committee members to confirm replicability and reliability of coding and themes. Finally, an external reviewer (a doctoral student with experience in coding and interpreting qualitative data) examined the study’s coding and thematic analysis. The reviewer reviewed the documentation provided by the researcher (e.g., transcripts, subthemes and themes) and supported the appropriateness of the codes and logical structure of themes and subthemes (Creswell & Miller, 2000). 28 Chapter 3: Study findings This section provides a description of the study participants as well as the results from the template analyses organized according to the research questions. A visual representation of the final template is presented along with descriptions of the main themes and subthemes identified from the participants’ interviews. Where applicable, representative quotes from the interview transcripts have been included to illustrate and support each theme or subtheme. 3.1 Participants Representatives from 15 out of the 46 companies contacted agreed to participate in this study. The participants’ recruitment process is shown in Figure 3.1. Figure 3.1 Participants’ recruitment The characteristics of companies that were represented by the participants are presented in Table 3.1. These characteristics are divided in three groups: organizational structure, nature of workforce, and WHPP. 46 Potential participants 30 CCS contacted via email 14 Recruited at EMA event 2 Contacted by another participant 29 Not interested 8 Declined 21 Didn’t respond 17 Agreed to participate 2 Dropped out 1 Not directly involved with program 1 Lost to follow up 15 Participants 29 Regarding the organizational structure, 12 out of 15 participating companies had fewer than 2,000 employees. Half of the participants were either in the education industry or were part of the federal or provincial government, and 10 out of 15 had at least one union operating within their business. In terms of the nature of the workforce, more than half of the companies had a majority of women in their workforce. In a little more than half of the companies (9 out of 15), the average age of their staff was over 40 years old. The majority of the companies (12 out of 15) had a workforce with English as their language of preference. In relation to WHPPs, 10 out of 15 had offered a WHPP for more than five years. Regarding the type of program, 6 out of 15 participants reported having a comprehensive program and 4 companies identified having a mixed approach to their WHPP. Most of the companies (10 out of 15) did not have an individual whose sole responsibility was the WHPP, rather it was one of many tasks of a staff member in a leadership position. More than half (9 out of 15) had used WellnessFits at least once, either in its entirety or some elements, of it in their program. 30 Table 3.1 Participants’ company characteristics Characteristic Number Organizational Structure Number of employees 1-100 3 100-300 4 300-1,999 5 2,000 + 3 Type of industry Aviation / transportation 1 Tourism / hotels 2 Education 4 Technology / IT 1 Government Provincial / Federal 4 Charity / Non-profit 1 Insurance 2 Unionized status Yes 10 No 5 Nature of Workforce Sex composition Mostly male 5 Mostly female 8 Even 2 Average Age 30-34 3.5* 35-39 2.5* 40-44 3.5* 45+ 5.5* Employees' language of preference English 12 Mixed 3 * When a company presented a broader interval, it was divided in half 31 Characteristic Number Workplace Health Promotion Program Number of years since first offering 1-5 5 6-7 3 8-14 3 15 + 4 Current type of program Comprehensive 6 Individual 5 Mixed 4 Responsible for the program Staff fully dedicated to the program 5 Is included as part of other tasks 10 Position of responsible staff member Advisor/ Analyst / Specialist 6 Manager / Coordinator 4 Director 5 WellnessFits User No 6 Used before, but not currently 3 Currently use parts of it / customized 6 3.2 Research question 1: What is the employer motivation to offer a WHPP? With the objective of knowing employer motivations for implementing a WHPP, participants were asked to share their perceptions about their company’s definition of workplace health promotion (WHP), the reasons why their company implemented a WHPP, and the perceived benefits of offering the program. The final template is shown in Figure 3.3. Two main themes were identified: improve employees’ health and wellbeing, and leveraging the benefits for the company. 32 Figure 3.2 Motivations for offering WHPPs (final template) 3.2.1 Theme 1: Improve employee health and wellbeing Organizations expressed motivation to improve their staff’s health and wellbeing and to foster healthier lifestyles among their staff. Some participants defined WHP as helping employees improve their physical and mental health by promoting healthier behaviours such as increased minutes of daily PA, encouraging better diets and nutrition, developing mental health resiliency inside and outside work, reducing stress, and promoting general well-being. In addition, some participants referred to having happy employees inside and outside of work. This is illustrated by one participant comment: “Keep people healthy and ensure that they are not only being able to be resilient in the workplace, but outside of the workplace, so that they don't feel one is necessarily impacting the other” (Participant 15). 33 Some participants also pointed out the importance of helping employees with early detection of chronic conditions (e.g., cancer, diabetes) through onsite clinics: “Our mammography clinic has caught at least one-person early detection of breast cancer. So, I think those are all benefits. Our health fairs have caught people who had no idea that they had high blood pressure, and they went off to their doctor and the doctor was able to catch early enough. We caught some people who had boarder line diabetes didn't know they had it. So, I think the health fairs provide an opportunity for that” (Participant 14). Providing Resources Several participants mentioned that having a WHPP is an effective way to provide health and wellness resources to their staff. Some talked about offering support in times of need, others about providing resources to raise awareness and to educate, and others about providing spaces supportive of health and safety. Participants also mentioned the importance of informing employees about the resources available and encouraging their use. This is exemplified by one participant’s comment: “It's about making sure that people know about all the varied resources that they have available to them. As public-sector employees, we do have a large and vast number of resources available to us, which I'm not sure everybody always knows and or necessarily takes advantage of. So, we try to promote that as much as possible” (Participant 11). Some participants recognized that the traditional approaches to health promotion at the workplace were focused on occupational safety and protecting the employee from external 34 hazards. Incorporating wellbeing components to promote health at the individual level were necessary to offer an integrated approach to employee health. Therefore, they implemented the WHPP to address this gap, as stated in this participant’s quote: “Safety is a stuff that kinda harm the outside of your body. Occupational health is almost stuff that happens inside of your body, we need to care about that. And then they [the company] said - well, and if that's our philosophy there is this other bucket which kinda makes everything come full circle -” (Participant 4). 3.2.2 Theme 2: Benefits to the company Some participants acknowledged that they were motivated to offer a WHPP because of its well-known benefits. Four main subthemes were identified: cost savings, effect on employees’ work performance, sense of community, and reputation that the company cares about the employee. 3.2.2.1 Cost savings Some participants mentioned that implementing the program resulted in cost savings from a decrease in disease or stress incidence. Some participants observed savings in the reduced number of paid sick-days due to absenteeism and disability. Others mentioned savings in health-related costs, such as the cost of additional benefits (e.g., complementary health insurance). One participant identified itself as responsible for employee health-related costs and therefore they used the program as a strategy to reduce these costs: 35 “If you are going to be offering benefits to your employees you also need to be offering solutions to reduce those costs through a HW program because they need to be able to balance themselves out” (Participant 2). 3.2.2.2 Employee work performance Some participants noticed their WHPPs improved the work environment and created a more engaged workforce due to increased morale and satisfaction at work, healthier and energized employees, and an increased sense of belonging and loyalty. One participant expressed it as follows: “We do a lot of work here around engagement. And so, I think that's a big one for us is that if people are healthier, if they feel better [...] if they have more energy they're going to be more engaged in their workplace. And we want an engaged workforce, and people who are proud of the work they're doing, they want to be here, they're excited to take part in what they're doing, and be doing their work” (Participant 15). Some of the outcomes that were most appealing to the participants were the decrease in absenteeism, presenteeism and disability rates due to improved employee physical and mental health. However, some participants stated that this was not the main purpose of the program: “I supposed when we first started a specific goal, if you will, of the program was to reduce our attendance, a reduced absenteeism I should say, right? Which has occurred […] the committee has agreed that that's not the primary purpose anymore, or measure of success” (Participant 11). 36 Other participants acknowledged the impact that health has on the staff’s work performance and productivity. They suggested that the healthier the workforce, the better their productivity, as illustrated by this participant: “I truly believe that a healthy, happy, active employee is far more engaged, people would do more […] we try to put things in place to help people to do their jobs effectively and efficiently, so that they don't feel burnt out […] I think that by doing that they [employees] are just a little bit more productive, they are lot happier and more productive” (Participant 10). 3.2.2.3 Sense of community Participants sought to forge a sense of community among the workforce since they recognized that WHPPs created a better workplace in terms of open communication, good will, social support, and reciprocity. One participant expressed it as follows “I would say it creates a lot of goodwill. So, we give this [WHPP] and we care, and we would do all these things for you, and it's a give and take. So, that creates good will for the team to then give back, and be okay with doing some things outside of their comfort zone, or doing some things […] like once in a while, because it's a give and take. So, creating good will is a big deal” (Participant 8). Another reason to implement WHPPs was to encourage interdepartmental interaction and team building, especially for multisite companies that want to engage distant sites. This is illustrated by this participant quote: 37 “I think that the staff here, we feel a little bit disconnected from the [headquarters] and by bringing in some of the same sort of kinda perks that the [headquarters] gets down here, people just feel like they're that much part of a larger thing. Everybody likes to feel like you are part of larger thing” (Participant 3). Other participants mentioned including employees’ families in the program, either by allowing access to the materials, or actively encouraging them to participate in the activities. One participant mentioned that: “The [activity] went to, so well we decided: - well, you know what? Why not offer to people spouses as well? - So, it's hard for them to get onsite, obviously, to do some of it, but a lot it's a web-based app that people can go in, log what they are doing, online resources are there. And we had an uptake in people's significant others participating. And then obviously it helps with our employee's participating because now they are holding each other accountable” (Participant 4). 3.2.2.4 Reputation that the company cares about the employees Participants mentioned that companies also implemented WHPPs because they wanted to be recognized as a company that cares about employee health and wellbeing. Many participants recognized the importance of letting their employees know that the company values them beyond the work they were hired to do by demonstrating commitment to supporting employee health and wellbeing. This is exemplified by the following quote: 38 “It makes people feel like their employer is not just this stand off-ish thing that's providing them with salary after doing the assigned task. But, it's creating a safe space because you are spending the majority of your life in the walls or in the confinement of your occupation. So, if your employer is taking care of you as a whole human being, I imagine that does a lot of positive things for the human psyche: knowing that they [employees] are being taken care of, whether or not that is the true responsibility of the employer from an ethical stand point” (Participant 2). Retention and recruitment Some participants mentioned that having a WHPP in place helped them to be recognized as an organization that offers high quality working conditions and thus aided both employee retention and the attraction of new talent. One participant described it as: “I think that there is a growing demand for it, and I think that organizations, if they want to attract the best staff and best people, the most talented people, and keep those most talented people then they'll need to lead, they'll need to look to ensure that doing things like this [WHPP] to achieve that” (Participant 13). Some participants also suggested that the program not only helps retain employees, but also helps employees develop their skills (e.g., leadership skills). One participant said that they offered a WHPP to compensate for a lack of wage increases: “We want to improve our retention, and based on our head office, of the corporation that owns us, it's challenging to provide them just monetary 39 increases in their wages. So, we try to look at other ways to improve our relation and keep the general health and environment at the workplace well” (Participant 5). 3.3 Research question 1: Are the activities of the program shaped by the motivations? Participants described how program activities were influenced by the motivations for offering the program. Two themes were identified: Promote healthier lifestyles and promote sense of community. 3.3.1 Theme 1: Promote healthier lifestyles 3.3.1.1 Increase awareness and education Many companies offered activities to educate employees about health and wellness. There was a broad variety of topics covered including: PA, diet and nutrition, financial literacy, sun safety, and mental health. The learning styles used ranged from in-person meetings (such as “lunch and learns” and talks from external experts), to the use of online resources (such as webinars, teleconferences and videos). As an example, one participant mentioned: “We have lunch and learns, we call them - chew on this - where we bring in people, professionals, people known in their fields to talk about different things that support like stress management, time management, dog training, you name it, things that people care about” (Participant 8). Many of the participants mentioned that their program’s information was posted on a website, either company-owned or hosted by an external provider. Information uploaded on the websites included the program outline, periodic newsletters, calendar of activities, results from screenings, fitness tracking and nutrition achievements, amongst others. Website information 40 was updated frequently to constantly remind the staff of the resources available. Some companies used resources from other parties such as their EAP/EFAP or from WellnessFits. One participant commented that: “We have our own page on our website that's called – Wellness - […] Once you are an employee you get access to it. You look at the page and you can find all of the corporate discounts that are currently available, you can find anything that we are sort of affiliated with. So, the West Van Run for instance in the spring we offer some free participation, so if you wanna run you can sign up for free, if you are an [employee] and so. The sort of promotional pieces are there as well” (Participant 7). 3.3.1.2 Promote behaviour change All the companies offered activities that promoted healthier lifestyles including PA, nutrition, and mental health. The most recurrent activities where those that promoted PA through onsite fitness classes like running or walking clubs, onsite gym, walking meetings, boot camps, yoga, meditation, hip-hop, and Zumba. Another common activity was individual or group challenges either in the form of single day events or over longer periods of time (such as running for several weeks and tracking daily progress). Some sent computer reminders to participate in stretch breaks. Other companies supported employee-led activities by providing resources or funding, as this participant described: “We support […] group activities. So, we've taken a portion of our budget and every year there's an application process. And so, for people and staff who are looking to promote a wellness activity in the workplace, they can put their 41 application forth for full or partial funding, just depends on how far our budget can go to support that” (Participant 11). Other companies offered corporate discounts at offsite facilities such as gyms, community centers, or massage therapists. Some others offered programs to support health promotion strategies such as smoking cessation or healthy New Year's resolutions. One participant mentioned that: “We've got a smoking cessation program. So, if you want to quit smoking we provide structure, the resources, and there is a page around that we have on the education side of it” (Participant 4). An important topic for most participants was mental health support for their employees. Some companies focused on helping employees to develop mental health skills such as mindfulness, resiliency skills, meditation, and gratitude activities. Others offered spaces to take breaks such as rooms where employees can use coloring books, puzzles or crosswords. A small number of companies offered awareness campaigns and events. Some companies also offered counselling services in different styles including peer-to-peer support programs or the EAP/EFAP resources. As an example, one participant commented: "Under mental health we have a lot of different resources, but mindfulness has been one of the big ones that we've been doing a lot lately. We do a lot of education around mental health, but mindfulness programs are the ones we find target individual resiliency skills the most and help to build those" (Participant 15). 42 Many companies offered onsite health and wellness events to provide screening and medical counselling. Most of them consisted of health risk assessments using common screening services such as biometrics, blood pressure, cholesterol, and glucose testing. Others offered more specific screenings like mammography for breast cancer. In addition, some companies offered one-on-one consultations with a health care provider (family doctor or a nurse) to provide tailored recommendations depending on the results of the screening. A few companies also offered flu shots during winter season. These events varied from a single wellness day to a health fair that lasted for two to three days. “Another big part is health screening. We run health screening clinics […] there's blood pressure, cholesterol, blood glucose, height, weight. And then, we have them put their information into a health risk appraisal through our EAP now” (Participant 9). With regard to nutrition, some companies offered healthy lunches for their employees either as potlucks ran by employees or provided free of charge by the company. Other participants spoke of providing cooking classes and sharing healthy recipes. One company had a nutrition challenge to track the number of healthy diet options taken per day. This is illustrated by this participant’s comment: “So, we provide lunch which is salads, lots of different ingredients, and a protein like a chicken, the ability to make a fit wrap every day at no cost to [employees]. So, that's a big one ‘cause it helps people eat well, it brings them together in a common place. So, it's about building community and getting to know people better over food, stops you from sitting at your computer. There is 43 nothing but good things that come out of offering people food that's healthy” (Participant 8). Various companies offered ergonomic options for their staff. Some did ergonomics assessments, others offered various desk options depending on each employee’s needs including: standing desks, exercise balls, kneeling chairs, sit-stand desks, and seated desks. “Now we provide the desk, and the computer, and the chair but it's not a one-size-fits all model. So, some people have exercise balls that they sit on, some people have standing desks, some people have kneeling chairs. Nobody has gone to the point of asking for a treadmill desk yet” (Participant 10). 3.3.2 Theme 2: Promote sense of community 3.3.2.1 Participate in community events Some participants mentioned that their staff were encouraged to participate in social and community events, both as individuals (e.g., mental health week) or on behalf of the company (e.g., bike to work week, fundraising walks and the Sun Run). Others mentioned that they organized social events such as Easter egg hunts, team breakfasts, or Christmas lights tours to promote a sense of community. This participant’s quote is an example: “We try to engage in other external activities that encourage being fit but also maybe it ties with our mandate a little bit. So, employees arrange for a group of staff to participate in the autism walks, we've done the cancer walk, so there's those kind of things” (Participant 11). 44 3.3.2.2 Interdepartmental events Other participants mentioned having interdepartmental activities (e.g., fitness or trivia challenges) to promote employee interaction across the organization. One participant illustrated this point as follows: “We run a [staff] sports day every year. So, that is a fun end of year sort of celebration, where teams get dressed up in costumes, or they come and represent their department or unit that they are part of. And we offer sort of inclusive events and activities, so it's not just athletic ability and talent and spirit, it's team work” (Participant 15). 3.4 Research question 1: Program evaluation As a way to validate that the outcomes of the WHPPs were being met, participants spoke about their program evaluation. Some companies had frequent evaluations while others did not have a formal evaluation of their program in place. A small number of participants explained that they had conducted WHPP evaluations in the past but do not currently assess WHPPs outcomes. Most participants said that the main reasons to evaluate the program were to guide future actions, develop informed strategies for program delivery, and focus on areas of interest to the employees. As stated by this participant: “The participants' evaluations of what they thought of the event, what they found most useful […] we ask them - are you motivated or inspired to change your lifestyle? What are you gonna change? -. So, if everybody says - my eating habits - then we might try go back to that worksite and do an 45 intervention, or provide them information, or something to help them do that” (Participant 9). The areas for evaluation identified by participants can be grouped into three main themes: employees’ health and wellbeing, employees’ work performance, and engagement and usage. The final template is shown in Figure 3.4. Figure 3.3 Evaluation of WHPPs (final template) 3.4.1 Theme 1: Employees’ health and wellbeing 3.4.1.1 Change to healthier lifestyles Participants spoke about the importance of evaluating changes in their employees’ health. Most of the companies relied on self-reported data from employees regarding achieving fitness or diet goals. Fewer used more formalized approaches such as pre-post measurement of various biomarkers like weight, stress and anxiety levels, and number of people quitting smoking. 46 “I'm a firm believer that anything that gets measured gets done […] we on almost all of our programs attach metrics to them so that we can determine: here is where we started, here is what we did as an intervention, and here is what the results were” (Participant 14). Some companies tracked the aggregate utilization results from screening events and/or got data on the number and type of resources used from their EPA/EFAP provider, as mentioned by this participant: “We track general levels of Employee Family Assistance utilization through our EFAP provider. So, at the end of the year our HR department usually gets a summary report to see what types of services were accessed, which resources online were garnered” (Participant 2). Some participants evaluated the effectiveness of education session materials with metrics such as level of understanding, level of awareness increased, and willingness to make a behaviour change. One participant described it as follows: “We had a whole day where you had somebody start off like – okay, what do you do now? - And then we went through different exercises, activities, knowledge-based things. And then at the end it's like: - okay, what can you do with this knowledge compared to what you started off with from the day? –” (Participant 12). 47 The overall results were positive but moderate. Some participants mentioned that some employees had major life transformations like losing a lot of weight or learning about a disease in the early stages and acting to control it (e.g., pre-diabetes). “What we know is that any of the lifestyle change programs that we have done, I have seen improvements in all of the parameters” (Participant 14). Participants of companies with programs implemented less than 5 years ago acknowledged that, although progress was slow and that results will only be manifest in the long term, there had been a positive change in employees’ health compared to before program implementation. “Out of the 800 people we surveyed, we got over 300 people responded to the survey and out of that the 87% or 84% had said that they had made changes, and 17 had quit smoking […] We have also had several employees basically tell us - we saved their lives - because they found out that they had health risks that they wouldn't have otherwise know about, like high blood pressure, high cholesterol, things like that where they've gone and got it attended to right away [...] we call those - our safes -” (Participant 9). Fulfills needs and interests of the staff Companies also evaluated whether the program was fulfilling their employees' needs and interests in HW. Some participants asked their staff for feedback on the program (e.g., things they find appealing, things they dislike, suggestions for future). Others asked the employees to share their perception of how much the company supports their health and wellness. Overall, most of the participants acknowledged that different things are appealing to different people at 48 different times; however, there was consensus in that people were no longer interested in attending “lunch and learns.” In general, participants found that employees perceived the companies to be very supportive of their health and wellness. One participant mentioned that employee satisfaction was evident by the reciprocity seen when staff volunteered for activities outside their regular working hours. As an example, this participant mentioned: “Our employee engagement survey [...] there are questions in there that are about - do you feel that we support your HW? - . We get like a rating, but that's just like a total rating of a general feeling that somebody has [around health and wellness]. And that rating is really high, it's like 4.5 out of 5. So, that's nice” (Participant 8). Many of the participants said there had been few negative outcomes. Some said that there was little abuse of the program or evidence that the program had negatively affected employee health. Others mentioned that a couple of employees were injured while playing sports. Participants with newly implemented programs recognized that the program had not been in place long enough to show negative outcomes, as expressed by this participant: “I don't think there was anything negative that people went backwards in terms of their wellness. I don't think there was anything that we could have done to make people feel like - I don't want to be healthy - or anything like that” (Participant 6). Several participants mentioned that they received individual complaints, but these complaints were manageable and in some cases anticipated. This participant’s comment is an example: 49 “I think there is always those individuals who feel that the employer does not belong in the space of HW and that they shouldn't be dictated or told to be engaging in anything other than the work that they were hired to do. So, I’ve heard of situations where employees become resentful of HW activities that are promoted and would choose to either: number one, not engage in the activity, which is kind of self-exclusion, or choose to be more vocal about their perceived nanny state of the employer. So, that might be considered the negative outcome” (Participant 2). 3.4.2 Theme 2: Employees' work performance 3.4.2.1 Absenteeism, attendance and presenteeism Companies also measured changes in employee work performance. Some participants talked about measuring changes in absenteeism/attendance and presenteeism. This is illustrated by the following quote: “We do measure quantitative metrics with employee attendance [...] some of the benefits, like I said, we use a [external company] to measure our employee absences, which is really useful data all the way around to see and track employee attendance, but that becomes a priority in our unionized environment as well as a more mandatory protocol and process” (Participant 2). The results were mixed: some companies found a decrease in the number of sick days/stress leave after the program was implemented while one participant mentioned that there was no correlation between the program and a recorded decrease in absenteeism rate. For example, a participant mentioned that: 50 “I took a look at the absenteeism, that was the biggest one, and disability case management […] I took a look at what we were doing [WHPP] and was there a decrease in absenteeism. There wasn't a strong correlation, unfortunately. Because I couldn't say that this was a cause, it wasn't a cause and effect principle” (Participant 10). Another company found that employees participating in the program had a higher presenteeism rate than expected. This is illustrated by the following quote: “I think that what we've found is that there was a higher level of presenteeism than we've anticipated, which could be considered a negative outcome” (Participant 14). 3.4.3 Theme 3: Engagement and usage Companies were interested in measuring the level of engagement in the program and the use of the resources provided since they considered this to be a key indicator of the program success. Some participants counted the number of employees attending events; others measured engagement based on the number of visits to websites such as the EAP/EFAP; some relied on employees’ self-reported data on access and usage. For example, one participant said: “We usually track attendance at all our lunch and learns to see how many people had attended. We track general levels of EAP utilization […] we offered a health risk assessment online through our benefits portal and we can track who has used that” (Participant 2). 51 Some reports were more mixed. A subset of participants claimed their engagement rates were high and had increased over time, while others had low engagement rates and less involvement than anticipated. One participant expressed it as follows: “I didn't think it go as well as it has […] I just thought it would take longer for people to get on board with the program, but it didn't seem to take as long. So, that was an unforeseen outcome” (Participant 5). 3.5 Research question 2: What are the factors affecting implementation of WHPPs? Participants were asked about the factors they perceived to be facilitators and barriers to the implementation of their company’s WHPP. Participants were also asked about lessons learned throughout the process and about the way in which their organization provides staff access to the program. Most of the components mentioned were facilitators in their presence and barriers in their absence. The factors identified were grouped according to the organizational decision level at which they occur. In general, organizations follow a hierarchical leadership in which each level is responsible for specific aspects of the business (Sanders & Wood, 2014). Usually, there are three levels of decisions within an organization: strategic, tactical and operational. Strategic decisions have been defined as “what” the company wants to achieve and the direction of the entire company in the long-term; these are usually broader plans involving the values and goals of the organization (Harrington & Ottenbacher, 2009; Sanders & Wood, 2014). Tactical decisions are those related to “how” to advance the strategic decisions in the medium term; these generally have more detailed action plans to determine how resources and middle management will be assigned (Harrington & Ottenbacher, 2009; Sanders & Wood, 2014). Finally, operational decisions are those that impact the short-term management of daily 52 operations in functional areas of the organization (Harrington & Ottenbacher, 2009; Sanders & Wood, 2014). The factors identified by participants were only at the strategic and tactical decision levels. The final template is shown in Figure 3.2. Figure 3.4 Factors affecting the implementation of WHPPs (final template) 3.5.1 Theme 1: Strategic factors Research participants identified factors that set the course and direction of the WHPPs within the organization. These factors related to establishing the objectives and strategies the WHPPs should follow. Four main subthemes were identified: employee health and wellness needs assessment, plan and objectives, part of culture, senior leadership buy-in, and defined budget. 3.5.1.1 Defined budget Several respondents identified budget as an important factor affecting their WHPP. Others talked about the importance of having a defined budget to be spent on the program in 53 terms of scalability by increasing the number and quality of resources offered to staff. This is reflected in this participant’s statement: “Having a budget is also very important to do what you need to do. There are many things that you can do for free, but if you really want to take it to the next level then you'll need to have assigned some budget to that” (Participant 13). Similarly, participants considered a limited budget to be a constraint to program implementation. Some referred to the inability to offer additional and improved activities to staff. Others mentioned that employees wouldn’t attend an activity if there was a direct cost to them for attending: “As soon as we add an element of cost to the employee it [engagement] drops off by 90%” (Participant 3) Participants recognized that the program required a lot of monetary resources due to the types and quality of activities offered, incentives and prizes, marketing and communications materials, and to expand the outreach for multisite companies. One participant mentioned that the program’s return on investment was low because of the limited budget designated to it: “We don't have a very big budget considering how many employees we have, right? So, if you look at the return on investment [ROI] it's hard, you know? It's very little investment. To the organization's credit, the program's been around for a very long time, but it's hard to look at big ROI numbers if you haven't invested much in the first place” (Participant 9). 54 Representatives from publicly funded companies and not-for-profit organizations talked about feeling constrained to freely allocate their resources because they are compelled to present a justification to the donors/contributors, some of whom might consider such expenditure to be unjustified. “Because we're public sector and because we are very mindful of citizens’ view of how tax payer dollars are being used [… ] there is only so much that you can do at minimal or no budget […] there's lots that you can do but sometimes, I think the committee would prefer to do more and just can’t” (Participant 11). On the other hand, representatives from private companies spoke of having limited time from implementation to a demonstration of a return on investment being expected. This was a challenge as most of the effects of these programs are only seen in the long term. The following quote from one participant exemplifies this situation: “We have very good leadership support for the success of wellness, but I think it's our short leash. So, there is only a certain amount of time that they'll [senior leaders] give us to see a return on our investment. But no, I think that's the only area [barrier]” (Participant 1). 3.5.1.2 Employee health and wellness needs assessment One of the most recurrent factors mentioned by participants was the customization of the program to employee needs and interests in relation to health and wellness. Most of the participants mentioned that the program goals were grounded in the aspects of health and wellness that are important to their staff. This assessment included current needs related to 55 physical health (e.g., obesity, diabetes), mental health (e.g., stress, anxiety), adopting healthier lifestyles (e.g., increase physical activity, healthy diets), and habit change (e.g., smoking cessation), among others. These data came mainly from surveys, health screenings, employee -and family- assistant program (EAP/EFAP) usage reports and individual requests from staff. Participants also recognized that these needs and interests are dynamic, and as such surveys were conducted on an ongoing basis, as exemplified by one participant quote: “I think making sure that if you're starting a new program you make sure that the program is reflective of the desires of the staff. ‘Cause if the workshops that you are offering are not reflective of what they are looking for, you are not gonna get people out” (Participant 14). On the opposite side, many participants mentioned that not meeting employee interests regarding wellness and health was a barrier to program implementation. Participants spoke of employees not being interested in participating in the program because it was not appealing to them, or because they did not like the style in which it was being delivered. Despite choosing activities that were appealing for most of the staff, some employees were left out. Others spoke of low turnout for activities that were assumed to be of interest to staff, but staff were not consulted or the programs were not tailored to their needs. One participant mentioned that: “Interest is challenging because a lot of people find the traditional mechanisms of healthy eating, and PA as not being as exciting anymore. So, they are always looking for something different. So, sometimes when we offer healthy eating workshops people don't come because either they are not interested, or they've heard it all before” (Participant 2). 56 Another participant added that it was also important to manage staff expectations, because even though the program is customized to meet the employee needs and interests, it doesn't mean they are going to deliver on everything, as stated below: “I think that is not understanding staff appetite for a program like this from the beginning, not getting a good understanding of what the staff want from this program; and ensuring that there is a level of engagement from staff as well; and that we are meeting those expectations or managing those expectations, depending on what they are, and getting that alignment, I think is also really important. But, it's easier said than done” (Participant 13). Employees’ buy-in and involvement Another key factor that participants identified was the necessity of employee buy-in and involvement in the program. For instance, many participants stressed the importance of reassuring their staff that the true intention of the program is health promotion and not employee monitoring (e.g., attendance, drug testing), particularly in trying to get union support. If employees don’t trust the true purpose of the program, they won’t participate in the activities. For instance, one participant said: “One of the things right at the very beginning was there was a lot of skepticism about whether or not it was really going to be a HW committee, or if it was disguised to be an attendance management program. There's some skepticism about it, which is fair. And so, I think one of the greatest successes of this program over these last few years is that that skepticism is no longer there. I 57 think people very much see it as a HW program, they appreciate it” (Participant 11). In addition, participants also spoke about having employees actively involved in the program either by leading activities or actively promoting the program. As one participant pointed out: “Anything that's employee led is usually successful, because they are motivated to get people involved” (Participant 8). 3.5.1.3 Part of culture Some participants also mentioned that health promotion is an important part of the company's organizational culture. They acknowledged the importance of incorporating health promotion into company values and aligning it with the organization’s mission and vision. This is exemplified by one participant’s comments: “One of the things that we're looking at right now is to link it [the program] with our organization development strategy. Which means that now we are looking at how do we deliver programs that align with the values, how do we deliver programs that link into some of the strategic directions of the organization” (Participant 14). 3.5.1.4 Plans and objectives Participants also spoke about having a structured approach to the program. These included defining the main objectives based on the employee needs assessment and identifying clearly the issues to target. Some participants defined key areas on which their program was 58 based, such as physical and mental health, education, and supportive environments (social and physical). This is exemplified by this statement: “We sort of have them [activities]in buckets when we think about health and we think about the determinants of health. So, we look at physical health, we look at mental health and wellbeing, and we look at nutritional health, and we think about wellbeing are built in natural environments. So, spaces, places, nature, buildings and inclusion and connection, so that social connection piece. So, those are really our five prior areas that we have. And then in all of our programs we try to ensure that any activity, any initiative fit within those” (Participant 15). Additionally, participants mentioned that their program was integrated into their company’s business strategic plan and important dates. Many of them said they plan WHPPs activities early to avoid rushed implementation. Fewer participants defined how program effectiveness was measured. Some talked about incorporating factors to allow the program to be scalable and sustainable in the long term. One participant expressed it as: “At the beginning taking an strategic approach to implementing the program, and also maybe including the person who is responsible for it in the planning meetings at the beginning of the year, or whenever the planning meetings take place, so that it can be integrated as part of the board of planning process. So, if we know that people are busy in June because we have a campaign then, or what is that campaign and if there is healthy spin that we can put to it, or is 59 there a way that we can engage staff and that. Just ensuring that is intuitive within the strategic plan for the next year” (Participant 13). In contrast, participants identified that the program not being part of the business’s objectives reduced accountability, and therefore acted as a barrier. As part of the strategies used in the planning of WHPPs, participants were asked if they used the WellnessFits program offered by the CCS. WellnessFits From the 15 participants, 5 identified themselves as users of the program, 4 as past users but not currently, and 6 had never used the program, 2 of whom said they hadn’t heard about the program before. Participants also shared their perceptions about the program. There were two main themes identified: WellnessFits is a good program, and WellnessFits is too generic. Most participants considered that WellnessFits was a good WHPP. Some mentioned that it is a cost-effective program that is easy to access and implement. Others referred to it as an appealing way to engage staff. Many suggested that the program was a good option to launch off a new program. Some participants mentioned that the program has a good reputation and has been recommended by other users. As stated by one participant: “It was something that was easy to incorporate into kinda the day to day life down here. For example, the sit-stand desk is one of the biggest things that I got from the conference and so, that's something that we've been introducing to the staff around here. So, they seem to be manageable ideas and ways that we can incorporate here without costing a whole ton of money, but still having a fairly substantial impact on the staff” (Participant 3). 60 Many participants recognized the high quality of the resources provided through the program, and several identified them as useful and shared them with their staff. Some participants stressed the importance of having the initial survey and close counselling and follow-up from the WellnessFits coordinator. Other participants mentioned that, although they don’t use the whole program, they do take some parts of it that are useful for their particular needs, as illustrated by one participant: “We use their survey. We got them [CCS] to come in and present the results to us around what they had found and then we’ve kept in touch with them. And I have an HR advisor who is also sort of the active wellness person and the two of us receive all of their communications ‘cause they [CCS] are quite good at updating information and saying: - this is mental health week, this is heart month - or whatever. So, it's good for us because we can piggyback on that and send information to our employees” (Participant 6). In contrast, some participants considered WellnessFits to be an overly simplified program that does not allow for a customized approach. Participants commented that the resources provided are too generic and not of sufficient relevance to employees, as described by one participant: “I would say the big one is we are very big believers in creating ourselves we’re a - do it yourself DIY culture - for sure. And because feedback and constant communication is such a big part of who we are, the thought of outsourcing something like this to a company that doesn't know us, doesn't live our culture, doesn't get that, just doesn't make sense for us” (Participant 8). 61 3.5.1.5 Senior leadership buy-in Some participants mentioned having buy-in from their company’s executive team as an important factor for the implementation of WHPPs. Participants acknowledged the importance of having their support because they provided the resources and direction to ensure the continuity of the program. Moreover, some participants mentioned that leaders need to be seen as role models by actively participating in the program. As illustrated by one participant: “I think having senior management team involved and supportive of it. That need to have that level of input and level of direction from senior management team, otherwise it's just staff trying to push it from the middle or the bottom out, and it's so much harder then to get people interested” (Participant 13). On the other hand, some participants identified the lack of buy-in from top level leadership as a barrier to implementation as it reduced certainty that the program was going to be a priority in the future. One participant referred to the limited vision of wellness that some of the company leaders have, specifically their failure to see the scope of WHPPs extending beyond traditional offerings, such as fitness classes, and into the overall organizational culture: “[It’s] also challenging to bridge the gap of understanding for our senior leaders of as to what actually comprehensive successful WHPP needs to be. It's not about providing a gym and then explain why no one is going. So, really understanding what is health promotion, what does it mean. Is more than just providing education and a resource, we need to have, we need to feel it in our culture” (Participant 1). 62 3.5.2 Theme 2: Tactical factors Participants identified key factors related to the execution of the program implementation. Nine subthemes were identified: characteristics of the activity, communications and marketing, economic and human resources, geographic outreach, incentive use, learning from experience, leveraging existing resources, management buy-in, and timing. 3.5.2.1 Characteristics of the activity Participants mentioned that the implementation of the program was affected by the characteristics of the activities offered. Three main categories were identified: employees being held accountable, ease of engagement, and inclusiveness. Ease of engagement Many participants talked about the importance of making it easy for the staff to participate in the activities offered by the program. The comments were related to how accessible and manageable the activities were. One participant stated that: “There were things that everybody could do if they wanted to, and it was easy to sign up or be a part of it, no restrictions” (Participant 6). With regard to accessibility, some participants mentioned having resources available at any time at a variety of locations. Others identified having a quick and simple sign-in process. Some participants spoke about offering activities at a time and place that maximized ease of engagement (e.g., lunch time). Restricting the length of the activity was also flagged as important for increasing employee engagement. This is illustrated by the following participant’s comment: “They [employees] can access them [activities] during worktime it's helpful. So, the fact that we bring them here during the day, the fact that we serve the 63 lunch here, the fact that the gym is here, those things help. It does not mean that we want people to be here 24 hours a day, but the fact that it's close by is very very helpful. We try to come up with ways that it's easy for them to access” (Participant 8). Many participants mentioned having a low uptake when the sign-in process was not quick or easy. Some participants mentioned having low engagement if the requirements for registration were long, complicated or required specific items (e.g., access to a computer). Others said that if the activity was offered outside of their worksite, or if the activity per se added additional tasks to their work day, they would have low engagement. As an example, one participant mentioned: “It's difficult to get people to participate and keep track, so as just add one more task to log on to the system, to say: - yes, I want to participate - or one more task to get them to say: - oh, this interests me -, or even just feedback from the survey was relatively low. So, I would say that's still a challenge for us, is to engage more of the population in participation” (Participant 7). Other participants mentioned that some employees thought that participating in the program would be too demanding in terms of time and commitment and, therefore, chose not to participate. For instance, one participant said: “Where we try to push boundaries a little bit more and get people to do things over and above, that's where we've struggled” (Participant 13). 64 Employees held accountable Another common characteristic of WHPP activities was that they were designed to make employees accountable for their own health. Some participants referred to it as assuring their employees that they had control over the program by providing different options from which to choose, and not making it mandatory to participate. This was described in one participant’s quote: “What works well is things that people can find tangible, so they can touch it, they can see it, they can interact with it. So, things that people like engaging in, activities that they can interact with” (Participant 1). Others mentioned that they found success when people monitored their progress on healthy behaviours for competitions or challenges. This was seen as a way to keep the activity at the forefront of employee minds, as this participant exemplified: “"With the [program] the success is that people are… what's the expression? - what gets measured gets done -. The fact that people are tracking their exercise and their healthy things, I think just brings it top of mind, they are more likely to continue doing it” (Participant 9). Inclusiveness and variety Some participants mentioned that they had success in offering activities that were inclusive of all employees, as well as in offering a wide variety of activities. Participants spoke about the importance of being mindful about different activities attracting different participants, and keeping in mind that the overall goal of the program was to deliver something for everyone. 65 Some participants said that they configured the program to be flexible and adaptable in activities, structure and even goals, as the following participant stated: “We are nimble enough where each year we can customize things. So, we try not to have big shifts. At the end of the day our philosophy is still the same: we've got the 3 pillars. But if Zumba didn't work out well the previous year, we are able to take it off, list if off for exit, and deliver a new program” (Participant 4). A small number of participants mentioned that they provide at least one different activity every month to keep people interested in the program. In terms of inclusiveness, some participants said that the activities needed to be simple enough for everyone to understand them. Others mentioned that they offered activities in various forms and levels so that everyone could participate regardless of their readiness level (e.g., PA level). This is exemplified by the following quote: “We decided we'll do like a different activity each month that will just keep promoting wellness in the workplace. The main success’s been we've been offering things that they can do on their own or in a group, and nothing like overly strenuous. It's all at your own pace and stuff” (Participant 6). 3.5.2.2 Communication and marketing Several participants identified having effective communication and marketing strategies as important factors for the successful implementation of the program. In some instances, these were seen as the most important ways to allow employees have access to the benefits of the program. 66 In terms of communication, participants mentioned that the program needed to be broadly advertised to maximize reach through the use of a variety of resources (e.g., electronic or printed materials) and through different channels (e.g., website, word of mouth, emails, in person sessions). Others suggested providing simple and clear messages and communicating one message at a time on an ongoing basis. Many participants spoke about having introductory sessions for their new hires. For instance, one participant stated: “I think mostly it was all about communication. That we invited them [employees] to join us for a lunch and talk about what we were doing, what our program was. We are all on email, so we are able to send out emails that had videos and things like that in them” (Participant 6). Regarding marketing strategy, some participants talked about focusing on the benefits to the employee in a positive and fun way. Others spoke about making it easy for the staff to identify the program by either creating a brand or by making the people in charge of the program visible to the staff. One participant said: “It goes back to kinda marketing again, it's how do you grab people, you're gonna grab them with how this can benefit them. So, we go with that: how can it benefit you personally, how can it benefit your family, how can it benefit your work, or your professional career advancement. So, we've always kinda look at is as: - why does this matter to you, and why you might be interested in this -. So, we definitively focus on those benefits as a lead in for whatever the program is that we're going to be running, so that they know right off the back: - why should I care? Why should I be interested in this? -” (Participant 15). 67 Limited communication and poor marketing were identified as barriers to program implementation. Some participants talked about reaching only certain areas or people because they only used one communication channel (e.g., only send emails). As an example, one participant said: “Not enough communication about the importance, and the ease of use, and how we're removing the barrier to accessing this information by providing this. So, I think people think is therein or maybe we are only getting 20% readership on some of those communications. We need a much more comprehensive approach to get the message out there, which we are working on” (Participant 1). Others mentioned that their marketing strategy was not effective in announcing the activity as inclusive of different levels, or that the message was not appealing to the entire workforce and, therefore, some employees felt excluded. One participant described this situation as follows: “On the offering we have a core conditioning section. It's kinda boot camp, again when we came out the way that it was marketed to people, might have been a little bit too hardcore so, it was intimidating. Again, we got feedback people said: - well, you say the first line it's available to all activity levels -. But then you go and explain all the things you're gonna be doing and people said: - I don't wanna be doing that, it's way too hard for me -. So, the marketing of the activities and even on how” (Participant 4). 68 3.5.2.3 Human resources dedicated to the program Most of the participants acknowledged the importance of having a single staff member responsible for the WHPP, either full time or part time, in the success of the program implementation, as stated by this participant: “I think it's important to have a staff, appoint a person who is responsible for the program, who is leading the program, and having that connection with them [employees]. As a team member, being an advocate for it [the program] and then having that connection there. And maybe mentoring that staff person to implement and to really drive the program forward is important” (Participant 13). Participants also mentioned having a Wellness Committee comprised of staff from different sectors of the organization to be important. These committees acted as a bridge between staff and the organization concerning health and wellness and helped encourage communication. Other companies relied on volunteers and key employees to advocate for the program called “champions”, “ambassadors” or “reps”. This is exemplified by one participant: “We have a lot of success when we get buy-in from other, I guess I would call them “champions” on our [worksite]. So, we have a network of folks that we know we can go to, who are already personally interested in health and wellbeing. Maybe they've had a personal experience that's changed their physical health or their mental health. And so, we look to this group of people as a way of getting everybody else sort of excited about it. So, we know that we can go to this network of people. We communicate with them throughout the 69 year, we send them an annual little gift during the holidays to thank them for the work that they're doing. So, they're sort of our ambassadors, I would say, out within our different departments and units. So, we really really lean on them for help when we are preparing an initiative or when we're rolling out an initiative so, they can help with that. So, I would say that's been really really successful” (Participant 15). Some participants mentioned the workload that WHPP delivery added to the person in charge of the program. Others stressed that if management of the program is not a part of the assigned person’s job description, the delivery might be limited by the time this person can assign to it: “I think the key areas that we haven't been successful is where we haven't had the resources, or the people haven't had the time to commit to implementing things properly. And I think that that has lead to… not that we hadn't been successful, but just missed opportunities of things that have been mediocre instead of excellent” (Participant 13). Two participants also mentioned that the people involved in the program were always the same and they might get apathetic about the program, and that they should be rotated: “I think one of the things is that, maybe is weakness or doesn't works as well as I would hope, it’s usually the same people that always come forth to promote new ideas, or to promote new initiatives and they get tired after a while. So, I would say trying to find a way to encourage more people to take an active role is a struggle” (Participant 11). 70 3.5.2.4 Geographic outreach Representatives of big and multisite companies spoke about the issues of reaching out to all their locations, especially remote sites, or workers whose work activities are not directly inside the company. As stated by this participant: "The challenges are getting across all of our locations in BC geographically […] when we want to get involved with certain campaigns throughout the year it is very challenging to get a lot of our locations to participate because we don't simply have the people in those locations to get the enthusiasm and to really to do it" (Participant 1). On the same note, one participant mentioned that part of their success was attributable to having their staff located in the same building because that made it easier to reach out to them. 3.5.2.5 Incentive use Some participants talked about the use of incentives to encourage engagement or to recognize employee efforts in achieving a goal. The incentives varied in kind (e.g., food, promotional items, draw prizes), or came in the form of public announcements and recognitions inside or outside the workplace (e.g., lunch for participants who completed the program, EMAs). Moreover, participants mentioned that employees take pride in earning these promotional items. This was illustrated by this participant: “Even though the prizes are things like water bottles you could go and buy, there is a sense of earned. So, people take pride in the fact, I mean it’s something that again, if you think about it you could just go buy a water bottle 71 you don't have to, but when people earn it there is sense of pride in earning it, and I think that helps them continue on” (Participant 9). Participants also mentioned a lack of incentives resulted in low engagement. 3.5.2.6 Learning from experience Participants also spoke about the importance of learning both from their own and others’ experiences. Some participants used their past experiences as learning opportunities to improve their program and to acknowledge the company’s current level of understanding and readiness regarding health and wellness. A few of them spoke about piloting the program or even testing in-house wellness products that they would offer to their customers. Many participants considered their experiences as representing a learning curve in improving program implementation and growth. With regard to learning from others, a few participants mentioned that they adapted some strategies found to be successful for other companies into their own program. These strategies were found either in the literature, by networking, or by getting guidance from health and safety agencies. One company had participated in some research projects in partnership with a university. This is exemplified by the following quote: “I did a lot of research. I looked at what was happening in other industries, industries like us. I also talked to people, asked them […] And we've made changes along the way” (Participant 10). 3.5.2.7 Leveraging existing resources Participants talked about taking advantage of existing resources as another factor affecting program implementation. A frequent theme was making the most of current 72 organizational structures and personal relationships at the workplace to deliver the program, particularly with unions and other groups (e.g., human resources, health and safety committees). Another strategy was to utilize material and resources of other programs and partner agencies whose agendas include health promotion. For instance, many participants mentioned using their EAP/EFAP resources, and some even considered these to be part of their WHPP. Fewer participants spoke about their company WHPP complementing the government’s basic requirements in terms of Occupational Health and Safety Programs. One participant stated that: “What resources we have, what we can leverage off that already exist, are there committees or other employee's resources groups that already have a similar agenda or similar module that we can build off” (Participant 1). Other programs that promote health Participants also mentioned other programs that promote health at their worksite. EAP/EFAP were the most frequently mentioned programs, followed by Occupational Health and Safety Program and activities as part of the North America Health and Safety Week. Others mentioned employee benefits that promote health such as complementary healthcare coverage, dental, and life insurance, retirement plans and health spending accounts. Some companies offer extra days-off to spend on wellness. Others talked about having facilities supportive of health, coaching programs and onsite clinics. One participant mentioned having flexible work policies. 3.5.2.8 Management buy-in Participants identified middle management (e.g., direct managers, supervisors) buy-in as another important factor for successful program implementation. Some participants commented that managers are the starting point in allowing employees to use part of their work hours to 73 participate in the program. Encouragement from managers, allowing employees to allocate hours of their workday to participate in the activities, and communicating the program positively, were also seen as key factors in program success. This was mentioned by one participant as follows: “I think one of the other things was that it was hard for people to leave their desks. And so, we found that when we got the approval from the managers for the health-check day and they encourage their staff to attend that more people came” (Participant 3). Participants identified that when managers were not aware of the benefits of the program on productivity, they wouldn’t encourage engagement or support the program by allowing staff to actively participate in the activities. Instead they would prioritize meeting project deadlines even if employees were interested in participating in the activities. As one participant put it: “It [barrier] also was a bad timing. Because you've got management doing things to employees in the background. So, when you say: - oh, let's have this wellness event […]- it's kinda like: - I'm too busy with my regular work, I can't take time off to come to your wellness event, specially when your wellness event is talking about workload, work-life balance, taking breaks, that kinda stuff and yet my manager is making me work like long hours, over time, extra duty because of this project that's going on - […] So, they just didn't engage” (Participant 12). 3.5.2.9 Timing Several participants talked about staff time constrains as a barrier to program engagement. Some participants spoke about experiencing a general increase in the company’s 74 workload, and how employees would rather spend their time doing their tasks than attending an activity. Some inferred that this situation was because the company doesn’t have defined parameters on how much time employees can allocate to wellness; others because of strict timings that were specified in unionized contracts; and some others because employees were receiving mixed messages about participating in the program and meeting deadlines. One participant illustrates this point as follows: “Within the union constraints of their collective bargaining agreement, it makes engagement in HW in the workplace during work hours sometimes impossible. So, their half an hour lunch is a half an hour lunch, and if they don't have the ability to flex an extra 15 min they can't attend lunch and learns that are 45 min long, or they would have to leave half an hour after and maybe not to be able to eat their lunch properly. Those types of restraints are really challenging to work within” (Participant 2). Some participants spoke of the difficulties in selecting a time for the activity that is suitable for different work shifts and work locations. This is exemplified by a participant’s comment: “We don't have everybody working in the office at the same time. So, we have some people who are on different shifts, and we also have some people who are hourly and so, they are not sure if they sign up to go on a walk with the rest of us would they get paid? And I think they, rather than approach their supervisor whether they would or not, they just don't bother” (Participant 6). 75 3.6 Research question 3: What are the commonalities and differences in factors and motivations in companies considered to have promising practices relative to those without this achievement? With the purpose of identifying the commonalities and differences between companies considered to have a WHPP following promising practices with those companies that had not reached these standards, the results of 2017 EMAs winners and runners-up employers were compared against the remaining participants. A total of four winners and two runners-up were identified; the remaining nine were not recognized by 2017 EMAs. Below is a description of factors that were emphasized by 2017 EMAs winners. It is important to note that many of the participants who did not win a EMA in 2017 had won an EMA in previous years or had similar recognitions by other agencies. The review of the data indicated that there were no striking differences between these two groups. 3.6.1 Motivations 3.6.1.1 Improve employees’ health and wellbeing One of the key reasons mentioned by the 2017 EMAs winners for providing a WHPP was wanting to improve their staff health and wellbeing. They also mentioned they were looking to increase awareness and education around health and wellness, as illustrated by this quote: “We want to provide our employees benefits to make them well and healthy currently at their workplace […] and keep the team all around healthy” (Participant 5). 76 3.6.1.2 Benefits to the company Reputation that the company cares Winners also brought attention to the benefits that a WHPP has for the reputation of the company. Being recognized as a company that cares about its employees both inside and outside of the workplace yields various benefits including employee engagement, retention and attraction of talent. One participant described it as follows: “I think a big benefit might be the differentiator […] a lot of organizations have leverage their wellness programs. For us, we know, we get feedback within our engagement surveys of how much people appreciate [it]. Also realize, when I kinda look around and hear of other colleagues and friends or organizations, the [participant’s company] really stands out. So, it's a differentiator for us” (Participant 4). Employees work performance Finally, the 2017 EMAs winners stressed the benefits of WHPPs on employee work performance. They observed an increase in productivity that they attributed to improved morale and engagement. The following comment from one winner serves as an example: “I think wellness as a goal is a great goal for any organization. I think if people are well, either physically or mentally, they show up better, they are better colleagues, they are better friends, they are better employees, they are better everything” (Participant 7). 77 3.6.2 Factors affecting implementation 3.6.2.1 Strategic factors Employee needs assessment on health and wellness The 2017 EMAs winners and runners-up participants (“winners” hereafter) stressed the importance of doing a needs assessment as one of the first steps when implementing a WHPP. The results of such assessments were used to define the main objectives of the program and to ensure the employees would participate in the activities and buy into the program. Winners also mentioned studying the trends regarding extended benefits usage including number of medications consumed and number of resources used from EAP/EFAP. They also conducted employee surveys and approached the staff on a regular basis, as exemplified by the following quote: “I think the employee engagement piece helped […] getting feedback from all the different employee groups, so that you could hear individually what they were interested in […] So, I think success came from asking first, not just assuming people wanted this. We made sure that they saw their input and then we tried to deliver on what they asked for” (Participant 7). Leadership buy-in Winners emphasized the value of having the top leadership team members on board with the program. They said that when leaders were supportive of WHPPs, employees felt more positively about the program. In addition, some said that when leaders were seen actively participating in the program, they served as an example to inspire employees. One participant’s quote illustrates this point: 78 “I think that's one of the reasons I think, you know, certainly in the early days, our CAO very much supported the program and it was through his support at the senior management table that really helped us get off the ground. And that's critical even today with any organization who's going to start, one might need the executive management team on board with it and visibly participating in the programs” (Participant 14). 3.6.2.2 Tactical factors Communications and marketing Another key factor mentioned by the 2017 EMAs winners was having an effective and broad communications strategy. They pointed out the importance of having different channels to disseminate the program to broaden its outreach. Some suggested having a simpler and clearer way to communicate key messages to enable everyone to understand the true intentions of the program. One example is the following comment: “It works well when we have a number of people on board communicating the same messages. So, we have key contacts at all our locations to promote our messaging and get it out there in our notice boards […] I think a big part of it has been delayering the number of messages and the number of resources and things going on. There was a lot of noise so, I think it helps when as an organization you really decide what your priority is” (Participant 1). 79 Characteristics of the activity Finally, the winners highlighted the need to make it easy to participate in WHPP activities. They talked about providing activities that employees could easily engage in during work hours. One participant said that: “We wanted something that grabbed people right away, made them think: - oh this wellness thing, this is kind of interesting - and then to continue to be actively involved as we went along. So, something quick and engaging was really our target” (Participant 7). Leveraging existing resources One factor that the winners stressed was using resources from existing programs and other areas where objectives were related to health and wellness, particularly OHS and the EAP/EFAP. Furthermore, they suggested taking advantage of existing relationships to build engagement and buy-in. One participant mentioned that: “I think our organization had a lot of good relationships with the health and safety team and HR [human resources] at the time with all the different business units out there. So, I think it worked well because they leveraged those relationships” (Participant 4). Learning from experience Winners also spoke about the importance of making the most out of every situation and seeing negative outcomes as learning experiences. No outcome was considered unsuccessful, but rather as an opportunity to improve the delivery of the program. They expressed satisfaction with the current status of their WHPPs. As stated by this participant: 80 “I think that with each program it's not so much about the program that didn't work as learnings when you first introduce a program. So, for example, the first time that we offered our team challenge, there was a lot of learning that came out of that, that informed when we run it the next year. And so, I think what didn't work so well was that many of us were new to it, like my wellness committee weren't event planners. So, they had to grow the skills pretty quick” (Participant 14). 3.7 Additional information 3.7.1 Future of the program Participants spoke about future plans for the program. Two main themes were identified: keeping the program as it is, and expanding or adjusting the program. The final template is shown in Figure 3.5: Figure 3.5 Future plans for WHPPs (final template) 81 3.7.1.1 Theme 1: Keeping the program as it is Some participants had plans to maintain the program’s status quo mainly because they had limited resources, while others considered the program to have proven its success by achieving its goals. One participant said: “It'd be great to develop or even have somebody who owns it more and can do something more significant with it. Right now, I think there is no real plans in expanding it too much further until we have either someone dedicated to do it or can put together like a group that might want to do it together” (Participant 8). 3.7.1.2 Theme 2: Improve or expand the program Most participants had plans to improve or expand their program. Three main subthemes were identified: increasing or optimizing resources, customizing to current needs, and strategic approach. 3.7.1.2.1 Increasing or optimizing economic and human resources Many participants discussed the economic resources assigned to the program. Some talked about increasing the budget in order to increase the number of options or services offered to staff as well as increasing the quality of existing options. Others talked about getting extra staff to be responsible for the program, either by hiring more personnel or allocating more hours to the existing responsible staff member: “We are going to be doing things a little bit differently in the future. We're hoping to get like an actual budget line item that would help us coordinate a 82 little bit better and offer some more either reduced rate or free” (Participant 3). Participants of companies with limited budgets talked about finding a more efficient distribution of existing resources, and some suggested partnering with external providers to offer discounts and free resources to employees. Others talked about promoting the use of existing resources like those provided by the EAP/EFAP providers. One participant mentioned that: “I don't know that we are gonna necessarily get more budget, but every year the committee is trying to get more, be more creative you know, with what we have” (Participant 11). 3.7.1.2.2 Customize to current needs and interests Include new activities Many participants talked about offering new activities. Participants spoke about including a mental health component including education and techniques to help employees cope with stress, anxiety, and mental illness. Others mentioned including counselling services and skill development, as illustrated by this quote: “Our goal is to expand into mental next year. So, stress, anxiety, mental illness, mindfulness. So, thinking about meditation and those kinds of things that individuals can use to relieve their stress” (Participant 7). Some others mentioned offering activities to improve physical health such as fitness facilities and nutrition counselling; others talked about reducing health risks, such as offering smoking cessation programs. 83 Increase satisfaction, engagement Various participants restated their commitment to meeting employee needs and interests in relation to health and wellness. To achieve this, participants spoke about updating assessments of employee needs and interests in health and wellness and incorporating ongoing program delivery evaluation to enhance the appeal of the WHPP to staff. As an example, one participant commented: “Just continue to meet the needs of our workforce. Maybe move away from stuff that isn't working, just because something that we offered for certain years doesn't mean [that] it's what people still wanna continue to do” (Participant 4). Some participants said they would like to increase the number of employees engaging with the program and participating actively, particularly employees who had not previously participated in any program activity. Other participants talked more broadly about the importance of having healthy and happy employees, as stated by this participant: “I think our end goal is to have healthy happy workers, because they are the most beneficial for the business in general” (Participant 5). 3.7.1.2.3 Strategic approach Plans and objectives Several participants expressed a desire for their program to have a more strategic approach in order to achieve the goals of the WHPP. Some participants mentioned having clear and defined objectives with scheduled activities for the entire year. Other participants mentioned changing the WHPP to a comprehensive program or filling WHPP gaps and addressing missed 84 opportunities identified in the past. Some expressed interest in exchanging information with other companies to share experiences and learn about successful practices. “I hope that longer term we would be able to develop it [WHPP] and make it a more robust program. As I said, right now we don't have longer term goals or a big strategy in place. It is more at the beginning of the year, but we’ll look at modules that we want to implement at different times, and stuff that’s really manageable for the group of staff that's on the committee” (Participant 13). Most companies were considering using the WellnessFits program in part or as a whole. Many participants recognized the quality of the resources provided and had plans to share them with their staff through their website or via newsletter. Others talked about using the counselling and guidance offered. One participant said that: “I don't know that we would use the program in its entirety. I think that, when I had a quick scan at their webpages, there's some great resources on there that we can tie in [link] with our wellness pages [websites]. I think it would be a link that we would list in our resource section of our wellness pages to say: -hey, here is another reliable site to get some information on some health and wellness topics -” (Participant 14). A few participants said that they wouldn’t consider offering WellnessFits as the approach did not align with their future objectives and directions. As stated by this participant: “I would probably say probably no, just out of how we approach life and doing things ourselves. So, let's leave it at that” (Participant 8). 85 Part of organizational culture Some participants mentioned that they planned to include health promotion as part of the overall organizational culture of the company. In this way, they hoped employees would come to identify health as an important benefit of working for the company not only because of the program, but also because of the health-supportive environment provided by the organization through policies and available resources. This is exemplified by this participant’s comment: “To have it fully integrated as part of our culture. So, if somebody ask you: -what's the culture of the organization? - That they include it as part of their initial answer - that we are focused on healthy workplace and healthy life here, and that's part of working here -. I'd like to see that more than it is now” (Participant 7). Evaluation Participants also spoke about outcomes that they considered worthy of measurement in the future. Many participants wanted to know the amount of time employees were willing to invest in the program. Some participants also mentioned that they would like to know the reasons why people took days off, the effect of the program on productivity, and the impact of sleep on work performance. Others talked about creating a baseline measure of employees’ current lifestyles and health conditions against which to compare the effects of the program in the future, such as chronic disease incidence. Others talked about measuring the effect of having an organizational culture supportive of health and wellness on employee health. Measuring the return on investment and the value added to the company was also mentioned. Other participants said that they would like to compare their WHPPs to other companies’ programs with regard to 86 outcomes and activities. Some participants stated that they wouldn’t want to measure anything additional, but instead focus on analyzing data that are already being measured. Finally, one participant recognized that knowledge of the benefits of WHPPs had increased considerably in the last few years, and this knowledge should be spread to other companies interested in implementing WHPPs and to employees about the benefits of participating in them. 87 Chapter 4: Conclusion This chapter presents a summary and interpretation of the study findings and compares them to the existing literature. It reviews the strengths and potential limitations that could affect the results of the study. The chapter concludes with a discussion of the implications of the findings for future research, as well as recommendations for future WHPPs guidelines. 4.1 Summary of findings This exploratory study aimed to conduct a thorough examination of employer perspectives of WHPPs implemented in their companies in BC, Canada. The results of this study are based on data from individual qualitative interviews with representatives of these companies. Research participants were representatives from a convenience sample of the businesses that participated in the 2017 EMAs from the CCS BCY. Based on initial expressions of interest, representatives from 46 companies were invited to participate in this research, and 15 agreed to take part. The individual interviews were audiotaped, transcribed, and analyzed guided by the research questions. Data repetition emerged on the third interview and from the tenth interview on, no new information was identified and data saturation was reached. Overall, the findings suggest that employers are supportive of WHPPs. Participants had positive comments about the different aspects of the program on which this study focused: motivations, implementation, and future plans. As noted, the existing Canadian literature on WHPPs is limited, and few studies identify factors affecting the implementation of these programs. For the purpose of this study, the findings were compared to a Canadian study by Renton in 2011 (Renton et al., 2011), another Canadian article which also included the US experience by Morrison in 2008 (Morrison & MacKinnon, 2008), one recent US study on WHPPs promising practices by Kent in 2016 (Kent 88 et al., 2016), as well as the recommendations of three Canadian organizations: the Canadian Centre for Occupational Health and Safety, Canadian Cancer Society, and Healthlink BC (BC Ministry of Health, 2017; CCOHS, 2018; CCS, 2018b). Specific findings for each research question are discussed in detail below. 4.1.1 Motivations for implementing a WHPP Study participants’ motivations for offering a WHPP were grouped into two main themes: improving employee health and wellbeing, and benefits for the company. Helping the staff to have healthier lifestyles and providing the resources to do so was the most frequently mentioned motivation for the individuals interviewed. This finding was supported by other studies (Morrison & MacKinnon, 2008; Renton et al., 2011) and agencies (BC Ministry of Health, 2017; CCOHS, 2018; CCS, 2018b). Moreover, participants acknowledged the impact that health has on employee work performance. Participants shared the premise that healthier employees are more productive, and that they would benefit from having more productive staff in terms of their overall business success. In a similar manner, Morrison and colleagues identified staff as the crucial factor for a company’s success and the importance, therefore, of the employer investing in keeping employees healthy. Besides productivity, other indirect benefits that companies can take advantage of included improved morale and engagement, reduced absenteeism and presenteeism rates, an increased sense of community, and reduced health-related costs. Despite cost savings being one of the outcomes that companies mentioned focusing on when implementing a WHPP, study participants clarified that this was not the ultimate goal of the program. Instead, health promotion was seen as the primary aim. This finding is in contrast to the data in the US literature (Kent et al., 2016), where healthcare costs savings are the main driver for companies to implement WHPPs. This difference may reflect the differences in health 89 care systems between these two countries: American companies would be financially motivated to provide WHPPs given that companies often pay for healthcare insurance for their employees whereas Canadians companies costs in this domain are much less (usually limited to public health insurance contributions and extended benefits) given the publicly-funded health care system in Canada. Another interesting finding is that companies take advantage of the effects that offering a WHPP has on their reputation for being a company that cares about its staff. This effect can then be used as a strategy to recruit and retain talent. Along the same lines, Renton and colleagues found that companies now offer a WHPP because it is increasingly becoming an expectation of employees. This finding is particularly relevant to today’s cohort of the Canadian workforce, where younger employees now look for working environments that allow them to have a balance between their professional responsibilities and their personal lives (HRPA, 2016; Loughlin & Barling, 2001). 4.1.2 Factors affecting implementation The factors that participants identified as affecting the implementation of the program were found to be facilitators for success in their presence, and barriers to success in their absence. For the analysis, the factors were grouped according to organizational decision level in strategic factors and tactical factors. It is important to note that there were no operational factors mentioned by the participants. Operational factors are those that take place in the lower levels of the organization that require a high level of detail for their practical application. For example, determining the number of materials needed for the activities or ordering food for the cafeteria. This might be reflective of the high-ranking positions of the majority of interviewees thus making them less likely to be dealing with the daily operation of the program. Although this 90 might be seen as a limitation of the study, previous research has shown that successful project implementation needs only two types of decision level factors: strategic and tactical (L. Schultz, P. Slevin, & Pinto, 1987). Schultz and colleagues proposed a two-stage model based on common critical factors from previous project implementation research. The first stage includes strategic factors related to the conceptualization and early planning of the project, and the second stage includes the tactical factors associated with the actual implementation or task accomplishment of the project. Overall, the findings regarding the factors affecting the implementation of the program confirmed those found in the existing literature. This suggests that the study sample was adequate to identify key factors for successful WHPP implementation. The similarities between previous studies and the findings of the present study are summarized in Table 4.1, which is organized according to the results of this study. 91 Table 4.1 Summary of similarities on factors affecting the implementation WHPPs between study findings and existing literature Study findings CCOHS, 2018 CCS, 2018 Healthlink BC, 2017 Kent et al, 2016 Morrison et al, 2008 Renton et al, 2011 Country Canada Canada Canada Canada US US and Canada Canada Name Factors affecting implementation Key elements Keys to success Best practice Model Key elements Key elements Facilitators and barriers Type Research Recommendations Recommendations Recommendations Research Research Research Factors Affecting Implementation Strategic factors Leadership buy-in        Plans and objectives       Evaluation      Customize to needs       Employees buy-in       Part of culture     Tactical factors Leverage existing resources       Health care professionals*  Financial institutions*  Communication and marketing       Use incentives     Economic and human resources     Management buy-in    Geographic outreach   Learn from experience   Timing   Characteristics of the activity Inclusiveness and variety   Ease of engagement   Held employees accountable**  * Item found in previous studies but not in the present study ** Item found in the present study but not in the previous literature 92 There are several common factors found across the studies, especially those in the strategic domain. Upper level leadership buy-in and active participation in the program were key factors identified as affecting the success of WHPPs. This finding is supported by other studies (Kent et al., 2016; Morrison & MacKinnon, 2008; Renton et al., 2011) and also was suggested by Canadian agencies (BC Ministry of Health, 2017; CCOHS, 2018; CCS, 2018b). Leadership support of WHPPs is crucial in strategic decisions such as setting the direction of the program and its sustainability in terms of priorities and budget allocation. Participants also identified having defined plans and objectives based on current employee needs and lifestyles as another important factor affecting program implementation. This finding is similar to results of other studies (Kent et al., 2016; Renton et al., 2011) and agency suggestions (BC Ministry of Health, 2017; CCOHS, 2018; CCS, 2018b). Among the emerging promising practices for WHPPs that Kent and colleagues identified was including health promotion as an important part of the organization’s culture. This should be included in every aspect of the company’s business, and includes actions such as providing policies, procedures and a social and physical environment supportive of health and wellness. Morrison also argued that integrating health and wellness into the company’s culture was key for the program’s sustainability in the long term. Notably, even though evaluation was mentioned as a key factor in strategic planning, formal evaluation was only conducted by a few participating companies, and in most cases, the evaluation lacked scientific rigor. This situation was also mentioned by Goetzel and colleagues in 2007 (Goetzel et al., 2007). They argue that formal program evaluation is not generally undertaken in the context of the corporate environment. This may be either because employees don’t have the skills needed to conduct these types of evaluation, or because companies don’t 93 have the budget or time to perform them. In most of the cases, WHPP evaluations were undertaken by the person responsible for the program, and the metrics used were considered adequate to fulfill their internal purposes which in most cases were the program’s justification to stakeholders. Another factor identified was employee buy-in and involvement throughout all stages of the program, from planning to engagement. Previous work has also supported this as a key factor in successful program implementation (Kent et al., 2016; Morrison & MacKinnon, 2008; Renton et al., 2011) and by Healthlink BC (BC Ministry of Health, 2017). This study found that employee buy-in was achieved in two ways: building trust by reassuring employees that the true purpose of the program was health promotion and they were guaranteed confidentiality, and fulfilling the employees’ needs and interests around health and wellness. Kent suggested that successful implementation depends on the way employees respond to the program, which in turn depends on their level of involvement during the different phases of the program. Similarly, Morrison and colleagues presented a list of suggestions to increase employee engagement including the use of incentives, broad and ongoing communication, assurance of confidentiality, offering activities during working hours and providing programs inclusive of all employees. Study participants also described leveraging existing resources for the implementation of the program. These resources were not limited to material or educational resources, but also those from other departments, such as human resources, and existing relationships such as those with unions, other programs and agencies that promote health like EAP/EFAP, insurers, government and pharmaceutical companies. Similar findings were reported by other research (Kent et al., 2016; Morrison & MacKinnon, 2008) and agencies (BC Ministry of Health, 2017; CCOHS, 2018; CCS, 2018b). Morrison also argued that companies should take advantage of 94 health professionals and financial institutions to promote their WHPP, approaches not mentioned by participants in this study. Broad and effective communication and marketing strategies were also mentioned by participants in this study as important factors in successful program implementation. This finding is supported by other research studies (Kent et al., 2016; Morrison & MacKinnon, 2008; Renton et al., 2011) and agencies (CCOHS, 2018; CCS, 2018b). The communication about the program should be clear, and at the same time, it should motivate employees to participate. To increase the outreach of WHPP messages, companies should use multiple channels and styles. Additionally, creating a brand and having a marketing strategy for the program with a focus on the benefits for the employee should help capture employee attention and interest. Similarly, Kent identified having strategic communications as one of the emerging trends in WHPP best practices. Communication was identified as a key factor in encouraging employee participation and engagement with the program by addressing some of the barriers to the program’s success. Many of the characteristics of communication strategies that Kent and colleagues suggested were found in this study including: communications that were branded, tailored to the audience, multi-channeled, and frequent and bidirectional, the latter meaning that there was ongoing dialogue between employees and the company regarding health and wellness. One characteristic identified here but not in other studies was that employees should be held accountable for program outcomes to increase their perception of control over the program. The most common way to do so was by making employees track their progress through techniques including electronic aids such as personal tracking devices (e.g., Fitbits or pedometers). This finding is probably related to the increasing use and commercialization of these devices in recent years, and also because many of the study participants identified 95 “challenges” (such as achieving a certain number of steps per day) as one of the main activities in their programs. 4.2 Strengths and limitations The strengths of this study include: 1. Interviews with participants from companies with WHPPs in line with promising practice guidelines provide a good source of lessons learned on factors key to facilitating and inhibiting successful program implementation. 2. By conducting an in-depth study of 15 participants, extensive knowledge was gained about the most important issues concerning WHPPs from the employer perspective. 3. The qualitative approach to analyzing the data allowed for the identification of commonalities among these highly individualized programs, as well as the critical factors that contributed to program success. 4. Data were collected using open-ended questions that allowed research participants to express freely their own perspectives without a predetermined point of view. 5. This is one of the few studies to examine the employer perspective on WHPPs in BC, Canada. A number of limitations of this study should be considered when interpreting results, including: 1. The small sample size and participants self-selection limits the transferability of this study. Many of the companies invited to participate either declined participation or did not respond to the invitation, and the information publicly available about these companies is limited. This may introduce non-response bias. In addition, the participant’s self-selection into the study could lead to homogeneity in the results, making the findings 96 only applicable to companies willing to participate, to certain industries, and to a context similar to BC, Canada. Nonetheless, the findings confirmed many of the findings in previous literature, providing evidence that the study sample was an adequate representation of companies. 2. Although this study attempted to compare programs considered to follow promising practice standards against others, the selection criteria were not adequate to identify different categories of companies. Many of the participants who did not win a EMA in 2017 had won an EMA in previous years or had similar recognitions by other agencies. Therefore, the study aimed to identify commonalities and differences between companies with programs adhering to promising practice guidelines versus others was not fully achievable. Excluding less successful WHPP examples and focusing only on the successful ones may have led to positivity bias. 3. This study is solely based on self-reported data. Therefore, the respondents may have been led by social desirability bias to present a more positive impression of their company’s WHPP. However, efforts were made to control for this potential bias. The interviewer was a neutral party – a graduate student, the interviews took place in a private setting where the participant felt comfortable - their worksite, and the interviewer reiterated that confidentiality was guaranteed. 4. Despite acknowledging that some of the benefits of the program will only be manifest in the long term, most of the participants referred to short-term outcomes, especially when talking about program evaluation. It was not possible to determine whether these outcomes were maintained in the long-term because participants either did not have this information or were not aware of how to use these data for evaluation. 97 5. The data collection and analysis of the results were performed by a single observer with English as her second language, making it subject to interviewer bias. To control for this bias, the student tried to remain objective throughout the analysis by adhering to an iterative process of coding and confirmation by reading the transcripts and consulting with the thesis committee members; in addition, an external reviewer supported the appropriateness of the themes and subthemes devised by the student. 4.3 Implications and recommendations The findings of this study have several implications and recommendations for future WHPPs: 4.3.1 Recommendations for future research 1. Future studies should consider incorporating other approaches that allow for broader transferability of results. The sample should include a mix of industries and company sizes that is representative of the entire province. Ideally, this sample should be selected at random from a list of companies in BC that have implemented WHPPs. 2. Since this study failed to identify companies with less successful WHPPs, future research should consider different approaches to identifying companies that were unable or unwilling to implement a WHPP, or that had an unsuccessful WHPP implementation. This would allow representation of a different perspective - companies with less successful programs, and thus allow for a comparison with the results found in this study. 3. Future studies should consider including objective measures in addition to the self-report measures in order to provide other indicators of WHPPs outcomes. One type of objective measure to be considered is data documenting environmental changes in the worksite: for example, people who participate in the activities, or trends in cafeteria and vending 98 machines sales. Using multiple sources of data will strengthen the study by allowing for data cross-validation and consistency testing (Patton, 2002). 4. The results of current WHPP evaluations should be used to inform future research on developing effective implementation models. Particularly, such evaluations could be important for companies not doing so, should budget pressures become more difficult in the future. 5. There is a need for studies that include longer follow up times. This study’s findings align with those of previous literature, suggesting that many of the benefits of WHPPs are seen in the long-term, yet little is known about long-lasting behaviour change. 6. Future studies might consider a team of researchers for data collection and analysis. By using a variety of researchers, the potential for bias that comes from a single person doing both tasks would be avoided. This investigator bias can be reduced in two ways: by validating the consistency of data collected, and in analysis (Patton, 2002). 7. Other researchers might consider selecting exploratory mixed methods designs to take advantage of both quantitative and qualitative data. This strategy would allow for a more complete understanding of the employers’ perspective on WHPPs than qualitative design alone (Creswell, 2017). 4.3.2 Recommendations for future practice The findings of this study demonstrate that companies in BC have a growing interest in WHPPs and these programs are becoming more accepted in Canada (Sun Life Financial & Harris/Decima, 2013). Particularly, participants recognize that WHPP advocates, such as CCS, CCOHS and Healthlink BC, can support companies interested in providing this type of program 99 to their staff. These recommendations were grouped into three main themes: resources, type of support and advocacy and public outreach. These are shown in Figure 4.1: Figure 4.1 Recommendations for WHPPs advocates (final template) 4.3.2.1 Resources Participants suggested providing free resources such as educational materials, promotional articles or expert speakers. Some mentioned providing access to an electronic platform that employees can access online to review the available resources and where they can keep track of their progress. Currently, the CCS provides these types of educational resources free of charge on its website under the name “Healthy Workplaces” (CCS, 2018). WHPPs advocates should consider developing an online tracking tool or app for employees to track their healthy behaviours to be offered free of charge to businesses. 4.3.2.2 Type of support Study participants also recommended that WHPPs advocates should offer an integrated approach to the design and implementation of WHPPs. This approach should be flexible enough 100 so that programs can be tailored to the characteristics of each audience, and should allow for companies to pick and choose from different components. In addition, this approach should include an initial assessment of the target population’s needs concerning health and wellness as well as the organization’s commitment to implementing this type of program. Participants also advised that going beyond the traditional approach to health and wellness – PA and nutrition – was warranted, extending to the inclusion of other components, such as financial literacy. They also suggested providing individualized guidance and counselling for companies that had difficulties at different stages of the program including design, implementation, and evaluation. For example, participants highly valued the in-person consultation provided by WellnessFits in the past. Currently, the CCS still promotes the WellnessFits approach to WHPPs as an static resource on its “Healthy Workplaces” website (CCS, 2018). However, they do not offer in-person consultations. WHPP advocates should consider resuming in-person consultations at different stages of the program, similar to those once offered by WellnessFits. Participants suggested that specialized organizations, such as the CCS, should leverage their knowledge to offer specialized programs and resources to companies, such as cancer screening and support for people living with cancer. They also proposed changing the branding of the messages from a fear or reactive perspective into more positive, innovative, engaging, and fun messages with a focus on prevention. Currently the CCS offers materials on cancer prevention and support for employees living with cancer on their “Healthy Workplaces” website (CCS, 2018). However, few participants were aware of this resource. The CCS should consider implementing actions to increase the awareness of these resources. 101 4.3.2.3 Advocacy and outreach The findings of this research and other literature highlighted the need to increase the knowledge of WHPPs among BC companies and employees. Participants suggested that WHPP advocates should gather knowledge of these programs to construct a business case for WHPPs and make this available to interested companies. Participants also advised having adequate and effective advertisement strategies about the services offered to expand outreach. The CCS currently provides evidence-based information to support the benefits of offering WHPPs in their “Healthy Workplaces” website (CCS, 2018). However, again, few participants were aware of this resource. As detailed above, the CCS currently provides many of the resources study participants recommended being made available on their “Healthy Workplaces” website (CCS, 2018). However, the awareness of these resources is very limited and needs to be increased. The CCS should consider developing a broader communication strategy about the resources available for companies regarding WHPPs. Participants recommended creating partnerships between WHPP advocates and companies interested in implementing or improving their WHPPs to increase the effect and outreach of the available resources. Particularly, they suggested building alliances with government agencies that enforce labour legislation in BC. Currently, the “Healthy Workplaces” from the CCS is promoted by “Healthy Families BC” and the BC government. However, efforts should be made to expand the outreach through other partners such as WorkSafe BC. Finally, participants were eager to share their experiences and to know more about the experiences of other companies; therefore, advocates should facilitate a formal network that allows for the exchange of information related to WHPPs. WHPPs advocates should consider being the point of contact to facilitate networking for companies interested in this knowledge 102 exchange. In addition, WHPP advocates should consider creating a database of companies that have implemented WHPPs and gather some basic information about the program including starting year, type of program, position of the person responsible for the program, and willingness to share information about the program. This database would represent a dynamic resource for information exchange and would also facilitate self-directed networking. 4.4 Conclusions The increasing rates of chronic conditions in Canadians is a priority concern. The demographic characteristics of the Canadian workforce make the worksite a suitable setting to reach a large portion of the population. The findings of this study demonstrated that BC employers recognize the value of offering a WHPP to both employees and to the business itself. WHPPs are increasingly becoming an accepted practice in BC’s corporate world. Nonetheless there are still many opportunities to improve WHPP practices. The findings suggest that having a holistic approach to the program’s implementation, that includes attention to strategic and tactical factors, would increase the likelihood of successful program implementation. Engaging employees in every aspect of the program, starting by identifying their needs and interests concerning health and wellbeing, and building trust and buy-in into the program, is essential. This involvement can likely raise engagement rates, a key indicator of a WHPP’s success. Additionally, participants identified that incorporating ecological approaches to support employee health and wellbeing would be likely to positively influence the success of WHPPs. Having comprehensive WHPPs that focus not only on individual change but also on incorporating health into the culture of the company, was consider crucial. For example, environmental changes that promote PA, such as incentivizing the use of stairs, is an example of 103 an environmental change, and rewarding employees who achieve healthy lifestyles through awards and recognitions illustrates a structural change in the organization. The outcomes of effective WHPPs may bring benefits to both the workforce and to the company. The benefits at the individual level are employees with healthier lifestyles with the associated reductions in the risk of NCDs, while the company takes advantage of the benefits in productivity of a healthier and more energized workforce. In addition, this study demonstrated that WHPPs are increasingly becoming an expected employer resource by the new generations of workers. By exploring employer perspectives on WHPP, this study confirmed that many of the promising practices for program implementation reported in the literature are also relevant to companies in BC. Companies recognized that access to educational resources and individual counselling could ease the difficulties of implementing this type of programs. Nonetheless, there is still a need for dissemination of the information regarding promising practices for WHPP implementation among companies in BC and encouraging the adoption of this knowledge into practice. Organizations such as the CCS could play an important role in leading such initiatives. Moreover, since evidence on WHPPs effectiveness in Canada is still undergoing, this knowledge dissemination would aid to grow the literature on WHPP effectiveness and ultimately transition these promising practices into best practices. This study adds to the body of literature on WHPPs in Canada. 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SAGE. 113 Appendices Appendix A Literature review - search strategy • Canada as the program setting: o Canada / or Canadian /or Can* • Program carried out in the workplace: o Workplace /or worksite /or occupational health /or occupational health services o adult /or middle age • Program aimed at enhancing physical activity, healthier diet, smoking cessation, weight loss, reduce absenteeism or reduce presenteeism: o physical activity/or motor activity / or exercise/or fitness o diet /or nutrition o weight loss /or body weight o delivery of health care / employee incentive plan / health behaviour/ preventive health services /or health promotion /or health status/ or risk reduction behavior /or wellness /or health education /or health benefit plans, employee / or insurance, health/ or managed health care programs /or incentive plan /or motivation/ or employee incentive plan /or holistic health /or occupational health services o smoking/ smoking cessation / or health education / drinking behaviour/ or alcohol drinking/ or drinking • program tackling chronic disease, cancer, CVD, obesity, diabetes, metabolic disease or sedentary behaviour: o cancer/or neoplasms /or cardiovascular disease /or chronic disease /or obesity /or metabolic disease /or attitude to health/or obesity/ or diabetes/ or sedentary* 114 Appendix B Interview INTERVIEW OUTLINE We are interested in knowing what you think about different aspects of health promotion programs that you offer at your worksite. You are free to stop this interview at any time, or ask that the recording be stopped. You will not be identified by name or by company name in the recording or in the transcript of this interview. General description of your company: The following questions will help me to describe your company in terms of its organization, workforce, and health promotion (WHP) program. Organizational structure: 1. Number of employees: ____________ 2. Type of industry: _________________ 3. Unionized status: ________________ Nature of the workforce: For each of the following questions, please tell me which option best describes the characteristics of your employees: 1. Sex composition:  Mostly male  Mostly female  Balance between male and female 2. Average age: ________________ 3. Language of preference: 115  English  Other language. Please specify other languages used by many of your employees  Mix WHP program: For each of the following questions, please tell me which option best describes your WHP programs: 1. Number of years since the company first introduced any WHP program to the staff: ___ 2. Type of program:  Individual activities  Comprehensive program (wider approach, interconnected actions) 3. Who at your worksite is responsible for overseeing the WHP program? ______________ What is the position of this person/group? _________________ 4. How does your organization define “workplace health promotion”? 5. When did you first offer the Wellness Fits program developed by the Canadian Cancer Society? (If organization didn’t participate in WellnessFits, please skip to Question 6) a. Do you still offer WellnessFits? b. Why did your company first decide to implement WellnessFits? c. Why did you think that the Canadian Cancer Society approach would work for your company? d. What factors did you consider when you were designing the program? e. Do you provide other workplace health promotion programs? 116 6. When did you first offer a workplace health promotion program? (If organization participates in WellnessFits, please skip to Question 7) a. Do you still offer a workplace health promotion program? b. Why did your company first decide to implement a WHP? c. Why did you think that a workplace health promotion program would work for your company? d. What factors did you consider when you were designing the program? e. Do you provide other workplace health promotion programs? f. Have you considered offering a WellnessFits program, developed by the Canadian Cancer Society? g. If so, why do you think this approach would work for your company? h. If not, why don’t you think this approach will work for your company? 7. Please tell me about your current worksite health promotion activities. Elements affecting implementation: 1. Can you talk about the successes of the program? What worked well? 2. What were the factors that made the program successful? 3. Please tell me about what didn’t work as well as you hoped? 4. What did you experience as barriers to the success of the program? 5. Please tell me some of the lessons you have learned in this process. a. What would you have done differently? b. What advice would you give to another company that was considering offering a workplace health promotion program? 117 Perceived benefits: 1. What do you think are the benefits of offering a WHP program to employees? a. How was your program set-up to help employees to experience these benefits? 2. Did you measure benefits or the impact of the WHP program? a. If so, how did you do it? b. What did you find out? c. Do you think there are other outcomes that would be worthwhile measuring in future programs? 3. Were there any negative outcomes of the program that you didn’t expect? 4. What are your company’s plans to offer a WHP program in the future? a. Would the program be WellnessFits or another program or programs? b. What kind of program(s) and why? c. What would the goals be for future programs? 5. What kinds of WHP programs need to be developed for the future? If you had to give advice to the Canadian Cancer Society about what else they could do to improve worksite health promotion, what would you recommend? Is there anything else you’d like to tell me about your program, or worksite wellness more generally? Thank you very much for your time. I look forward to sending you a summary of the results when the study is finished. And good luck with your program!
Thesis/Dissertation
eng
Population and Public Health
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Employers' perspective on workplace health promotion programs in British Columbia, Canada
Text