Bethuel Best

PREVENTING CHRONIC DISEASE P U B L I C H E A L T H R E S E A R C H , P R A C T I C E , A N D P O L I C Y Volume 12, E67 MAY 2015

ORIGINAL RESEARCH

Enhancing Workplace Wellness Efforts to Reduce Obesity: A Qualitative Study of

Low-Wage Workers in St Louis, Missouri, 2013–2014

Jaime R. Strickland, MA; Amy A. Eyler, PhD; Jason Q. Purnell, PhD;

Anna M. Kinghorn, MS; Cynthia Herrick, MD; Bradley A. Evanoff, MD, MPH 

Suggested citation for this article: Strickland JR, Eyler AA, Purnell JQ, Kinghorn AM, Herrick C, Evanoff BA. Enhancing Workplace Wellness Efforts to Reduce Obesity: A Qualitative Study of Low-Wage Workers in St Louis, Missouri, 2013–2014. Prev Chronic Dis 2015;12:140405. DOI: http://dx.doi.org/ 10.5888/pcd12.140405.

PEER REVIEWED

Abstract

Introduction The objective of this study was to examine workplace determin- ants of obesity and participation in employer-sponsored wellness programs among low-wage workers.

Methods We conducted key informant interviews and focus groups with 2 partner organizations: a health care employer and a union repres- enting retail workers. Interviews and focus groups discussed work- site factors that support or constrain healthy eating and physical activity and barriers that reduce participation in workplace well- ness programs. Focus group discussions were transcribed and coded to identify main themes related to healthy eating, physical activity, and workplace factors that affect health.

Results Although the union informants recognized the need for workplace wellness programs, very few programs were offered because in- formants did not know how to reach their widespread and diverse membership. Informants from the health care organization de- scribed various programs available to employees but noted sever- al barriers to effective implementation. Workers discussed how

their job characteristics contributed to their weight; irregular schedules, shift work, short breaks, physical job demands, and food options at work were among the most commonly discussed contributors to poor eating and exercise behaviors. Workers also described several general factors such as motivation, time, money, and conflicting responsibilities.

Conclusion The workplace offers unique opportunities for obesity interven- tions that go beyond traditional approaches. Our results suggest that modifying the physical and social work environment by using participatory or integrated health and safety approaches may im- prove eating and physical activity behaviors. However, more re- search is needed about the methods best suited to the needs of low-wage workers.

Introduction Obesity, a major risk factor for diabetes, affects more than one- third of adults in the United States and is associated with several demographic and socioeconomic factors, including low income (1). Several studies have found that obesity rates are generally higher among working class occupations than professional occu- pations, even after controlling for demographic factors (2,3).

From a sociological perspective, the environments in which people live and work are strong influences on obesity and diabetes (4,5). The work environment is especially important because many adults spend a significant amount of time at work and because obesity affects employers through reduced productivity and ab- senteeism as well as increased health care costs and disability (6). Numerous studies acknowledge the negative health consequences of workplace factors such as stress, low autonomy, poor coworker and managerial support, and unhealthy physical work environ- ments (2,7). These workplace risk factors may be more common

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and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.

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in low-wage and working-class jobs and may explain some occu- pational differences in obesity prevalence (2,8).

Promoting health through worksite wellness programs is a nation- al priority. The Affordable Care Act creates new incentives to pro- mote employer wellness programs and encourage opportunities to support healthier workplaces (9). The National Institutes of Health and the Centers for Disease Control and Prevention have targeted worksites as a priority location for health interventions because they offer an efficient means of delivering and evaluating pro- grams and provide opportunities to reach socially disadvantaged populations (10,11). However, data for the effectiveness of work- place health programs are limited and may not be generalizable to all types of workers (6,11–13). National data show that blue-col- lar and service workers are less likely to work for an employer who offers health promotion activities and are less likely to parti- cipate in such programs when offered (14).

This study focused on a little-studied health disparity — work- place health promotion among low-wage workers. The objective of the study was to examine through interviews and focus groups 1) worksite culture, environment, and policies that influence healthy eating and physical activity; and 2) barriers that reduce worker participation in workplace health promotion programs. An understanding of how the workplace affects health behaviors is can inform design of effective interventions to reduce and prevent obesity.

Methods We partnered with a large health care system and a national labor union representing retail workers to recruit study participants. Qualitative data collection included interviews with key inform- ants (eg, employer representatives, union leaders, benefits admin- istrators) and worker focus groups with both partner organizations. The workforce in the union was relatively homogenous with re- gard to income and included workers in jobs such as cashier and merchandise stocker. Within the health care system, we targeted hospital work departments and locations that employed a large proportion of low-wage workers, including housekeepers, patient care technicians, and food service workers. This study was ap- proved by the Washington University institutional review board.

We interviewed 10 individuals from the union partner: 4 local uni- on leaders, 5 store representatives, and 1 health benefits adminis- trator. Key informants were recruited in person or through email, and interviews were conducted in person or over the telephone. We asked about current and previous wellness initiatives offered to employees, employee participation in these initiatives, and po- tential barriers to participation. Informants were also asked about

workplace factors that influenced health behaviors (ie, physical activity and healthy eating) and employee attitudes about health and wellness.

We conducted a total of 9 focus groups involving 61 workers. Twenty hospital employees (4 men and 16 women) participated in 4 groups. Forty-one unionized retail workers including 12 men and 29 women participated in 5 focus groups. Focus group parti- cipants were recruited through their work department, store, or local union hall. The research team attended union meetings to re- cruit members in person and posted flyers in break rooms at selec- ted stores and hospital departments. We used a semistructured script to guide focus group discussions. The scripts covered 11 broad domains with follow-up questions and prompts for each do- main (Table 1). All group discussions were audio recorded and transcribed. Transcriptions were entered into QSR International’s NVivo 10 software (QSR International Pty Ltd), and all were coded by 2 independent raters using a predefined code book based on the domains in the focus group script. After initial coding and consensus of all transcripts, we applied a phenomenological ap- proach for data analysis to find the “essence” or common themes across individual experiences (15). The purpose of the thematic analysis was to answer 2 questions: “what impacts healthy eating and physical activity” and “what can be modified at the work- place?” Through systematic review and discussion, codes were merged and grouped under main themes. Each transcript was re- read and re-coded for consistency.

Results Key informant interviews

The informants indicated that very few wellness programs related to weight management were offered to retail workers. The union- sponsored health plan covered some costs for nutritional counsel- ing, but that benefit was not well advertised. The employer- sponsored initiatives such as an onsite gym or weight loss pro- grams were primarily available to employees in the corporate of- fices, not to workers in retail stores. Both the union and employer representatives recognized the need for workplace wellness pro- grams but were unsure about how to proceed with developing and implementing a program to reach their diverse and widespread workforce.

Informants described various programs available to employees but noted several barriers to effective program implementation, in- cluding lack of management commitment at some levels, limited budgets, and communication and advertising limitations. One in- formant described results of a focus group conducted among em- ployees of 1 hospital department regarding awareness of existing

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wellness programs and preferred methods of communication; res- ults indicated that most workers were unaware of the wellness pro- gram and did not regularly use company email, which was the primary method of communicating information about the well- ness program. Workers preferred to get information via personal email, text message, or in person. Workplace wellness efforts within the health care organization varied by worksite; some sites were more successful in promoting and delivering their wellness initiatives than others. Informants thought the size of organization and motivation of appointed representatives for each location in- fluenced program success. An informant from a smaller hospital mentioned several successful wellness initiatives at her location, including an onsite gym, exercise classes, and 2 weight-loss chal- lenges each year, and an informant from a larger hospital dis- cussed struggles to find effective communication methods to reach all worker groups.

Worker focus groups

The final list of themes from the focus group analysis included 10 work-related themes and 10 general themes (Table 2). Workers commonly discussed how their job characteristics contributed to their health. For example, they mentioned that physical demands and stress of their jobs left them too exhausted or unmotivated to exercise or plan healthy meals (Table 3). Many also described how the physical environment affected their health (eg, small work area, concrete floors). Past or current company programs and pri- orities was another common theme identified, although details var- ied by group. Overall, the retail workers talked about lack of well- ness programs; some mentioned store weight-loss competitions and previous company campaigns but felt that their employers and union did not prioritize health and wellness. Responses of the health care worker groups differed; those working in a large hos- pital setting were much less aware of wellness initiatives and felt less company or management support for health promotion. Many were aware of the onsite gym and the weight-loss program, but cost, work schedule, and home responsibilities made it difficult to participate. Conversely, a group working in a smaller clinic felt tremendous upper-management support and described numerous workplace supports, including a produce garden at the worksite, access to exercise equipment, afternoon stretch breaks, and healthy potluck lunches.

Workers also discussed schedules and breaks as having a signific- ant impact on their healthy eating and physical activity. For many retail workers, their schedules varied week-to-week, making it dif- ficult to maintain any routine. Workers from both organizations stated that short and interrupted breaks made it difficult to eat healthy. They discussed how food options —healthy or unhealthy and purchased or provided for free (eg, incentive lunches, holiday

parties) — affected their eating behaviors at work. Workers from both organizations felt that their workplaces had a lack of quick, convenient, and low-cost healthy food options. Moreover, in all groups we heard that free food was almost always unhealthy. Nearly all workers commented that social support and accountabil- ity to coworkers would improve their ability to initiate and main- tain healthy behaviors.

General themes were those that may be related to the workplace but also extended into workers’ personal lives. For example, work- ers often discussed how intrapersonal factors (eg, motivation, will- power) and home life (eg, responsibilities, family support) af- fected their health behaviors both in the workplace and at home. Workers often discussed how their jobs influenced their health in terms of not having the money, time, or energy to exercise or plan healthy meals. Some workers also discussed the roles that health issues and transportation played in initiating and sustaining healthy behaviors.

Discussion This study highlights factors related to obesity as described by 2 low-wage work groups; our findings are consistent with results from a similar study among low-wage workers in various indus- tries (8). The workplace was often viewed as a barrier to healthy eating and physical activity; however, workers supported the concept of workplace health promotion and offered suggestions for overcoming many of the identified barriers. As demonstrated in this study, the workplace may be effective in engaging popula- tions at risk for obesity and related illnesses, though it may be ne- cessary to go beyond traditional workplace wellness approaches. Using more innovative methods may increase program reach, ef- fectiveness, and sustainability.

Policy changes have increasingly been recognized as essential components of worksite health promotion (16) and are more sus- tainable than individual-level behavior interventions (17). Policies promoting a culture and environment conducive to reducing obesity can be a strong catalyst to behavior change. These can in- clude top-level policies, such as offering a health care plan that has wellness options or implementing organizational policies that provide for access to low-cost healthy foods at the worksite, en- courage active transportation to and from work, or allow for flex- ible work schedules to encourage lunch or break-time physical activity. The work environment (both indoor and outdoor) is also an important component of behavior change and can have a signi- ficant impact on behavior choice (18). An environment that en- courages less sedentary work and more physical activity could in- clude well-placed and maintained stairwells for stair use versus el- evators or distant parking.

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Changes solely in the workplace environment may not be enough to encourage healthy behaviors (19). Health behavior decisions are affected by the social context in which they are made, such that the social support and social norms surrounding a health issue have a substantial effect on how that health behavior is perceived. Changing social norms and fostering a supportive work environ- ment for the desired behavior is a necessary complement to the other levels of intervention. Social norms have been studied as a way to promote nutrition (20) and physical activity (21).

Workplace participatory approaches may foster social support and help to overcome organizational and employee barriers to pro- gram success. Most worksite weight-loss programs have relied on a top-down approach, rather than a participatory approach based on employee involvement in the design of interventions (22). In workplaces where employees generally have little influence on their work environment, similar to those sampled in this study, participatory approaches can result in better program implementa- tion and subsequent health improvement (22). The recently de- scribed Healthy Workplace Participatory Program (HWPP) in- cludes work environment changes, as well as healthy eating and physical activity interventions (23). A small study based on HWPP found promising changes in behaviors and weight loss in a pre–post evaluation of a participatory worksite intervention (24). To our knowledge, this HWPP-based study is the only controlled study to date using a worker health participatory program to attain weight loss. Future research should implement and evaluate work- place participatory interventions for weight loss.

Workplace wellness programs should also use effective commu- nication strategies to engage workers from diverse work groups and backgrounds. As demonstrated with the health care system in this study, many low-wage workers were not aware of the well- ness programs that were available to them. The same programs, however, have good participation from other work groups in the health care organization, primarily because of the method of com- munication. Rapid changes in information technology have en- abled new interventions that use mobile telephones and other mo- bile devices (mHealth). These techniques show great promise for weight reduction in low-income populations (25), and such inter- ventions are readily scalable to larger populations (13).

Although we did not directly ask about incentives, several parti- cipants discussed monetary incentives as a possible motivator to eat healthy and exercise. The use of incentives is common in workplace wellness programs; employers could maximize the be- nefits of incentives by incorporating lessons from behavioral eco- nomics. For example, the increasingly popular approach of deliv- ering incentives through health insurance premium adjustments is unlikely to be as effective as more frequent and immediate re-

wards for behavior. This is because people tend to discount the fu- ture, meaning that they respond more readily to immediate than delayed costs and benefits (26). The participants in our study com- monly discussed cost as a barrier to eating healthy and exercising. As suggested by others (27), low-income workers may be more likely to change and sustain healthy behaviors if provided with financial support for healthy food and participation in other weight-loss activities. Employers should also be aware of the lim- itations of incentives for behavior change. Recent reviews have shown behavioral effects to be relatively short-lived after incent- ives are removed (27), and considerable attrition is found in work- place programs for weight loss (28). More research is needed to determine the optimal timing, magnitude, and structure of incent- ives, but results to date suggest that incentives may need to be an ongoing feature of the workplace to have maximum impact.

Finally, employers may consider integrating traditional occupa- tional safety and health programs (ie, those that focus on health hazards unique to the workplace) with health promotion and well- ness programs (ie, those that focus exclusively on lifestyle factors off the job). The Total Worker Health program was launched by the National Institute of Occupational Safety and Health (NIOSH) to support the development and adoption of research and best practices to integrate these approaches and address health and safety risks at multiple levels, including the work environment (physical and organizational) and individual behaviors. This integ- rative approach may lead to greater adoption of interventions by management and workers and hence to improvements in the health of workers (11), but more research is needed to evaluate both the development process and the effectiveness of integrated programs (29).

The results of this study can help inform future worksite interven- tions for low-wage workers; however, our study has several limit- ations. First, we collected data from key informants who could be contacted or agreed to be interviewed. Second, although the parti- cipants in the focus groups represented a range of positions and worker groups, they were limited to those available during the im- plementation of the focus group discussions. Although using a convenience sample may be a limitation, those who elected to par- ticipate in the interviews or focus groups were able to provide helpful insights on the topic. Future intervention planning would need to be preceded by additional input from a broader participant base. Third, the information we collected may not be generaliz- able to other health conditions or work settings. Despite these lim- itations, the key informants and focus group participants provided rich and potentially actionable information on addressing obesity at the worksites of these worker populations.

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Workplaces can provide an effective venue for engaging low-in- come populations at risk for obesity and related illnesses. Results of this study suggest that future worksite interventions for low- wage workers can improve reach, effectiveness, and sustainability if they embrace more innovative methods than those used in cur- rent workplace wellness programs. Future interventions should ad- dress workplace policies and environment and social norms that affect health behavior decisions. Communication strategies and financial incentives should be better aligned with the needs of low- wage workers. Workplace participatory programs are a promising approach to engage workers in health improvement.

Acknowledgments This study was supported by NIH/NIDDK P30DK092950, Wash- ington University Center for Diabetes Translation Research (WU- CDTR), and by the Washington University Institute of Clinical and Translational Sciences Award, UL1 TR000448, from the Na- tional Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the WU-CDTR, National Institute of Diabetes and Digestive and Kidney Diseases, NCATS, or NIH. We ac- knowledge the support of the Washington University Institute for Public Health for cosponsoring, with theWU-CDTR , the Next Steps in Public Health event that led to the development of this article.

Author Information Corresponding Author: Jaime R. Strickland, MA, Division of General Medical Sciences, Washington University School of Medicine, 660 S Euclid Ave, Box 8005, St. Louis, MO 63110. Telephone: 314-454-7337. Email: [email protected].

Author affiliations: Amy A. Eyler, Jason Q. Purnell, George Warren Brown School of Social Work, Washington University, St. Louis, Missouri; Anna M. Kinghorn, Cynthia Herrick, Brad A. Evanoff, Washington University School of Medicine, St. Louis, Missouri.

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the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.

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Tables

Table 1. Focus Group Domains and Questions, Qualitative Study of Low-Wage Workers, St. Louis, Missouri, 2013–2014

Domain Questions Examples, Clarification, Follow-ups, Probes

Work schedule Tell us about a typical work day. How many hours do you usually work? What opportunities do you have for breaks?

Healthy eating priority Is eating healthy a personal priority for you? Do you try to eat healthy? What do you do at home to eat healthy? Are you satisfied with your diet?

Eating at work When do you eat while at work? What do you eat while at work?

How do you decide what you will eat while at work?

Exercise priority Is regular exercise a personal priority for you? Do you try to exercise? How often, where do you exercise? Are you satisfied with your level of physical activity?

Physical activity at work What kind of physical activity/exercise do you do at work?

Do you do anything in addition to your normal work routine to be more physically active? (eg, take the stairs, walk during break times)

Worksite health facilitators What aspects of work at [organization] seem to help you or your coworkers stay healthy while at work?

Current wellness or safety programs that are helpful? Helpful aspects about physical environment or company policies that promote health? What qualities of your job make you feel good? Keep you fit? Do your work relationships contribute to health? How?

Worksite health barriers Which aspects of your work or work environment get in the way of being healthy?

Are there things about your work tasks or the way work is organized that make it difficult for you to take care of your health? What aspects of work prevent you from engaging in healthy activities outside of work?

Health concerns What health issues are you most concerned about for yourself?

How concerned are you about missing work due to illness/injury?

Current wellness programs Are you aware of any health and wellness programs currently or previously offered to employees? (ie, weight-loss, smoking cessation)

Have you or any of your coworkers participated in any of these wellness programs?

Communication How does your employer communicate important information to you?

What about health information?

Future workplace programs How likely are you to participate in workplace wellness programs in the future? What about nutrition and exercise programs, specifically?

What factors might influence your decision to participate? (ie, cost, location, other). How can your employer/union do a better job of promoting wellness in employees?

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Table 2. Main Focus Group Themes and Number of Associated Coded References, Qualitative Study of Low-Wage Work- ers, St. Louis, Missouri, 2013–2014

Theme (N)a Topics Included

Work-related theme

Job characteristics (196) Physical and mental demands, stress, physical environment, safety, workplace rules

Company priorities and programs (165) Company health promotion programs, perception of company priorities for employee health

Food options (105) Food options at work (free or available for purchase)

Communication (92) Communication of health information, preferred methods of communication

Work schedule (75) Schedule, time of day worked

Social support/accountability (72) Desire for social support or being held accountable, camaraderie

Management support (48) Perception of management support, employee–management relationships

Facilities (45) Aspects of current facility related to health or suggestions for changes to facilities

Breaks (40) Relationship between breaks and health behaviors

Other (24) Knowledge from job, suggestions for general workplace changes

General theme

Intrapersonal (168) Motivation, willpower, impulse, desire to be healthy/look good

Financial (132) Company discounts, cost of food, gym memberships

Home life (94) Cooking at home, food restrictions, outside environment, other priorities/responsibilities

Time (75) Not enough time, availability of quick options

Energy (53) Lack of energy, need energy

Food preferences (49) How eating habits/preferences affect food choices

Planning (45) Lack of routine, difficulties of planning, reasons behind planning or not planning

Convenience (33) Convenience of food options, wellness programs; choices that require little effort

Personal health (20) Physical and mental health as barriers to eating well or participating in physical activity

Transportation (16) Influence of transportation on participation in wellness programs a N = number of times this theme was referenced.

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Table 3. Sample Comments and Coded Themes, Qualitative Study of Low-Wage Workers, St. Louis, Missouri, 2013–2014

Comment Theme Coded

“If any employer is really serious about wanting a healthier work environment and employees then they have to make sure they have the proper rest time. I am squishing my two 15-minute breaks together to make my half-hour lunch.”

Company priorities and programs, breaks

“I think I would [go to the workplace gym] because I think somebody would go with me from here. You’d have a buddy. You have so many friends inside of [the store]. I mean I have friends at other [stores] and I could be like ‘Hey, meet me at our gym.’”

Social support-accountability, company priorities and programs

“When I first started working here I thought it was the oddest thing that I would walk to the cafeteria and I would see nurses, techs, eating when they are walking, eating at the elevator . . . but now I know why they do that, you know, ‘cause sometimes that is all the time they get.”

Breaks, time, job characteristics

“And that's another thing, they got a lot of good different varieties during the day, but at night, there is not much to choose from.”

Work schedule, food options

“But it is funny because they put [smoking cessation ads] in the break room but the smokers don’t go in the break room, they go outside. So nobody saw it.”

Communication

“And I have to say, she [upper-level manager] don’t throw it down your throat . . . I don’t think anybody does. They put the option out there and it’s your choice to participate or not. They give us the resources to use and they say here, now it is up to you They will promote something [monthly] that most of us probably didn’t know . . . to help us.”

Company priorities and programs, management support

“I feel like not having set schedules makes it kinda hard to exercise, because sometimes you work early in the morning, sometimes you’ll work late at night. Throws off your sleep schedule.”

Work schedule

“If you’re too tired and you’re stressed out, you don’t want to do anything but eat that fattening food and curl up in a little ball and go to bed. You don’t plan for tomorrow; you just have to get through the day.”

Planning, energy

“I’m a food addict, I’ll admit it; I like food. I have all intents and purposes of going to the salad bar and picking the good lettuce, the good stuff, the good fruits, the good vegetables, but man as soon as that [BBQ smoker] hits me, I’m gone!”

Intrapersonal, food preferences

“I prepare my lunch every morning. I work and then I actually walk every day . . . up to 5, 6, 7 miles every day . . . except for today because all of us had double shifts. So that's it, I have the will power, I’m not gonna lie. Most people don’t know me, but I’ve dropped a ton of weight. I was quite large and I just made a goal this year that I was gonna take care of myself.”

Intrapersonal, planning, work schedule

PREVENTING CHRONIC DISEASE VOLUME 12, E67

PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY MAY 2015

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,

the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.

www.cdc.gov/pcd/issues/2015/14_0405.htm • Centers for Disease Control and Prevention 9