545106 research-article2014
SJP0010.1177/1403494814545106Is workplace health promotion research in the Nordic countries really on the right track?S. Torp and HF. Vinje
Scandinavian Journal of Public Health, 2014; 42(Suppl 15): 74–81
Original Article
Is workplace health promotion research in the Nordic countries really on the right track?
Steffen Torp & Hege Forbech Vinje Department of Health Promotion, Buskerud & Vestfold University College, Norway
Abstract Aims:The aims of this scoping review of research on workplace health promotion interventions in the Nordic countries were to investigate: how the studies defined health; whether the studies intended to change the workplace itself (the settings approach); and whether the research focus regarding their definitions of health and use of settings approaches has changed in the past five-year period versus previous times. Methods: Using scientific literature databases, we searched for intervention studies labelled as “health promotion” in an occupational setting in the Nordic countries (Denmark, Finland, Iceland, Norway and Sweden) published from 1986 to 2014. We identified 63 publications and qualitatively analysed their content regarding health outcomes and their use of settings approaches. Results: The reviewed studies focused primarily on preventing disease rather than promoting positive measures of health. In addition, most studies did not try to change the workplace but rather used the workplace as a convenient setting for reaching people to change their behaviour related to lifestyles and disease prevention. Participatory and non-participatory settings approaches to promote well-being and other positive health measures have been used to a minor degree. The recent studies’ definitions of health and use of settings approaches did not differ much from the studies published earlier. Conclusions: Workplace health promotion in the Nordic countries should more often include positive health measures and settings approaches in intervention research. It is important to anchor workplace health promotion among important stakeholders such as unions and employers by arguing that sustainable production is dependent on workers’ health. Key Words: Intervention, occupational, scoping review, setting approach, work engagement
Introduction Health promotion is the process of enabling people to increase their control over the determinants of health and thereby improve their health [1] as a result of healthy public policy and health education for all [2]. Thus, the core of health promotion is addressing fundamental and underlying determinants of health and consequently preventing social inequity in health. The most influential document providing guidelines for health promotion is the Ottawa Charter for Health Promotion [3], which reflects a holistic view on what health is, since it states that health is a resource for everyday life and a positive concept emphasizing physical, social and personal resources.
Work is an important factor influencing health, since workers represent half the world’s population [4] and because workforce well-being is closely related to enterprise and national productivity and thereby the whole population’s well-being. Focusing in particular on working life, the Luxembourg Declaration on Workplace Health Promotion in the European Union [5] reflects many of the same perspectives on health promotion as does the Ottawa Charter. Workplace health promotion is related to at least two other approaches or strategies to improving workplace health: 1) wellness programs with focus on individuals’ lifestyle, and 2) occupational health and
Correspondence: Steffen Torp, Department of Health Promotion, Buskerud & Vestfold University College, P.O. Box 2243, N-3101 Tønsberg, Norway. E-mail: [email protected] (Accepted 2 July 2014) © 2014 the Nordic Societies of Public Health DOI: 10.1177/1403494814545106
Is workplace health promotion research in the Nordic countries really on the right track? 75 safety with focus on work related physical risk factors [6,7]. Most experts and declarations (see for instance [5–10]) argue that workplace health promotion should apply a holistic approach by including both these approaches in addition to focusing on psychosocial and organizational work factors. Workplace health promotion should have the aim of making structural changes of the production to secure a health promoting and meaningful working situation. Definition of health How health is defined inevitably determines what determinants research focuses on and thereby also affects health policy. In research in medicine and other health-related disciplines, health has most commonly been defined as normal bodily functioning and thus the absence of disease or disorders [11]. Such a definition implies a focus on therapy and on risk factors to prevent bodily malfunction. One argument against the biomedical definition of health as something negative in terms of absence of disease has been that it should be possible to define health in its own right, that is, as something positive. Most definitions in this respect includes well-being and function [12]. WHOs [13] health definition, Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, emphasizes clearly the positive aspect of well-being. Well-being is often related to the concepts of quality of life and happiness [14,15], and in work settings, well-being has often been relabelled as job satisfaction, positive affect, work engagement and intrinsic motivation [16]. Defining health as a function or ability has been done by for instance Illich [17], Parsons [18] and Hjort [19]. While giving special attention to the increase in chronic illnesses in high-income countries, Huber et al. [20] rather recently criticized the WHO health definition [13] and called for a more dynamic definition based on the resilience or capacity to cope and maintain and restore one’s integrity, equilibrium and sense of well-being. They defined health as having the ability to adapt and to self-manage in face of physical, social and emotional illnesses and constraints that are more or less chronic. Fugelli and Ingstad [21] studied laypeople’s concept of health and ended up with six categories; wellbeing, function, nature, sense of humour, coping and energy. They hold that health in a lay perspective is a holistic, relative and individual phenomenon that resembles expert definitions of health as something positive and holistic.
Antonovsky’s [22,23] theory of salutogenesis (salute = health, genesis = origins) is meant to complement the traditional pathogenic perspective on health. Salutogenesis is an important theoretical framework within health promotion, understanding health as holistic and dynamic, moving and evolving on an imaginary continuum from ease to disease. The salutogenic perspective permits identifying factors keeping individuals from moving towards the dis-ease end of the health ease– dis-ease continuum. This approach allows us to recognize and study the combination of “health assets” that are most likely to lead to higher levels of overall health, well-being and achievement. Salutogenesis embraces the need, stated in the Ottawa Charter, to focus on people’s resources and capacity to create health [24]. Occupational health and safety personnel have focused less on therapy and more on preventing disease and accidents compared with health workers in other health service sectors. With regard to the Ottawa Charter’s [3] action mean of re-orienting health services, the Nordic occupational health services are rather well developed since their work is guided by work environment acts emphasizing psychosocial and organizational factors and system approaches for health and safety. In the 2005 version of the Norwegian work environment act’s very first paragraph (§1–1) [25], it is even claimed that the purpose of the act is “to create a health-promoting and meaningful working situation”. Nevertheless, their focus has been, and still is, mainly on risk factors and preventing disease [26,27] rather than on promoting health defined in a positive and/or holistic manner as advocated by most health promotion textbooks, guidelines and experts [2,28]. In this paper, we do not want to take a stance on what definition is the most applicative in workplace health promotion, but we believe that how health is defined or measured in workplace health promotion stakes out an important difference between health promotion and most other disciplines dealing with work-related health. Settings approach There are three main approaches in health promotion: the issue approach (such as reducing smoking and preventing injury), the population approach (such as healthy aging) and the settings approach (such as health-promoting schools) [29]. The Ottawa Charter [3] states that people create and live health within the settings of their everyday life, and WHO has therefore advocated a settings approach to promoting public health for many
76 S. Torp and HF. Vinje years. Several WHO projects have been initiated within such settings as cities, schools, universities, prisons, hospitals and workplaces. It has been claimed that workplace health promotion is particularly interesting and important since work strongly influences many people in and outside working life and because workplaces, employers and employees are crucial for the activities performed in most other focused settings. There is no consensus on what a settings approach is, but most authors dealing with the topic [30–32] agree that the core is recognizing that people live their lives in complex social, cultural, economic and political environments that may enhance or harm health in various ways. This means that changing the fundamental and underlying determinants of health requires modifying aspects of the settings themselves instead of solely trying to change the health behaviour of individual people. This recognizes that both the problem or challenge and the solution lie within the setting and thereby are closely related to the activities normally occurring in the setting. In work life, this means the production of goods or services by the enterprise. Health promotion therefore requires focusing on physical, social and organizational factors, applying a whole-system way of thinking [30]. Thus, health promotion activities may perfectly well be performed in a setting without applying a settings approach. An example of a non-settings approach is using the workplace as a convenient setting to reach people to try to change their behaviour related to diet or physical activity. Much has been written about what health promotion is or should be, and an extensive amount of epidemiological descriptive studies have investigated determinants of health. Theoretical and descriptive studies are important in health research, but, according to our opinion, the studies are not very helpful health promotion wise if they do not ultimately result in any behavioural or environmental change that leads to improved health. Therefore, the core of a discipline is mirrored in what kind of actions or interventions are performed and what kind of aims these interventions have. The aims are reflected in what kind of outcome measures one is concerned with. This is also the case for workplace health promotion. This scoping review of research in the Nordic countries labelled as “health promotion” in working life investigates how intervention studies defined or described health; whether they used a settings approach; and whether the studies’ focus regarding these two topics has changed in the past five-year period compared with previous times.
Material and methods Torp et al. [33] performed a scoping review study on workplace health promotion research in the Nordic countries performed from 1986 until 2008. The current study builds on their work but has been extended with more recent research and with other topics. Further, the current study includes only intervention studies. We included peer-reviewed articles published from 1986 until 2014 in the scientific journals included in the research databases ISI, PubMed, CINAHL and PsychInfo. The inclusion criteria were: 1) at least one author had to be affiliated with an organization or research institution in the Nordic countries; 2) the study had to focus on health explicitly related to occupational factors or occupational groups; and 3) had to include an action or intervention measuring some kind of an outcome of the intervention. Figure 1 describes the total article selection. First, we used the search terms “health promotion” and Denmark, Finland, Iceland, Norway or Sweden, and found 3742 results. We searched further with “workplace” or “occupational” and got 558 hits. After reading all titles and abstracts, we deleted duplicates and studies not meeting the inclusion criteria Nordic country (criterion 1) and occupational factors or groups (criterion 2) and ended up with 232 studies. Of these, 169 were excluded because they did not include an action or intervention with some kind of outcome measures (criterion 3). The remaining 63 studies constituted the material included in this review. Analysis We performed qualitative content analysis [34] on all 63 studies to analyse their ways of describing health. The analysis comprised four steps: 1) read and reread to identify meaning units expressing views on health; 2) translate the units of meaning into theoretical expressions; 3) condense meaning and develop categories; and 4) articulate themes expressing the studies’ different ways of defining health. In Step 1, the studies were read and re-read to identify how health was described by the researchers. The manifest and explicit ways of describing the term had our main focus in this step. In Step 2, we wanted to translate the found phrasings of health into theoretical expressions. As none of the studies had defined health explicitly, we tried to tie the terms used in the studies to theoretical definitions of health. In Step 3, the analysis turned into a cross-case venture, aiming at condensing the various ways health was described in the studies into meaningful categories. In Step 4, we ended up developing six main categories
Is workplace health promotion research in the Nordic countries really on the right track? 77
Figure 1. Article selection.
meaningfully comprising the different ways health had been described in the 63 studies. This study builds on the study performed by Torp et al. [33] who analysed workplace health promotion studies regarding their use of settings approaches with the same analysis strategy as described above. Since we wanted to compare our results on intervention studies’ use of settings approaches from 2008 until 2014 with Torp et al.’s results from 1986 until 2008, we used a template organizing style [35] using the categories they ended up with; non-settings approach, participatory settings approach and non-participatory settings approach. Although we present the results in this literature review with quantitative measures in part, such a literature review with its inclusion and exclusion and categorization of studies is based on qualitative analysis, including a hermeneutic approach based on the researchers’ previous understandings of the topic. Regardless of whether the studies used qualitative or quantitative research methods to investigate the health effects of the interventions, often described as outcome variables in quantitative studies and descriptive themes in qualitative studies, we label the effects in this study as “outcomes” or “health measures”. Results Definitions of health The studies included did not explicitly define health or their underlying understanding of the concept.
Therefore, we based our analysis on the studies’ descriptions of the health outcomes. Our analysis generated six categories of health-related measures: health behaviour, disease and injury, absenteeism, work ability, general health, and positive health. Most studies used more than one outcome measure related to health. In addition, several studies included outcome measures related to the working environment, productivity and satisfaction with the intervention, but these measures were not included in the present analysis. The category of health behaviour measures included mainly lifestyle measures such as healthy eating, physical activity and non-smoking: that is, behaviour mostly detached from the core activities of the enterprise. In addition, some of the health behaviour measures focused on working techniques and using personal protective equipment at work, whereas others aimed at changing eating habits at work by changing the food provided in the enterprises’ canteens. The health behaviour measures were often complemented with physiological and physical outcome measures such as maximal oxygen uptake, blood pressure and body mass index. We therefore categorized such measures in the health behaviour category. The disease and injury measures constituted the category most studies used as outcome measures and included traditional health measures defined as the absence of disease or injury. Examples are mental disorders, musculoskeletal pain, allergy, mental strain and accidents.
78 S. Torp and HF. Vinje The absenteeism category included absenteeism without known reason, sick leave prescribed and not prescribed by a physician and disability retirement. One study included also a measure of presenteeism: that is, being at work despite being ill. Some studies used work ability as an outcome measure, mostly measured using questions from the Finnish Work Ability Index [36]. Work ability may seem to be a positive health measure, but many studies defined work ability in terms of reduced ability to work because of symptoms related to disease. The Finnish Work Ability Index includes items on both what can be regarded as pathogenic and salutogenic measures related to both work and to a person’s health. Some studies measured general health by asking such questions as: “In general, how would you describe your health?” Others used multi-item measures of health-related quality of life, mostly with questions from the SF-36 Health Survey [37]. Like the work-ability measures, the health-related quality of life indices used questions related to both health problems and positive indicators of health. The measures categorized as positive health measures were related to well-being or other explicitly positive health conditions. Examples are multi-item measures of self-esteem, coping, work engagement and job satisfaction. Only a couple of the positive health measures were explicitly related to work, such as job satisfaction and work engagement. The six categories represent three different descriptive themes: a traditional biomedical and pathogenic way of defining and describing health (health behaviour, disease or injury and absenteeism); a salutogenic way emphasizing health as something positive and not the mere absence of disease (positive health); and a way of defining or describing health that cannot be regarded as either pathogenic or salutogenic (work ability and general health). Overall, about three quarters of the outcomes used in the intervention studies were categorized within the pathogenic theme, one eighth within the salutogenic theme and another eighth within the “neutral” theme.
Almost two thirds of the intervention studies used the workplace as a setting to reach individuals for health-promoting activities rather than focusing on the setting itself, and were therefore categorized as non-settings approaches. The studies focused mainly on changing health behaviour related to lifestyle factors such as diet, smoking and physical activity. Some studies acknowledged the importance of the work setting for health but did not apply a settings approach, since they aimed at changing the workers’ behaviour rather than the setting. About one fourth of the studies were categorized as participatory settings approaches. The studies were defined as participatory since they used group process interventions enabling the workers to have a voice in how the interventions were conducted by such means as search conferences, problem-based learning groups and health circles. Most of these studies used psychosocial measures as indicators, since they wanted to change the organizational culture. Studies in this category used more qualitative research methods than the studies categorized in the other two approaches. About one sixth of the studies attempted to change the setting by use of a top-down approach and were categorized as using a non-participatory settings approach. Examples are studies that aimed at improving health by changing the physical work environment without involving the employees in deciding what should be changed or how. Other studies tried out reduced work hours or introduced new sick leave regulations. Changes in health promotion research in recent years Of the 63 intervention studies included, 6 (10%) were published in 1986–1998, 12 (19%) in 1999– 2003, 16 (25%) in 2004–2008 and 29 (46%) in 2009–2013. The studies published after 2008 did not differ much from the previous studies in how they defined health or used settings approaches. Discussion
Settings approaches We categorized the studies as using a non-settings approach, a participatory settings approach or a non-participatory settings approach [33]. The definition of a settings approach used here reflects that the researchers recognized that both the problem and the solution lie within the setting and that the intervention aimed at changing the setting itself, but the definition does not necessarily imply a wholesystem approach as suggested by, for instance, Dooris [30].
About three quarters of the health measures used as outcomes in workplace health promotion intervention research performed in the Nordic countries were related to pathogenic health outcomes. Only one eighth of the outcomes were regarded as explicitly positive health outcomes such as self-esteem and job engagement. Most of the studies did not use a settings approach, since the intervention primarily aimed at changing workers’ lifestyle behaviour rather than changing the work setting itself. Compared with earlier studies, the workplace health promotion
Is workplace health promotion research in the Nordic countries really on the right track? 79 intervention research does not seem to have changed much in the most recent five-year period regarding their definitions of health or their use of settings approaches. Methodological limitations Studies within occupational medicine, psychology and ergonomics that are not labelled as health promotion could probably have been defined as health promotion and therefore be included in such a review. Omitting such studies may therefore seem to be a limitation, but the aim of this study was to review only studies representing research or researchers relating explicitly to health promotion as a discipline. On the other hand, using the search term “health promotion” may not necessarily imply that the study can be defined as a health promotion study. It can be argued that the results of this study depend on too broad inclusion criteria resulting in a wider array of studies than those explicitly relating to workplace health promotion as a discipline. To investigate how workplace health promotion is performed and how health promotion define health, it is necessary to look upon studies involving some kind of an action or intervention with clear aims and measures. Therefore, we included only studies with some kind of an action or intervention and not theoretical and descriptive analytical studies. By having these inclusion and exclusion criteria, it might be that some studies describing practice without testing the effects of a described action or intervention approach might have been omitted. We included only studies published in peer reviewed scientific journals. Many studies within workplace health promotion are published in the grey literature such as reports from universities and other research institutions Although the quality of such studies may be questioned, it might be that such studies are different from those published in scientific journals regarding outcome measures and the use of settings approaches. In addition, it might be that studies with such approaches are more difficult to get published in scientific journals compared to studies with more traditional measures and study/ intervention designs. Health, disease and settings The workplace health promotion research performed in Nordic countries definitely does not differ much from traditional disease prevention, as shown in other review studies on work-related health [38–40]. It seems somewhat strange that so few health promotion studies used positive health measures, since
health promotion documents rather explicitly express that health is a positive concept related to physical, mental and social well-being and not the mere absence of disease. Even research on salutogenesis and relationships between the sense of coherence [22] and health have mostly used disease measures as outcomes [41]. Psychology is a discipline closely connected to health promotion, since psychology is supposed to contribute to make peoples’ lives fulfilling in addition to healing mental disorder. In accordance with our results, occupational health psychology has documented that publications on negative states such as depression and anxiety exceed publications on positive states such as happiness and life satisfaction by a ratio of 16:1 [42]. Most of the studies we included were categorized as non-settings approach studies. That is, they did not intend to change the setting itself and aimed at changing health behaviour by using individual focused interventions. De Franck and Cooper [43] and Giga et al. [39] have shown similar results within stress management research. Studies on public health policy in the Nordic countries indicate that disease prevention in both Denmark [44] and Norway [45] has become more oriented towards changing individual behaviour rather than focusing on the environment and settings determinants of health and behaviour. This is in accordance with our results, indicating that even the recent intervention studies on workplace health promotion in Nordic countries focus on modifying behaviour and preventing disease rather than on promoting health with settings approaches. One reason may be that it is easier to receive funding and conduct research focusing on individuals rather than on more complex settings, and that it is easier to use validated health and work environment scales rather than not readily available qualitative and quantitative methods designed for evaluating complex whole-system settings approaches [46]. Further, getting studies using mixed-methods approaches accepted in scientific journals might be more difficult compared with studies using more traditional well-tested methods. Occupational health and safety, human resource or workplace health promotion? Several authors [e.g. 5,6,8,47] have described what workplace health promotion is, or should be, and argues that the approach includes more than what traditionally has been the focus in occupational health and safety. In line with these authors, we claim that it is necessary to include approaches with other outcome measures than disease and lifestyle
80 S. Torp and HF. Vinje measures and that the approaches should include whole system approaches. When saying that, it is important also to underline that the traditional occupational health and safety focus on risk factors and prevention of disease must be included in health promotion, but that more studies using (participatory) settings approaches with positive health outcomes should be performed. According to our opinion, it is not important whether the work is called “health promotion”, “occupational health and safety” or “human resource”, or any other label, but rather that the aims and approaches used are in accordance with health promotion guidelines to improve workers’ and other inhabitants’ health and also to prevent social inequity in health. To achieve this, it is of ultimate importance to anchor health promotion activities among stakeholders such as the unions, managers and enterprise owners [47] by communicating that health issues are closely related to the production and other core activities of enterprises. The job demands–resources model [48] is one model (among others) that may be applicable in this respect since it combines neatly the perspectives of health with the perspectives of productivity. The model is highly research-based and it is also very educational in explaining why and how workplace health promotion differs from traditional risk-oriented health and safety. The model clearly suggests that two distinct pathways or processes are important for work-related health. One pathogenic process, called the health impairment process, leads to burnout and disease. This process is primarily driven by high job demands. The other, the salutogenic process, which is called the motivational process, results in positive outcomes such as health, commitment, good performance and productivity. The motivational process is primarily driven by job resources through work engagement. The model emphasizes that many different demands and resources may be important for either burnout or engagement and that these determinants differ between settings and between occupational groups. This means that there are no universal determinants, and the possible determinants have to be explored in every setting. The possible determinants should be explored by engaging employees working in the setting. This is in accordance with a participatory settings approach. Conclusion Based on the results of this scoping review, it seems that workplace health promotion intervention research in the Nordic countries is not on the right track, since the research resembles traditional disease prevention and thereby does not focus very strongly
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SJP0010.1177/1403494814545106Is workplace health promotion research in the Nordic countries really on the right track?S. Torp and HF. Vinje
Scandinavian Journal of Public Health, 2014; 42(Suppl 15): 74–81
Original Article
Is workplace health promotion research in the Nordic countries really on the right track?
Steffen Torp & Hege Forbech Vinje Department of Health Promotion, Buskerud & Vestfold University College, Norway
Abstract Aims:The aims of this scoping review of research on workplace health promotion interventions in the Nordic countries were to investigate: how the studies defined health; whether the studies intended to change the workplace itself (the settings approach); and whether the research focus regarding their definitions of health and use of settings approaches has changed in the past five-year period versus previous times. Methods: Using scientific literature databases, we searched for intervention studies labelled as “health promotion” in an occupational setting in the Nordic countries (Denmark, Finland, Iceland, Norway and Sweden) published from 1986 to 2014. We identified 63 publications and qualitatively analysed their content regarding health outcomes and their use of settings approaches. Results: The reviewed studies focused primarily on preventing disease rather than promoting positive measures of health. In addition, most studies did not try to change the workplace but rather used the workplace as a convenient setting for reaching people to change their behaviour related to lifestyles and disease prevention. Participatory and non-participatory settings approaches to promote well-being and other positive health measures have been used to a minor degree. The recent studies’ definitions of health and use of settings approaches did not differ much from the studies published earlier. Conclusions: Workplace health promotion in the Nordic countries should more often include positive health measures and settings approaches in intervention research. It is important to anchor workplace health promotion among important stakeholders such as unions and employers by arguing that sustainable production is dependent on workers’ health. Key Words: Intervention, occupational, scoping review, setting approach, work engagement
Introduction Health promotion is the process of enabling people to increase their control over the determinants of health and thereby improve their health [1] as a result of healthy public policy and health education for all [2]. Thus, the core of health promotion is addressing fundamental and underlying determinants of health and consequently preventing social inequity in health. The most influential document providing guidelines for health promotion is the Ottawa Charter for Health Promotion [3], which reflects a holistic view on what health is, since it states that health is a resource for everyday life and a positive concept emphasizing physical, social and personal resources.
Work is an important factor influencing health, since workers represent half the world’s population [4] and because workforce well-being is closely related to enterprise and national productivity and thereby the whole population’s well-being. Focusing in particular on working life, the Luxembourg Declaration on Workplace Health Promotion in the European Union [5] reflects many of the same perspectives on health promotion as does the Ottawa Charter. Workplace health promotion is related to at least two other approaches or strategies to improving workplace health: 1) wellness programs with focus on individuals’ lifestyle, and 2) occupational health and
Correspondence: Steffen Torp, Department of Health Promotion, Buskerud & Vestfold University College, P.O. Box 2243, N-3101 Tønsberg, Norway. E-mail: [email protected] (Accepted 2 July 2014) © 2014 the Nordic Societies of Public Health DOI: 10.1177/1403494814545106
Is workplace health promotion research in the Nordic countries really on the right track? 75 safety with focus on work related physical risk factors [6,7]. Most experts and declarations (see for instance [5–10]) argue that workplace health promotion should apply a holistic approach by including both these approaches in addition to focusing on psychosocial and organizational work factors. Workplace health promotion should have the aim of making structural changes of the production to secure a health promoting and meaningful working situation. Definition of health How health is defined inevitably determines what determinants research focuses on and thereby also affects health policy. In research in medicine and other health-related disciplines, health has most commonly been defined as normal bodily functioning and thus the absence of disease or disorders [11]. Such a definition implies a focus on therapy and on risk factors to prevent bodily malfunction. One argument against the biomedical definition of health as something negative in terms of absence of disease has been that it should be possible to define health in its own right, that is, as something positive. Most definitions in this respect includes well-being and function [12]. WHOs [13] health definition, Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, emphasizes clearly the positive aspect of well-being. Well-being is often related to the concepts of quality of life and happiness [14,15], and in work settings, well-being has often been relabelled as job satisfaction, positive affect, work engagement and intrinsic motivation [16]. Defining health as a function or ability has been done by for instance Illich [17], Parsons [18] and Hjort [19]. While giving special attention to the increase in chronic illnesses in high-income countries, Huber et al. [20] rather recently criticized the WHO health definition [13] and called for a more dynamic definition based on the resilience or capacity to cope and maintain and restore one’s integrity, equilibrium and sense of well-being. They defined health as having the ability to adapt and to self-manage in face of physical, social and emotional illnesses and constraints that are more or less chronic. Fugelli and Ingstad [21] studied laypeople’s concept of health and ended up with six categories; wellbeing, function, nature, sense of humour, coping and energy. They hold that health in a lay perspective is a holistic, relative and individual phenomenon that resembles expert definitions of health as something positive and holistic.
Antonovsky’s [22,23] theory of salutogenesis (salute = health, genesis = origins) is meant to complement the traditional pathogenic perspective on health. Salutogenesis is an important theoretical framework within health promotion, understanding health as holistic and dynamic, moving and evolving on an imaginary continuum from ease to disease. The salutogenic perspective permits identifying factors keeping individuals from moving towards the dis-ease end of the health ease– dis-ease continuum. This approach allows us to recognize and study the combination of “health assets” that are most likely to lead to higher levels of overall health, well-being and achievement. Salutogenesis embraces the need, stated in the Ottawa Charter, to focus on people’s resources and capacity to create health [24]. Occupational health and safety personnel have focused less on therapy and more on preventing disease and accidents compared with health workers in other health service sectors. With regard to the Ottawa Charter’s [3] action mean of re-orienting health services, the Nordic occupational health services are rather well developed since their work is guided by work environment acts emphasizing psychosocial and organizational factors and system approaches for health and safety. In the 2005 version of the Norwegian work environment act’s very first paragraph (§1–1) [25], it is even claimed that the purpose of the act is “to create a health-promoting and meaningful working situation”. Nevertheless, their focus has been, and still is, mainly on risk factors and preventing disease [26,27] rather than on promoting health defined in a positive and/or holistic manner as advocated by most health promotion textbooks, guidelines and experts [2,28]. In this paper, we do not want to take a stance on what definition is the most applicative in workplace health promotion, but we believe that how health is defined or measured in workplace health promotion stakes out an important difference between health promotion and most other disciplines dealing with work-related health. Settings approach There are three main approaches in health promotion: the issue approach (such as reducing smoking and preventing injury), the population approach (such as healthy aging) and the settings approach (such as health-promoting schools) [29]. The Ottawa Charter [3] states that people create and live health within the settings of their everyday life, and WHO has therefore advocated a settings approach to promoting public health for many
76 S. Torp and HF. Vinje years. Several WHO projects have been initiated within such settings as cities, schools, universities, prisons, hospitals and workplaces. It has been claimed that workplace health promotion is particularly interesting and important since work strongly influences many people in and outside working life and because workplaces, employers and employees are crucial for the activities performed in most other focused settings. There is no consensus on what a settings approach is, but most authors dealing with the topic [30–32] agree that the core is recognizing that people live their lives in complex social, cultural, economic and political environments that may enhance or harm health in various ways. This means that changing the fundamental and underlying determinants of health requires modifying aspects of the settings themselves instead of solely trying to change the health behaviour of individual people. This recognizes that both the problem or challenge and the solution lie within the setting and thereby are closely related to the activities normally occurring in the setting. In work life, this means the production of goods or services by the enterprise. Health promotion therefore requires focusing on physical, social and organizational factors, applying a whole-system way of thinking [30]. Thus, health promotion activities may perfectly well be performed in a setting without applying a settings approach. An example of a non-settings approach is using the workplace as a convenient setting to reach people to try to change their behaviour related to diet or physical activity. Much has been written about what health promotion is or should be, and an extensive amount of epidemiological descriptive studies have investigated determinants of health. Theoretical and descriptive studies are important in health research, but, according to our opinion, the studies are not very helpful health promotion wise if they do not ultimately result in any behavioural or environmental change that leads to improved health. Therefore, the core of a discipline is mirrored in what kind of actions or interventions are performed and what kind of aims these interventions have. The aims are reflected in what kind of outcome measures one is concerned with. This is also the case for workplace health promotion. This scoping review of research in the Nordic countries labelled as “health promotion” in working life investigates how intervention studies defined or described health; whether they used a settings approach; and whether the studies’ focus regarding these two topics has changed in the past five-year period compared with previous times.
Material and methods Torp et al. [33] performed a scoping review study on workplace health promotion research in the Nordic countries performed from 1986 until 2008. The current study builds on their work but has been extended with more recent research and with other topics. Further, the current study includes only intervention studies. We included peer-reviewed articles published from 1986 until 2014 in the scientific journals included in the research databases ISI, PubMed, CINAHL and PsychInfo. The inclusion criteria were: 1) at least one author had to be affiliated with an organization or research institution in the Nordic countries; 2) the study had to focus on health explicitly related to occupational factors or occupational groups; and 3) had to include an action or intervention measuring some kind of an outcome of the intervention. Figure 1 describes the total article selection. First, we used the search terms “health promotion” and Denmark, Finland, Iceland, Norway or Sweden, and found 3742 results. We searched further with “workplace” or “occupational” and got 558 hits. After reading all titles and abstracts, we deleted duplicates and studies not meeting the inclusion criteria Nordic country (criterion 1) and occupational factors or groups (criterion 2) and ended up with 232 studies. Of these, 169 were excluded because they did not include an action or intervention with some kind of outcome measures (criterion 3). The remaining 63 studies constituted the material included in this review. Analysis We performed qualitative content analysis [34] on all 63 studies to analyse their ways of describing health. The analysis comprised four steps: 1) read and reread to identify meaning units expressing views on health; 2) translate the units of meaning into theoretical expressions; 3) condense meaning and develop categories; and 4) articulate themes expressing the studies’ different ways of defining health. In Step 1, the studies were read and re-read to identify how health was described by the researchers. The manifest and explicit ways of describing the term had our main focus in this step. In Step 2, we wanted to translate the found phrasings of health into theoretical expressions. As none of the studies had defined health explicitly, we tried to tie the terms used in the studies to theoretical definitions of health. In Step 3, the analysis turned into a cross-case venture, aiming at condensing the various ways health was described in the studies into meaningful categories. In Step 4, we ended up developing six main categories
Is workplace health promotion research in the Nordic countries really on the right track? 77
Figure 1. Article selection.
meaningfully comprising the different ways health had been described in the 63 studies. This study builds on the study performed by Torp et al. [33] who analysed workplace health promotion studies regarding their use of settings approaches with the same analysis strategy as described above. Since we wanted to compare our results on intervention studies’ use of settings approaches from 2008 until 2014 with Torp et al.’s results from 1986 until 2008, we used a template organizing style [35] using the categories they ended up with; non-settings approach, participatory settings approach and non-participatory settings approach. Although we present the results in this literature review with quantitative measures in part, such a literature review with its inclusion and exclusion and categorization of studies is based on qualitative analysis, including a hermeneutic approach based on the researchers’ previous understandings of the topic. Regardless of whether the studies used qualitative or quantitative research methods to investigate the health effects of the interventions, often described as outcome variables in quantitative studies and descriptive themes in qualitative studies, we label the effects in this study as “outcomes” or “health measures”. Results Definitions of health The studies included did not explicitly define health or their underlying understanding of the concept.
Therefore, we based our analysis on the studies’ descriptions of the health outcomes. Our analysis generated six categories of health-related measures: health behaviour, disease and injury, absenteeism, work ability, general health, and positive health. Most studies used more than one outcome measure related to health. In addition, several studies included outcome measures related to the working environment, productivity and satisfaction with the intervention, but these measures were not included in the present analysis. The category of health behaviour measures included mainly lifestyle measures such as healthy eating, physical activity and non-smoking: that is, behaviour mostly detached from the core activities of the enterprise. In addition, some of the health behaviour measures focused on working techniques and using personal protective equipment at work, whereas others aimed at changing eating habits at work by changing the food provided in the enterprises’ canteens. The health behaviour measures were often complemented with physiological and physical outcome measures such as maximal oxygen uptake, blood pressure and body mass index. We therefore categorized such measures in the health behaviour category. The disease and injury measures constituted the category most studies used as outcome measures and included traditional health measures defined as the absence of disease or injury. Examples are mental disorders, musculoskeletal pain, allergy, mental strain and accidents.
78 S. Torp and HF. Vinje The absenteeism category included absenteeism without known reason, sick leave prescribed and not prescribed by a physician and disability retirement. One study included also a measure of presenteeism: that is, being at work despite being ill. Some studies used work ability as an outcome measure, mostly measured using questions from the Finnish Work Ability Index [36]. Work ability may seem to be a positive health measure, but many studies defined work ability in terms of reduced ability to work because of symptoms related to disease. The Finnish Work Ability Index includes items on both what can be regarded as pathogenic and salutogenic measures related to both work and to a person’s health. Some studies measured general health by asking such questions as: “In general, how would you describe your health?” Others used multi-item measures of health-related quality of life, mostly with questions from the SF-36 Health Survey [37]. Like the work-ability measures, the health-related quality of life indices used questions related to both health problems and positive indicators of health. The measures categorized as positive health measures were related to well-being or other explicitly positive health conditions. Examples are multi-item measures of self-esteem, coping, work engagement and job satisfaction. Only a couple of the positive health measures were explicitly related to work, such as job satisfaction and work engagement. The six categories represent three different descriptive themes: a traditional biomedical and pathogenic way of defining and describing health (health behaviour, disease or injury and absenteeism); a salutogenic way emphasizing health as something positive and not the mere absence of disease (positive health); and a way of defining or describing health that cannot be regarded as either pathogenic or salutogenic (work ability and general health). Overall, about three quarters of the outcomes used in the intervention studies were categorized within the pathogenic theme, one eighth within the salutogenic theme and another eighth within the “neutral” theme.
Almost two thirds of the intervention studies used the workplace as a setting to reach individuals for health-promoting activities rather than focusing on the setting itself, and were therefore categorized as non-settings approaches. The studies focused mainly on changing health behaviour related to lifestyle factors such as diet, smoking and physical activity. Some studies acknowledged the importance of the work setting for health but did not apply a settings approach, since they aimed at changing the workers’ behaviour rather than the setting. About one fourth of the studies were categorized as participatory settings approaches. The studies were defined as participatory since they used group process interventions enabling the workers to have a voice in how the interventions were conducted by such means as search conferences, problem-based learning groups and health circles. Most of these studies used psychosocial measures as indicators, since they wanted to change the organizational culture. Studies in this category used more qualitative research methods than the studies categorized in the other two approaches. About one sixth of the studies attempted to change the setting by use of a top-down approach and were categorized as using a non-participatory settings approach. Examples are studies that aimed at improving health by changing the physical work environment without involving the employees in deciding what should be changed or how. Other studies tried out reduced work hours or introduced new sick leave regulations. Changes in health promotion research in recent years Of the 63 intervention studies included, 6 (10%) were published in 1986–1998, 12 (19%) in 1999– 2003, 16 (25%) in 2004–2008 and 29 (46%) in 2009–2013. The studies published after 2008 did not differ much from the previous studies in how they defined health or used settings approaches. Discussion
Settings approaches We categorized the studies as using a non-settings approach, a participatory settings approach or a non-participatory settings approach [33]. The definition of a settings approach used here reflects that the researchers recognized that both the problem and the solution lie within the setting and that the intervention aimed at changing the setting itself, but the definition does not necessarily imply a wholesystem approach as suggested by, for instance, Dooris [30].
About three quarters of the health measures used as outcomes in workplace health promotion intervention research performed in the Nordic countries were related to pathogenic health outcomes. Only one eighth of the outcomes were regarded as explicitly positive health outcomes such as self-esteem and job engagement. Most of the studies did not use a settings approach, since the intervention primarily aimed at changing workers’ lifestyle behaviour rather than changing the work setting itself. Compared with earlier studies, the workplace health promotion
Is workplace health promotion research in the Nordic countries really on the right track? 79 intervention research does not seem to have changed much in the most recent five-year period regarding their definitions of health or their use of settings approaches. Methodological limitations Studies within occupational medicine, psychology and ergonomics that are not labelled as health promotion could probably have been defined as health promotion and therefore be included in such a review. Omitting such studies may therefore seem to be a limitation, but the aim of this study was to review only studies representing research or researchers relating explicitly to health promotion as a discipline. On the other hand, using the search term “health promotion” may not necessarily imply that the study can be defined as a health promotion study. It can be argued that the results of this study depend on too broad inclusion criteria resulting in a wider array of studies than those explicitly relating to workplace health promotion as a discipline. To investigate how workplace health promotion is performed and how health promotion define health, it is necessary to look upon studies involving some kind of an action or intervention with clear aims and measures. Therefore, we included only studies with some kind of an action or intervention and not theoretical and descriptive analytical studies. By having these inclusion and exclusion criteria, it might be that some studies describing practice without testing the effects of a described action or intervention approach might have been omitted. We included only studies published in peer reviewed scientific journals. Many studies within workplace health promotion are published in the grey literature such as reports from universities and other research institutions Although the quality of such studies may be questioned, it might be that such studies are different from those published in scientific journals regarding outcome measures and the use of settings approaches. In addition, it might be that studies with such approaches are more difficult to get published in scientific journals compared to studies with more traditional measures and study/ intervention designs. Health, disease and settings The workplace health promotion research performed in Nordic countries definitely does not differ much from traditional disease prevention, as shown in other review studies on work-related health [38–40]. It seems somewhat strange that so few health promotion studies used positive health measures, since
health promotion documents rather explicitly express that health is a positive concept related to physical, mental and social well-being and not the mere absence of disease. Even research on salutogenesis and relationships between the sense of coherence [22] and health have mostly used disease measures as outcomes [41]. Psychology is a discipline closely connected to health promotion, since psychology is supposed to contribute to make peoples’ lives fulfilling in addition to healing mental disorder. In accordance with our results, occupational health psychology has documented that publications on negative states such as depression and anxiety exceed publications on positive states such as happiness and life satisfaction by a ratio of 16:1 [42]. Most of the studies we included were categorized as non-settings approach studies. That is, they did not intend to change the setting itself and aimed at changing health behaviour by using individual focused interventions. De Franck and Cooper [43] and Giga et al. [39] have shown similar results within stress management research. Studies on public health policy in the Nordic countries indicate that disease prevention in both Denmark [44] and Norway [45] has become more oriented towards changing individual behaviour rather than focusing on the environment and settings determinants of health and behaviour. This is in accordance with our results, indicating that even the recent intervention studies on workplace health promotion in Nordic countries focus on modifying behaviour and preventing disease rather than on promoting health with settings approaches. One reason may be that it is easier to receive funding and conduct research focusing on individuals rather than on more complex settings, and that it is easier to use validated health and work environment scales rather than not readily available qualitative and quantitative methods designed for evaluating complex whole-system settings approaches [46]. Further, getting studies using mixed-methods approaches accepted in scientific journals might be more difficult compared with studies using more traditional well-tested methods. Occupational health and safety, human resource or workplace health promotion? Several authors [e.g. 5,6,8,47] have described what workplace health promotion is, or should be, and argues that the approach includes more than what traditionally has been the focus in occupational health and safety. In line with these authors, we claim that it is necessary to include approaches with other outcome measures than disease and lifestyle
80 S. Torp and HF. Vinje measures and that the approaches should include whole system approaches. When saying that, it is important also to underline that the traditional occupational health and safety focus on risk factors and prevention of disease must be included in health promotion, but that more studies using (participatory) settings approaches with positive health outcomes should be performed. According to our opinion, it is not important whether the work is called “health promotion”, “occupational health and safety” or “human resource”, or any other label, but rather that the aims and approaches used are in accordance with health promotion guidelines to improve workers’ and other inhabitants’ health and also to prevent social inequity in health. To achieve this, it is of ultimate importance to anchor health promotion activities among stakeholders such as the unions, managers and enterprise owners [47] by communicating that health issues are closely related to the production and other core activities of enterprises. The job demands–resources model [48] is one model (among others) that may be applicable in this respect since it combines neatly the perspectives of health with the perspectives of productivity. The model is highly research-based and it is also very educational in explaining why and how workplace health promotion differs from traditional risk-oriented health and safety. The model clearly suggests that two distinct pathways or processes are important for work-related health. One pathogenic process, called the health impairment process, leads to burnout and disease. This process is primarily driven by high job demands. The other, the salutogenic process, which is called the motivational process, results in positive outcomes such as health, commitment, good performance and productivity. The motivational process is primarily driven by job resources through work engagement. The model emphasizes that many different demands and resources may be important for either burnout or engagement and that these determinants differ between settings and between occupational groups. This means that there are no universal determinants, and the possible determinants have to be explored in every setting. The possible determinants should be explored by engaging employees working in the setting. This is in accordance with a participatory settings approach. Conclusion Based on the results of this scoping review, it seems that workplace health promotion intervention research in the Nordic countries is not on the right track, since the research resembles traditional disease prevention and thereby does not focus very strongly
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