Impact of Worksite Wellness Programs on Health-Related Outcomes in White Collar Workers-A Narrative Review

Introduction

Physical activity (PA) can be defined as “any bodily movement produced by skeletal muscles which results in energy expenditure, expressed as Metabolic Equivalents of the Task (METs). Physical activity intensity is categorized as light (1.5-2.99 METs), moderate (3.5- 2.99 METs) and vigorous (>6 METs).¹ The current global recommendation on PA is 150 min of moderate-intensity physical activity or 75 min of vigorous-intensity physical activity per week to achieve substantial health benefits. Physical activity has a positive influence on both physical and mental health and is considered as an important factor in the prevention of cardiovascular diseases (CVD).² PA also lowers the risk of diabetes, breast cancer, and depression, thereby eliminating 6% to 12% of major non-communicable illnesses.³

Sedentary behavior (SB) is “any waking behavior characterized by an energy expenditure ≤1.5 METs during sitting or lying posture.’’ Common examples of SB are TV watching, computers, or other desk-based jobs. Out of all the activities, “sitting” dominates; so it can be referred to as sitting time. SB and PA both have different determinants and hence should not be used interchangeably.⁴

Office-based workplaces are currently one of the largest occupational groups globally.⁵ Desk-based office workers are subjected to numerous environmental cues that encourage prolonged periods in a seated static posture which is an economic hazard in the work environment. Research has shown that those in a sedentary occupation can accumulate highs of 11 hours/day of sitting time in a working day and can therefore have a 20% increased chance of premature mortality.^6,7

The poor health habits of many workers, growing rates of chronic diseases, and the rising cost of health benefits have created a new interest in workplace wellness programs. Workplace wellness is any workplace health promotion activity or an organizational policy created to support healthy behavior in the workplace and improve health outcomes. It often comprises activities like health education, medical screening, weight management, on-site fitness programs, etc. Workplace wellness programs can be categorized as primary, secondary, or tertiary prevention efforts.⁸

1. Primary prevention programs include stress management, exercise, and healthy eating promotion.
2. Secondary prevention programs include smoking cessation programs and screening for high BP and other cardiovascular disease-related risk factors.
3. Tertiary prevention aims at controlling or reducing the symptoms.

Over the past 20 years, Worksite Wellness Programs (WWP) has seemingly taken off. These programs have moved from providing health information to counseling and fitness delivery to using monetary rewards to incentivize employers to stay well.⁹ Employers have increasingly invested in workplace wellness programs to improve employee health and reduce healthcare costs. However, there is little evidence on how effective these programs are. This study is unique in reviewing the impact of Worksite Wellness Programs on health-related outcomes among white collar workers. Many studies related to Worksite Wellness Programs very often tend to focus more on physical health outcomes and neglect or give minimal importance to mental health outcomes. The objective of this study was to critically review the impact of Worksite Wellness Programs on physical and mental health outcomes in white collar workers.

Materials and Methods

Data sources and search strategy

A methodical search of literature was performed to investigate the effectiveness of Worksite Wellness Programs on health-related outcomes in white-collar workers. Electronic databases including PubMed/ Medline, Web of Science, and CINAHL were screened. Search strategy consisted of MeSH terms such as “White-collar workers”, “Worksite wellness programs”, “Mental health”, “Sitting time”, “Sedentary jobs’’, “Health programs”, as well as a combination of these terms. Papers published between 2010 and 2020 were included. Studies were required to be published in English language and only human subjects were screened.

Study selection process

The primary researcher initially read through the titles and abstracts to identify the articles that met the inclusion criteria. After reviewing the abstracts, two authors independently scrutinized the full-text documents for relevance. Further, if any discrepancies existed, a discussion took place until reviewers were satisfied with the final inclusion.

Inclusion and Exclusion criteria

The study mostly included randomized controlled trials. Pre-posttest intervention studies, Quasi-experimental comparison studies, and cohort studies were also considered. The inclusion criteria for the studies were as follows: (a) Full-text available articles (b) Studies published from 2010 to 2020 (c) Studies including only adult working population over the age group of 18 years (d) White-collar workers of either gender which included managerial, professional, health care workers, technical, clerical and all other desk-based or sitting jobs (e) Only those studies which gave a detailed description of the type of intervention conducted, measures and results were included in the study.

Studies were excluded if they (a) did not involve the adult working population (b) included a population other than white-collar workers (e.g., blue collars/pink collars) (c) if the studies did not report the results adequately.

Data extraction

All information linked to study design, study population, sample characteristics, objectives, outcome measure, and key results were recorded on a data recording spreadsheet by principal authors.

Data analysis

After considering the differences in the individual findings regarding the design outcomes and objectives.

Results 

Description of Health-Related Outcomes

1. Lifestyle Characteristics

Six out of nine studies showed remarkable differences in the lifestyle characteristics of the participants. The daily number of steps was 5,811 before intervention which increased by 3,429 steps to 9,240 post eight weeks. There was a significant decrease in the BMI, Waist-hip ratio, and fat mass in the participants and a statistically substantial difference in the fat mass between program completers and non-completers. There was no significant difference in self-efficiency or perceived benefit of exercise. In another study, the time spent in MVPA increased in the intervention group whereas in the control group, the inactive time was reduced and the time spent in light intensity was found to be more. The usage of stairs during work was reported to have increased in subjects wearing pedometers.¹¹

In one study, after 18 months, the rates of self-reported outcomes increased in the intervention group as compared to the control group for engaging in regular exercises (69.2% vs 61.9%) and for actively managing weight (69% Vs 54%).¹⁷

Anna-Puig et al., reported a significant reduction in waist circumference by 2.2 cm from initial to the end of follow up, while in the control group, there was a decline by 3.1 cm during the same period.¹⁸ In two studies, the daily occupational sitting time was found to have reduced in the intervention group.^15,18 No difference was found between MVPA and daily stepping in both the groups.

No changes in body composition were found. Fat mass and % of fat mass, fat-free mass, and its percentage showed no significance in the intervention period. However, 51% of participants reported improvement in Exercise stages of change (ESC), and the Virtual intervention improved motivations toward physical activity in participants.¹²

2. Cardio-metabolic Markers

Only one study measured the cortisol levels in participants and found no statistically significant variation between both the groups in the primary levels of cortisol. However, there was an increase seen in employees aged over 40 years in comparison to younger employees.¹⁰

In a study by Lynn Clemow, the systolic blood pressure (SBP) of participants in intervention group reduced by 7.5 mmHg compared to the subjects in control group between baseline and follow-up of 10 weeks. The difference in the diastolic measurements was not significant.¹⁴

No significant changes were observed in SBP and DBP in the healthy subgroup over six years in the findings reported by JY Eng. However, the SBP in the hypertension subgroup was reduced by 2,36 mmHg/ year. Significant improvements in the SBP were found among participants who were at risk of HTN. Significant improvements were found in the diastolic BP among hypertension and at-risk subgroups. This study assessed the effectiveness of low-intensity workplace health program on BP and found that the overall SBP improved by 0.1 mmHg/year and DBP improved by 0.2 mmHg/ year.¹⁶

2. Mood States

Four out of nine studies measured the mood states of participants and significant differences were measured. In a study done by Michishita et al., post 10 weeks of intervention, “fatigue-inertia” was reduced, and vigor activity and friendliness in the POMS2 elevated. Brief Job Stress Questionnaire (BJSO) items of interpersonal stress were found to be reduced in the IG.¹¹

Another study reported that the percentage of employees in the IG experienced less stress at the end of the test (80%) compared to the beginning (87%). Symptoms like dyspepsia, palpitation, and chest pain were found to be reduced.¹⁰

Significant improvements in the scores of emotional exhaustion and depressive rumination, as well as anxiety, dysphoria and hostility in favor of the intervention group were noted.¹⁵

3. Job Satisfaction and Performance

Three studies assessed job satisfaction and performance levels among participants. The job demand score was found to be remarkably reduced at the end of the study and an increased level of satisfaction with job was found in the treatment group.¹⁰ A significant difference was reported in job dedication and job absorption at 12 months. Variations at six and twelve months in favor of IG were found for job performance and recovery from work fatigue. No changes were found in terms of job satisfaction.¹¹

4. Cognitive Function

Reaction time at 3, 6, and 12 months for the corresponding level all in favor of IG compared with the control.¹⁵

5. Quality of Life

Quality of life was examined in one study by Edwardson et al., which included four individual domains. Betweengroup differences were found in two domains i.e., psychological and environmental domains in favor of IG.¹⁵ Participants in the IG compared with CG reported an enhancement in the psychological environment and overall quality of life.

Discussion

Worksite Wellness Programs

Our findings suggest that worksite wellness program has a positive impact on physical and mental health outcomes in white-collar workers. A total of nine studies were evaluated. Different worksite wellness interventions were used in all the studies. Two out of nine studies used multi-component intervention which included organizational strategies, behavioral and environmental strategies like height-adjustable workstations, regular exercise sessions, stress, and weight management programs.

Five out of nine studies included behavioral interventions like the active rest program 3000 more steps program and stress management techniques.^13,14,20 A study conducted by Anna Puig-Ribera used an internet-delivered intervention named “W@WS”. W@ WS is an effective web-based program used to reduce occupational sitting time.¹⁸ Wattanapisit et al., included a virtual run intervention program which was a three phase intervention that recorded running and walking activities using an online platform.

Alexopoulos et al., emphasized educational interventions that focused on educating the employees about relaxation techniques and other lifestyle health management programs.¹⁰

Worksite Wellness Programs and Physiological Outcomes

Six out of nine studies showed significant differences in physical health characteristics. The web-based program was effective in decreasing the everyday occupational sitting time, while it simultaneously showed an increase in the daily step count in employees. The observed changes in step counts and sitting time were significantly associated with an average waist circumference reduction. The program also showed a positive correlation in preventing chronic diseases.

Another study by Duchkee showed a positive effect on BMI, step counts, fat mass, and waist-hip ratio and thus had a positive correlation. However, it showed a negative correlation for self-efficiency and perceived benefits of exercise among employees.¹³ In another study, though the program improved motivation towards PA in employees, there were no significant improvements in BMI and therefore had a negative impact on the participants.¹² The practice of active rest program showed a positive correlation in improving PA and personal relationships in employees.¹¹

In the remaining two studies which included multi-component interventions, greater rates of certain positive self-reported health behaviors were reported but had a negative correlation for clinical measures of health, healthcare spending, and employment outcomes.¹⁷ No significant difference in the cortisol level of employees was observed and thus the strategy had a negative impact.¹⁰

Significant reductions in the SBP were found. The effect on DBP was moderate and was non-significant.¹⁵One out of the nine studies corresponded with a specific stressful period because of the increased financial crisis which had a negative impact on the income and safety in Greece.¹⁰

Worksite Wellness Programs and Psychological Outcomes

Four out of nine studies evaluated the psychological health outcomes of the participants. Scores of emotional exhaustion and depressive rumination showed substantial betterment and had a positive impact.¹⁵ In another study, there was a positive correlation between number of exercise sessions and a change in the items of vigor activity in POMS2.¹¹

Significant reductions were reported in stress-related symptoms like dyspepsia, chest pain, palpitation, and psychological job demands and thus had a positive effect.¹⁸ A study by Edwardson also reported significant improvements in dysphoria, hostility, and anxiety levels of the participants.¹⁵

The type of strategy administered may play a major role in determining the outcome, be it physiological or psychological. The highest level of evidence was found in support of multi-component strategies followed by environmental strategies leading to an overall reduction in sitting time and betterment of other health-related outcomes. Environmental or multi-component strategies particularly incorporating sit-stand workstations prompted significant changes over other strategies.

Implications for practice

Multicomponent strategies incorporating behavioral, educational, organizational, or environmental strategies are beneficial in combating the health risk behaviors, with more emphasis on the environmental modifications.

Limitations

Heterogeneous study methods and outcome measures were recognized across the studies, and thus, a metaanalysis cannot be performed. Similarities between publications were difficult to assess because of the diversity of outcome interventions reported, as well as inadequate information about the programs provided in numerous articles.

Future Recommendations

• a) Common units to be used for reporting of outcomes to facilitate comparison of future studies.
• b) RCTs with long term follow-up (>1 year) assessments are needed to understand the actual impact of the different strategies on health and work-related outcomes and their related reduction in sedentary time.
• c) RCTs incorporating innovations like bike desks in offices, cycling workstations should be considered.
• d) Working populations having little or no flexibility and control over work such as workers involved in call center work and data processing, university employees, should be addressed in future studies.

Conclusion

The studies yielded mixed results regarding the impact of wellness programs on health-related outcomes. There exists a strong evidence demonstrating the impact of worksite wellness programs on major physiological outcomes such as blood pressure, BMI, waist circumference, sitting time, step count, waist to hip ratio, fat mass, and so on. Significant reductions in major psychological outcomes such as stress-related symptoms, anxiety, and depression were reported. However, the evidence on the impact of WWP on domains such as work productivity, job performance, absenteeism, and cognitive functions is insufficient or remains inconclusive. The validity of those findings is reduced by the lack of meticulous evaluation strategies.

Conflict of interest

None