Why people engage in a weight loss intervention at their workplace - a stratified case study

Aim

The aim was to explore reasons for HCW’s engagement in weight loss projects at their workplace and the incentives a municipality, a manager at a home-care centre, and a project manager have to launch such projects.

The FINALE-health study

Three Danish municipalities in Jutland were contacted by email and invited to participate in the FINALE-Health project. Randers municipality immediately agreed to participate. The two remaining municipalities were then given written information that the project had the participants needed for the study, and the two remaining invitations were redrawn. Randers municipality had nine care areas, and two care areas were drawn to participate. The same manager led both home-care centres. The home-care centres showed great interest in increasing their employers’ health, had a suitable amount of HCW’s and were not already involved in other health-promotion projects. For detailed description of workplace recruitment see Christensen at al. 2011 [1]. The intervention lasted for 12 months with 144 employees participating, divided in a control and an intervention group. The study was designed as a singled-blinded RCT. Tests were performed at baseline and after three and 12 months. The intervention combined nutrition counselling, cognitive behavioural training and targeted physical exercise, and aimed to increase weight loss and work capacity among HCW’s [10].

Design and participants

A stratified case study was conducted to explore the informants’ reasons for participating in the weight loss project. The informants were selected among those who in different roles took part of the project; a representative from the municipality, the manager at the home-care centre, the project manager and six healthcare workers, summing nine informants. Among the HCW’s, two informants had participated in the intervention, two had been in the control group and two had not been part of the project. The HCW’s are presented with different age, weight, weight loss and job (evening and day shifts). This variation in involvement and characteristics was prioritized to cover a broad spectrum of potential issues for participation.

Data collection and analysis

Municipality and management considerations

Project manager considerations

Hereby, the project manager puts much emphasis on what provides the best results. Her concerns are firstly scientifically and secondly how to increase the well-being of the HCW’s.

The project manager express the opinion that we as a society have an obligation to help the employees at risk of wearing themself out, even if they feel a bit pressured to participate. With this standpoint the project manager shares the ideas of joint responsibility presented by the government and the manager at the home-care centre.

Employee considerations and positions

The employees were influenced by several factors when engaging in a weight loss project. These can be classified as a. focus on health and weight loss, b. pressure from the environment and c. struggle for recognition.

Productivity and economics

The fact that the municipality was focused on a possible economical gain does not come as a surprise, as obesity is a recognized cost to the workplace as well as to the society. That the management wished to engage in weight reduction to reduce sickness absence and increase work productivity, in order to provide a good service, is supported by other findings. In a study by Gates, employees with a high BMI were significantly less productive than employees with a low BMI [12]. Another study found that workers with obesity were more likely to report lost productivity time, compared to normal or overweight workers [13]. Goetzel et al. also found that employees with obesity are more expensive due to sickness absence, productivity losses and medical care, compared to employees with normal weight [14]. Results from a simulation model on workplace obesity interventions showed that a weight loss of at least 5%, could result in annual savings for medical care and reduction in sickness absence [15].

Health improvements

The primary goal for both the project manager and the manager at the home-care centre was to improve the health of the HCWs. They agreed with the government approach of a healthy lifestyle being a shared responsibility. The managers expressed desire to help promoting health of their employees is described as a will or need to take care of a specific group, recognized as being in need of such attention. However, as a general tendency in the society, this urge to help a specific group is not unproblematic and at the workplace it may change the relations between employer and employees [16]. The care is usually well intentioned and is often perceived as positive by the recipient, but the outcome is not necessarily positive. Not because the help is not beneficial, but because it simultaneously can leave the recipients powerless. By caring for others, the provider is emphasizing that the recipients are unable to take care of themselves. This can leave the recipients powerless and give more power to the provider. On the other hand, some studies show that participants who enter a weight loss project have a need for additional support. By providing knowledge on weight loss and a healthier lifestyle, these projects in fact helped the participants in obtaining a weight loss [17]. Thus, the project manager and the manager at the home-care centre’s desire to improve the HCW’s health, can both be seen as leaving the HCWs powerless, but also as means to empower the HCWs in order to achieve a healthier lifestyle.

Social inclusion and recognition

Most of the employee’s were motivated to participate because of a desire to live healthier and to lose weight. This is consistent with findings by Jain et al. and Herriot et al. [3, 18]. They describe a desire to improve appearance and increase fitness. Although, the findings in this study is in accordance with other studies, not all participants in weight loss interventions prioritise their own health, despite known risks and prevention-strategies, as shown in a study by Morrison et al. [19].

The informant’s describe a feeling of pressure to participate from their environment and this is corroborated by findings in a study by Whale [20]. The latter describe that the participants felt a social pressure to lose weight because the government and the media, portrayed a powerful positive image of thinness and beauty [20]. On the other hand there can be a pressure from the HCWs own social relations and interaction with the obesogenic environment, undermining a weight loss [17, 20]. This is a contradiction to the environmental pressure identified in the present study.

The HCW’s experience of pressure to participate in the weight loss intervention may also be interpreted as a desire for social inclusion and a struggle for recognition. Being obese is often seen as a personal and a moral failure, and those who do not comply with the social expectations of being a responsible and a healthy citizen often experience stigmatization, social rejection and exclusion [21]. Other peoples and our own wishes, expectations and actions, influence a desire to gain recognition and to try to live up to the norms in a society, in order to be included in the community [22–24]. It is important to signal that you can manage yourself and live up to the norms of accepted appearance, as obesity is seen as a sign of weakness [25]. This pressure may be especially hard for HCWs who feel that they should be role models as workers in the health care sector. The need to be a role model is consistent with findings by Puhl et al. from 2013. The authors examined the effect of physicians’ body weight on their patients attitudes and concluded that health providers’ excess body weight may negatively affect their patients’ perception of their credibility and their level of trust and that their patients were less likely to follow their advice [26]. Based on these considerations, it is understandable if HCWs with obesity feel compelled to lose weight. The help they can get from the FINALE-Health can therefore seem appealing, and a desire for social inclusion rather than an internal motivation for losing weight. It should therefore be a concern in future weight loss interventions, how to best motivate employers such as health care workers. They are characterised as people in the lower end of the social classes, who are known to have a higher frequency of obesity problems, as well as risks for lifestyle diseases. We must therefore strive to find internal motivation factors that can help lover social class groups to succeed in obtaining a healthy lifestyle, as well as helping with external motivation factors, to overcome equality in health.

The present study is nested within the Finale-Health study [1]. It aimed primarily at decreasing musculoskeletal pain by increasing general health. The intervention was therefore targeted to increase physical healthy everyday activities, physical fitness and muscle strength, and decrease blood pressure, waist circumference, body fat and BMI. The study significantly improved all these health measurements besides muscle strength and musculoskeletal pain after a one-year follow-up [10], and was thus improving general health among health-care workers. As health-care workers are a high-risk population of several lifestyle diseases, it is important to find ways to improve their health. Several studies underpin the difficulties with maintaining a sustainable weight loss after a weight loss intervention. As general health can be improved and risk of lifestyle diseases decreased by increasing physical healthy activities and a healthier diet, future studies, also at the workplaces, should maybe focus at these improvements, especially if the targeted population do not have internal motivations to lose weight [27, 28].

Methodological reflections

To obtain the broadest perspective of the subject, the researchers choose the principle of maximum variation in the selection of the informants. This gave the researchers a wider range of knowledge and the opportunity to select informants who could provide a large spectrum of information. Despite the effort, it is not a guarantee, that all views are represented. More views could have been obtained, had we used a larger sample and gathered data using another approach, such as open questionnaires. On the other hand this would hinder the possibility to ask further questions in depth, as we wished for in the present paper.