‘Stakeholder Involvement’
Background paper prepared for the WHO/WEF Joint
Event on Preventing Noncommunicable Diseases in
the Workplace (Dalian/ China, September 2007)
Authors:
John Griffiths
Hayley Maggs
Emma George
Contact author:
John Griffiths
work2health ltd
E:
john@work2health.org.uk
T:
+44 (0) 2920 388 477
M: +44 (0) 7798 502 548
F:
+44 (0) 8707 626 208
W: www.work2health.org.uk
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1
Section
Page
1.
1.1
Introduction
Preamble
3
3
1.2
Historical perspective
5
1.3
The strengths and weaknesses of the setting
6
1.4
The business case and other drivers for workplace health promotion
6
2.
Promoting healthy diets and physical activity in the workplace – who
9
are the stakeholders?
9
2.1
Rationale for stakeholder involvement
2.2
2.3
Stakeholders and partners
The key stakeholders, the rationale for their involvement, their role and
competency
9
10
2.4
A model of stakeholder engagement
18
2.5
2.6
Stakeholders as enablers and resistors
Promoting good nutrition and physical activity in the workplace – the
resource implications for stakeholders
20
23
3.
3.1
Interaction between stakeholders
Mechanisms of interaction between different stakeholders
24
24
3.2
Barriers to the stakeholder interaction and possible ways to overcome
these barriers
29
4.
Examples of multi stakeholder activities / programmes / experiences:
30
4.1
Regional example
39
4.2
4.3
4.4
Country examples
NGO led example
Company led examples
31
33
34
5.
Conclusions and recommendations
36
6.
Limitations of the paper
38
7.
References
39
2
1.
Introduction
Preamble
Being in employment is health enhancing, with people in employment
enjoying better levels of health than those who are unemployed
(Waddell, 1). In addition to providing an income, work can also lead to
improved self image, a sense of purpose to life, social interaction and
personal development (Waddell, 1).
The workplace has long been considered a suitable setting in which to
promote health and well being. There are several reasons for this, not
least of which is that the workplace is a setting in which a large
proportion of the adult (working aged) population can be reached
with messages about health and well-being. Associated with this is that
many people who make up the workforce come from groups who are
traditionally hard to reach with messages about health, wellbeing and
lifestyle, such as males and lower socio-economic groups.
A second major driver for workplace health promotion (WHP hereafter)
is that it has a positive impact on the economic well-being of an
organisation and, in turn, the creation of wealth in the community as a
whole. Key reasons that provide a rationale for WHP activity include:
•
•
•
•
The aging population in many countries and the need to have
older people who can remain healthy and economically active
The increasing diversity of the workforce
The requirement for high levels of workability among employees
The need to recruit and retain high quality employees
To have a workforce that is fit, flexible and efficient (workability)
requires an organisation to have policies and approaches that:
•
•
•
Enable and equip people to remain in work later in life
Reduce the loss of experienced workers from the workforce i.e.
improve retention
Improve the quality of life both inside and outside work for all
workers especially older workers
Given the known benefits that accrue to organisations (and their
employees) that implement workplace health promotion initiatives, the
considerable potential of workplace health promotion can clearly be
seen.
However employer engagement in the promotion of employee health
and well being is far from high. The key question then is how can more
employers be encouraged to become involved and what systems and
measures need to be in place in order for this to happen?
The immediate need for action to be taken is made more pressing by
demographic change and the continuing rise in lifestyle related
chronic diseases such as obesity, Type II mature onset diabetes, CHD
and stroke, the statistics for which are alarming. In 2006 the World
3
Health Organisation estimated that there were 1.6 billion adults (aged
15+) who were overweight and at least 400 million adults who were
clinically obese, predicting that by 2015 approximately 2.3 billion adults
will be overweight and more than 700 million obese (WHO, 2). Similar
statistics relating to Type II diabetes and CHD are of equal concern
with an estimated 120 million people world-wide affected by type 2
diabetes which is predicted to almost double to 215 million by 2010
(British Nutrition Foundation, 3) and an estimated 17 million people
each year dying of cardiovascular diseases, in particular heart attacks
and strokes (WHO, 4).
As this paper will describe, the workplace provides an ideal setting in
which to raise awareness and promote behaviour change in terms of
nutrition and physical activity, but that to achieve the considerable
potential of the workplace all stakeholders must be completely
committed and fully involved.
In order to aid our understanding two complementary definitions of
workplace health promotion should be examined. The first, from
Wynne (5) states that WHP, “is directed at the underlying causes of ill
health; combines diverse methods of approach; aims at effective
worker participation; and is not primarily a medical activity, but should
be part of work organisation and working conditions”. The second
definition was developed by the European Network for Workplace
Health Promotion (ENWHP) in 1997. This states that, “WHP is the
combined efforts of employers, employees and society to improve the
health and well-being of people at work” (6). This is achieved through
a combination of:
•
•
•
Improving the work organisation and the working environment
Promoting the active participation of employees in health activities
Encouraging personal development (6)
The ENWHP statement goes on to note that WHP involves an
organisational commitment to improving the health of the workforce;
providing employees with appropriate information; having policies and
practices which help employees to make healthy choices; and
recognising that organisations have an impact on people.
Using the WHO Ottawa Charter (7) as a basis, a template for WHP
activity can be developed. This shows that WHP is based on:
•
•
•
•
•
the building of healthy corporate policy
the creation of a supportive working environment
the development of employee skills (and knowledge) which are
conducive to health
the strengthening of workforce action towards health
the re-orienting of occupational health services
Many countries, and indeed notable WHO documents, set out clear
public health targets. These range in scope from specific targets on
4
lifestyle issues such as a reduction in the levels of morbidity and
mortality linked to certain behaviours e.g. tobacco and alcohol use, to
more general targets focusing on the health consequences of socioeconomic factors such as a reduction in inequalities in health.
It can be reasonably concluded that WHP offers considerable
potential in terms of the achievements of these targets and
consequently bring about improvements in levels of public health. This
statement is born out by research findings focusing on the outcomes of
workplace interventions. The vielife / IHPM Health and Performance
Research Study (8) was the first prospective controlled study that
explored the link between health and productivity in the workplace.
The findings of the research highlight how health promotion
programmes within the workplace can significantly improve the health
status of individuals and enhance quality of life, as well as improve
work performance by 8.5 % and reduce short term sickness absence. If
this effect were to be multiplied across all the employers in a country
then the impact on overall employee wellbeing would be
considerable, with benefits to health at a population level being
experienced for many years in the future.
1.2
Historical perspective
One of the first, if not the first report, to identify the workplace as a
setting in which people’s health could be improved was the Lalonde
Report published by the Canadian Ministry of National Health and
Welfare in 1974. The purpose of the Report was, ‘to unfold a new
perspective on the health of Canadians and to thereby stimulate
interest and discussion on future health programs for Canada’ (9). In
setting out a possible health promotion strategy several courses of
action were identified, including those that relate to the workplace
and to the importance of stakeholder involvement in the promotion of
employee health and well being e.g. ‘Enlistment of the support of
employers of sedentary workers in the establishment of employee
exercise programs’; and ‘Enlistment of the support of trade unions
representing sedentary workers in obtaining employee exercise
programs.’ Lalonde(9).
The issue of stakeholder involvement was also referred to in the Ottowa
Charter (7), where it is stated that, ‘health promotion demands
coordinated action by all concerned: by governments, by health and
other social and economic sectors, by nongovernmental and
voluntary organisations, by local authorities, by industry and by the
media’ and on the specific issue of work it is noted that, ‘Work and
leisure should be a source of health for people. The way society
organizes work should help create a healthy society (Ottowa Charter,
7).
Since Ottowa a number of international and national developments
have taken place and workplace health promotion has developed
rapidly in many countries. Arguments supporting WHP particularly in the
5
context of the business case and return-on-investment have grown in
strength as more evidence and data has become available.
1.3
The strengths and weaknesses of the setting
It is widely acknowledged that the workplace offers a setting that is
conducive with the promotion of health activities. The identification of
the workplace as an appropriate vehicle to effectively promote health
is recognised by writers such as Fielding et al (10) who perceive that
the workplace is an advantageous setting not only because of the
significant proportion of time spent at work by the large majority of the
population, but also because it offers an opportunity to utilise peer
pressure to encourage employees to make desirable alterations to
their health habits. Chu et al (11) echo such sentiment, recognising
that the workplace offers the ideal infrastructure to support the
promotion of health to a wide audience as its impact upon the
physical, economic and social well-being of the workers will in turn
impact upon their families, communities and thus wider society,
therefore ensuring that the benefit is far reaching.
The WHO (12) perceive that such a strategy can impact not only upon
the health of people living in developed countries, but also upon those
living in the developing world, through their assertion that a
fundamental strategy in poverty alleviation will be to get healthy
workers to raise healthy families.
Further strengths that are notable for the promotion of health within a
workplace setting are attained by both the organisations and
individuals involved. From an organisational perspective, the
promotion of health within the workplace can be advantageous as it
offers an improvement in staff morale, a positive corporate image, a
reduction in turnover, absenteeism, health care costs and risk of
litigation and an improvement in morale and productivity (WHO, 12).
Equally, the employees of an organisation that embarks upon a health
promotion programme benefit too from a safe and healthy working
environment, improved health, well being, self-esteem and job
satisfaction, and a reduction in stress (WHO, 12).
However health promotion activities in the workplace may encounter
some difficulties which need to be addressed at the outset of any
programme in order that adaptations can be implemented
accordingly. Key feasibility and sustainability considerations in the
implementation of workplace health initiatives can include seasonal,
temporary, irregular, mobile, migrant and shift workers (Peltomaki et al,
13), whilst acknowledgment that labour management mistrust can
impact upon the success of WHP programmes is also an important
consideration (Janer et al, 14).
1.4
6
The Business case and other drivers for workplace health promotion
Workplace health promotion (with particular reference to non
communicable disease prevention addressing nutrition and physical
activity) is being presented on an international platform by economic,
as well as societal drivers . Within the developed countries of the world,
there is a substantial economic cost directly relating to a lack of
physical activity and poor nutrition. The Canadian Fitness and Lifestyle
Institute (15) estimate the cost of physical inactivity in Canada to
amount to $5.3 billion ($1.6 billion of which are direct costs and $3.7
billion of which are indirect), whilst the cost of obesity is placed at $4.3
billion ($1.6 billion of which are direct costs and $2.7 billion of which are
indirect) annually in health care expenditures. In England, the cost of
inactivity is estimated to be £8.2 billion annually which accounts for
both the direct costs of treating the lifestyle diseases that result, as well
as the indirect costs of sickness absence (Department of Health, 16).
Further, America suffers excessive costs with the price of obesity in 2000
estimated at $117 billion ($61 billion direct and $56 billion indirect),
mostly associated with the diagnosis and treatment of type 2 diabetes,
coronary heart disease, and hypertension (United States Department
of Health & Human Services, 17) whilst an estimated 9.4% of U.S. health
care expenditures are directly related to physical inactivity and
obesity. (Centers for Disease Control and Prevention, 18).
The economic ramifications of poor nutrition are equally eminent in the
developing world. Horton (19) suggests that micronutrient deficiencies
alone cost India US$2.5 billion, whilst the productivity losses (for manual
workers) that surmount from stunting and deficiencies in iodine and
iron, are responsible for a 2.95 percent total loss of the countries GDP.
Such costs however are not reflective of the impact that non
communicable diseases can have upon organisations and it is
important to stress that employers may absorb a significant amount of
the costs as detailed above through sickness absence, staff turnover
and reduced productivity (Adeyi et al, 20).
These reasons outlined above, coupled with an ageing workforce,
globalisation and the need to remain competitive, have meant that
many organisations have recognised the value of introducing
workplace health promotion programmes, particularly which aim to
directly tackle the nutrition and physical inactivity of their workforces.
Within the developed world, interventions have been introduced within
the workplace that are concerned with physical activity and nutrition,
in recognition of the benefits that can be attained at both
organisational and individual level. In Sweden, AstraZeneca (formerly
Astra AB), a pharmaceutical company, has introduced a regular
breakfast meeting at which nutritional food options are served, whilst
also making provision to improve the health of its staff through the
introduction of seminars on health related subjects, keep fit exercises
at the workplace and sports programmes (European Network for
Workplace Health Promotion, 21) Similarly in Greece, ElaÏs, a food
production company, provides its staff with a gymnasium and
professional trainers and a canteen and restaurant that provide
healthy, high quality food European Network for Workplace Health
Promotion, 22).
7
Within the developing countries, there is evidence of large scale
interventions being introduced in workplaces that attempt to alleviate
the problems associated with nutritional deficiency in the adult
populations. Doak (23) highlights a large scale intervention in India
that has been introduced in multiple worksites and which incorporates
exercise, counselling in family nutrition and healthier menu options in
the cafeteria, whist also making reference to South Korea which has
programmes at worksites that offer health and nutrition counselling
and education services. Further, on a smaller scale, Doak (23) draws
attention to selected work site programmes in Tanzania that
emphasise the importance of exercise to their staff.
8
2.
Promoting healthy diets and physical activity in the workplace – who
are the stakeholders?
A broad range of stakeholders have a legitimate interest in diet and
physical activity interventions in the workplace. In addition to those
that might naturally be considered to be stakeholders in workplace
health activities – employers, employees, trades unions, company
insurance funds and ministries of health and labour for example, other
stakeholder groups need to be involved. These include private sector
organisations representing the agricultural industry, food producers
and retailers, and transport and leisure interests.
2.1
Rationale for stakeholder involvement
The fundamental question to be asked when considering these issues
is, ‘Why should any potential stakeholder wish to become involved in
the promotion of health and well being in, and through, the
workplace?’ Several answers are possible, and in reality stakeholder
involvement may well be based on a mixture of some or all of them.
They include:
altruism – we do it because we believe it is the right thing to do
irrespective of cost
investment – we do it because we perceive that there will be a return
on our investment. This can be tangible e.g. an employer might expect
that sickness absence costs will diminish, and / or intangible – the
workforce will see that we are a caring employer and commitment
and morale might rise as a consequence
compulsion – we do it because we have been told we have to. The
significant risk with this approach is that we will do the absolute
minimum
lost opportunity – we do it because the potential benefits are so great
that we cannot afford not to, or that our competitors are doing it, thus
we must do the same to maintain our market position
•
•
•
•
2.2
Stakeholders and partners
With multi-agency involvement it is sometimes difficult to distinguish
between stakeholders and those agencies who may not be
‘stakeholders’ in the full sense of the word but who are working as
partners in the intervention. To clarify the situation it is necessary to
examine the meaning of the terms ‘stakeholder’ and ‘partner’.
The term ‘stakeholder’ has numerous definitions, many of which are
linked to the context in which the term is being used. Two general
definitions are useful in the context of this paper – the first of these is
that a stakeholder is a person or group with an interest, involvement or
investment in something;
(http://www.nchsd.org/uploadedfiles/Keys%20to%20Successful%20Req
uest%20Legislation.ppt#277) ,and, in the second the word is used to
describe people who will be affected by a project, or who can
influence it, but who are not directly involved in doing the work.
(http://www.lse.co.uk/FinanceGlossary.asp?searchTerm=&iArticleID=92
7&definition=stakeholder)
9
A partnership on the other hand is defined as a relationship between
individuals or groups that is characterized by mutual cooperation and
responsibility, as for the achievement of a specified goal:
http://www.answers.com/topic/partnership?cat=biz-fin
Can different stakeholders work in partnership to promote diet and
physical activity? – The answer is an unequivocal ‘Yes’ and the ideal
conditions for such working are explored later in Sections 2 and 3.
Do all partners have to be stakeholders? – The answer is, ‘theoretically
no, but in reality more often than not, yes’.
2.3
The key stakeholders, the rationale for their involvement, their role and
competency.
Table 1 provides examples of the stakeholder groups and describes their
potential role and competency in the context of workplace health promotion
and diet and physical activity interventions in particular. In considering the
information set out in the table we need to bear in mind that the overarching
reason for the involvement of any of the stakeholders is the beneficial
outcomes that their involvement brings to them or to those they represent,
examples of these outcomes are set out in the table. In the case of
governments this may well be improvements in public health, the creation of
a healthy society etc. But this will not be a legitimate reason for other
stakeholders to become involved. For these, employee productivity,
organisational efficiency and increase in profit will be the driving force.
The roles of individual stakeholders can vary in different circumstances, e.g.,
the role of the Trade Unions may initially be reluctant participant but having
seen the benefits of workplace health promotion they may become
proactive champions. This also means that roles can be interchangeable.
The exception of this principle is the leadership role. Whilst all stakeholders can
take the lead in workplace health initiatives, certain groups of stakeholders,
such as employees, can never manifest true leadership as they do not possess
the organisational authority necessary to act in a full leadership role.
Where there is mutual respect for one another’s goals, and an understanding
that the achievement of positive outcomes will mean different things for
different stakeholders, then significant progress can be made in developing
and implementing nutrition and physical activity programmes that will protect
and improve health.
10
Table 1: Stakeholders of workplace health promotion, and their associated roles
Stakeholder
Rationale for engagement
Potential role
Competency
Examples of practice
International organisations
UN Family –
WHO
ILO
World Bank
United Nations Economic
Commission for
•
Africa (ECA)
• Europe (ECE)
• Lain America and the
Caribbean (ECLAC)
United Nations Economic and
Social Commissions for
1. Asia and the Pacific
(ESCAP)
2. Western Asia (ESCWA)
Food and Agriculture
organisation of the United
Nations (FAO)
Creating access to sustainable
and productive employment,
the improvement of health, the
development of healthy
communities, the equitable
treatment of citizens and the
creation of fair and civil
societies are key goals for
international organisations such
as those listed.
Promote the workplace
as a key setting for
health and encourage
and enable
developments at
country level through:
• Possession of and
access to technical
knowledge and
expertise
WHO – Global strategy on
diet, physical activity and
health
Stakeholder
Rationale for engagement
Potential role
Competency
Examples of practice
Supranational Organisations
Good population health is
essential for developments in
the economy and community.
Employment opportunities and
inward investment are
facilitated by a labour market
that is characterised by high
levels of fitness and health.
Very similar to the role of
international
organisations with the
additional roles of public
health policy
development, health
service development
and the promotion of
the workplace as a
setting for health.
•
Possession of and
access to technical
knowledge and
expertise
EU – the European Network
for Workplace health
promotion / ‘Move Europe’
Campaign
•
Access to key
officials and leaders
within countries and
regions
http://www.enwhp.org/index.ph
p?id=83
EU
ASEAN
Poor health is both a symptom
and a creator of inequality.
Preventable disease reduces
people’s ability to work,
removes valuable resources
from society and reduces
economic performance at both
country and organisational
level.
•
Advocacy
•
Research
•
Capacity building
•
Dissemination of
good practice
•
Investment in pilot
programmes
• Access to key officials
and leaders within
countries and regions
•
Opportunities to
commission
http://www.who.int/dietphys
icalactivity/strategy/eb11344
/en/index.html
ASEAN Regional Action Plan
clearly identifies the
workplace as a setting
through which the
11
developments in
public health and
WHP
population can benefit from
information about their
health and access resources
to promote their health, e.g.
good nutrition, safe drinking
water, and physical activity.
http://www.aseansec.org/8625.
htm
Stakeholder
Rationale for engagement
Potential role
Competency
Examples of practice
National and local Government
e.g.
Government at all levels has
responsibility for disease
prevention and health
protection at a societal and
community level.
Ensure that the policy
framework in which
organisations operate
includes workplace
health promotion.
• Developers of health
related public policy
Australia - ‘Eat Well’ and
‘Active Australia’ strategies
• Developers of
agricultural / food
policy
Employers are accountable to
government for the health and
safety of their employees, the
protection of the environment
and, through fiscal measures,
i.e. the payment of taxes,
employers are contributors to
the finances of the country.
Create an environment
which is proactive in
terms of promoting
health and well being
and in particular create
opportunities for
employers to participate
in health promotion
initiatives through
national and local
health campaigns,
accreditation / award
schemes and capacity
building.
• Responsible for public
health and safety
http://www.health.gov.au/intern
et/wcms/publishing.nsf/Content
/health-pubhlth-strateg-foodnphp.htm
Ministries of Health, Labour and
Safety
Local and municipal
governments
• Responsible to the
constituency for
health and well being
• Commissioners and
providers of capacity
building and training
on relevant topics
http://www.health.nsw.gov.au/
public-health/healthpromotion/activity/campaigns/
active-australia/index.html
Brazil National Food and
Nutrition Policy
http://bvsms.saude.gov.br/bvs/
publicacoes/national_food.pdf
New Zealand - Healthy
Eating – Healthy Action
Oranga Kai – Oranga
Pumau: A strategic
framework 2003
http://www.moh.govt.nz/health
yeatinghealthyaction
Spain Código De
Autorregulación De La
Publicidad
De Alimentos Dirigida A
12
Menores,
Prevención De La Obesidad
Y Salud
http://www.aesa.msc.es/aesa/
web/AESA.jsp
UK
England: Health, work and
wellbeing strategy
http://www.dwp.gov.uk/publica
tions/dwp/2005/health_and_well
being.pdf
Scotland: Healthy Working
Lives
http://www.healthscotland.org.
uk/hwl/index.cfm
Wales: Health Challenge
Wales
http://wales.gov.uk/topics/healt
h/improvement/hcw/?lang=en
Stakeholder
Rationale for engagement
Potential role
Competency
Examples of practice
NGOs
In 2001Anheir et al estimated that
around 40 000 international NGO’s
were operating. If NGO’s working
within countries are added to this
total then several million NGO’s are
in existence. The World Bank
classifies NGO’s in two ways –
‘advocacy’ and ‘operational’, (24).
Operational NGO’s can be
international, national or community
based. They are primarily
concerned with the design and
implementation of development-
Advocacy and
developmental.
Advocacy in
encouraging the
acceptance of diet and
physical activity as key
health goals, and the
workplace as a setting in
which to promote health
by other stakeholders.
Developmental in
establishing and
disseminating good
• Technical expertise
West Australia Healthy
Business
(The Charter that the NGO
adheres to will shape the
level of involvement that it
will have in WHP activity.)
• Knowledge and
understanding of the
issues and processes
www.healthybusiness.asn.au
/
• Able to bring
resources to
developments
• Pan-national
coverage
13
related projects.
practice.
Advocacy NGOs defend or
promote a specific cause by raising
awareness, encouraging
acceptance and increasing
knowledge through lobbying, press
work and activist events.
In fulfilling their roles, NGO’s are
ideally placed to promote good
practice in population health, public
health and economic development.
Promoting and supporting the
development of a healthy society
and productive must include
disease prevention and health
promotion and through their
legitimate roles NGOs are ideally
placed to facilitate this process.
Stakeholder
Rationale for engagement
Potential role
Competency
Civil society
A society which seeks the common
good of all is one in which the
protection and promotion of health,
the creation of well being and the
protection of human rights are key
facets.
Holds government and
employers to account
on issues relating to the
public health, the
provision of information
and access to facilities /
products relating to diet
and physical activity
and the prevention of
lifestyle related diseases.
• Beneficiary of whp
Article 25 of the UN Declaration Of
Human Rights, addresses the issues
of standards of living and health
and well being, and a civil society
will seek to ensure that these basic
human rights are met. This point is
underpinned by the Luxembourg
14
Advocates good
practice in terms of the
workplace as a setting in
Examples of practice
Declaration on workplace health
promotion which states that,
Workplace Health Promotion (WHP)
is the combined efforts of
employers, employees and society
to improve the health and wellbeing of people at work.
http://www.enwhp.org/fileadmin/d
ownloads/Luxembourg_Declaration
_June2005_final.pdf
which to promote
health.
Is supportive of
organisations who seek
promote health and well
being and is accepting
of policies and
procedures which do
this.
Stakeholder
Rationale for engagement
Potential role
Employers
Need a fit and productive workforce
if they are to remain competitive,
viable and able to deliver products
and services.
Become involved in
national / local
programmes and
projects designed to
promote employee
health and well being.
• Responsible for a
captive audience
which is often
difficult to reach
with positive health
messages
Where appropriate raise
awareness of employees
of the benefits of good
nutrition and physical
activity and of the
benefits of safe food
preparation and
storage.
• Systems in place –
corporate policies,
communication
strategy, provision of
food and water etc
that enable
awareness to be
raised and
employees to take
greater ownership of
their health and well
being
Employers as key stakeholders in
WHP – Gilmartin, (25); Arneson and
Ekberg, (26)
Create a supportive
working environment i.e.
ensure that any foods
available for purchase
meet healthy eating
criteria and that staff
can take breaks to eat
and exercise
Competency
Examples of practice
Health at Work: The
Corporate Standard
http://newydd.cymru.gov.uk
/topics/health/improvement
/health-at-work/corporatestandard/?lang=en
• Provides training to
key staff on the
importance of
nutrition and
physical activity
15
(such groups would
include OH staff,
catering staff and
managers)
Stakeholder
Rationale for engagement
Potential role
Competency
Employees
Ultimately are the recipients and
beneficiaries of WHP. Engagement
of this group is crucial for WHP to
have an impact at on
organisational and societal level.
The key participants in
workplace health
improvement
programmes.
• Through participation
in WHP and then
transfer agents of
knowledge and
behaviour to life away
from work, this group
are the enablers of
significant public
health improvements.
Employee ‘champions’ of WHP
programmes assist in the
implementation of programmes and
have a key role sustaining employee
engagement.
Trades Unions
16
Historically trades unions have
always had an involvement in
health. In their early days it was the
union that provided its members
with support should they become ill.
In more recent times trades unions
have been actively involved in the
driving up of standards of safety
within workplaces and often provide
training for their members on issues
such as health and safety.
Messengers – messages
received through WHP
are taken into the wider
community by this
group.
Enablers of change –
raising awareness
among members of the
benefits of good
nutrition and exercise.
Advocates of change –
working with employers
to bring about
improvements at the
workplace which are
conducive to health e.g.
the promotion of good
nutrition and exercise
• Often have very
effective
communication
mechanisms with
members and
employers
• Promoting members
well being is a
legitimate and
historical role of trades
unions
Examples of practice
Stakeholder
Rationale for engagement
Potential role
Competency
Examples of practice
Company health insurance
funds
Company health insurance funds
collect fees from employees and
uses this money to pay the health
care costs of those they insure.
Advocates of WHP
• Technical expertise
Germany:
Funders of WHP
• Able to share knowhow of the setting and
health
BKK Workhealth Project 2002
Having a client base that is healthy
reduces treatment costs.
Engagement in the promotion of
health through the workplace is
being recognised by company
health insurance funds as a
legitimate role which benefits the
employee (better health), the
employer (more efficient and
productive workforce) and
themselves (reduced treatment
costs).
Other private sector
organisations
Agriculture / Food
production
The agriculture industry and food
producers through production
methods and pricing policy are able
to directly influence the foods that
employers purchase for serving in
the workplace.
An integral part of the supply chain
from farm to consumer.
Providers of food and
ingredients for prepared
foods that meet
nutritional standards
http://www.bkk.de/bkk/cont
ent/show.php3?id=10000003
86&nodeid=455
• Able to provide
resources for WHP
AOK Healthy Companies
• Able to act as
advocate of good
practice and the
inclusion of WHP on
employers agendas
http://www.aokbv.de/imperia/md/content/
aokbundesverband/englishv
ersion/pdf/healthy_compani
es.pdf
• Technical expertise
• Provider of product
• Can influence
purchasing patterns
through pricing and
marketing
Caterers – providing food in the
workplace that is not going to cause
ill health and sickness absence in
the short and longer term is going to
be beneficial to the organisation
and staff.
17
2.4
A model of stakeholder engagement
The success of a programme that tackles chronic disease in the workplace
relies heavily in the involvement of the stakeholders identified above. The
following model has been developed to provide a framework of stakeholder
engagement to be used by those responsible for implementing health
promotion programmes. The model describes 4 phases during which different
stakeholders are primarily involved. The model illustrates how the dynamic
involvement of stakeholders can change through the phases of
engagement. The 4 phases presented in the model are qualitatively different
from each other, pose different challenges for successful implementation and
have different key stakeholders.
Drawing on Figure 1, generally, the closer the stakeholder is to the centre of
the circle the greater their overall involvement to a workplace health
programme. Therefore, we can see that typically employees and employers
have a greater role in an intervention than do agencies such as NGOs or
international organisations. In other words, stakeholders in the microenvironment often have a greater role in the realisation of an intervention
than do those in the macro-environment. There are exceptions to this
principle, for example, government initiatives to raise population health
through a workplace programme. Clearly, in such circumstances the role of
the government is absolutely key.
It is important to note that all stakeholders have the ability to interact with one
another in order to facilitate the implementation of an intervention. However,
some stakeholders are more likely to interact than others. It is clear that an
employer and a NGO are more likely to be in dialogue than an occupational
health provider and the government. See Section 3 for more discussion on
interaction of stakeholders. Dialogue between stakeholders should be
promoted at all times to ensure the intervention is optimally implemented,
overcoming any resistors (see section 2.4).
The first phase of engagement is termed ‘initial involvement’. This phase may
involve all stakeholders, but it is characterised by the involvement of
‘champions’ or a group of organisational representatives (both employer,
employees, and occupational health) that are highly motivated to drive
forward the workplace health agenda within the organisation. During this
phase the goals of the ‘champions’ and the workplace health programme
are set out, and a strategy for the second phase, ‘dissemination’, is decided.
The ‘dissemination’ phase is led by the champions but aims to engage the
entire workforce. The importance of the influence that trade unions can have
on the uptake of the workforce of any interventions must not be underestimated. In the macro-environment, the private sector, such as insurance
providers, may have an input during this phase. ‘Dissemination’ involves the
roll-out of interventions and programmes that address chronic disease in the
workplace. This phase is strongly dependent upon large amounts of
information being provided to the audience of the intervention that is both
clear and easily understood and that explains the need to become engaged
in such programmes.
18
The third phase is ‘maintenance’ and consists of the tireless exchange of
information about the need and benefits of any programme or intervention.
Again the champions have a key role to play during this phase, as do trade
unions. The employer has a responsibility to maintain the support for the
programme, in terms of time and money being expended. This
‘maintenance’ phase is often reinforced and rejuvenated by the fourth and
final phase ‘feedback’.
The ‘feedback’ phase continuously loops back into the ‘maintenance’
phase. It involves the input from all stakeholders. Feedback can be obtained
through existing organisational communication mechanisms so long as they
are deemed to be effective by both employee and employer. Feedback
monitors progress as well as identifies challenges and failures, and must be
perceived as a means by which to learn and improve activities undertaken in
the ‘maintenance’ phase. The learning arising from feedback means that the
‘feedback’ phase will occasionally loop back into ‘roll-out’ and ‘initial
involvement’ phase.
Figure 1: A model of Stakeholder Engagement
19
2.5
Stakeholders as enablers and resistors
Each of the stakeholders described so far in this paper has the potential to
play a significant role in the development of good practice in the promotion
of diet and physical activity where the workplace is concerned. But, are all
the relevant stakeholders actively engaged in a positive way, and, if not, are
they adopting a neutral position or may they even be operating in a negative
way i.e. actively resisting developments within the setting?
Positive stakeholder engagement is not guaranteed – vested interests,
maintenance of the status quo and a failure to recognise the potential of the
setting are among the many reasons why this might be so. Table 2 describes
the characteristics that might be shown by a stakeholder at different positions
on the spectrum of stakeholder involvement.
Table 2: The enablers/resistors spectrum
The spectrum of stakeholder involvement
Resistor
Enabler
Severe resistors
Moderate
resistors
Mild resistors /
Mild enablers
Moderate
enabler
Very proactive
enabler
Unable or
unwilling to
change
Unlikely to
change without
compelling
evidence
Easily moved
from one
position to
another
Is involved
through
signposting to
interventions
Convinced of
the benefits of
involvement and
assumes an
ambassadorial
role
Awareness of
the benefits of
involvement and
takes action
Has identified
clear role in
terms of own
involvement
Cannot see any
benefits of
becoming
involved
Position may be
influenced by
vested interests
Lack of
awareness of
the benefits of
involvement
Facilitates
access to
interventions
Given the strength of the business case and the health case for the
involvement of workplaces in the promotion of diet and physical activity
programmes, advocates and champions of change must make all
stakeholders aware of the benefits that can be achieved through the positive
and active engagement, and, if they do not become positively engaged, of
the increase in premature death and preventable disease and the burden
this places on themselves, the wider society, on efficiency and profit, and on
individual workers and citizens.
Table 3 briefly describes how stakeholders can act as enablers of workplace
health and conversely, how they can act as resistors to workplace health. In
some circumstances the strength of a resistor is sufficiently strong to result in
inactivity of a stakeholder. It is the function of health advocates and those
stakeholders who have adopted this proactive approach towards WHP to
move remaining stakeholders from the right hand column of the table to the
left.
20
Table 3: Stakeholders as resistors and enablers of WHP
As a health enabler
Stakeholder
Health advocacy i.e. placing WHP / diet
and exercise on the public agenda
International
organisations
(WHO, ILO etc)
Sharing experience / knowledge
managers
As a health resistor
Only fulfilling own agenda
Not prepared to work in partnership with
others
Unwilling to share information or
contribute to developments at supra or
intra country level
Commissioning the development of
good practice (pilot projects)
Providing support through technical
advice and guidance
Creates opportunities for multistakeholder working
As a health enabler
Develop public health policy that
recognises the importance of the
workplace as a setting in which to
promote health
Stakeholder
National,
regional, local
government
Recognises diet and physical activity as
important components of health related
interventions in the workplace
As a health resistor
Fails to recognise that workplaces are
important settings for health promotion
Despite the evidence, has difficulty in
accepting that WHP brings benefits to
organisations, communities and society
Considers that it is inappropriate for
government to influence practice within
workplaces
Demonstrates this commitment through
the resourcing of appropriate workplace
projects and interventions
Considers that health resources would
be better spent on treatment rather
than prevention
Creates opportunities for multistakeholder working
Acts as a mediator between potentially
conflicting interests e.g. the agricultural
sector, food retailers and consumers
(employers procuring food for staff
canteens / restaurants can be
considered to be consumers)
As a health enabler
Stakeholder
Advocates for the development and
maintenance of public health policy
that embraces diet and physical activity
and recognises the workplace as a key
setting in which to promote health
NGOs
As a health resistor
Fails to recognise that workplaces are
important settings for health promotion
Considers that health resources would
be better spent on treatment rather
than prevention
Encourages and enables the
development of good practice in diet
and physical activity interventions in the
workplace
Creates opportunities for multistakeholder working
As a health enabler
Stakeholder
Uses the democratic process to put
pressure on stakeholders to recognise
the importance of diet and physical
activity interventions with the workplace
as a key setting for health
Civil Society
As a health resistor
Considers that disease prevention and
health promotion are not priorities for
health
Considers that lifestyle topics such as
diet and exercise are within the control
of the individual and that individual
choice is the determinant of behaviour
Rejects the concept of the creation of
environments – such as the workplace,
that are conducive to health
21
As a health enabler
Stakeholder
Recognise that employees are the most
important resource that an organisation
has at its disposal and that the long term
success of the organisation is closely
linked to the health, well being and
fitness for work of its employees
Employers
As a health resistor
Adopts the view that, ‘the health of our
employees is their affair, not ours’
Willing to take practical steps to
encourage and enable good nutrition
and the taking of appropriate exercise
by employees
Promotes the safe preparation and
storage of food by those who take their
own food into work
Encourages staff to take their breaks
and to take exercise in their breaks
when possible
Discourages the use of the car as a
means of transport to and from work
As a health enabler
Follows nutritional guidelines in the
sourcing, preparation and serving of
food
Incentivises the sale of more nutritional
food choices through promotions and
price
Stakeholder
Procurers and
preparers of
food in the
workplace
Raises awareness of the health benefits
of nutritional food and a good diet
As a health resistor
Staff canteen / restaurant run on purely
commercial lines – more popular, but
sometimes less healthy choices are
readily provided, less popular but more
healthy choices are available in a
limited way and may be priced more
highly
No investment in the training of catering
staff on nutritional issues
Invests in the training of catering staff on
nutritional issues
As a health enabler
Stakeholder
As a health resistor
Raise awareness among member
organisations of the benefits of WHP,
good nutrition and exercise promotion in
the workplace
Employer
organisations
Fail to recognise the link between
employee health and well being and its
promotion in the workplace, and
organisational success
Stakeholder
As a health resistor
Promotes the strong business case for
WHP to member organisations
As a health enabler
Active and willing participants of
workplace health and well being
programmes
Supportive of organisational change
that supports health and well being
Communicate the positive health
messages acquired in work in settings
away from the workplace e.g. home
and community
Shares skills and knowledge acquired in
work in settings away from the
workplace e.g. home and community
22
Employees
Consider that any attempt by an
employer to directly or indirectly
influence the lifestyle of the employees
to be inappropriate
As a health enabler
Stakeholder
As a health resistor
Trades unions
Views anything done by employers with
suspicion and resistance (Johansson and
Partanen, (27) (Sorensen et al, 28)
As a health enabler
Stakeholder
As a health resistor
Recognises the importance of the
nutritional value of food and takes steps
to produce food ingredients and
products that meet nutritional guidelines
Agriculture
industry / food
producers
Powerful advocates for employee
health and WHP
Raise awareness and provide training so
that union representatives within
companies are aware of the
importance of good nutrition and
physical activity
Makes available resource to support
developments in companies and
supports employers who are proactive in
addressing nutrition and exercise issues
with their workforce
Not responsive to pressure to move
towards more healthy nutrition in the
workplace
Is responsive to market forces where
these are adopting the principles of
good nutrition and healthy eating
Does not use inappropriate pricing
policy as a means of reducing healthy
choice
2.6
Promoting good nutrition and physical activity in the workplace – the
resource implications for stakeholders
With so many competing demands on the often limited resources that can be
used to promote good health – both within companies and organisations and
in the wider community, many stakeholders will ask themselves the question –
‘How much will becoming involved in the promotion of good nutrition and
exercise in the workplace cost?’ The answer to the question is that a lot can
be achieved with little resource, so long as stakeholders are committed to the
process and see it as a sustained, long term process rather than a short term
‘one-off’ activity.
Much has been written on the processes of behaviour change, social
marketing and organisational development. What is clear is that in health
terms the processes rarely lead to instant change. Stakeholders first need to
recognise therefore that they are in the process for the long term. Developing
a public health strategy, creating the tools, resources and capacity to deliver
it, and then using them to do so – are not achieved over night.
Nevertheless, for many of the stakeholders with a vested interest in diet,
exercise and workplace health, the cost of their involvement is still not great.
In addition, they have a number of assets at their disposal that can be used
to promote health. These include:
• Staff – In many circumstances the major investment cost is that of staff
time. At the macro level, this will be the time of officials and experts to
develop strategies, plans and tools and then monitor and evaluate
their effectiveness. At company or organisational level it includes the
time for employees to attend planning meetings, brief their colleagues,
23
•
•
•
attend training (training does not necessarily mean participating in
expensive courses many miles from base, it can include shadowing,
benchmarking and mentoring, and use e-learning, desk research and
individual learning), and leading, supporting and participating in the
interventions.
Knowledge, skills and understanding - one of the great benefits of
partnership working is that different stakeholders bring different assets
to the project. For example in a country based nutrition programme,
officials from the ministry of health and public health professionals will
have a clear appreciation and understanding of the nutrition goals,
while representatives of business community will know what is needed
to make the programme work in companies. The sharing of these
assets and the pooling of knowledge and skills can prevent expensive
mistakes being made and inappropriate and unworkable programmes
being developed.
Technical resources – research, marketing, project management,
resource design etc are all technical skills which can be shared as
stakeholders work in partnership.
Economic resources – In a world where the demands on health
funding are strong and the level of resources is often limited economic
resources need to be used with care and with justification. However,
some financial commitment is required to initiative and sustain
programmes. Some stakeholders will be more able to allocate these
resources than others, but ‘in kind’ resourcing can prove to be as
valuable as direct financial support.
The issue of stakeholders working in partnership is more fully discussed in
Section 3.
3.
Interaction between stakeholders
As the previous section outlined, action by individual stakeholders can
bring about positive health benefits. However there is little doubt that
even greater benefit (the synergistic effect) can be obtained through
stakeholders working in partnership with one another for their mutual
benefit. Such partnerships profit from having clear and achievable
goals and realistic plans. During the lifetime of an intervention
stakeholders may become more or less involved, so a flexibility
principle should underpin any interaction between stakeholders.
Several modes of stakeholder interaction are set out below.
3.1
i.
Mechanisms of stakeholder interaction
Public Private Partnership - is a system in which a government
service or private business venture is funded and operated
through a partnership of government and one or more private
sector organisations. These schemes are sometimes referred to
as PPP or P3.
In some types of PPP, the government uses revenues derived
from taxation to provide capital to the project (on occasion
resourcing may be of the ‘in kind’ type). Resources may be used
as an initial capital investment or as maintenance funding. The
actual programmes or services are run jointly with the private
24
sector or under contract. In other types of PPP, capital
investment is made by the private sector on the strength of a
contract with government to provide agreed services.
Examples of PPP being used in a public health context are rare,
most health related PPP projects being concerned with the
development and operation of major capital projects such as
hospitals. However the lack of PPP projects in public health does
not mean that this mechanism of joint working is invalid; rather it
is just few public health PPP’s have been formed yet!
One example of project which might be considered to be a PPP
project in which WHO (Euro) was involved) was the WHO
European Partnership Project to Reduce Tobacco Dependence.
Set up in 1999, for an initial three-year period, the objective of
the project was to bring about a reduction in tobacco-related
death and disease. The Partnership Project comprised private,
non-commercial and public sector partners, including the
pharmaceutical sector at the European level and in four target
countries, France, Germany, Poland and the United Kingdom. In
2001, the Czech Republic joined the project. A wide range of
technical reports, professional and lay resources and guidance
documents were produced as a result of the work of the
project.
ii.
Platform lead by government
The development of an enterprise culture within a society
provides another means of tackling health issues. To remain
competitive, societies need to demonstrate to potential
investors that the population from whom the workforce is drawn
is fit and able to work. Being able to work requires potential,
certain levels of educational attainment and training as well as
a level of health that enables the individual to meet the physical
and mental requirements of the job. Ministries of Finance,
together with enterprise and inward investment agencies also
need to give serious consideration to population health.
Government (both national and local) is ideally placed to take
a lead / be an enabler of diet and physical activity
programmes in the workplace. In the first instance it is a major
employer in its own right, and can and should lead by example
promoting good nutrition and the incorporation of appropriate
exercise into its own employees’ daily routine. It also has the
opportunity to influence actions at organisational and individual
company level in a number of ways. These include:
a.
Public health policy
In setting the agenda for developments at both a national and
local level, public authorities should identify the role of the
workplace as a setting in which to promote health. Public health
policy – especially where it addresses disease prevention, health
promotion and rehabilitation – should provide a framework for
health development within the context of employment and the
25
workplace. Developments at company / organisational level
should therefore dovetail with national and local policy and
contribute to the achievement of health goals and targets.
To enable this to happen national public health strategies need
be developed in a way that engages with and involves other
national and local stakeholders.
An example of this approach is that adopted by the Welsh
Assembly Government in its Health Challenge Wales initiative,
available at
http://new.wales.gov.uk/subsite/healthchallenge/?lang=en .
Health Challenge Wales is a call by the Government of Wales to
people and organisations to work together for a healthier
nation. Health Challenge Wales is the national focus of efforts to
improve health and well-being. It recognises that a wide range
of factors - economic, social and environmental - have an
impact on health, so that action in all these areas can help
create a healthier nation. Several workplace initiatives are
funded by the Government but are branded Health Challenge
Wales, and each of the major projects requires that companies
who become involved evidence their workplace health efforts
with an action plan that addresses nutrition and physical activity
as well as other lifestyle related health topics.
b.
Seed funding / pump priming
Making available limited resources – usually in the form of grants
or time limited pump priming (regular amount of project funding
for a fixed period) – to facilitate the development of projects
and programmes can be of great benefit. Care needs to be
taken to ensure the viability of the project / programme, and in
agreeing to fund specific activities it a requirement should be
that all applicants set out the aim and objectives of their project
together with a detailed plan on how these will be achieved
and how resources will be managed.
Good communication is essential between the funding body as
is good governance on the part of the giver and receiver of the
funds and resources.
c.
Project development
A third way in which government can stimulate and promote
action within organisations is through the development of
national and local initiatives such as campaigns and award
schemes. A high profile media led campaign addressing health
related behavior that has elements designed for use in
workplaces and for people in employment makes it easy for
employers to become involved.
When the message that people see on TV, hear about on the
radio or read about in their newspapers is also presented to
them in the workplace then employees are more likely to
recognise and act on the message and make the change to
their behavior that will result in health benefits. Messages about
26
food hygiene, preparation and storage of food, the importance
of good nutrition and the benefits of exercise are ideal topics for
this type of campaign.
Other types of national / local workplace projects include
accreditation and award schemes. Here companies receive
advice and guidance from external agencies such as ministries
of health, employment, labour on how to meet specified health
criteria. Evidence if offered by the company on how this has
been achieved and if the evidence is satisfactory then an
award and the recognition and positive PR that comes from
possessing such an award is gained by the company.
Award schemes provide a positive incentive for companies to
develop workplace health programmes, reinforce the idea that
such companies ‘care’ for their employees and enables the
company to be recognised as an ‘employer of choice’.
d.
Fiscal measures
In a limited number of circumstances government support for
local action can be demonstrated through fiscal practice.
Examples of this type of support could include tax incentives for
companies who are able to prove that they are investing in the
health and well being of their employees. Proof would need to
be measured against a pre determined set of criteria and would
need to be independently and objectively assessed.
e.
Dissemination of good practice
One of the ways of developing good practice at company
level is to identify and disseminate models of good practice. This
is often done in the context of business excellence, but less
frequently in terms of investing in the health and well being of
employees. National and local government in partnership with
employer and employee organisations is in a position to
promote good practice and excellence in this way.
f.
Capacity building
The development of sustainable interventions at company level
is often dependent on just one or two people – usually
enthusiasts who fulfill the role of ‘championing’ the process
because of their personal commitment and enthusiasm. Yet,
what happens when one of these people is promoted, moves to
another site, or is given new responsibilities – the workplace
health promotion programmes are quickly under threat.
More people within companies need to be provided with basic
knowledge and skills on health and well being issues – for some
e.g. human resources, health and safety and occupational
health, employee health and well being naturally forms part of
their role anyway, but the full potential (for both the company
and its employees) of promoting health may not have yet been
provided to them.
27
The development of a reservoir of skills within organisations is a
vital way of ensuring a long term sustainable approach and
local and national government together with training providers
has a key role to play in facilitating this process.
iii.
Employer and employee led initiatives
The links between work and health are clear with those in
employment enjoying better levels of health than those who are
unemployed. However the world of work can still jeopardise a
persons health and well being. Unsafe working practices, high
levels of stress and inflexible working arrangements provide
examples of the negative factors which can have a detrimental
effect on employee health and consequently on the health and
well-being of their families.
Therefore it is very much in the interest of employers and
employees to ensure that work is a healthy rather than a health
damaging aspect of life. However the relationship between the
two in terms of leadership is interesting. Employers can exert
leadership because in most circumstances they hold a position
of power and authority, although how that is used will determine
whether or not the leadership is positive. In promoting diet and
physical activity they therefore have the opportunity to use this
power and authority in a beneficial way so far as the employees
are concerned. Employees on the other hand clearly have
more than a slight interest in their own health and well being,
are consequently stakeholders in workplace health promotion,
may even display evidence of leadership in planning and
organising the approach – but do so under the (tacit) authority
of the employer. In other words employees might, in some
circumstances be considered to be leaders without power.
Employers and employees (and those who represent them)
must work to optimise this relationship, and where possible
employers and society should empower employees so that they
become leaders with power, champions of change.
Currently many joint activities often focus on health and safety
issues, but there is equal legitimacy in exploring the potential to
influence lifestyle and health. It is easier to do this where a
framework for action exists, be it health and safety legislation, or
a national public health strategy. However the lack of these
does not prevent joint action being taken. Common goals need
to be sought, trust between partners needs to be created and
maintained, and actions need to be underpinned by clear
stakeholder commitment – demonstrated though active and
public support, and the allocation of resources (people, time,
materials and money).
iv.
28
International Organisations (e.g. the EU, WHO, ILO)
Through research the development of priority actions and an
understanding of the health challenges faced by countries,
international organisations have the opportunity to view the
strategic situation and then identify potential stakeholders at the
national and local level with whom they can collaborate. In
some circumstances the support of an international organisation
will mean that other agencies are prepared to commit resource
to the intervention.
3.2
Barriers to the stakeholder interaction and possible ways to overcome
these barriers
Partnership and collaborative working are often presented as a
panacea with which to solve particularly complex issues and problems
that exist within the fields of policy, politics, strategy and planning, in a
wide range of international contexts (Armistead et al, 29). Partnerships
within the context of health promotion focus specifically upon health
outcomes rather than goals and thus partnerships / collaborative
working within this sphere can be defined as “a voluntary agreement
between two or more partners to work cooperatively towards a set of
shared health outcomes” (Gillies, 30). Proponents of partnership
suggest that its benefits offer mutual gains for all stakeholders involved
(Kochan and Osterman, 31) however there can also be significant
barriers to stakeholder collaborative working which will be discussed
within an international setting.
There are various prerequisites that can ensure successful partnership
working, and Gillies (30) recognises good practice partnerships to
place emphasis upon the sharing of power, responsibility and authority
for change. However it is vital that these are addressed at the outset of
any collaboration to avoid any issues that could arise, resulting in
barriers to effective interaction between the stakeholders. Huxham (32)
identifies the key significant barriers to such interaction to include
common aims, distribution of power, issues relating to trust,
membership structures and leadership.
29
4.
Examples of multi stakeholder activities / programmes / experiences
In seeking to identify examples of good practice the following have
been chosen as they are well established, that is they have been
sustained for some time, and they draw on the support and
commitment of several stakeholders. In each case information has
been obtained from the programme / company website or the
organisation itself.
4.1
Regional example
a.
The European Network for Workplace Health Promotion
‘Move Europe’ Campaign
Stakeholders: The European Union Commission, The ENWHP
Members (An informal network of national occupational health
and safety institutes, public health, health promotion and
statutory social insurance institutions), Companies
Description: The initiative is designed as a campaign which sets
quality standards for Good Practice in WHP, identifies complying
models and disseminates these results throughout Europe.
30
i.
Based on an intensive review of other quality models and
existing literature, the ENWHP members have developed
together a high level quality standard ("quality model"),
which results in the production of corresponding tools.
ii.
Companies from participating countries can fill out an online
questionnaire for the "Company Health Check" available in their
national languages, and assess the quality of lifestyle-related
health promotion programmes.
iii.
A gradual status and selection model enables companies to
participate and identifies good models on different levels:
Companies can participate as "Move-Europe Companies" and
can qualify for selection as Models of Good Practice. Exemplary
Models which are considered particularly suitable for transfer in
other countries will be invited to present their activities in health
promotion on a European Conference to be held in Rome in the
beginning of 2009.
iv.
An advocacy and alliance building strategy will tie national
interest and expert groups to the campaign and thus increase
its impact. Using a dual-level-partnership model, with opening
meetings in every country and on European level, relevant
stakeholders and experts will be recruited, helping to further
widen the scope for participation and to deepen the
penetration in national WHP markets.
v.
Marketing and PR instruments (e.g. contest, "labels", media work,
concluding conference) will be employed to create added
value for participating companies, members and partners,
helping to raise the campaign’s awareness.
vi.
National dissemination symposiums in every country, (organised
by the NCOs with national stakeholder communities) and a
European conference (organised by the secretariat) will
facilitate the process of a Europe-wide exchange of knowledge
and experiences, support the dissemination process.
The results of the campaign will be thoroughly documented,
evaluated, elaborated and made accessible in all countries via reports
and distribution, translated and adapted recommendations, fact
sheets and guidelines. (Text taken from the ENWHP website:
http://www.enwhp.org/index.php?id=83 )
4.2
Country Examples
The examples in this category are all award / accreditation schemes.
Examples have been selected from Singapore and the United
Kingdom.
a. The Singapore HEALTH (Helping People Achieve Life-Time
Health Award)
Stakeholders: The Singapore Government, participating
companies
Description: The Singapore HEALTH Award is presented by the
Health Promotion Board to give national recognition to
organisations with commendable Workplace Health Promotion
(WHP) programmes. It is an important way of showing
appreciation to organisations that strive to help their employees
lead healthy and vibrant lives. The award addresses 4 key areas,
namely physical activity, nutrition, mental health, and tobacco
control. It is assessed on the following criteria:
o Programme Positioning and Organisation
o Programme Planning
o Programme Evaluation and Results
o Programme Comprehensiveness
Programme Comprehensiveness examines the programme
focus and the elements incorporated in the WHP programme to
enable and support a healthy workplace. The key elements in
this category are ‘A Balanced Approach’, i.e. that the
organisation puts equal emphasis on each of the three
components:
• Lifestyle and Personal Health Skills:
o Provides information and education to increase
awareness and knowledge about health (e.g.
disseminate information and organise workshops and
courses).
o Incorporate strategies to encourage attitude and
behavioural changes (e.g. motivation and incentive
• Environmental Supports:
o Creates a supportive physical environment (e.g.
canteen that serves healthier food choices and
provision of water coolers).
• Organisational Policies:
31
o
Establishes rules and guidelines to ensure a healthy
workforce and safe environment.
For further information visit:
http://www.hpb.gov.sg/hpb/default.asp?pg_id=2115
b.
UK – Wales, Health at Work: The Corporate Standard
Stakeholders: The Welsh Assembly Government, participating
organisations (the programme is endorsed by a wide variety of
organisations including the Wales Trades Union Congress, The
Health and Safety Executive, The EEF Wales (Manufacturing
Employers organisation), The British Heart Foundation Wales and
the Food Standards Agency)
Description: The Corporate Health Standard, run by the Welsh
Assembly Government, is the quality mark for workplace health
promotion in Wales. It is presented in Bronze, Silver, Gold and
Platinum categories to public and private sector-organisations
implementing practices to promote the health and well-being
of their employees.
Like other workplace quality initiatives, it is a progressive
programme and organisations are reassessed every three years.
The work to achieve the Standard is consistent with the Business
Excellence Model, which drives quality and organisational
development in many organisations.
Sections on nutrition and physical activity are included in the
assessment process and to gain an award an organisation will
have to show that criteria appropriate to the level of award the
organisation is seeking are being met, e.g. for an organisation
with a catering provision the following criteria must be met.
Bronze
Silver
32
1.
Provision of a healthy balanced menu using the balance of
Good Health Model
2.
Participation in national events e.g. 5 a day
3.
Clearly identified healthy food choices
4.
Provision of information about healthy eating
5.
Suitable facilities for breast feeding mothers
6.
4 of the Health Choice criteria are incorporated into menus
1.
Active marketing of healthy choices
2.
Healthy vending
3.
Training for catering staff
4.
Healthy choices at corporate functions and social events
5.
Minimum of 1 event held per year to highlight/raise
awareness of healthy choices
6.
Extend policy to contract/catering providers used by
organisation
Gold
7.
A minimum of 8 Healthy Choice criteria are incorporated
into menus
1.
Links with lifestyle screening and support being available for
staff wanting to lose weight
2.
A minimum of 12 healthy choice criteria are incorporated
into menus
(Text taken from:
http://newydd.cymru.gov.uk/topics/health/improvement/healt
h-at-work/corporate-standard/?lang=en )
4.3
NGO led examples
Western Australia Healthy Business
Stakeholders: The Cancer Council Western Australia, National Heart
Foundation of Australia (WA Division), Diabetes WA and Healthway
(Note: Healthway was established in 1991 under the Tobacco
Control Act as a statutory body. One of its roles being to, ‘fund
activities that promote health, particularly that of young people,
and provide research grants to organisations engaged in health
promotion programs and research’).
Description:
The WA Healthy Business originated from a pilot project developed
by a partnership between the charities mentioned above and
funded by Healthway.
From July 2003 until August 2005, seven WA workplaces
participated in the study. This study enabled these organisations to
identify the main health areas of concern for employees and
observe their working environment for physical activity, nutrition,
smoking and sun protection. The seven organisations developed,
ran and evaluated their own workplace health promotion
programs with support from the pilot project.
WA Healthy Business is primarily aimed at blue collar workplaces to
improve the long term health outcomes of their
employee's, however it is also available to a range of workplaces
The aim of the project is to support Western Australian workplaces
and their staff in the delivery of workplace health promotion (WHP)
through a range of strategies. This includes:
• Capacity building workshops for organisation
employees
• Information and resources through the WA Healthy
Business website
• Education sessions on health issues
• Health information kits
• E-newsletters
• Healthy Business Coordinator
• Workplace case studies
33
The project is focused on the leading causes of death and disability
in Australia and the factors associated with them, two of the
leading ones being diet and physical activity.
For further information visit: http://www.healthybusiness.asn.au/
4.4
Company led examples
a. Caixa Geral de Depositos
Stakeholder: Company and employees
Description: Caixa Geral de Depositos is an international banking
and finance organisation based in Lisbon, Portugal employing just
under 20 000 people.
Given the links that exist between diet, exercise and wellbeing, the
occupational health team at Caixa Geral de Depositos has placed
nutrition and exercise at the centre of the well being activities. The
corporate approach to healthy nutrition has involved an analysis of
long term absenteeism and the development of a multifactoral
intervention consisting of three elements – consultations on nutrition
issues with at risk groups, the provision of information and the
greater involvement of occupational health services and an
enhancement of the quality of food on offer.
The first aspect of the intervention involved the provision of 1:1
consultations on the theme of healthy nutrition, with the goal of
‘promoting health through an adequate food regimen and
reducing the prevalence of nutrition related diseases’.
In 2005 440 consultations were carried out and results indicate that,
both men and women who participated in the programme were
able to reduce their weight – with men showing greater levels of
weight loss.
In terms of the workforce as a whole, the internet is used
disseminate information on the calorific content of the staff
restaurant menu, and a number of key recommendations have
been implemented. These include making the ambience of the
restaurant more pleasant – provision of music, flowers and
attractive décor, presenting the healthier options in a more
attractive way, implementing theme weeks, providing free yoghurt
or fruit and incentivising the purchase of healthy food choices by
pricing them more competitively. In addition a process of
continuously raising awareness of the benefits of a healthy diet has
been put in place.
(For further information visit http://www.enterprise-forhealth.org/fileadmin/texte/EfH_Healthy_Lifestyle.pdf)
b. Torun Energa (Poland)
Stakeholder: Company and employees
Description: Torun Energa is an electricity supply company based in
the town of Torun in Poland and employs approximately 1450 staff.
Promoting the health and well being of employees has long been a
priority corporate goal, and wherever possible links have been
made to family and community life as well.
34
Diet and physical activity have been identified as action areas for
the WHP programme. Awareness raising materials were produced
for employees using information received from the Scientific
Council of the Institute of Mediterranean Diet and Functional
Nutrition appointed by the Polish Association of Research on
Sclerosis, the Council of Healthy Diet Promotion and the Institute of
Food and Nutrition in Warsaw.
Wherever possible employees are encouraged to modify their diets
and take appropriate exercise. To facilitate the taking of exercise,
the company purchases subscription for employees to a wellness
centre where the instructors offer advice on exercise and diet and
use of the centre is increasing.
35
5.
Conclusions and recommendations
1.
Stakeholder commitment
This paper has demonstrated that the major stakeholders have
a key role to play in the continuing development of workplace
initiatives to tackle lifestyle related disease. If the potential of the
workplace is to be realised as a setting in which diet and
exercise issues can be addressed then first and foremost
stakeholders need to recognise that their commitment should
be public and sustained.
Public, because this demonstrates a conviction that action is
needed, and sustained, because changing attitudes, beliefs
and behaviours be it at the individual or the organisational level,
takes time.
2.
Stakeholder collaboration
It is usual for several stakeholders to be involved in WHP
programmes. Different stakeholders bring different perspectives,
skills, understanding, and resources to the relationship and this
must be recognised as a strength. In working together,
stakeholders should utilise these differences in the building of
strong and effective interventions.
However it may be necessary for historically held positions to be
moderated, for example at the local level, trade unions working
in partnership with company managers to create a healthy
working environment in which opportunities to exercise and
consume a healthy diet are readily available to all staff; and at
the national level, government working with private sector
organisations to bring about improvements in population health.
The basic principles of collaborative working need to be in
place – sharing of power, responsibility and authority for
change. The successful adoption of these principles requires
trust between stakeholders, good communication and an
absence of blame when progress becomes difficult.
3.
Stakeholder engagement
The improvement of population health, making private and
public sector organisations more effective and successful are
goals that many stakeholders possess independently of one
another. Their ability to influence these goals in isolation is not as
great as their ability to influence them when working
collaboratively with others.
Given the commonality of goals and the beneficial health,
business and community outcomes, potential stakeholders need
to identify ways in which they can collaborate, and means by
which they can do so.
The engagement of stakeholders is facilitated when they are
‘buying in’ i.e. committing to, a clear plan of action which has
36
objectives which they can relate to and agree with. Leaders at
all levels of workplace health promotion development need to
consider how to gain this buy in by stakeholders as plans and
proposals are created and consulted on. Having clear strategies
whether they relate to health, enterprise development or
regeneration etc provide a good starting point. When these are
backed up by sound action plans, clear and deliverable goals
and when the all the benefits of the intervention are clearly
stated for each of the stakeholders, then engagement of the full
range of potential stakeholders is more likely.
4.
Involving other stakeholders
Tackling the issues of diet and physical activity comprehensively
can often require the involvement of range of stakeholders and
other organisations. In the context of nutrition and diet for
example all organisations in the supply chain from farm to
consumer should be involved if at all possible. This means that
food is produced to the highest possible nutritional standards, is
transported in the least environmentally harmful way and is
prepared in ways that meet standards of hygiene and
nutritional content.
5.
Evidence based interventions
A great deal of evidence is now available on the effectiveness
and benefits of workplace health promotion. In order to
maximise the impact of their involvement stakeholders should
ensure that programmes are planned and developed using the
evidence base as a foundation.
6.
Resources
WHP in general and lifestyle interventions in particular do not
normally require huge capital outlay. Companies do not need
to install multi-suite gymnasia, swimming pools and tennis courts
etc for their staff in order to promote exercise. The key message
is not that all staff should become elite athletes, rather that all
staff should incorporate the appropriate amount of exercise into
their daily routines so that their risk of developing CVD, Type 2
diabetes etc are reduced.
All stakeholders have something to contribute to WHP and as
has been stated previously this does not need to be in the form
of direct financial aid. The contribution of all stakeholders
(financial and in kind, knowledge, skills and experience) should
therefore be valued and appreciated.
37
6.
Limitations of this paper
1.
Whilst this paper has identified stakeholders in WHP programmes and
detailed their respective roles, it is beyond the scope of this paper to
establish definite and sophisticated criteria for action to implement
WHP programmes. Stakeholders obviously have a hugely significant
role in putting a programme into action, and Table 1 demonstrates the
potential roles, and thus actions, that each stakeholder can become
involved with. Future research should seek to establish practical criteria
for stakeholders to move WHP programmes forward.
2.
The theoretical model of stakeholder engagement presented in
Section 2 is as yet untested. Further work in this area should look to
evaluate the accuracy and validity of the model through observed
application of the model.
3.
In developing the paper we sought to include examples of practice
from both the Developed and the Developing World. Finding examples
from the Developing World was very difficult and their absence is an
indicator of the disparity which exists. Care needs to be taken in simply
transferring the experience of stakeholders in the Developed World
and assuming that it can be directly applied in the Developing World.
Transfer of experience and knowledge needs to be undertaken
sensitively with due regard to political, social and cultural contexts.
38
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