Health Promotion International Advance Access originally published online on September 16, 2005
Health Promotion International 2005 20(4):351-359; doi:10.1093/heapro/dai023
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Evaluation of empowerment processes in a workplace health promotion intervention based on learning in Sweden
National Centre for Work and Rehabilitation, Department of Health and Society, Linköping University, SE-581 83 Linköping, Sweden
Address for correspondence: Hanna Arneson National Centre for Work and Rehabilitation Department of Health and Society University of Linköping SE-581 83 Linköping Sweden E-mail: hanna.arneson{at}ihs.liu.se
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SUMMARY |
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The aim of this study was to evaluate a theory-based method for workplace health promotion (WHP) with regard to possible facilitation of empowerment processes. The intervention tool was the pedagogic method known as problem-based learning (PBL). The aim of the intervention was to promote empowerment and health among the employees. The intervention was implemented in three organizations within the public sector in Sweden, in a bottom-up approach. All employees, including management, in each organization, were offered the opportunity to participate (n = 113) and 87% (n = 97) participated. The intervention was implemented in 13 groups of six to eight participants who met once a week over a period of 4 months. The predetermined overall goal of the intervention was to promote employee health within the organizational setting. A facilitator in each group and a group-specific mutual agreement guided the intervention, as did the problem solving process. The participants set goals and developed strategies to reach their goals between the meetings. Thirty informants were interviewed in seven focus groups after the intervention about the intervention method and the process, following a semi-structured theme guide. The phenomenographic analysis resulted in six descriptive categories: reflection, awareness and insight, self-direction and self-management, group coherence, social support and actions. The results correspond to established theories of components of empowerment processes. The method initiated processes of change at organizational, workplace and individual levels as the participants examined their work situation, determined problems and initiated solutions. Social support and group coherence were expressed as essential in order to transform challenging strategies into action and goal realization. The findings indicate that systematic improvements of social support and group coherence among employees ought to be facilitated by the organization as a health-promoting arena. PBL appears to be a profitable and powerful instrument with the potential to enable empowerment.
Key words: workplace health promotion; empowerment; problem-based learning
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HEALTH PROMOTION AND EMPOWERMENT |
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 TOPSUMMARY HEALTH PROMOTION AND EMPOWERMENT WORKPLACE HEALTH PROMOTION (WHP)INTERVENTION USING PROBLEM-BASED...IMPLEMENTATION OF INTERVENTIONINTERVENTION METHODMETHODSRESULTSDISCUSSIONREFERENCES |
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Health is associated with quality of life for the individual and with wealth in society (Nutbeam, 1998
). Health is also commonly considered to be a resource that supports productivity in organizations. Health, or rather its absence, has become a major issue in several western countries, with increasing rates of sick leave particularly for rather vague mental and stress-related disorders (Nystuen et al., 2001). Different views on health may entail different approaches to health promotion. According to an action-theoretical approach to health (Nordenfelt, 1987), health promotion involves processes and possibly also structures aimed at strengthening the ability of the individual to act, and to promote contextual conditions for action. Nordenfelt also includes the individual's ability to formulate and process vital goals as an important aspect of health (Nordenfelt, 1987).
A central feature of action-oriented health theories is empowerment, which is essential in health promotion. According to the World Health Organization (WHO), empowerment aims to mobilize vulnerable individuals and groups by strengthening their basic life skills and enhancing their influence on underlying social and economic conditions (Nutbeam, 1998). WHO define empowerment as a process through which people gain greater control over decisions and actions affecting their health. It has been suggested that as the individual's control over decisions and actions affecting health is increased, health is enhanced. Psychological health (Noblet, 2003) and psychological functioning and subjective health (Mikkelsen et al., 1999) are associated with the employees' degree of control.
Empowerment is suggested to encompass individual goals (e.g. ability, autonomy, control and self-efficacy) and acts as a process (Hansson and Björkman, 2005) leading to increased influence over decisions that impact on the individual's life (Nutbeam, 1998). Participation and self-directed activities are then crucial. True empowerment in this sense requires the individual to make decisions and to actively participate in events that shape her/his life. According to Brooking and Bolton and Swift and Lewin, empowerment processes involve the individual identifying problems and formulating vital goals and strategies to overcome the problems and achieve the goals (Swift and Lewin, 1987; Brooking and Bolton, 2000).
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WORKPLACE HEALTH PROMOTION (WHP) |
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TOPSUMMARYHEALTH PROMOTION AND EMPOWERMENTWORKPLACE HEALTH PROMOTION (WHP)INTERVENTION USING PROBLEM-BASED...IMPLEMENTATION OF INTERVENTIONINTERVENTION METHODMETHODSRESULTSDISCUSSIONREFERENCES |
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The concept WHP has been used in a broad sense, not least in the scientific literature, where it often includes disease prevention. In fact, most reported WHP interventions aim at disease prevention by focusing on individual lifestyle to reduce health risks, often based on methods directed towards the individual (Wilson et al., 1996
, Harden et al., 1999; Pelletier, 1999; Peltomäki et al., 2003). Evaluations stress that interventions focusing on individual risk factors alone are insufficient. Other and additional characteristics for WHP interventions are important and desirable (Noblet, 2003); these include:
- Participation, including autonomous and self-directed formulation of tasks, goals, methods and strategies, as well as evaluation. Participation is reported to stimulate creative learning (Mikkelsen and Saksvik, 1999; Ellström, 2001), empowerment (Swift and Levin, 1987; Brookings and Bolton, 2000) and health (Israel et al., 1996; Kristensen, 2000).
- Social support, preferably reciprocal and facilitated in groups (Rogers, 1977; Bandura, 1998; Hogan et al., 2002; Noblet, 2003).
- Individual and organizational learning (Mikkelsen and Saksvik, 1998; Ellström, 2001).
- A systematic model (Wynne, 1997) on a continuous basis over time, enabling time for learning and reflection (Schumann, 1998).
- An ecological approach including authorization of the WHP from the employer, involvement and commitment from management and bottom-up as well as top-down activities (Israel et al., 1996; Kristensen, 2000).
- The creation of a health-promoting setting in the organization rather than focusing only on the individual level (Bandura, 1998; Nutbeam, 1998).
Although studies of individual lifestyle risk reduction dominate, there are examples of empirical studies of WHP intervention approaches based on these characteristics (e.g. Nielsen et al., 2003). Among such studies, some aim to develop a supportive environment in the organization. A supportive environment is, in this context, characterized by an ecological perspective and extensive employee participation, encompassing both a bottom-up as well as a top-down perspective. Although most studies have the main focus on process evaluations (Hugentobler et al., 1992; Tessaro et al., 2000; Saksvik et al., 2002), some report outcomes e.g. improved social climate, social relations and stress reduction (Elo and Leppanen, 1999; Konradt et al., 2000). Mikkelsen and Saksvik reported positive effects on commitment, management style, intellectual stimulation and individual consideration (Mikkelsen and Saksvik, 1999). Several studies report improvements in job characteristics, leadership and management and in learning climate (Mikkelsen and Saksvik, 1999; Mikkelsen et al., 2000).
The outcome reporting intervention studies share some methodological features: initial identification of problems in organization-specific conferences followed by working groups and the development of action plans. In all studies the personnel at the workplace participated in every step of the process. The working groups, e.g. health circles (Konradt et al., 2000), social networks for informal systems (Tessaro et al., 2000), health promotion teams (Elo and Leppanen, 1999) and ‘work groups’ (Mikkelsen and Saksvik, 1999; Saksvik et al., 2002), included roughly five to 15 participants who met in recurrent group sessions over a limited time-period (3–18 months). A trained facilitator periodically supported some of the working groups.
The group sessions enabled participants to discuss and identify problems, plan change and actions and evaluate the process and outcomes. These elements are fundamental in creative learning (Ellström, 2001) and were utilized in the intervention by Mikkelsen et al. (Mikkelsen et al., 2000), who focused on opportunities for learning.
Learning conveys new ways of understanding and interacting with the context (Ellström, 2001). Also, processes of change always comprise learning in some sense. Behavioural changes in lifestyle essentially involve learning at the individual level, while changes in organizational practise (e.g. routines, structures or systems)—mediated by individual learning or problem solving—are the essence of organizational learning. Individual and organizational learning is associated with enhanced health, improved psychological functioning, coping ability and reduced job stress (Mikkelsen et al., 1999; Mikkelsen and Saksvik, 1999). Ellström suggests that overlapping conditions promote both learning and health at work (Ellström, 2001).
Very few studies have hitherto implemented health-promoting interventions that encompass all or most of the core characteristics for WHP.
The aim of this study was to evaluate whether a WHP intervention comprising the core characteristics, based on problem-based learning, facilitates increased control over decision and action, i.e. empowerment processes.
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INTERVENTION USING PROBLEM-BASED LEARNING (PBL) |
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TOPSUMMARYHEALTH PROMOTION AND EMPOWERMENTWORKPLACE HEALTH PROMOTION (WHP)INTERVENTION USING PROBLEM-BASED...IMPLEMENTATION OF INTERVENTIONINTERVENTION METHODMETHODSRESULTSDISCUSSIONREFERENCES |
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Since the core processes in WHP are based on learning, a pedagogic method was implemented and evaluated as a tool for facilitating processes of change. PBL is a structured method (Figure 1) based on learning theories (Dewey, 1916
; Silén, 2000) often implemented in universities (Maudsley, 1999). The method has also been used in health promotion and rehabilitation, resulting in improved self-rated health after chronic diseases, as well as empowerment and social support at individual, group and organizational levels (Ekberg, 1997; Tingström et al., 2002; Medin et al., 2003). PBL may be used in an ecological approach, comprising contextual processes and bottom-up as well as top-down activities.
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PBL is process-oriented and requires active participation by group members. It is implemented in groups of six to eight. The activities in the group are guided by a goal, e.g. WHP. The participants examine their work situation and identify problems in relation to the goals. Based on the problem identification, the participants set sub-goals and develop strategies to reach the sub-goals between the meetings. This active, self-directed and continuous problem-solving process supports learning (Maudsley, 1999
). The strategies used while trying to solve any problem are at least as important as the results, since the strategies can be transferred to other related situations (Dewey, 1916; Silén, 2000).
In each group the problem-based work process is supported by a facilitator whose role is to ensure that the work is goal-directed, and to support the participants in developing constructive group processes (Rogers, 1977).
The group setting offers reflection and feedback in problem solving (Silén, 2000) as well as empathy and unconditional positive attention (Rogers, 1977), elements suggested to be of importance in learning and processes of change. Respect and acceptance are facilitated as ideally all participants can express themselves on equal conditions while others are listening. The interaction during group work is supported by a mutual agreement determined at the very first meeting. In the process of formulating the agreement the participants are challenged to problematize central circumstances as how they want the group work to be characterized. Examples are the participants' own responsibility for active participation, secrecy and time keeping.
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IMPLEMENTATION OF INTERVENTION |
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The problem-based method was implemented in three organizations within the public sector in Sweden; one management department, one dental clinic and one municipal school. These organizations all volunteered to let employees participate in the intervention for 2 h per week, over 4 months. In the school the employees were the initiators. In the other organizations the managers initiated the contact with the research group. The implementation process took place during spring 2001, involving several meetings with the organizations.
The overall goal of the intervention, ‘to promote employee health within the organizational setting’ and the PBL-method were presented by the researchers/authors, and thoroughly discussed, at organization-specific staff meetings where all employees were invited. Participation in the intervention was a joint decision among employees and managers in each organization. The PBL-intervention ran as planned during autumn 2001 and spring 2002.
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INTERVENTION METHOD |
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All employees, including management, in each organization were invited to participate (n=113) and 87% of the work force (n=97) participated. Eighty-five of these were women and 12 were men. The average participant was 47 years old and had been working for 10 years in the present workplace. The PBL groups were strategically composed out of the participating employees, with regard to heterogeneity in work tasks, duration of employment, age and gender. In all, 13 groups operated over 4 months. Each group met on average nine times. During the intervention period two organizations changed their managers.
All organizations had the same predetermined overall goal (to promote employee health within the organizational setting), while the process goal was empowerment. They all used the same PBL method. The bottom-up approach enabled the groups to work with what they themselves considered as organizational and work place prerequisites for health. The working groups determined and prioritized problems (hindrance and possibilities), and prepared action programmes for the implementation of changes involving the organization, work tasks, the work group and individual conditions. The intervention ended after 4 months with a seminar, where the action programmes were presented by the groups and subsequent development and ways to maintain health promotion processes within the organization were discussed.
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METHODS |
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Interviews about the process were carried out in focus groups (Krueger, 1994
) after the intervention. Two persons from each working group were selected strategically with respect to sex, age, position and duration of employment. Altogether 30 informants contributed in seven focus group interviews. None refused to participate. Twenty-four of the informants were women, corresponding well to the overall gender distribution. The informants were aged from 29 to 63 and the duration of employment ranged between less than 1 year and 38 years. The interviews followed a semi-structured theme guide comprising themes of experiences of participating in the intervention, and consequences of the intervention in terms of workplace and organizational changes and health. The first author moderated all interviews. Colleagues of the moderator served as observers (one observer/interview). Interviews lasted for 1.5–2 h, took place at the informants' worksite and were audio taped and transcribed verbatim.
Data analysis
The phenomenographic method (Sjöström and Dahlgren, 2002) was used to analyse data. In the search for divergences the interviews were analysed separately by both authors. The analysis encompassed seven consecutive steps: familiarization through reading the transcripts, compilation, in which the respondents' answers are brought together and the most significant elements identified; condensation in which central parts are identified from longer answers or dialogues. Similar answers are classified in the grouping step, followed by a preliminary comparison of categories, when the categories are demarcated, examined and revised. Naming of the categories according to content is followed by a contrastive comparison of the categories: the unique character of each category is described. The result of the analysis is a pattern of descriptive categories generated from the data.
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RESULTS |
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Data revealed six sub-categories: reflection, awareness and insight, self-direction and self-management, group coherence, social support, and action and activities. The sub-categories are illustrated with indented paragraphs.
Reflection
A majority of the informants stated that their way of thinking, and their approach towards themselves changed during the intervention. Self-consciousness and self-awareness was reported to have improved, conveying increased self-esteem and enhanced health. After reflection on conditions for health, they prioritized themselves and their health, rather than mainly giving priority to the production.
You know your own, my, place of work. Yes, you should be fine in your place of work. I don't think that one thought like that before. It's actually my place of work here. We've found out that's how we think. (Pre-school teacher)
Awareness and insight
The informants stressed that the work in the problem-based groups encouraged discussions, debates and reflection (e.g. ‘How come that I am doing/saying/reacting as I am’). According to the informants these discussions improved their awareness of informal workplace conditions. They said the group process allowed time to complete and finalize discussions they found interesting. The discussions had elucidated their work situation, and facilitated understanding of experiences and thoughts of co-workers. They often recognized that co-workers shared their experiences and opinions. This insight caused relaxation and confidence and a feeling of not being alone. The informants expressed that the intervention enhanced their insight about their own and others' needs, and facilitated support of each other.
You know, the discussions have given me at least insight into where I maybe have to set bounds too, and think about what's important and what's valuable. (Civil servant)
Self-direction and self-management
According to the informants, PBL stimulated the formulation of problems and strategies for solving work-related problems. These self-directed activities are further described in ‘Action and activities’ below. All informants felt that the predetermined overall goal of the intervention was relevant. In the PBL groups, the informants stressed that they mostly discussed problems of immediate interest, usually issues that irritated them. The PBL method promoted the participants' own activity.
Quotation by a teacher to illustrate the category, by comparing former experiences of development work compared to PBL:
Yes, if someone just stands talking in front of us and we just sit and listen. Then nothing has happened. I don't think so. Because we're used to sitting quietly and just listening to someone lecturing or feeding us with something that in one ear and out the other most of the time. (Teacher)
Group coherence
The participants described how they achieved affinity and special group coherence while implementing the problem-based method. They judged themselves to have become a group during this work and to have gained knowledge and understanding about each other both professionally and in private. Confirmation and acknowledgement were also benefits expressed by the informants. Informants who were newly employed reported that the PBL intervention promoted their rapid integration into the fellowship. Similar experiences strengthened group coherence. Positive group coherence was expressed as strong in the problem-based groups and it was also reported to have spread to the workplace. The informants expressed that group coherence facilitated daily work situations when support of some kind was needed.
One gets a special feeling, just as you (other respondent) say, with our group. You get to know each other in a whole different way, I think. Then you realize: ‘So you think just like me! I would never have guessed that!’ That's what I appreciated the most. Or I mean you think that I'm the only one thinking like this and then you discover that it isn't just me. I think that's been great. (Dental nurse)
Social support
The informants expressed that being a group rather than being alone was a major advantage of the problem-based process. The working groups were described as socially very profitable. The sense of community and being united were stressed to highly benefit the informants as the social support in the group strengthened both the individuals and the group.
According to the informants they usually accomplished activities aimed at improving underlying structures as a group, or as a whole worksite, rather than as an individual. They described how they sometimes encountered resistance while persisting in processes of change and demands towards management. They reported that when individuals had to comment unfavourably on the management, a feeling of discomfort occurred even though the whole group supported the process. They stressed that without the group there would probably not have been any achievements and that the social support and group coherence facilitated processes of change. Attempts to change the organizational structures were enabled by the sense of power of being a group.
But that's what I think has been so great about this work, that we're actually a group that... I mean, you don't have to go in to the manager and say: I think, but we think in this group, and I'm the one, who plead our cause. Then you know that you have everyone behind you and that everyone supports this. It's a thing that makes you feel strong, I think so at least. (Dental nurse)
Action and activities
The informants expressed how PBL generated action in order to improve the work situation for the participants. The actions were reported to have been directed towards the surrounding conditions and in the organization, at the workplace and at the individual level. As this study focuses on the empowerment processes preceding the actions, this part of the results is only a sample, a more thorough presentation is found in Arneson and Ekberg (Arneson and Ekberg, 2002).
An example of an action directed towards the surrounding conditions is the participants from the dental clinic who informed their patients about their arduous work situation in the local newspaper. At the organizational level some working groups participated in the recruitment of a manager. At the workplace level groups criticized and discussed shortcomings and needs at the worksite with the management and new working methods were proposed. Rearrangement of furniture at the dental clinic reception improved the working situation for the receptionists. The informants reported that many social events were organized at workplaces as a consequence of the intervention. At the individual level, the participants were mostly concerned about stress management and lifestyle issues.
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DISCUSSION |
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The purpose of the present study was to assess whether the problem-based method facilitates empowerment processes. Six categories emerged from the analysis of the interviews: reflection, awareness and insight, self-direction and self-management, group coherence, social support and actions. Reflection and awareness combined with insight seemed to have promoted a self-directed process of problem-solving including formulation of problems, goals and strategies and activities (Arneson and Ekberg, 2002
). Reflection, awareness and insight are key elements in development processes, and might have emerged from the structure of the method, with recurrent meetings and time to finish interesting discussions (Schumann, 1998). The intervention enabled the members of the working groups to participative in self-directed identification of work-related problems and solutions, which is reported to stimulate empowerment (Rogers, 1977; Swift and Levin 1987), health (Israel et al., 1996) and creative learning (Ellström, 2001). The participants reported that the intervention generated a high degree of social support and group coherence, which is considered to be essential elements of learning and developmental processes (Freire, 1972; Rogers, 1977), and for health promotion (Hoogan et al., 2002; Noblet, 2003). Self-managed actions to overcome problems and achieve the goals are natural concluding steps in the empowerment process (Swift and Levin, 1987; Brooking and Bolton, 2000), and may conceivably facilitate future development processes in the organization. Empowerment defined as a process through which people gain greater control over decisions and actions affecting their health (Nutbeam, 1998) requires self-directed processes for identification of problems, goal-setting and development of methods and strategies to reach the goals as well as action for goal-fulfilment (Swift and Levin, 1987; Brookings and Bolton, 2000). The categories are therefore interpreted as comprising empowerment processes.
The gap between formulation of strategies and methods and implementation of actions and goal realization is nevertheless hard to bridge. The informants illustrated how comparably simple goals were easy to achieve, due to constructive and self-directed processes for problem solving and decision-making, which Dholakia and Bagozzi (Dholakia and Bagozzi, 2002) reported support action and goal realization. The informants, however, felt that other actions met resistance. Social support and well-developed group coherence were expressed as vital in order to transform troublesome and challenging strategies into action, activities and goal realization. Strategies and actions for problem solving seem to be facilitated by social support in achieving goal realization in development processes that required organizational changes. The need for social structure, networks and support for personal change is in accordance with Bandura (Bandura, 1998) and promotes health in terms of general well-being, psychological health and symptomatology (Hogan et al., 2002). Development of social network and social support implies determinants at several levels (Berkman et al., 2000), indicating that an ecological intervention process actually took place. The findings indicate that systematic improvements of social support and group coherence among employees ought to be facilitated by the organization as a health-promoting arena.
One major difference between PBL and other methods may be the role of the facilitator, who essentially supports the process and does not interfere in the content of the group work. Furthermore, PBL is a structured method for learning and problem solving in groups; the working method supports the work process towards predetermined overall goals. The rules of the working group are established in a joint, group-based mutual agreement that creates a common group feeling, further supported as the groups are closed groups throughout the intervention. These fairly firm structures of the method are believed to facilitate the participants to implement goal-directed change activities.
The authors' involvement in all stages of the intervention in this study seemed to represent a weakness and a risk for bias. This could have been avoided with an external evaluator. The data were however clear and distinct and indicated that empowerment processes were generated by the intervention. Also, the close involvement turned out to be an advantage as it resulted in a thorough insight. One technique to avoid biased data was to use observers who participated actively (e.g. asking for clarification) during the focus group interviews. Both authors carried out the data analysis independently to avoid biased interpretations. Moreover, the results appear to be reliable seeing that the informants' statements are concordant and unequivocal.
To conclude, the problem-based method appears to comprise prerequisites for empowerment processes (Arneson and Ekberg, 2005). It also seems to be a profitable and powerful instrument that enables and creates empowerment.
WHP is truly contextual according to Peltomäki et al. (Peltomäki et al., 2003), and all WHP interventions need to be adapted to the particular needs, culture and values of the specific worksite. This diversity obstructs any hope of a general WHP-programme. Nevertheless, the prerequisites for WHP may facilitate the planning and implementation of an intervention. The problem-based method encompasses these prerequisites and is also applicable in many contexts. Possible applications are in rehabilitation back to work (Ekberg, 1997), rehabilitation after cardiovascular diseases, including lifestyle modification (Tingström et al., 2002), and development of empowerment in itself. The apparent structure also enables the participants or the organization to use the working method for other purposes, e.g. organizational development.
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