Barriers and Facilitators to Worksite Wellness Program Engagement: Content Analysis
ABSTRACT
Background
Worksite wellness programs (WWPs) can improve employees’ physical and mental health, as well as work productivity. Yet engagement is often low and attrition high, limiting attainable benefits. The purpose of this research is to investigate perceived barriers and facilitators of employee engagement in WWPs to provide guidance on ways to increase retention and participation.
Methods
A comprehensive search of electronic databases PubMed, EBSCO, and Web of Science for relevant studies published in peer-reviewed journals through April 2023 was conducted. To be included, studies had to (a) be written in English, (b) be from the employee perspective, (c) assess either barriers and/or facilitators to engagement in a WWP, and (d) include adults ≥18 years. Common barrier and facilitator themes were derived through content analysis of included studies and reported based on frequency.
Results
A total of 4,013 studies were identified and 63 were included. Studies were conducted at locations such as large and small businesses, universities, hospitals, and military/police academies. Reported barriers were a lack of time, disinterest, inadequate incentives, lack of support, lack of communication, and distrust, as well as demographic factors, program issues, inconvenience, and personal health concerns. Reported participation facilitators included workplace and social support, demographic influences, intrinsic desire to improve health, diverse program offerings, desirable incentives, personalized programs, convenience, inclusivity, effective communication, and trust in the WWP.
Conclusion
Addressing employee barriers and facilitators, such as those highlighted in this review, could be an effective first step towards increasing engagement and retention in future iterations of WWPs.
INTRODUCTION
Increasing mortality from noncommunicable chronic diseases can be attributed to poor but modifiable lifestyle choices. Improvements such as increasing physical activity (PA) and adopting healthier dietary patterns can help reduce these risks (1). However, less than half of adults aged 18+ currently meet the suggested weekly PA guidelines for aerobic and muscle-strengthening activity (2). One key factor contributing to limited PA and increased obesity rates is sedentary occupations. In fact, some estimates indicate that working adults are spending upwards of 8.5 hours per day sitting at their desks (3). Additionally, millions of people are plagued by excessive psychological stress, which can exacerbate poor lifestyle choices (4).
Fortunately, worksite wellness programs (WWPs) offer unique opportunities to address these issues. For example, WWPs often include some variation of screening activities and health interventions that can focus on areas such as PA, nutrition, and mental health, all of which take place in or near the workplace (5). Despite their potential health benefits, employee engagement and retention in WWPs remain low, with one study indicating participation rates in some WWP activities were below 20% (5). One study followed the participation in a free on-site WWP at an organization of over 50,000 employees for 5 years and found only 1% (n = 518) of employees took advantage of the program despite receiving regular prompts to participate (6). These low participation rates are suggestive of significant barriers that limit initial engagement and long-term adherence.
The purpose of this review is to illuminate the most common barriers to WWP participation and highlight facilitators that have effectively motivated and retained employees.
METHODS
An electronic search of PubMed, EBSCO, and Web of Science was performed to locate existing eligible studies from 2013 to the time of the study. The following search terms were used to locate eligible studies: health promotion program AND employee AND engagement; worksite wellness program AND employee AND participation OR engagement; worksite wellness program AND employee AND participation AND barriers; workplace health program AND participation AND barriers; the syntax was modified to accommodate differences between search databases. To be included, studies had to meet the following criteria: (a) published in a peer-reviewed journal; (b) written in English; (c) from the employee perspective (rather than employers’ perspectives for accuracy); (d) assess either barriers and/or facilitators to engagement in a WWP, and (e) include adults ≥18 years. Titles and abstracts were initially reviewed to remove duplicates and those with titles unrelated to the focus of this review. Full texts were obtained for studies that met inclusion criteria. Reference lists were scanned thoroughly for additional publications that might warrant inclusion.
Data on barriers and facilitators were collected from each study included in the review. The analysis followed an inductive approach, in which themes were identified after thoroughly reviewing the studies and gathering relevant information. A content analysis process was then conducted to develop a coding scheme based on the most frequently reported results. Researchers collaborated to agree upon which themes would be included in the coding scheme. Any discrepancies were resolved through discussion until agreement was reached, ensuring that the final themes accurately reflected the data. Data were subsequently categorized and analyzed based on thematic coding to provide a comprehensive understanding of the underlying influences on employee participation.
Although the primary focus of the analysis was on identifying broader themes related to barriers and facilitators, specific examples were also noted and included when they were relevant to these themes. Although the scope of the review was not centered on a detailed examination of individual interventions, specific instances were documented to provide context and illustrate how certain strategies align with the broader themes identified. This approach allowed for a comprehensive understanding of both general patterns and notable specific interventions within the reviewed studies.
RESULTS
Study Characteristics
The electronic search of PubMed, EBSCO, and Web of Science resulted in the accumulation of 4,013 studies. Of those 4,013, many were removed when they contained titles, abstracts, and content irrelevant to the topic at hand or the study did not meet the inclusion criteria. This process left 63 studies for inclusion (see Supplementary Table 1). Articles were primarily excluded for the following reasons: results did not address barriers and facilitators to participation, did not reflect the employee perspective, did not specifically focus on WWPs, or were not peer-reviewed studies (e.g., dissertations, theses). Upon examination, details and results of each study were then collected from the remaining studies. A more detailed description of the search strategy can be found in Figure 1.
Citation: Journal of Clinical Exercise Physiology 14, 2; 10.31189/2165-6193-14.2.58
Below, we report the key characteristics of included studies, reported barriers and facilitators, and the main findings related to recruitment, engagement, and retention, from studies that reported those data. Given the large number of studies reviewed, we chose to summarize results and not reference every study in consideration of space. Please refer to Supplementary Table 1 for specific details of all included studies. Supplementary Table 2 provides themes and examples of barriers and facilitators.
Participant Characteristics
There were 341,868 individuals who participated in the 63 reviewed studies. Approximately 48% (n = 30) of the studies took place in the United States, 33% (n = 21) took place in Europe, 10% (n = 6) in Australia, 6% (n = 4) in Asia, 3% (n = 1) in Canada, and 3% (n = 1) in New Zealand. The number of participants in each study ranged from 6 to 205,672 based on study type. Though both males and female participants were adequately represented across the studies, their participation varied from study to study.
Participation Rates
Less than half of the included studies (n = 29) reported their participation, response, and retention rates. Of these studies, 25 reported response rates in which an average of 34% of eligible participants responded. Of the 4 studies that included actual participation rates in WWPs, an average of 17% of respondents participated in their organization’s WWP. In addition, attrition in most longitudinal studies remained high.
Workplace Wellness Characteristics
Among the various components and focuses of the WWPs in this review, PA was the most frequently observed factor (reported in 44 of 63 total studies). Most PA programs incorporated some sort of employee access to on-site fitness centers, tracking steps, or education sessions about PA. The next most common program focus was nutrition (n = 23). Many programs taught group and individual sessions about healthy eating, provided healthy meals, or had employees track their eating patterns. Other popular wellness program components included health coaching or meetings with a health professional (n = 15), health risk assessments or biometric screenings (n = 9), smoking cessation groups (n = 10), and mental health resources/education (n = 13). Other less frequently mentioned components included digital coaching modules (n = 4), financial management group education sessions (n = 1), and addiction and alcohol recovery/prevention meetings (n = 7). Though each WWP was designed differently, most had a combination of the above-mentioned components.
Barriers
Of the 63 articles included for content analysis, 52 (82.5%) reported barriers to employee engagement in WWPs. These frequently reported barriers were organized into 10 themes: time constraints, demographic factors, program issues, inconvenience, lack of need or interest, lack of support, health and well-being concerns, ineffective communication, lack of trust, and insufficient incentives. The percentage of the 52 studies reporting each theme is shown in Figure 2.
Citation: Journal of Clinical Exercise Physiology 14, 2; 10.31189/2165-6193-14.2.58
The most frequently mentioned of the 10 barrier themes was employee lack of time, which was reported in 61.5% of the 52 barrier studies (n = 32). More specifically, employees in several studies reported often choosing not to participate in WWPs because of conflicting work-related responsibilities, having rigid or unpredictable work schedules or feeling too busy (n = 14; 42.4% of barrier studies) (7–20). Other notable time barriers (n = 5) were conflicting family and personal commitments, as well as programs offered only outside of work (7,8,10,21,22).
Furthermore, certain demographic factors such as age, gender, socioeconomics, and occupation were reported in 38.5% of barrier studies (n = 20) to influence engagement in WWPs. Young age, specifically under 30, was the most frequently reported demographic barrier to WWP participation (n = 7) (11,23–27) followed by male gender demographic (n = 5) (23,28–31). Variable employment statuses, such as small businesses, part-time/hourly, and night shifts, were also a frequent demographic category barrier (n = 4; 20% of barrier studies) (13,32). These were followed by race (nonwhite), low income (classifications of “low income” varied based on study), single marital status, and smokers (n = 3 each factor) (11,23,25,27,29,33).
Additionally, program issues were mentioned in 36.5% of barrier studies (n = 19) as a barrier. Problems with WWP programming or design varied greatly and included topics such as insufficient resources and equipment (8,34,35), undesirable program intensity (10), mandatory involvement (35), poor inclusion/engagement (32), and technology issues (36). Technology issues included online platforms that were difficult to navigate, technical issues, or programs that involved complex enrollment processes (36).
In addition to program issues, inconvenience became a frequently discussed barrier (32.7% of barrier studies). The most frequently observed inconvenience factors were commute (n = 6) and programs operating outside of work hours (n = 4) (7,9,10,12,14,21,22,37). Others were issues with layout, equipment, and overall environment (15).
Next, several studies reported barrier themes related to a lack of interest or perceived need (32.7% of barrier studies). The most frequently observed factors in this theme were general disinterest and low prioritization of exercise (n = 10) (8,15,19,26,27,38–41) followed by preexisting workout routines and personal perceptions of good health (n = 9) (16,19,21,26,27,36,38,42–44).
Another common theme reported in 32.7% of barrier studies was a lack of organizational or social support. A lack of organizational/managerial support was reported most frequently (n = 11) (7,8,10,12,17,18,34,36,37,39,45). A poor work culture (n = 3) and the prioritization of productivity over health (n = 3) were also observed (8,15,20,28,31,39). When companies failed to encourage participation in WWPs or implement a supportive work culture prioritizing engagement, employees often reported feeling discouraged from participating (39).
Another 16 studies (30.8% of barrier studies) mentioned barriers related to physical, mental, and emotional health and were organized into the theme health and well-being concerns. Common barriers revolving around health and well-being were existing health conditions (n = 5) (11,13, 14,21,33), mental and/or physical limitations (n = 5) (8,15, 24,38,39), and high stress/fatigue (n = 5) (7,20,32,37,38).
In addition, the theme lack of effective program communication and information dissemination was mentioned in 23.1% of studies (n = 12) (10,14,16,27,28,36,39,40,46–49). This includes limited information or advertising about the program’s benefits, advantages, and relevance (46).
Lastly, the themes a lack of trust in the WWP (n = 10; 19.2%) and inadequate incentives (n = 8; 15.3%) were also frequently observed barriers. The major barriers under the lack of trust theme were concerns over privacy or confidentiality, which were reported in 8 of the 10 articles included in this theme (n = 8) (16,17,19,22,27,33,40,42). Other barriers included were a lack of confidence in the WWP (n = 1) and negative program perceptions (n = 1) (21,48). The inadequate incentives theme included reports of employees not feeling incentivized enough by money or benefits offered to participate in their WWP (12,13,25,40, 50–53).
Approximately 25% (n = 13) of the articles mentioned other barriers that did not fall into a major theme. They include barriers such as cultural and personal reasons (10,38,39), interpersonal barriers (28), preferred solitude (21,38), low self-efficacy/perception (20,28), enrollment issues (27,36,40), eligibility concerns (16), workplace/policy dissatisfaction (29,54), intent to resign/retire (21,29), and job restrictions (8).
Facilitators
Of the 63 articles included for content analysis, 61 (96.8%) reported facilitators for employee engagement in WWPs. Upon further analysis, 10 major facilitator themes emerged. The results below list the percentage of articles featuring facilitators related to those themes. These percentages are illustrated in Figure 3.
Citation: Journal of Clinical Exercise Physiology 14, 2; 10.31189/2165-6193-14.2.58
To begin, positive support was the most frequently reported major facilitator theme, noted in 49.2% (n = 30) of the studies that included facilitators. These studies referenced organizational, leadership, colleague, and family support (n = 26) (7,9,12–18,22,32,36,38–40,44,46,49,55–62). Some specifically identified facilitators in this theme were health positive workplace/environments (n = 9) (15,17,22,31,34,38,44,54,59), supporting schedules with flexibility/control (n = 3) (9,14,18), inclusion of family and friends (n = 3) (17,22,39), and supervisor engagement in WWP (n = 2) (34,39).
Moreover, certain demographic factors were identified as facilitators to engagement in WWPs in 36.1% of studies. The most frequently observed demographic factors associated with increased WWP engagement were gender (female) (n = 10) (23,28–31), older age (n = 7) (11,23–27), and postsecondary education (n = 5) (25,30,35,59,63), followed by higher income (classifications of “higher income” varied based on study) (n = 4) (11,23–25) and married status (n = 5) (23,25,33).
Moving beyond demographics, 36.1% of facilitator studies reported factors related to the theme desire to improve/maintain health (n = 22). Examples included employees’ desires to manage chronic health conditions and injuries (n = 4) (21,26,35,63), take proactive measures against future health issues (n = 5) (8,17,22–24), enhance fitness (8), manage current illness (21), and lower stress (8).
The next most frequently reported facilitator theme discovered was desirable program offerings, which was reported in 34.4% (n = 21) of the facilitator studies. Program attractiveness/comprehensiveness was the most frequently identified facilitator in this theme (n = 7) (19,36,39,48,62–64), followed by facilities and accessibility (n = 4) (8,15,36,60). The remainder of the facilitators varied widely and included factors such as diet and nutrition counseling (43,65), smoking cessation classes (30,37), PA (14,30), social components (12,44), mental health and stress management (12,43), and modern technology (57,65).
In addition to enticing program components, 29.5% of facilitator studies reported facilitators related to the theme incentives and financial benefits. The most frequent facilitator under this theme was general incentives (n = 14) (7,12, 22,24,32–34,38,39,41,51,52,62–66). Other noted facilitators were offered financial benefits (n = 4), free or reduced costs/memberships (n = 2), and workplace benefits (n = 1) (8,12,39,40,45,50).
Furthermore, personalized and flexible programs were important facilitators to participation in 23.0% of facilitator studies. In addition to personalized and flexible programs (n = 5) (12,14,30,34, 38), meeting employee needs was also included in the theme (n = 5) (12–14,30,39). Other reported facilitators were flexible format (n = 1), one-on-one counseling (n = 1) and usefulness of the program (n = 1) (14,43,48).
In addition to personalized and flexible programs, convenience and accessibility was a facilitator theme in 16.4% of facilitator studies. Frequently listed facilitators included in this theme were WWPs in which participation was allowed during work hours (n = 3) (14,37,63) and activities were easily accessible (n = 3) (8,36,40). This was followed by general convenience (n = 2) and flexible work hours (n = 2) (9,18,38,49).
Furthermore, the theme social and inclusive programs was found in data from 13.1% of facilitator studies (n = 8). The most frequently observed facilitator under this theme was a strong WWP social component (n = 5) (8,17,18,32,44). Other contributors to this theme were inclusivity/equal access (n = 2) and a WWP competitive nature (n = 2) (15,21,32,34).
Additionally, the facilitator theme communication and awareness was found in 9.8% of reviewed facilitator studies (n = 6). This theme included examples of effective communication for relaying information about program activities and benefits to employees (36,39,47,51).
The last major facilitator theme was trust in WWP, which was observed in 11.5% (n = 7) of the articles that listed facilitators. The main facilitator of trust was a positive attitude/belief towards the WWP (n = 5). Trust in safety standards (n = 1) (54) and privacy (n = 1) (40) were also noted facilitators.
There were many other facilitators observed that did not fall into a theme (n = 13) and consisted of ideas such as the desire to support the program (57), general interest (13), physician recommendation (66), and self-confidence in participation (20).
DISCUSSION
In many work environments, employees are subject to physically inactive tasks, exposure to unhealthy food choices, and excessive work-related stress. The combined effect of these factors has a negative impact on overall employee health and productivity in the workplace (4). Previous research examining WWPs has found them to be effective in improving physical (67) and mental health (68); however, persistently low participation rates limit the health-promoting benefits of WWPs. The purpose of this content analysis was to illuminate barriers and facilitators related to participation in WWPs in the hopes of offering guidance and direction to organizations with WWPs desiring to increase engagement and retention. The following actionable strategies are proposed to improve WWP effectiveness and maximize employee participation.
This review revealed several key takeaways that hold implications for future work based on the common themes discovered. First, it appears that several significant barriers severely limit WWP participation. Time constraints, demographic factors, program issues, and lack of interest are among the primary barriers discovered. There are many potential strategies organizations can implement to address these challenges in unique ways. For example, time constraints could be alleviated with flexible and diverse WWP activities that accommodate various work schedules (14). Participation might become more attractive to employees when WWPs prioritize convenience through on-site or virtual activities and user-friendly interfaces (8). Clear and regular communication channels can be established to inform employees about program objectives, updates, and wellness activities (41,47). Trust in WWPs can be built by highlighting positive experiences, incorporating evidence-based practices, and addressing privacy concerns. Worthwhile incentives and frequent recognition can motivate participation, as can personalized programs that align with individual health goals (14,39).
Conversely, studies that reported high participation had a variety of elements already in place that offer potential suggestions for effectively engaging employees in WWPs. For example, strategies like establishing positive organizational support, enticing program components, and appealing incentives should be considered and potentially implemented in future WWPs to maximize participation and therefore health benefits (17,22,48,69). Organizational leadership involvement and social support were reported in a majority of studies to contribute to a health-promoting work culture with enhanced engagement. Addressing demographic influences, such as age, gender, and income, ensures program elements can attract diverse employee groups. Continuous program evaluation can adapt WWPs to evolving employee needs, further contributing to the success of WWPs.
Through further investigation of each suggestion identified in this review, future researchers can better understand their influence and improve the layout of WWPs to encourage greater employee engagement.
Strengths
Observed WWP strengths in current literature include the diversity of programs that are offered to employees in or around the workplace. However, the precise elements within these programs that maximize engagement for minimal cost remain unclear. Future work aimed at understanding which elements are most attractive may result in more clear solutions for WWP attrition. Other strengths include the diversity of where the WWPs are implemented. The results suggest that diverse companies are implementing WWPs for their employees, highlighting that employers recognize the importance of initiatives aimed at increasing PA, improving diet, and addressing other health behaviors (e.g., reducing smoking and excessive alcohol consumption). These initiatives can have a positive impact on reducing absenteeism and presenteeism, thereby lowering expenditure on health care costs. For example, one meta-analysis indicated that for every dollar an organization spent on a WWP, there were estimated savings of $3.27 in employee health expenses and $2.73 in absenteeism costs (70). Thus, it is recommended that workplaces consider the barriers and facilitators reported in this review when developing their own WWP.
Limitations
Although our review offers valuable insights into WWP participation, it is essential to acknowledge the limitations inherent in this content analysis. First, the studies included were conducted using different methodologic designs and had different outcome measures, which potentially affects the comparability and generalizability of our findings. Additionally, the studies reviewed here used different time spans, and it was therefore difficult to measure longevity of employee engagement for long-term retention. Future research should aim to address these limitations by standardizing methodologies and exploring the complex interplay of factors influencing WWP participation.
Second, variables such as organizational culture, type of WWP, concurrent interventions, type of organizations, and resource availability potentially confound the relationships among studies in this content analysis. Overcoming these barriers will require collaborative efforts between researchers and organizational leaders to develop evidence-based interventions that effectively promote WWP engagement.
Finally, it is worth noting that some studies surveyed employees about their preferences for future WWPs rather than exploring reasons behind their current participation or nonparticipation in an established WWP. Consequently, although some studies reported actual barriers and facilitators, others reported those expected. These variations may have influenced common barriers and facilitators identified in this content analysis. Therefore, conducting a longitudinal study investigating employee perspectives of barriers and facilitators, both before and after a WWP is in place, would provide valuable insights into the effectiveness of such programs.
Participation
The findings of this study regarding response, participation and retention rates give insight to the actual range of influence WWPs have in organizations. When only a small percentage of eligible employees participate, many miss out on opportunities to improve their health. As such, employers struggle to decrease absenteeism, increase employee health, and lower health-related expenses. The consistently high attrition rates in longitudinal studies highlight the complex battle of retaining participants, pointing towards potential program fatigue or other underlying factors affecting prolonged commitment. Decreasing prominent barriers while promoting influential facilitators to participation could be one method employers use to improve employee engagement in these programs.
CONCLUSION
This content analysis highlights multiple factors that influence employee participation in WWPs. Our review identifies prominent barriers, such as time constraints, program issues, and lack of interest, that significantly limit engagement. Addressing these challenges through flexible program options (e.g., asynchronous activities and varied scheduling), clear and consistent communication channels (e.g., regular email updates and informational sessions), and robust organizational support (e.g., financial incentives, encouragement for employees to prioritize their health, and dedicated time during work hours for wellness activities) can significantly enhance participation rates. Additionally, the analysis underscores the important role of facilitators such as multifaceted health approaches, appealing program components, and program convenience in fostering employee engagement.
By illuminating these key barriers and facilitators, researchers and other health professionals can design programs that better address employee needs and preferences. This, in turn, may increase long-term engagement and thus improve health and wellness of employees. It is crucial for future research to continue exploring these dynamics and evaluate the long-term impact of various program elements on engagement and health outcomes.
Cultivating a workplace culture that prioritizes health, integrates personalized approaches, and addresses the multifaceted needs of employees will help organizations create a positive and supportive environment that promotes participation in WWPs. The success of these programs is strongly associated with their ability to resonate with the diverse workforce by fostering a comprehensive approach to employee health, productivity, and well-being.
Flow diagram of the entire selection process for studies included in this content analysis from start to finish. Specific reason for inclusion and exclusion of certain studies are also addressed in the diagram. WWP = worksite wellness programs.
Bar chart showing the percentage of studies reporting each common barrier theme for the 52 studies that reported barriers.
Bar chart showing the percentage of studies reporting each common facilitator theme for the 61 studies that reported facilitators.
Contributor Notes
Conflicts of Interest and Source of Funding: None.