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Moral issues in workplace health promotion

Purpose There is debate to what extent employers are entitled to interfere with the lifestyle and health of their workers. In this context, little information is available on the opinion of employees. Within the framework of a workplace health promotion (WHP) program, moral considerations among workers were investigated. Methods Employees from five companies were invited to participate in a WHP program. Both participants (n = 513) and non-participants (n = 205) in the program filled in a questionnaire on individual characteristics, lifestyle, health, and opinions regarding WHP. Results Nineteen percent of the non-participants did not participate in the WHP program because they prefer to arrange it themselves, and 13% (also) preferred to keep private life and work separate. More participants (87%) than non-participants (77%) agreed with the statement that it is good that employers try to improve employees’ health (χ2 = 12.78, p = 0.002), and 26% of the non-participants and 21% of the participants think employer interference with their health is a violation of their privacy. Employees aged 50 year and older were more likely to agree with the latter statement than younger workers (OR = 1.56, 95% CI 1.02–2.39). Conclusion This study showed that most employees support the importance of WHP, but in a modest group of employees, moral considerations may play a role in their decision whether or not to participate in WHP. Older workers were more likely to resist employer interference with their health. Therefore, special attention on such moral considerations may be needed in the communication, design, and implementation of workplace health promotion programs.


Introduction
Health promotion is a cornerstone of public health policy in most western countries. In order to reach as many individuals as possible, different settings are explored to provide health promotion programs. Because of the possibility to reach large groups, and the presence of a natural social network, the workplace is regarded as a promising context for health promotion. The World Health Organization (WHO 2010a) has described the workplace as one of the priority settings for health promotion into the 21st century, and the World Health Assembly of the WHO (2010b) endorsed the ''Workers' health: Global Plan of Action'', aimed to protect and promote health at the workplace. Workplace health promotion (WHP) is defined as the combined efforts of employers, employees, and society to improve the health and wellbeing of people at work. The European Agency for Safety and Health at Work (2010) describes that WHP should be achieved by promoting the participation of workers in the whole process of WHP. Employers are encouraged to provide health promotion activities to their employees. With the aim to become the worlds' healthiest country in 2020, Australia gives workplaces a key role in preventative health (Australian Government Preventive Health Taskforce 2008).
Individual health risk assessments and health risk reduction programs aimed at lifestyle are popular applications for WHP (for example Ott et al. 2010;Rocha et al. 2010). However, the participation in such programs varies considerably between companies and is often low (Robroek et al. 2009). Why are participation levels so low in these kinds of WHP? Do moral considerations regarding lifestyle interference play a role in the low participation levels? Rothstein and Harrell (2009) have argued that although many programs are partly justified by beneficence, the method of implementation may raise concerns about employer paternalism by overriding employee autonomy, and with the potential invasion of privacy. Already in 1986, Allegrantte and Sloan discussed how workplace health promotion may pose ethical problems. In 1987, Gordon presented her doubts on health promotion at the workplace and described that trust is an essential ingredient for successful health promotion. The debate still continues to what extent employers are entitled to interfere with the lifestyle and health of their workers. Where does undue interference begin? In this context, little information is available on the opinion of employees regarding WHP. Within the framework of a WHP program, we have investigated moral considerations among workers in relation to WHP offered by their employer.

Study design and population
The study is embedded in a larger study in which we investigated the effectiveness of a WHP program consisting of a physical health check with subsequent advice, and a website with general information, individualized advice and for the intervention group possibilities to ask questions and to monitor their own behavior. An extensive description of the study protocol is published elsewhere (Robroek et al. 2007). Employees working in six companies from different branches were invited to participate in the study. Participants received a questionnaire asking for individual characteristics, lifestyle, and health. A sample of 860 non-participants in the health care organizations (n = 2) and all non-participants in the commercial services organizations (n = 2) and in the executive branch of government (n = 1) received an abbreviated version of the questionnaire. In the other organization in the executive branch of government (n = 1), non-respondents were not invited to fill in the questionnaire because the program was initiated in the holiday period and communicated in a very limited way, and only 200 workers were allowed to participate. Therefore, most workers in that organization were unaware of the program. Due to privacy regulations, the questionnaire was send out only once without any reminders. In total, 213 employees out of 860 non-participants responded (24.8%).

Moral considerations
Non-participants were asked why they did not participate, with multiple responses possible. In addition, both participants and non-participants were asked to indicate on a 5-point scale ranging from ''totally disagree'' to ''totally agree'' to what extent they agree with five statements addressing their opinion on WHP (Table 1).

Additional information
In the questionnaire, participants were asked about age, sex, educational level, ethnicity, lifestyle, and health. Educational level was assessed as the highest level of education completed and was categorized into low (primary school, lower and intermediate secondary Lifestyle behaviors (physical activity, smoking, and alcohol intake) were dichotomized indicating whether they engaged in sufficient physical activity (at least 30 min of moderate to vigorous physical activity each day) (Craig et al. 2003), they currently smoked, and they had excessive alcohol consumption (at least 6 glasses on the same occasion at least once a week). Body mass index (BMI) was measured by asking for weight and height and classified as normal weight (BMI \ 25 kg/m 2 ), overweight (25 B BMI \ 30 kg/m 2 ), or obese (BMI C 30 kg/m 2 ). Self-perceived health was dichotomized into ''poor or moderate'' and ''good to excellent'' (Ware et al. 1996).

Statistical analyses
The opinion of participants and non-participants regarding WHP was compared with a chi-square test. Logistic regression analyses were used to analyze the relation between individual characteristics and health-related factors with having problems with employer interference concerning employees' health. All analyses were adjusted for company.

Results
In total, 513 participants and 205 non-participants were included in the analyses. Table 2 shows the characteristics of the study population.
Why do employees not participate in workplace health promotion?
Most non-participants gave ''I am healthy'' (41%) as their reason for not participating in the program, followed by practical reasons such as a lack of time, forgotten, or did not know about the program (27%). Nine percent of the non-participants did not participate because they are currently in treatment for health problems. However, a modest group of non-participants did seem to have objections to health promotion in the workplace setting, arguing they would like to keep private life and work separated (13%). Two percent thinks it is not the employers' task to offer health promotion programs, and 6% is concerned that their results may be made known to their employer or colleagues. Almost one-fifth of the non-participants preferred to arrange a lifestyle promotion program themselves (19%), what might also be related to moral considerations, e.g., the view that both spheres should be kept separated.

Role of moral issues in workplace health promotion
Almost all participants and non-participants found a healthy lifestyle important (90%) ( Table 1). Most participants (71%) and non-participants (65%) agreed with the second statement that their lifestyle is a personal matter. However, this did not lead to many concerns regarding the WHP. Actually, the majority of both participants and non-participants agreed that it is good that the employer tries to improve employees' health. However, we observed more participants (87%) than non-participants (77%) agreeing with the latter statement (v 2 = 12.78, p = 0.002). A small majority of the participants (58%) and non-participants (55%) agreed that it is good to stimulate colleagues to a healthy lifestyle, and more than a fourth of the non-participants (26%) and 21% of the participants agreed with the last statement that employer interference with their health is a violation of privacy. Particularly, employees who find lifestyle a personal matter feel that employer interference with their health is a violation of privacy (27.9% vs. 7.7% who disagree with the second statement, v 2 = 73.85, p = 0.000). Non-participants who did not participate because of reasons that might be related to moral considerations (e.g., keep private life and work separated, not the employers' task to offer health promotion programs, concerns that their results will be made known to their employer or colleagues, preference to arrange a lifestyle promotion program themselves) were more likely to think that employer interference with their health is a violation of privacy (OR = 2.20, 95% CI 1.12-4.32).
Who are the employees having problems with employer interference with employees' health?
As shown in Table 2, the reluctance against employer interference was in our study population not statistically significantly associated with an unhealthy lifestyle or a poor health. Older workers were more likely to resist employer interference with their health (OR = 1.56, 95% CI: 1.02-2.39). This was particularly the case among older non-participants.

Discussion
The importance of health promotion in the workplace setting is supported by employees. Although the most important reason for non-participation did not include moral issues, a modest group argued they would like to keep private life and work separated or preferred to arrange participation in a program themselves and not via their employer. Both participants and non-participants in the workplace health promotion program find a healthy lifestyle important, and most employees think it is good that the employer tries to improve the employees' health. Lifestyle and health factors do not play a major role in having reluctance against employer interference with employee health, but older workers are more likely to resist employer interference. Reasons for non-participation are partly based on convictions that stress the value of keeping private life and work separate. More evidence is needed on the relation between moral considerations and participation in other health promotion programs in the workplace setting. For instance, an important question is how to organize WHP in such a way that employer interference with the health of employees does not conflict with moral values, especially in older workers. In previous studies, higher participation in workplace health promotion was found when a more comprehensive approach was applied, integrating health promotion with occupation health (Hunt et al. 2005). Such comprehensive approach, not only focusing at the individuals and their lifestyle, but also at the work environment, might reduce potential concerns. Integrated workplace health promotion, focusing on both lifestyle and work factors, fits the concept of shared responsibility, in which both the employee and the employer are expected to take action to stay in good health. Furthermore, involvement of employees in the design and implementation of WHP may be important aspects to reduce possible barriers in participation. It has been noted that a participatory approach with active engagement of employees might be necessary for the success of a health promotion program (Henning et al. 2009). In ergonomics, a participatory approach has been shown to be successful (Rivilis et al. 2006), and also in health promotion frameworks, a participatory approach is recommended (e.g., linkage system in intervention mapping) (Bartholomew et al. 2006). A combination of a participatory approach and supervisor support might also enhance social support and subjective norms, which are important constructs in several sociocognitive models (e.g., theory of planned behavior) (Ajzenn 1991).
Although moral issues seem to play a modest role in the decision to participate or not in a WHP program, there are employees with concerns about the role of the employer and the possible violation of privacy. The age difference in having reluctance against employer interference deserves further attention. In a systematic review, no difference in participation in WHP was found between younger and older workers (Robroek et al. 2009). However, for older workers, the situation of health checks and the focus on lifestyle in the work setting may be new, while the younger workers have never known otherwise. When WHP is aimed at keeping an aging workforce healthy, special attention is needed to content and delivery of WHP and involvement of older workers in design and implementation may support better acceptance and participation. Although not statistically significant, all associations between lifestyle factors and agreeing with the statement that employer interference with employees health is a violation of privacy were in the same direction, indicating that workers with an unhealthy lifestyle or poor health are more likely to have reluctance against this employer interference. This may be related with the potential danger of ''blaming the victim''. Although it was communicated that all information would not be reported to their supervisor or employer, employees with an unhealthy lifestyle may fear potential consequences of participation.
Several studies showed that health promotion in the workplace setting might have beneficial effects on employee lifestyle and health, as well as on reducing sick leave (Groeneveld et al. 2010;Pronk 2009). Therefore, both employee and employer might benefit from WHP. However, our results suggest that moral considerations toward health promotion program at the workplace should not be neglected and in the communication, design, and implementation of a program deserve special attention.
The main limitation in this study was the low response among non-participants, which might induce selection bias. As described in the ''Methods'', due to privacy regulations, we only send out the questionnaire once without any reminders. Furthermore, it should be noted that the design and implementation of WHP across companies and countries will differ, and opinions of employees concerning employer involvement may also differ between cultures and countries. More research on this topic is needed in order to get insight into their potential influence on the effectiveness of WHP.
This study showed that employees support the importance of health promotion in the workplace setting, but in a modest group of employees, moral considerations may play a role in their decision not to participate in workplace health promotion. Older workers were more likely to resist employer interference with their health. Therefore, special attention on such moral considerations may be needed in the communication, design, and implementation of workplace health promotion programs.