It is important for the overall workplace health program to contain a combination of individual and organizational level strategies and interventions to influence health, including:. Workplace health programs are not add-on benefits but basic investments in human capital, similar to training, mentoring, and other employee development programs. Skip directly to site content Skip directly to page options Skip directly to A-Z link.
Workplace Health Promotion. Section Navigation. It is important for the overall workplace health program to contain a combination of individual and organizational level strategies and interventions to influence health, including:. The evidence-based strategies and interventions presented in this module are organized into these four main categories.
Workplace health programs are not add-on benefits but basic investments in human capital, similar to training, mentoring, and other employee development programs. Example: Encouraging both individual smoking cessation clinical referrals and smoke-free workplace policies will have a greater impact on tobacco use among employees than using only one of these interventions.
It may be more prudent to focus on one or two policies and programs at first and build on early successes, rather than implement several interventions with insufficient resources. Also, many effective interventions such as health-related policy changes exist that are low-cost, which is especially important for small-and-medium-sized companies that may not have extensive resources to dedicate to employee health.
An ecological perspective on health promotion programs. Health Educ Q. In this school, programme implementation was difficult. Few members of staff were trained, in spite of strong leadership on the part of the school head, and addition of the programme to the school policy plan.
Staff had little time to spend on new partnerships. See Table 4. Impact of the programme was perceived as very limited. The actions implemented after participation in the programme focused on enhancing the school climate, promoting autonomy, and organizing recess.
Not much consideration was given to innovation as actions were already included in existing pedagogical activities. The new knowledge introduced to pupils included themes such as way of life, eating habits, and the human body. The tools introduced during the training were seldom used by school staff.
Other difficulties included trust issues between parents and staff, and cases of psychiatric illness which were reported in some pupils. The programme was not a priority or central in school activities. Support from the institution and leadership on the part of the school head were reported as limited. Staff did not wish to assess programme impact.
The actions implemented after participation in the programme focused on themes such as health, conflict management, ill-being, and upgrades to the school-yard. The new knowledge introduced to pupils related to ways of life, eating habits and the human body.
Partnerships were developed on a one-off delegation basis, when specific issues required to be addressed e. The use of tools was not mentioned by school staff. They highlighted many conflicts, and cases of verbal and physical violence. Such important difficulties seemed to have impacted programme implementation. Staff pointed out the discrepancies between the values of the programme and the reality they experienced in the school. Impact of the programme was moderate.
Actions were either included into existing learning activities, or they were designed as an immediate solution to a significant problem.
The use of tools was not mentioned. Out-of-schools partners were asked to implement actions in schools on a delegation basis. The new knowledge introduced to pupils included themes such as way of life, eating habits and the human body. New partnerships were developed with the after-school club, community centre, however on a delegation basis. In each school, key factors were identified as clearly determining what type of impact resulted from the implementation of the programme.
Different combinations of key factors led to different types and expression of the impact of the programme as presented in Table 4. This situation resulted in the fact that staff seldom used the tools provided by the training.
Also few partnerships were developed in spite of the inclusion of actions in the school policy. Implementation of the programme in this school was in fact difficult, and the programme had very moderate impact.
This step involved consultation of stakeholders via group interviews and review of the research work. Our work put forward the substantial differences between the outcomes expected in the programme theory and those which were extracted from the field data. This was also the case of the support provided to school staff. This situation had an impact on the development of a health promotion approach in the schools.
The level of participation of school staff was not as it had been anticipated either. The activities implemented as a result of the programme were focused on a more holistic perspective of health and well-being. Also, some form of enhancement of the home-school relationship was reported but no clear relation with the programme could be made based on the data. Differences between the expected outcomes, set beforehand by project leaders, and actual outputs of the programme in the different contexts were made evident on different levels of implementation.
As an example, accession to and participation in the programme were lower than expected. Accession to the programme and participation were considered to be expected outcomes in this programme. One of the reasons for training to have been integrated in the programme design was precisely to improve accession and participation. Also , the support from intermediate implementation levels was variable in its form and intensity, while the programme integrated support as an intermediate, or first phase, outcome.
Other types of differences from what had been integrated in the design of the programme, and forms of variability in the outcomes were observed: variable usage of the tools proposed, different modes of implementation, different types of collaborations, and different types of partners involved. In terms of capacity building [ 69 ] at staff level, outputs ranged from none to the enhancement of the sense of legitimacy and self-competence, the development of new competencies, knowledge and skills, opportunities for curriculum development, the opening of new leads for reflection, enhancement of motivation, the strengthening of their sense of legitimacy and their convictions.
It has to be noted, that, unsurprisingly, in more vulnerable schools, where school climate was poor, programme implementation faced even greater difficulties and resulting outputs showed even greater differences. Results from the various studies highlight that contextual factors influence different aspects of the implementation process :. Five types of effects were identified: 1 hindering, i. Some factors acted on more than one level of implementation, e.
A cascade of effects occurred between different levels of implementation, e. This situation impacted whether the decision-makers were willing to delegate decision-making power to the district staff. This further impacted support to school staff, as higher delegation led to higher support thus stronger implementation at school level [ 6 , 21 , 34 ].
Recurrent combinations were searched for at different levels of implementation. Three factors, which were key determiners to the implementation process, were found to be combined repeatedly at district level : support from the Regional Education Authority [ 27 ]; support from the institutional hierarchy [ 35 ]; and implication of district and community stakeholders [ 32 , 34 , 70 ]. Recurrent combinations of factors were not identified at this level.
Six contextual factors were taken into account, comparisons were made between the schools; however but no TCE emerged See Table 4. Four factors were found to be combined recurrently: encouragement and support to staff by district team [ 35 , 44 ]; availability of staff [ 27 ]; means allocated [ 27 ]; and implication of staff [ 25 ].
Overall, this programme did not generate equivalent outcomes in every school although it had been designed to work and adapt to any context. It seems in more vulnerable schools, where school climate [ 44 ] is poorer, staff faced even greater difficulties during programme implementation. Altogether, no single theory could be drawn from the results, as combinations of determining factors were highly specific and variable.
Some of the factors and mechanisms identified in the programme theory were not activated as anticipated, for example accession [ 71 ] to the programme did not necessarily determine action. Nor did the inclusion of training, which had been thoroughly documented as an enabler of implementation [ 15 , 21 , 71 ]. The fact that the programme was initiated by a community decision-maker [ 21 , 70 , 72 ] did not strengthen the seemingly weak ties between the schools and the community.
The top-down [ 36 , 73 ] implementation mode impacted the implementation of the programme greatly. This conclusion from the results was unexpected as the inclusion of training [ 25 ] and support from the hierarchy [ 28 ] and the community [ 21 , 27 ] were documented as levers to successful programme implementation in other works. From an operational point of view, this result questions the hierarchical relationships [ 57 ] between management teams and local school staff.
Programmes cannot be implemented in French schools without the approbation of decision-makers at the district level. However depending on the way the programme was brought to the school by district level staff, the results of this process were different. The relationship between school staff and district level decision-makers of school management influenced the opportunities for school staff to show ownership and develop action.
This point emphasizes the need to give attention to programme initiation modes, and emphasizes the importance of negotiated planning [ 21 , 26 , 27 ]. Leadership and support from the school head, which were expected to enhance the accession of school staff to the programme, and the implementation of activities by school staff [ 17 , 71 ], was not a lever as anticipated.
Positive relationships and partnerships had already been put forward as a key factor by Mcisaac et al. School climate [ 44 ] was also an influential factor. A potential explanation for this, is that staff who are subjected to a poorer school climate and faced with the serious difficulties of their pupils will increase their chances of experiencing professional exhaustion or burnout.
Some of the features in the programme influenced the process of implementation, in line with what other authors have pointed out [ 15 , 21 , 71 ]. The content of the training was perceived as not being pragmatic and operational enough. Also, the support provided to develop partnerships was reported as insufficient or lacking.
One factor that was not anticipated was the name of the programme, which generated some reluctance to participate. Staff did not make sense of the name of the programme, which was unclear to them and inconsistent with their professional identity [ 57 ].
When staff perceived the programme as meeting their needs [ 21 ], and as coherent with existing practice [ 25 , 28 ], their implication was higher. Implication was greatly hindered in the opposite scenario. These findings are consistent with conclusions from other studies [ 26 , 27 ]. School staff did point out that in cases where the values conveyed through the programme were inconsistent with the reality of school life, even though school staff would adhere to such values, programme implementation was difficult.
The way in which the programme was brought to the schools played an important role in how further implementation took place. Different types of initiation modes were pinpointed: institutional initiation had a negative impact on further implementation, when the relationship between school staff and decision-maker was poor; but had a positive influence on school staff when it was perceived as a credential to what they were already doing [ 35 , 75 ].
Overall, top-down [ 36 , 73 ] initiation modes affected further implementation of the programme in a negative way. It would appear that the challenge for school staff was to identify areas, in which they could show ownership , and appropriation. Basically, when they felt that they were in control of successful project outcomes, initiation mode did not have as much of an impact.
Authors have pointed out that one of the issues pertaining [ 51 , 52 , 76 ] to the use of realist evaluation is how to define the three key terms: contextual factors, mechanisms and outcomes.
In addition to this, deciding which category to assign to an item of data is arduous. During this study, it became apparent that working backwards from outcomes was a way to ensure, as far as possible, that what was explored related to the implementation of the programme.
The use of this form of configuration enabled the researcher to narrow down the scope of collection, and ensured more consistency and stability in realist evaluation definitions. The same framework was used in another study belonging to a broader research project [ 37 ]. As the need to work with a stable set of definitions was underlined throughout the research project, the researcher used the causal loops [ 77 ] framework to model interactions and identify how contextual elements and outputs are linked within the whole dynamics of the process of programme implementation as presented in Darlington et al.
However, we wish to note that any configuration derived from this framework strongly relies on data collection, and it can be argued that contextual equations only partially account for what happened during the implementation process.
The degree of complexity in the interactions considered may have caused confusion, which is also one of the limits of this work. As a result of this analysis, CMO configurations were found to be intertwined between different levels of implementation.
This emphasizes the need to define what level of implementation is considered when programme outcomes are explored. Any given item may indeed be categorized as an outcome, a factor or a mechanism, depending on the level of programme implementation which is in focus during data analysis.
Even in cases when reported levers [ 15 , 17 , 21 , 27 , 57 ] are activated e. Yet, the potential of programmes is not in question here. It is the design of programmes and most of all the aim of the implementation process which requires reflection. Programme implementation can be used to create and develop life ecosystems which promote health for all and reduce health inequalities. The programme becomes a means to achieve different steps in this process.
Adequate achievements and goals can be set in coherence with the potential of the context. This requires to take into account existing enabling or hindering factors and the relationship between them. Selected programme features have to be included in the design of the programme based on the assessment of context specifics.
The way a programme is introduced should also be tailored to contextual specificities. This work proposes to use the realist evaluation framework in a different way from the method published in the initial book by Pawson and Tilley [ 59 ]. Our framework uses a dynamic and complex model of CMO configurations.
In the presented work, the use of this model enabled the researcher to put forward that CMO configurations are in fact dynamic constructions which need to be anchored and stabilized by using a starting point. Also, the point of focus has to be identified beforehand, e. In terms of the limitations of this work, the following issues stand out.
Data collection was not comprehensive. Some documents were not acquired, as schools did not wish to share them with the researchers e. Programme impact was not entirely accessible, and important data may have been overlooked or discarded. The process of categorization was strenuous and difficult. The vast area covered by the collection of the data added complexity to the research process.
Additionally, as paper format was used to collect some of the data, in some of the schools few data were collected. The set of data was found to be inadequate when it came to asserting the validity of the Typical Contextual Equations approach. In addition, the mechanisms involved in CMO configurations were difficult to identify. More work could have been done to conceptualize mechanisms [ 78 ], and collect evidence of mechanisms in the data. Schools offer great resources and opportunities for the implementation of health promotion programmes.
However, programme implementation is particularly challenging [ 4 , 5 , 17 ] in school settings, due to organizational issues [ 74 ], among other factors. The strong and specific professional identity of school staff clearly guides what type of action is undertaken [ 25 ].
The potential difficulties, opportunities, levers and barriers as regards health promotion programmes in school settings, which we attempted to present in this work, need to be anticipated and addressed before a new programme is introduced. In schools, staff, out-of-school professionals from the education, social and health sectors, as well as stakeholders and parents are brought together, and encouraged to work collectively on projects.
This process introduces complexity from the start of programme implementation and even before a programme is introduced. Programme implementation needs to be tailored to the expectations of stakeholders, adapted to their needs, and the resources which are available, as well as flexible enough to overcome potential difficulties.
We suggest that an extensive assessment of the specificities of the school and its surrounding environment is required prior to any form of programme implementation. More attention is needed in disadvantaged school contexts, as it seems that it is more difficult for school staff to embrace a global approach towards health. The use of the realist evaluation contributed to unpacking the process of programme implementation in school settings. A few adaptations were made to the framework in the course of the research.
Contextual factors interact in highly complex loops. Effects of such interactions are of five different types. This work is a contribution to implementation research in school settings and in the field of health promotion.
Further research is needed to identify contextual equations in other settings and communities, and to compare combinations of contextual factors, the effects of interactions between factors as well as to identify the nature of key factors.
The transferability of the typical contextual equation approach requires to be tested and confronted to other field experiences. Further research is needed on how different types of programmes operate in different types of contexts. This would provide useful guidelines and recommendations for health promotion programme designs. The broader research project involved statistical analysis of the quantitative data which shall not be presented here.
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