Factors influencing implementation of health-promoting interventions at workplaces: A scoping review

doi:10.21203/rs.3.rs-4941551/v1

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Factors influencing implementation of health-promoting interventions at workplaces: A scoping review

https://doi.org/10.21203/rs.3.rs-4941551/v1

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Background: Health promotion interventions in the workplace are effective in improving employee health. However, many interventions are temporary and cannot be sustained, and a comprehensive understanding of the factors influencing their implementation is limited. Therefore, this scoping review aimed to identify the barriers and facilitators influencing the implementation of health promotion interventions in the workplace using the implementation framework.

Methods: We searched PubMed, Web of Science, and Scopus from January 1986 to August 2022 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Consistent with the Arksey and O’Malley framework, two independent reviewers reviewed the titles and abstracts for its eligibility followed by full-text screening using a data extraction form. A narrative summary of the barriers and facilitators identified from the included articles was then synthesized and categorized into the Consolidated Framework of Implementation Research (CFIR). The barriers and facilitators identified were stratified according to implementation outcomes.

Results: Of the 38,384 articles identified, 610 articles wereeligible for the full-text screening, and 53 articles were included in the final analysis. Over 80% of the studies applied a qualitative or mixed-methods approach, and the most common topics of the interventions were reducing physical inactivity and promoting exercise (36%); and over 60% of studies targeted interventions in medium- to large- size organizations. Most of the factors were identified in the inner setting domain of the CFIR. Evidence strength and quality and leadership engagement were the predominant facilitators whereas structural characteristics, relative priority, and available resources were the most identified predominant barriers to the implementation of a workplace health promotion interventions.

Conclusion: The barriers and facilitators identified in this study can be used to implement a process to develop a strategy that targets the identified determinants to improve workplace health promotion interventions and their implementation.

workplace

implementation outcome

facilitators

barriers

factors

This manuscript provides an understanding of implementation outcomes at workplaces targeted to prevent the non-communicable diseases.
The factors associated with implementation of workplace health promotion interventions could be identified and classified into each construct of the Consolidated Framework for Implementation Research.
Clear idea on where the implementation is effective and which construct plays a vital role in facilitating the intervention programs can be identified.

Approximately three-fourths of the deaths worldwide are caused by some highly prevalent non-communicable diseases (NCDs), such as cardiovascular diseases, cancer, diabetes, and chronic lung disease (1). The World Health Organisation (WHO) and other relevant authorities worldwide support the Sustainable Development Goal three target four, which aims to reduce premature mortality by NCDs to one-third by 2030 (2). The WHO has extended its Global Action Plan 2013–2020 to ten more years to accelerate the progress in the prevention and control of NCDs (3).

The WHO highlighted the importance of the workplace in maintaining and promoting health of individuals’ health in the Third World Health Assembly in 1980 (4). Thus, the workplace is a valuable setting for providing NCD prevention interventions as it can reach many working adults for prolonged periods. According to the World Bank, the labor force reached approximately 3.46 billion (nearly 44% of the world’s population) in 2021 (5). With this increment, it can be assumed that employees spend a lot of time in the workplace, and the amount of time spent working has gradually increased worldwide, including the US (6). Furthermore, several work-related factors, such as prolonged working hours (7, 8), lack of motivation (9), sedentary work styles (10), overtime at work (11), and an unsanitary work environment (12), etc. have been associated with several NCDs, including cancer, cardiovascular diseases, diabetes, and behavioral risk factors for chronic diseases, which are prevalent in the working population. It has been estimated that the global economic burden caused by NCDs globally between 2011 and 2030 will be approximately half of the gross domestic product in 2010 (13), which will increase the burden on the employers because most of them are financed by the employee health insurance system (14). Thus, targeting workplaces could significantly contribute to population-level reductions to prevent various chronic diseases.

Evidence shows that workplace health promotion interventions (WHPIs) at workplaces are effective in improving employee health (15–17). Many organizations have introduced various WHPIs; however, these interventions are mostly provided by some large size industries. According to a survey conducted in 2017 by the Center for Disease Control and Prevention in America, nearly 92% of the worksites with more than 500 employees provided at least some form of worksite health promotion activity for their employees in 2017; however, the rate declined with a decrease in worksite size (18). The sustainable implementation of these WHPIs requires strong determination from the employers along with many resources and thoughtful processes from planning to the evaluation of the desired outcome (19). Many interventions are temporary or cannot be sustained because of a lack of commitment from the employers, poor intervention design or the employees’ unwillingness to participate in the WHPIs (20–22). Understanding these influencing factors can provide valuable insights for identifying subsequent implementation strategies. Several reviews have examined these influencing factors comprehensively or in specific areas (23, 24); however, to the best of our knowledge, none have organized them according to an implementation framework. Furthermore, as the barriers to and facilitators of implementation of WHPI implementation can differ by the worksite or organizational structures (25, 26), it is important to identify these factors across various levels.

The Consolidated Framework for Implementation Research (CFIR) provides a broad spectrum of implementation research in five different domains namely, intervention characteristics, outer setting, inner setting, personal characteristics, and intervention process (27). The CFIR provides an in-depth expression of ideas and helps researchers collect information, and analyze, and interpret the findings in terms of the effectiveness of their intervention (28). It can be applied before, during, and after the implementation of an intervention, and hence, can identify appropriate ways of developing an intervention, and implementing it, and helping gather information on the sustainability of the intervention (29). CFIR has been widely used in implementation research; hence, this scoping review aimed to identify the barriers and facilitators of WHPIs worldwide using CFIR and to identify the evidence gaps to make recommendations for future implementation research in health promotion at workplaces.

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review (PRISMA-ScR) checklist and reported our findings according to the Arksey and O’Malley framework. The protocol for this scoping review has been published previously (30).

2.1. Identifying research questions

We identified the following research question: What are the barriers and facilitators that have influenced the implementation of health promotion activities in the workplace?

2.2. Identifying relevant studies

We included all relevant studies (including qualitative, quantitative, and mixed-methods studies) evaluating the barriers and facilitators to implementing WHPIs. The studies were selected based on the following criteria:

2.2.1. Population

We included studies focusing on the stakeholders’ perspectives on barriers and facilitators to implementing WHPIs in their respective workplaces. Stakeholders perform direct roles in the implementation of WHPIs, including, but not limited to, employers and management personnel at workplaces. We excluded studies focusing only on diseased populations, such as those studies conducted among specific groups of populations with pre-identified risks or chronic conditions such as obesity, diabetes and hypertension.

2.2.2. Concept

Any health-promoting interventions performed at the workplace focusing on modifiable lifestyle-related NCD prevention to address diet, physical activity, weight control, and tobacco and alcohol use at the workplace (e.g., smoke-free policies at workplaces and workplace fitness programs) were considered in this scoping review. We limited our studies to those that focused only on interventions for NCDs. Interventions for mental health prevention and studies focusing on interventions for the prevention of other diseases or conditions, such as communicable diseases, neglected diseases, and injuries, were excluded.

2.2.3. Outcomes

Our major outcomes of interest were barriers and facilitators to WHPI intervention. However, we excluded studies that did not mention at least one of the following eight implementation outcomes as an outcome of these barriers and facilitators: acceptability, adoption, appropriateness, costs, feasibility, implementation (fidelity), penetration, and sustainability (31). We also excluded studies that focused only on the perceptions of the domain side or employees only. Based on the proportion of studies identifying the construct as a facilitator (Pf) or barrier (Pb) we termed the factors as predominant barriers (Pb > Pf) or predominant facilitators (Pf > Pb), however if the relative difference between Pf and Pb was similar, we termed them as indistinguishable factors (32).

2.2.4. Context: Industry types were classified based on the International Standard Industrial Classification of All Economic Activities.

2.3. Study selection

Using our search strategy, we searched PubMed, Web of Science, and Scopus from January 1st, 1986, to August 31st, 2022, according to the PRISMA guidelines using our search strategy. The identified articles were aggregated into Rayyan, the common software, and duplicates were removed. After the removal of the duplicates, two independent reviewers reviewed the titles and abstracts for its eligibility. Any conflicts between the two independent reviewers were resolved by a third reviewer. The studies included in the title and abstract screening were subjected to full-text screening, which was also done by two independent reviewers. Any conflicts between the reviewers were resolved by a third reviewer and the total number of included studies was finalized after resolving the conflicts. Further manual searches and the references of the included articles were checked to obtain any additional relevant articles.

2.4. Charting the data

The following information was extracted from the articles included in the full-text screening using a standardized data collection form: authors names, year of publication, country of publication, study design, framework used, study objective, study population, details of the intervention (such as type, size and setting of the intervention), implementation outcome reported, and the description of barriers and/or facilitators to WHPIs implementation. We then coded the extracted descriptions of barriers and/or facilitators using all 39 of CFIR's constructs using deductive content analysis (33). To preliminarily assess any coding conflicts, two independent reviewers extracted the relevant information from approximately 5% of the included articles and coded them. All the conflicts were resolved (34).

2.5. Collating, summarizing, and reporting the results

A narrative summary of the barriers and facilitators obtained from the included articles was provided in a data extraction form. A table of the numbers and percentages of each factor was then prepared, where the denominator was the total number of studies that identified facilitators or barriers. We also stratified the barriers and facilitators according to implementation outcomes.

2.6. Consultation

We consulted two public health nurses involved in WHPI to gain insight.

2.7 Ethical considerations

This study used findings from literature; therefore, ethical approval was waived.

A total of 38,384 articles were identified from three databases- PubMed, Scopus, and Web of Science-after removing the duplicates and were subjected to title and abstract screening. Only 610 articles were deemed to be eligible for the full-text screening, of which 557 articles were excluded because of irrelevant information on outcomes, publication type, study duration, and study design. Some articles were also excluded because they had domain-side perceptions of the barriers and facilitators of implemented workplace interventions or there was no evaluation of the implementation outcome. Hence, this scoping review reported the detailed synthesis of 53 articles (Fig. 1).

3.1. Study characteristics

Table 1 presents the characteristics of this study. Approximately half (53%) of the included studies were qualitative studies (N = 28), followed by 15 mixed-methods (28%) and 10 quantitative (19%) studies. There was an increase in the number of publications identifying the factors associated with the implementation of workplace interventions since 2015. Approximately 44% of the articles were from the US (N = 22), followed by countries in Europe (N = 13; 25%), Australia (N = 7; 13%), the United Kingdom (N = 4; 8%), and Asia, Africa, the Middle East, and Canada (N = 7; 13%). Detailed information on the included studies is provided in Supplementary Table 1.

Table 1

Information of studies included in the scoping review (N = 53).
Author (s)	Year of Publication	Country	Study design	Framework (if any)	Industry type	Intervention	Size of workplace	Implementation outcome
Ablah, E. et al (37)	2019	USA	Quan	Work well Kansas Strategic Framework	-	Tobacco cessation, physical activity, and healthy eating	Large enterprises	Implementation
Adams, E.J. et al (53)	2017	UK	Quali	RE-AIM framework	N, P	Physical activity	Large enterprises	Adoption, implementation, penetration, and sustainability
Allen, C. L. et al (42)	2015	USA	Quali	NA	I	Tobacco cessation, physical activity, and vaccination	Not specified	Adoption, implementation and penetration
Bailey, M.M. et al (49)	2018	USA	Quali	NA	-	Wellness	Micro, small, medium-sized, and large enterprises	Implementation
Banwell, C. et al (56)	2019	Australia	Quali	Cultural economy framework	-	Physical activity, healthy eating strategies and immunization	Small and medium sized enterprises	Adoption
Bramante, C.T. et al (83)	2017	USA	Mm	NA	A, C, M, O, P, Q	Physical activity	Medium-sized enterprises	Adoption
Cameron, J. et al (84)	2018	Australia	Quali	NA	C	Alcohol cessation	Medium-sized enterprises	Adoption and sustainability
Coffeng, J.K. et al (50)	2013	Netherland	Quan	Framework of Steckler and Linnan	K	Physical activity	Medium-sized enterprises	Implementation
Crane, M. et al (48)	2019	Australia	Mm	NA	A, B, D, E, F, G, H, I, K, O, M, L, P, Q, R, S, T	Wellness	Micro, small, medium-sized and large enterprises	Adoption
Danquah, I.H et al (52)	2020	Denmark	Mm	Nielsen & Randa framework	-	Physical activity	Not specified	Implementation and penetration
Dubuy, V. et al (65)	2013	Belgium	Quali	RE-AIM	-	Exercise	Small and medium-sized enterprises	Adoption, implementation and sustainability
Elling, D. L. et al (85)	2020	Sweden	Quan	NA	F, H, K	Alcohol cessation	Medium-sized and large enterprises	Adoption
Fitzgerald, S. et al (72)	2016	Ireland	Quali	Steckler and Linnan's conceptual framework	I, M, Q	Healthy eating strategies	Large enterprises	Implementation
Greenberg, K. L. et al (60)	2021	Israel	Mm	RE-AIM	O	Healthy eating strategies, physical activity, stress reduction, screening tests, smoking cessation, health awareness	Medium-sized and large enterprises	Adoption, implementation and sustainability
Hadgraft, N. T. et al (35)	2016	Australia	Quali	NA	G, M, Q	Physical activity	Small and large enterprises	Adoption, implementation and penetration
Hannon, P.A. and and Garson, G. et al (38)	2012	USA	Mm	NA	C, G, I, P, Q	Wellness	Medium-sized and large enterprises	Adoption and implementation
Hannon, P.A. and Hammerback, K. et al (36)	2012	USA	Quali	NA	C, G, I, P, Q	Wellness	Medium-sized and large enterprises	Adoption and implementation
Kava, C.M.and Parker, E.A. et al (86)	2018	USA	Quali	NA	C, G, F, K, L, O	Smoking cessation	Micro and small enterprises	Adoption and implementation
Kava C.M. and Ruiz, R.A. et al (87)	2022	USA	Quali	NA	C, P, Q	Smoking cessation	Small and medium sized enterprises	Adoption and implementation
Klasen, S.H. et al (40)	2021	Netherland	Quali	NA	B, C, K, P	Screening	Large enterprises	Adoption and implementation
Laing, S. S. et al (88)	2012	USA	Quali	NA	-	Physical activity, Healthy eating strategies, smoking cessation	Small and medium sized enterprises	Implementation
Leonard, K.S. et al (89)	2022	USA	Quan	NA	C, O, P, Q	Physical activity	Small and medium sized enterprises	Implementation
Li, R. et al (90)	2018	China	Mm	NA	Q	Healthy eating strategies	Medium-sized enterprises	Implementation and sustainability
Lidegaard, L. P. et al (39)	2021	Denmark	Quali	NA	C	Smoking cessation	Large enterprises	Adoption
Lier, L.M. et al (43)	2019	Germany	Quan	NA	C, I, R, O	Physical activity and wellness	Medium-sized and large enterprises	Penetration
Linnan, L.A. et al (66)	2019	USA	Quan	NA	A, B, C, E, G, H, I, J, K, L, M, N, O, P, Q, R, S	Wellness	Small, medium-sized, and large enterprises	Adoption and implementation
Mandal, G. et al (51)	2021	India	Mm	NA	-	Smoking cessation	Medium-sized and large enterprises	Implementation
Martinsson. C. et al (41)	2016	Sweden	Quali	NA	K	Incentives	Medium-sized and large enterprises	Adoption and implementation
Mastenbroek. et al (61)	2022	Germany	Quali	NA	K	Physical activity	Micro, small and medium-sized enterprises	Adoption and implementation
McCardel, R. E. et al (44)	2021	USA	Mm	CFIR framework	O	Physical activity and healthy eating strategies	Large enterprises	Adoption and implementation
McLellan, D.L. et al (54)	2015	USA	Quan	NA	A, B, C, E, G, H, I, J, K, L, M, N, O, P, Q, R, S	Wellness	Micro, small, medium-sized, and large enterprises	Implementation and sustainability
Mellor. et al (57)	2013	UK	Mm	NA	O	Wellness	Large enterprises	Adoption and implementation
Montini, T. et al (91)	2008	USA	Quali	NA	I	Smoking cessation	Large enterprises	Adoption and implementation
Morris, A.S. et al (82)	2019	UK	Mm	NA	J	Physical activity	Large enterprises	Implementation and penetration
Nelson, C. C. et al (92)	2015	USA	Quali	NA	C	Wellness	Small and medium-sized enterprises	Adoption and implementation
Person, A.L. et al (81)	2010	USA	Quali	NA	P	Wellness	Large enterprises	Penetration
Pitts, S. B. J. et al (63)	2016	USA	Mm	NA	Q	Healthy eating strategies	Medium-sized and large enterprises	Adoption and sustainability
Rantala, E. et. Al (47)	2021	Finland	Mm	NA	-	Healthy eating strategies and physical activity	Medium-sized and large enterprises	Implementation
Sargent, G.M. et al (59)	2018	Australia	Quali	NA	C, F, G, H, I, K, L, P, Q, R	Healthy lifestyle behavior and healthy environment	Small and medium sized enterprises	Implementation and penetration
Schouw, D. et al (46)	2018	Africa	Quali	NA	D	Healthy eating strategies and wellness	Large enterprises	Adoption, implementation and sustainability
Seaton, C.L. et. al (67)	2017	Canada	Mm	NA	H	Physical activity, Healthy eating strategies and incentives	Not specified	Adoption, implementation and sustainability
Sigblad, F. et al (58)	2020	Sweden	Quali	NA	F, G, Q, S	Physical activity	Medium-sized and large enterprises	Adoption
Strickland, J. R. and Eyler, A.A. et al (93)	2015	USA	Quali	NA	G, Q	Physical activity and Healthy eating strategies	Large enterprises	Implementation and penetration
Strickland, J. R. and Kinghorn, A.M. et al (55)	2019	USA	Mm	Formal evaluation framework	G	Physical activity and healthy eating strategies	Medium-sized enterprises	Implementation
Taylor, A.W. et al (45)	2016	Australia	Quan	NA	O, S	Wellness	Micro, small, medium-sized, and large enterprises	Adoption and implementation
Tenney, L. et al (94)	2021	USA	Quan	NA	-	Wellness	Small and large enterprises	Adoption and implementation
Verweij, L.M. et. Al (62)	2012	Netherland	Quali	NA	Q	Physical activity and healthy eating strategies	Large enterprises	Adoption and implementation
Vyth, E. L. et al (71)	2011	Netherland	Quan	NA	I	Healthy eating strategies	Large enterprises	Adoption and sustainability
Warehime, S. et al (76)	2019	USA	Quali	NA	G, K, M, Q	Wellness	Large enterprises	Adoption and implementation
Welch, A. et al (95)	2020	Australia	Mm	RE-AIM	O, S	Exercise	Medium-sized and large enterprises	Adoption, implementation and sustainability
Wipfli, H. et al (64)	2018	USA	Quali	NA	C, O, J, K, P, Q	Tobacco cessation, physical activity, wellness	Medium-sized and large enterprises	Adoption
Wyatt, K.M. et al (96)	2015	UK	Quali	NA	I, J	Wellness	Medium-sized and large enterprises	Implementation
Zou, G. et al (97)	2019	China	Quali	NA	C	Smoking cessation	Large enterprises	Implementation
Quali, Qualitative method; Quan, Quantitative method; Mm, Mixed method; -, Not available; Industry type: A, Agriculture, forestry, and fishing; B, Mining and quarrying; C, Manufacturing; D, Electricity, gas, steam, and air conditioning supply; E, Water supply, sewerage, waste management, and remediation activities; F, Construction; G, Wholesale and retail trade, repair of motor vehicles and motorcycles; H, Transportation and storage; I, Accommodation and food service activities; J, Information and communication; K, Financial and insurance activities; L, Real estate activities; M, Professional, scientific, and technical activities; N, Administrative and support service activities; O, Public administration and defense, compulsory social security; P, Education; Q, Human health and social work activities; R, Arts, entertainment, and recreation; S, Other service activities

3.2. Characteristics of the intervention and implementation outcome

Approximately 36% of the studies focused their intervention on reducing physical inactivity and promoting exercise followed by wellness interventions (25%), healthy eating behaviors (13%), smoking cessation (11%), alcohol and tobacco control (7.5%), and others. However, approximately 15 studies (28%) focused on multiple interventions. Most interventions were implemented in medium- to large-scale organizations (64%). Only a limited number of studies utilized implementation frameworks such as RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) or CFIR in their studies. Among the eight implementation outcomes, four outcomes (adoption, implementation, penetration, and sustainability) were used as barriers and facilitators. All studies had one or more implementation outcomes with most focusing on implementation of the intervention (44%) followed by adoption (37%) (Table 1).

3.3. Barriers and facilitators to implementation by CFIR domain

Table 2 shows the frequencies and proportions of barriers and facilitators to WHPI implementation across various CFIR domains and constructs. We have provided detailed codes of the facilitators and barriers across the five domains and 39 constructs of the CFIR in Supplementary Table 2.

Table 2

Proportion of facilitators and barriers by CFIR domains and constructs
CFIR domains and constructs	Facilitators (N = 46), n (%)	Barriers (N = 47), n (%)
Intervention Characteristics
Intervention source	1 (2%)	-
Evidence strength and quality	9 (20%)	4 (9%)
Relative advantage	4 (9%)	1 (2%)
Adaptability	4 (9%)	2 (4%)
Trialability	1 (2%)	1 (2%)
Complexity	3 (7%)	8 (17%)
Design quality and packaging	5 (11%)	4 (9%)
Cost	5 (11%)	9 (19%)
Outer setting
Employees’ needs and resources	3 (7%)	7 (15%)
Cosmopolitanism	1 (2%)	-
Peer pressure	1 (2%)	2 (4%)
External policy and incentives	7 (15%)	1 (2%)
Inner setting
Structural characteristics	3 (7%)	12 (26%)
Networks and communications	6 (13%)	7 (15%)
Culture	5 (11%)	9 (19%)
Implementation climate	2 (4%)	1 (2%)
Tension for change	2 (4%)	1 (2%)
Compatibility	6 (13%)	3 (6%)
Relative priority	-	12 (26%)
Organisational incentives and rewards	1 (2%)	-
Goals and feedback	2 (4%)	-
Learning climate	1 (2%)	-
Readiness for implementation	3 (7%)	2 (4%)
Leadership engagement	18 (39%)	14 (30%)
Available resources	9 (20%)	19 (40%)
Access to knowledge and information	6 (13%)	4 (9%)
Characteristics of individuals
Knowledge and beliefs about the intervention	5 (11%)	6 (13%)
Self-efficacy	-	1 (2%)
Individual stage of change	2 (4%)	2 (4%)
Individual identification with organisation	1 (2%)	2 (4%)
Other personal attributes	3 (7%)	1 (2%)
Process
Planning	2 (4%)	2 (4%)
Engaging	7 (15%)	2 (4%)
Opinion leaders	-	-
Formally appointed internal implementation leaders	4 (9%)	2 (4%)
Champions	3 (7%)	-
External change agents	5 (11%)	1 (2%)
Executing	-	1 (2%)
Reflecting and evaluating	-	-
N = total number of studies identifying facilitators and barriers in workplace health intervention, n = number of times CFIR constructs were reported in studies as barriers or facilitators, - = no studies identifying the construct as a barrier or facilitator

3.3.1. Intervention characteristics

Some constructs, such as evidence strength and quality of the intervention (20%), relative advantage (9%), and adaptability (9%), were identified as the predominant facilitators of WHPI implementation, whereas complexity of the intervention (Pf = 7% and Pb = 17%) and cost (Pf = 11% and Pb = 19%) were identified as the predominant barriers to implementation. Other constructs, such as intervention source, trialability, and design quality and packaging were identified as indistinguishable factors in the implementation of WHPI implementation (Pf – Pb ≥ 2%) (Table 2).

3.3.2. Outer setting

External policy and incentives (15%) were identified as predominant facilitators and employees’ needs and resources (Pf = 7% and Pb = 15%) as predominant barriers, whereas cosmopolitanism and peer pressure were identified as indistinguishable factors in WHPI implementation. (Table 2)

3.3.3. Inner setting

Most of the barriers and facilitators reported in the studies included in this review were in the inner setting of the CFIR domain. However, the identified factors were indistinguishable as barriers and facilitators in most of the constructs in the inner setting, such as networks and communication, implementation climate, tension for change, organizational incentives and rewards, and readiness for implementation. Compatibility (13%), goals and feedback (4%), leadership engagement (39%), and access to knowledge and information (13%) were identified as the predominant facilitators, whereas structural characteristics (26%), culture (19%), relative priority (26%), and available resources (40%) were identified as the predominant barriers. No study identified relative priority as a facilitator, whereas leadership engagement was the most identified factor among all (N = 32). (Table 2)

3.3.4. Characteristics of individuals

Few studies reported factors related to the characteristics of individuals as barriers or facilitators; among those that reported them, there was not a clear demarcation on either. These factors were the predominant facilitators or barriers. We identified only other personal attributes (7%) as predominant facilitators in this domain, while the rest were indistinguishable. (Table 2)

3.3.5. Process

Few studies reported factors related to the process of WHPI implementation. No construct in this domain was identified as a predominant barrier to implementation however, engaging (n = 7; 15%), stakeholders’ engagement (n = 2; 4%), formally appointed internal opinion leaders (n = 4; 9%), champions (n = 3; 7%) and external change agents (n = 5; 11%) were identified as the predominant facilitators, while the rest were indistinguishable. (Table 2)

3.4. Predominant barriers and facilitators according to CFIR constructs

Very few CFIR constructs (five out of 39) which were reported as predominant facilitators or barriers by ≥ 20% of the studies (Table 2). The detailed findings of these five constructs are given in the following subsections, and corresponding examples of the factors (barriers and facilitators) are provided in the Supplementary Table 2.

3.4.1. Evidence strength and quality

Among all other constructs in the intervention characteristics domain of the CFIR, evidence strength and quality were the only constructs with the strongest evidence, as more than 20% of the articles reported these as facilitators (N = 9), whereas four studies (9%) identified these as barriers because of a perceived lack of evidence in implementing certain interventions (35, 36). Hence, it was the predominant facilitator of the implementation of the intervention. The evidence to decrease the cost of intervention (37) and its perceived benefits to the employees (38–40) facilitated the implementation of the respective interventions. For example, Martinsson. C. et al conducted a focus group discussion, in which one of the participants mentioned, “What works as an incentive is if you know that other workplaces that have used a workplace health intervention and have achieved results. This is something that works” (41).

3.4.2. Structural characteristics

Approximately 26% of the studies (N = 12) identified the structural characteristics of the organisation such as high employee turnover rate (42), size of the organization (43–45), and limited ability to reach all workers (36) as barriers to WHPI implementation of an intervention. Three studies (7%) reported this construct as a facilitator owing to the diversity of team members (46) and the presence of a support system within the organisation (47). Hence, we considered structural characteristics to be a predominant barrier to implementation.

3.4.3. Relative priority

Relative priority was another predominant barrier (N = 12, 26%) identified within the inner setting with no studies reporting it as a facilitator. Conflicting priorities (48), difficulty in prioritizing the intervention over other organizational responsibilities (49, 50), and insufficient time provided to participate due to other responsibilities (51), etc. were the specific barriers identified and classified in this construct.

3.4.4. Leadership engagement

Leadership engagement was one of the most frequently identified factors among all other CFIR constructs (N = 32). Approximately 30% of the studies (N = 14) identified it as a barrier and approximately 39% (N = 18) as a facilitator. Hence, it was deemed a predominant WHPI implementation facilitator. For example, in a focus group discussion conducted by Danquah I.H. et al., one of the managers mentioned, “We support it and say that you can do it in your working hours, including spending time preparing for it and stuff like that. That’s needed, of course” (52). Barriers in leadership engagement include lack of support from leaders (50, 53–55), uncertainty of leaders’ commitment (38), whereas facilitators included support from leaders (52, 56), capacity of leaders to support implementation (38), leadership commitment (57), and positive attitudes (58).

3.4.5. Available resources

The availability of resources was the most frequently identified construct among the barriers, as 40% of the studies (N = 19) identified it as a barrier and only approximately 20% (N = 9) identified it as a facilitator. Therefore, this was a predominant barrier. In an interview conducted by Sargent G.M et al, one of the managers highlighted, “We probably wouldn’t be able to do it without the grant, especially given the financial constraints in that sector” (59). The availability of resources such as finance (60–62), working population, or employees (63), etc. were considered as facilitators, whereas insufficient funding and finance (45, 53, 64), time constraints (56, 65), and shortage of employees (66, 67) were considered barriers.

3.5. Barriers and facilitators according to implementation outcome

Table 3 shows the facilitators and barriers of each CFIR construct according to implementation outcomes. The most frequently applied implementation outcomes for the identified facilitators and barriers were implementation (N = 213), adoption (N = 181), sustainability (N = 51), and penetration (N = 42). Other implementation outcomes (e.g., acceptability, appropriateness, and costs) are not presented in the table because our focus was mainly on the facilitators and barriers to the implementation. Leadership engagement was the most frequently identified facilitator of adoption (6%) and implementation (6%), whereas it was the most frequently identified barrier to penetration (10%). The availability of the resources was the most frequently identified facilitator of sustainability (8%), and it was the most frequently identified barrier to implementation (6%), and sustainability (10%). Regarding penetration, networks and communications were the most frequently identified facilitators (7%), whereas cost (10%) and leadership engagement (10%) were the most frequently identified barriers, followed by available resources (7%) (Table 3).

Table 3

Proportion of facilitators and barriers across CFIR constructs by four most cited implementation outcome
CFIR domains and constructs	Adoption (N = 181)		Implementation (N = 213)		Penetration (N = 42)		Sustainability (N = 51)
	F, n (%)	B, n (%)	F, n (%)	B, n (%)	F, n (%)	B, n (%)	F, n (%)	B, n (%)
Intervention Characteristics
Intervention source	1 (1%)	-	-	-	-	-	-	-
Evidence strength and quality	6 (3%)	4 (2%)	6 (3%)	4 (2%)	1 (2%)	1 (2%)	1 (2%)	-
Relative advantage	3 (2%)	1 (1%)	2 (1%)	1 (0.5%)	-	-	1 (2%)	-
Adaptability	3 (2%)	2 (1%)	4 (2%)	1 (0.5%)	-	-	1 (2%)	1 (2%)
Trialability	-	1 (1%)	1 (0.5%)	-	-	-	-	-
Complexity	3 (2%)	5 (3%)	2 (1%)	4 (2%)	-	2 (5%)	1 (2%)	2 (4%)
Design quality and packaging	3 (2%)	2 (1%)	5 (2%)	2 (1%)	-	1 (2%)	1 (2%)	1 (2%)
Cost	3 (2%)	6 (3%)	3 (1%)	6 (3%)	2 (5%)	4 (10%)	-	4 (8%)
Outer setting
Patient needs and resources	3 (2%)	6 (3%)	3 (1%)	6 (3%)	-	1 (2%)	-	-
Cosmopolitanism	1 (1%)	-	-	-	-	-	-	-
Peer pressure	1 (1%)	2 (1%)	1 (0.5%)	1 (0.5%)	-	-	-	-
External policies and incentives	5 (3%)	1 (1%)	5 (2%)	1 (0.5%)	-	-	-	-
Inner setting
Structural characteristics	1 (1%)	8 (4%)	2 (1%)	10 (5%)	-	1 (2%)	1 (2%)	1 (2%)
Networks and communications	3 (2%)	3 (2%)	5 (2%)	5 (2%)	3 (7%)	-	1 (2%)	2 (4%)
Culture	3 (2%)	6 (3%)	5 (2%)	7 (3%)	-	1 (2%)	-	1 (2%)
Implementation climate	2 (1%)	-	2 (1%)	1 (0.5%)	-	1 (2%)	1 (2%)	-
Tension for change	1 (1%)	-	1 (0.5%)	1 (0.5%)	-	-	1 (2%)	-
Compatibility	4 (2%)	2 (1%)	3 (1%)	3 (1%)	-	1 (2%)	1 (2%)	-
Relative priority	-	7 (4%)	-	9 (4%)	-	2 (5%)	-	2 (4%)
Organisational incentives and rewards*	-	-	1 (0.5%)	-	1 (2%)	-	-	-
Goals and feedback	2 (1%)	-	2 (1%)	-	-	-	1 (2%)	-
Learning climate	-	-	1 (0.5%)	-	-	-	-	-
Readiness for implementation	2 (1%)	1 (1%)	2 (1%)	2 (1%)	-	1 (2%)	-	-
Leadership engagement	11 (6%)	7 (4%)	13 (6%)	13 (6%)	3 (7%)	4 (10%)	2 (4%)	3 (6%)
Available resources	7 (4%)	12 (7%)	7 (3%)	13 (6%)	1 (2%)	3 (7%)	5 (10%)	5 (10%)
Access to knowledge and information	4 (2%)	2 (1%)	5 (2%)	3 (1%)	2 (5%)	1 (2%)	3 (6%)	-
Characteristics of individuals
Knowledge and beliefs about the intervention	4 (2%)	5 (3%)	2 (1%)	3 (1%)	-	-	1 (2%)	1 (2%)
Self-efficacy	-	-	-	-	-	-	-	-
Individual stage of change	1 (1%)	1 (1%)	2 (1%)	1 (0.5%)	-	1 (2%)	1 (2%)	-
Individual identification with organisation	1 (1%)	-	1 (0.5%)	2 (1%)	-	-	-	-
Other personal attributes	-	-	3 (1%)	1 (0.5%)	1 (2%)	-	-	-
Process
Planning	1 (1%)	1 (1%)	2 (1%)	2 (1%)	-	-	1 (2%)	-
Engaging	5 (3%)	1 (1%)	6 (3%)	1 (0.5%)	-	-	3 (6%)	-
Opinion leaders	-	-	-	-	-	-	-	-
Formally appointed internal implementation leaders	1 (1%)	1 (1%)	4 (2%)	1 (0.5%)	-	1 (2%)	-	-
Champions	2 (1%)	-	1 (0.5%)	-	-	-	-	-
External change agents	4 (2%)	1 (1%)	4 (2%)	1 (0.5%)	-	-	1 (2%)	1 (2%)
Executing	-	1 (1%)	-	1 (0.5%)	-	-	-	-
Reflecting and evaluating	-	-	-	-	-	-	-	-
N = number of times CFIR constructs were identified in the respective implementation outcome, n = number of times CFIR constructs were identified as a facilitator or a barrier, F = facilitators, B = Barriers, “-” = information not available

3.6. Consultations

We consulted two public health nurses involved in WHPI to validate the study findings. They agree that the major predominant barriers and facilitators were reasonable from the perspective of the real-world situations. In addition, they reported that “formally appointed internal implementation leaders” in the process domain, which did not appear frequently in this review, could be highly influential factors because the presence and enthusiasm of the person in charge often changes the nature of health promotion activities in SMEs.

To the best of our knowledge, this is the first study to identifying the barriers and facilitators influencing WHPI implementation using CFIR. The CFIR organizes the information in common terms and hence helps in summarizing the findings from various studies using similar terminologies. Most of the studies identified the factors in the inner setting of the CFIR domain followed by intervention characteristics. We also identified the predominant facilitators, barriers, and some indistinguishable factors affecting the implementation of WHPI activities.

4.1. Predominant facilitators

Evidence strength and quality of an intervention, and the leadership engagement were the most frequently identified facilitators in this review, which is consistent with some other findings too. Interventions proven to be effective were often perceived well by the employees (68). Such interventions not only increase the employees’ interest in participation but also reduces the risk of NCDs in a given population (69). By contrast, poor-quality interventions lead to lower participation rate and higher dropout rates, which may also affect the sustainability of the intervention in an organization. Leaders’ decision-making is crucial to adopt the program, but their continuous support after the adoption would also has a significant impact on enhancing WHPI implementation, which leads to improved employee perceptions of the company's commitment to health promotion and further improves employee well-being (70).

Similarly, interventions that had more advantages or were flexible were perceived as having better implementation outcomes. (71, 72). Interventions that consider the needs of employees and are open to changes or amendments based on their needs have also been proven to have higher participation rates in other studies too. Likewise, having some forms of incentive is associated with an increase in the job satisfaction and employee performance, which was consistent with our findings too (73). The readiness of an organization for implementation by providing sufficient information, knowledge, engagement, and support from the leaders can also enhance the implementation. This is consistent with findings from previous studies that identified better job performances, and work behavior among employees where leadership engagement was optimal (74, 75). Engaging stakeholders, leaders, or champions in the process of implementation were identified as the predominant facilitators in this review, which is consistent with other studies (22). In feedback from Japanese public health nurses, the inclusion of a formally appointed implementation leader among those involved in the WHPI was identified as a strong influencing factor key to successful implementation. This factor was also identified as a predominant facilitator, but not as a predominant facilitator in this review. A possible reason for this may be the different systems in which health programs are provided: in the U.S. and elsewhere, vendors provide programs in general, whereas in many smaller companies in Japan, general affairs and human resources staff serve in tandem.

4.2. Predominant Barriers

Lack of awareness of employees’ needs and resources as well as the inability to meet them owing to the organizational structure can be one of the biggest barriers to WHPI implementation (58, 76), which is consistent with some previous findings (77). Moreover, having other priorities over the intervention was also hindered implementation, which was consistent with previous findings (78). The unavailability of resources such as money, time, and manpower were the most identified barrier in adoption, implementation, and sustainability. Many previous studies have supported this finding as a major barrier to the implementation of WHPIs (79). However, available resources were not the predominant facilitator of implementation. This means that the mere presence of resources is not sufficient for success that WHPI cannot be implemented well without the engagement of leaders.

Complex and financially challenging interventions were identified as the predominant barriers in this review, which is also consistent with some other studies (80). Having secure funding or budget, and low-cost interventions enhance WHPI implementation; however, having insufficient funds or higher intervention costs can hinder the sustainability of an intervention. Hence, it is important to examine the cost-effectiveness and feasibility of an intervention before its implementation.

4.3. Indistinguishable factors

Although many indistinguishable factors were identified in this review, there were some important factors which were considered as both facilitators and barriers in more than 10% of the included studies. Some studies identified having a well-designed (60) and sustainable interventions (72) as facilitators for its implementation; however, others identified lengthy programs (81), and poor intervention design (40) as barriers. Networks and communication are important components of implementation. However, whether it is a facilitator, or a barrier depends on the situation. For example, in a study by Morris A.S et al., one of the team leaders stated, “The only thing that I was doing was when the mails were coming through on a Monday, that’s when I would pick up with P13 (referring to a study participant) so that would be the catalyst for the conversation with P13 to tell him or ask him how it’s going, that mail was a conversation starter for me to be fair”. However, other team leaders mentioned, “I think a lot of people would have looked at it [recruitment email] and thought more work if I [am] being honest with you” (82). Hence, it is important for the managers and program implementers to choose the correct way of communicating with employees to enhance their active engagement. Similarly, having adequate knowledge and a good perception of the intervention enhances implementation but not having proper knowledge could act as a barrier to implementation. Thus, it is important to provide knowledge regarding the intervention, outlining its benefits to employees’ health, so that they can perceive it well.

4.4. Strengths and limitations

This scoping review identified the factors associated with WHPI implementation using the CFIR, which enabled the results to be presented in a comprehensive and systematic manner. However, this review has some limitations. First, the interventions identified in the included articles were diverse, and we were unable to identify the facilitators and barriers by intervention type. Second, the facilitators and barriers by industry type were not examined, although the industry types were diverse. The heterogeneity of intervention and industry types may limit generalizability as these variables may affect implementation differently. Furthermore, in our review protocol, we reported a plan to extract health outcomes, if measured, and the changes in health outcomes after the intervention (whether they worsened, did not change, or improved after the implementation). However, because there were very few papers reporting the health outcomes of the target intervention, we had to deviate from the protocol and exclude the extraction of health outcomes.

This review identified and synthesised barriers and facilitators for WHPI implementation as using CFIR, an implementation science framework. Most factors associated with WHPI implementation exist in the characteristics of the intervention and the inner setting. The predominant facilitators affecting WHPI implementation were evidence strength and quality (intervention characteristics), and leadership engagement (inner setting), whereas the predominant barriers were structural characteristics (inner setting), relative priority (inner setting), and available resources (inner setting). The next step in the implementation process is to develop a strategy that targets the identified determinants to improve WHPI implementation.

NCDs

non-communicable diseases WHO,World Health Organisation

WHPIs

Workplace Health Promotion Interventions

CFIR

Consolidated Framework for Implementation Research

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Ethical approval and consent to participate

This study used data from existing literature; hence, ethical approval and consent to participate were not required. All methods were performed in accordance with the relevant guidelines and regulations.

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Authors’ information

Aliza K C Bhandari: [email protected]

Kaung Suu Lwin: [email protected]

Phuong The Nguyen: [email protected]

Zin Wai Htay: [email protected]

Drishti Shrestha: [email protected]

Junko Saito: [email protected]

Akiko Yaguchi-Saito: [email protected]

Erika Ota: [email protected]

Taichi Shimazu: [email protected]

Funding

This work was supported by the National Cancer Center Research and Development Fund (30-A-18, 2021-A-19) and Japan Society for the Promotion of Science (JSPS) KAKENHI Grant-in-Aid for Scientific Research (21K17319, 23K24584, 24K13496) awarded to JS and TS, (https://kaken.nii.ac.jp/ja/grant/KAKENHI-PROJECT-21K17319/, https://kaken.nii.ac.jp/ja/grant/KAKENHI-PROJECT-23K24584/, https://kaken.nii.ac.jp/ja/grant/KAKENHI-PROJECT-24K13496/). The funding parties had no role in the study design, data collection and analysis, decision to publish, or manuscript preparation.

Author contributions

Conceptualization: JS; methodology: AKB, KSL, PTN, ZW, DS, JS and AYS; validation: AKB and JS; Formal analysis: AKB; Investigation: AKB, KSL, PTN and JS; Resources: JS and TS; Data curation: AKB, KSL, PTN, ZW, DS, JS and AYS; Writing - original draft preparation: AKB; Review and editing: AKB, KSL, PTN, ZW, DS, JS, AYS, EO and TS; Supervision: JS, EO and TS; Project administration: AKB, KSL, PTN, ZW, DS, JS, AYS, EO and TS. All the authors have read and approved the final manuscript.

ACKNOWLEDGEMENT

We acknowledge the support from the National Center Consortium in Implementation Science for Health Equity (N-EQUITY) from the Japan Health Research Promotion Bureau (JH) Research Fund (2019-(1)-4), and JH Project fund (JHP2022-J-02) for this study.

Availability of data and materials

Not applicable

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Factors influencing implementation of health-promoting interventions at workplaces: A scoping review

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Abstract

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Contributions to the literature

1. Introduction

2. Methods

2.1. Identifying research questions

2.2. Identifying relevant studies

2.2.1. Population

2.2.2. Concept

2.2.3. Outcomes

2.3. Study selection

2.4. Charting the data

2.5. Collating, summarizing, and reporting the results

2.6. Consultation

2.7 Ethical considerations

3. Results

3.1. Study characteristics

3.2. Characteristics of the intervention and implementation outcome

3.3. Barriers and facilitators to implementation by CFIR domain

3.3.1. Intervention characteristics

3.3.2. Outer setting

3.3.3. Inner setting

3.3.4. Characteristics of individuals

3.3.5. Process

3.4. Predominant barriers and facilitators according to CFIR constructs

3.4.1. Evidence strength and quality

3.4.2. Structural characteristics

3.4.3. Relative priority

3.4.4. Leadership engagement

3.4.5. Available resources

3.5. Barriers and facilitators according to implementation outcome

3.6. Consultations

4. Discussion

4.1. Predominant facilitators

4.2. Predominant Barriers

4.3. Indistinguishable factors

4.4. Strengths and limitations

5. Conclusion

Abbreviations

Declarations

Competing interests

Authors’ information

Funding

Author contributions

ACKNOWLEDGEMENT

Availability of data and materials

References

Supplementary Files

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