Chronic diseases are the leading causes of mortality and morbidity among working-age adults.¹ Risky health behaviors such as tobacco use, sedentary lifestyle, and poor nutrition are strongly linked to chronic disease.^2,3 Working-age adults regularly engage in these behaviors.^2,4

Workplace health promotion (hereafter WHP) can reach a large proportion of adults⁵, and employers increasingly recognize the impact of modifiable health behaviors on their bottom lines.^2,5 Most employers believe they can reduce their health care costs by influencing employees to adopt healthier lifestyles.⁶ Employers’ costs are also affected through increased absenteeism, presenteeism, and higher-than-average turnover among employees with chronic diseases.²

Workplaces employing more than 1,000 people are most likely to offer WHP,^7,8 and most of what we know about WHP is based on large workplaces. Research on employee perceptions of WHP has focused primarily on those working for large employers.^9-11

WHP efforts at small and mid-sized companies are less studied but still important. Fifty-five percent of employees are employed by companies with less than 1,000 total employees,¹² and many of these are low-wage (annual household incomes < $35,000).¹³ Employees receiving low wages are more likely to exhibit risky health behaviors compared to the higher-paid workforce.^4,13

Our previous work focused on WHP at mid-sized companies in low-wage industries; most were not offering much WHP.^14,15 Reasons included lack of financial resources and staff time, as well as doubts around return on investment, both overall and for their particular industries. Many employers believed that employees did not want their employers involved in their health, anddoubted whether employees would be interested in WHP. Employers also repeatedly expressed concern about being viewed as intrusive by employees.

But are these perceptions accurate? Do employees in low-wage industries lack sufficient interest and resent employer interference in their health? Several prior studies suggest that employees in smaller, lower-wage industries are generally receptive to WHP,^16,17 although most research around employee attitudes toward particular programs and policies did not focus specifically on those working in low-wage industries.^18,19 There is also a lack of research on what employees in these industries believe about the appropriateness of employer involvement in employee health behavior, what types of programs are most appealing or feasible in these settings, and how best to promote them.

Further complicating the picture, some research indicates that employees holding salaried, full-time positions in white-collar industries are more likely to participate in WHP,^20,21 even while their lower-wage counterparts may have more need for programs aimed at encouraging behaviors that reduce risks for chronic disease. A significant body of research demonstrates disparities in health outcomes associated with income and social class, with employees of lower socioeconomic status suffering disproportionate rates of disease compared to those of higher status.^4,22,23 In comparison to higher wage earners, employees with low wages are also significantly more likely to use tobacco, be physically inactive, and eat poorly.²⁴ Thus it is not surprising that WHP researchers have advocated for focusing more effort on understanding attitudes and behaviors of working-class employees to develop WHP programs that are both appealing and effective for this group.²⁵

The primary purpose of the research described below is to better understand the attitudes of employees in low-wage industries (hereafter “employees” unless otherwise specified) toward WHP, including views on appropriateness of employer involvement in employee health, level of interest in WHP overall and in specific WHP programs, and preferences around promotion and communication. We sought to dig deeply into the beliefs of employees to develop a comprehensive portrait of this under-studied population's attitudes around diverse aspects of WHP.

In addition to examining WHP aimed at employees, we also explored the potential for extending WHP to spouses and/or partners (hereafter “partners”). Many employers in low-wage industries offer some form of health insurance to partners, so partners impact their overall healthcare costs. Research indicates that personal health decisions are strongly influenced by partners.^26-29 Including partners could increase the effectiveness of WHP both through expanding the reach of employer-based wellness efforts and by improving employee adoption and maintenance via social interaction with the partner.

Our previous work indicates that low-wage employers are open to involving partners, but only if employees supported it and didn't view WHP extended to employee partners as intrusive or inappropriate.¹⁵ Currently, little is known about whether including partners in WHP would appeal to employees and partners, or what types of programs would elicit the most interest. Thus a secondary purpose of this research is to better understand the attitudes of both employees and their partners around including partners in WHP efforts.

This study utilized a qualitative approach. Semi-structured, in-person interviews were conducted with couples (defined as romantic partners, married or unmarried, who live together). Interviews, which are well-suited to gathering detailed information on topics that lack a well-defined knowledge base, allow for in-depth probing and the opportunity to explore unexpected responses.

Couples were interviewed together by one interviewer. All participants signed informed consent forms prior to being interviewed. Each couple received either $50 ($25 per person) or $100 ($50 per person) as a thank-you for their time. The incentive increased towards the end of the recruitment period due to difficulties in recruiting couples. Protocols and survey instruments were approved by the University of Washington's Institutional Review Board. In preparing this manuscript, we followed the consolidated criteria for reporting qualitative research (COREQ) guidelines.³⁰

Interviews took place in Seattle, Washington. Most of the interviews were conducted in a conference room at the University of Washington Health Promotion Research Center; a small number of participants preferred to be interviewed at their residence.

Couples were recruited through paid announcements in local newspapers, online postings (Craigslist, Seattle Times.com), and flyers posted in approximately 25 Seattle-area workplaces. Six of these workplaces participated in a prior workplace health promotion intervention study conducted by the research team.

Couples were eligible to be interviewed if they lived together, and if at least one partner currently worked in one of five target industries (accommodation/food services, education, health care/social assistance, manufacturing, and retail trade). These industries were selected because they are low-wage (mean salaries < $45,000), and among low-wage industries, these five employ the most U.S. employees (at the time we designed this study).³¹ Because we did not screen participants on their annual household income, we refer to employees in low-wage industries as opposed to low-wage employees.

Interviews were conducted between September 2010 and April 2011. Couples were interviewed by one of three members of the research team: PAH (PhD), KH (MA), and CCT (MPH). Each interview lasted approximately 60-90 minutes. To ensure accuracy, all sessions were audiotaped. Health surveys were administered by the interviewer.

Interviews were recorded and transcribed verbatim by a commercial transcription service (Proof Positive Transcriptions, Garland, TX). Transcripts were imported into Atlas.ti, a software program for managing and analyzing qualitative data. A member of the research team (PAH) developed the coding structure by first reading through the transcripts and identifying prominent themes. Guided by grounded theory, she then incorporated feedback from other research team members, resulting in a final set of codes and sub-codes. The coding structure is available from the authors on request.

To ensure consistency in how codes were assigned, two team members (KH, CCT) jointly coded the first four interviews. The remaining interviews were then individually coded by the same team members, who periodically reviewed each other's coding to confirm agreement in coding decisions. During this process, minor adjustments were made to the coding structure. Both the interview guide and the coding structure are available from the authors on request.

Interviews were conducted with 42 couples (84 individual participants). Demographic characteristics of participants are presented in Table 1. Participants were slightly younger, more likely to be African-American, and less likely to be Hispanic than residents of King County, Washington (where Seattle is located).³³ The industries most frequently represented were health care/social assistance and food service/accommodation. Although participants held a range of jobs, the most common were food server, healthcare assistant, and child care provider. None of the qualifying participants held a senior-level or managerial position.

Key findings identified from the final set of coded material are presented in Table 3. Representative quotes are presented below.

No participant thought that it would be inappropriate for their employer to offer Active For Life. About a fourth reported that they would not be interested in participating. The remaining participants either expressed some degree of interest in participating or thought coworkers might be interested.

Among those employees positive toward AFL, a large number commented on how such a program could build employee morale or bond them with their coworkers.

A sizeable number of participants were unsure about whether they would actually participate, but could see how such a program might be beneficial.

A few stated that, while AFL did not appeal to them personally, they expected that their coworkers might react positively.

Overall, participants were positive toward AFL, and comfortable with their employers offering it.

The majority of participants reacted positively toward employer-sponsored gym discounts, either for themselves or for coworkers.

About a fourth of the participants noted that their interest level would depend on the location of the gym.

Several participants wondered whether they or their coworkers would actually use it, referring to past experiences with employers who offered gym memberships that generated initial enthusiasm among employees but lack of long-term commitment.

However, most of the participants could see value in an employer sponsoring gym discounts, even if uptake was uncertain.

Of the participants who reviewed the cancer screening brochures, a large majority were interested in receiving this type of information from their employer. The most frequent positive comments centered on the usefulness of the information to them personally. Some also suggested that by providing such a brochure, employers could demonstrate a concern for their employees’ health.

Among the very few with negative comments, most focused on not needing or already knowing the information contained in the brochure.

To determine whether interest in particular WHP example programs differed by participants’ current levels of risk, we looked at participants’ self-reported physical activity and cancer screening behaviors. Were the participants most favorable toward these types of programs already leading healthy lifestyles? We found that physically inactive participants expressed levels of interest in AFL and gym memberships similar to those meeting physical activity recommendations. In each group, half or more of the participants were positive toward their employers offering these programs. Similarly, most participants over age 45 were interested in receiving information about cancer screening regardless of whether they personally were up-to-date for the cancer screenings for which they were age-eligible.

We asked all participants about a behavior change they tried to make within the past year. Consistent with the types of WHP they were interested in receiving, most reported trying to change their eating habits, get more physical activity, or lose or manage weight. Several participants tried to quit smoking or drink less alcohol. The remainder reported trying to change other behaviors, most commonly related to obtaining specific health care services or improving dental health. Most participants attempted to change health behaviors that standard WHP programs address.

Most employees we interviewed view WHP as both appropriate and, depending on the type, somewhat to very appealing, with programs addressing healthy eating and physical activity generating the most interest. Many also support efforts to expand WHP to partners, especially if it was logistically practical. Those who lack interest in WHP did not think they would be offended if it was present at their current workplace. Many also view WHP as morale-boosting and evidence that their employers care about their health. Interestingly, the most common reaction to being asked about the appropriateness of health programs offered via the workplace was skepticism that their employers would ever take on such a role.

That employees consistently indicated that they would appreciate working for an organization that prioritized employee wellness is notable given our previous research with human resources managers.¹⁵ We were struck by the disconnect between what these managers told us about potential negative employee reactions to WHP versus what employees themselves expressed. While human resources managers at low-wage worksites voiced the opinion that employees might perceive WHP efforts as intrusive and disrespectful of privacy, employees at similar worksites were nearly uniform in their assertion that WHP efforts demonstrated positive employer intent. Even employees who questioned their own interest in participating in WHP were consistent in the view that WHP signals concern for employee health.

Although most participants expressed interest in some type of WHP, it is not possible to determine from these interviews the percentage of employees that would sign up to participate, or sustain participation, in WHP efforts. Expressing interest in a hypothetical program and participating in an actual program are not the same. For example, more than half of the employees we interviewed expressed interest in gym memberships, but very few of those who currently or in the past had access to free or subsidized gym memberships mentioned having enrolled. Some previous research indicates that employees in low-wage industries are not as likely to participate in WHP as their higher-wage counterparts.^20,21

Research suggests that these differences in participation rates may relate less to lack of motivation than to larger social and contextual influences that construct formidable barriers to employee participation.³⁶ These barriers include lack of familiarity with WHP or awareness of its value, as low-wage industries are less likely to offer it;^37,38 working conditions that hinder involvement such as shift or production line work;³⁶ and power differentials between management and labor, which may create suspicion around management-sponsored programs aimed at employee behavior change.³⁶ That many of the employees we interviewed touched on such challenges supports the need for additional studies, ideally designed to help researchers both better understand the social and contextual factors affecting participation and what can be done to address them.

Despite questions around increasing participation, a central finding in this study is that employees in low-wage industries generally welcome efforts by employers to improve employee health, especially those related to increasing physical activity and supporting healthy eating. As these are the two areas of health behavior for which participants were most likely to report having recently struggled, they likely considered potential WHP with their present personal needs in mind. In addition, both employees and their partners were positive toward employers expanding WHP to partners. Further research could explore in detail what types of physical activity and healthy eating programs, as well as other forms of WHP, would be most likely to attract and sustain participation among both employees and partners.

Employees in low-age industries and their partners are interested in WHP, especially if it addresses the health behaviors they care most about and is promoted effectively. As the Affordable Care Act continues to roll out, low-wage employers will be motivated to learn more about how to offer effective WHP that also appeals to their employees. These findings can be used to create and deliver programs that are tailored to the particular interests and needs of this workforce, and potentially to their partners as well.