Introduction

Healthcare workers-defined as individuals engaged in the provision of healthcare services either as employees of healthcare institutions and programs or in a capacity separate from their own, whether qualified or unqualified, and subject to either public or non-public regulations [¹]-have received much attention in the last years due to their high rates of occupational stress, burnout, illness, labor turnover, sickness absence, cardiovascular risk, and risk of obesity in comparison with other working sectors [²-⁵]. Health personnel are particularly prone to the effects of stress [⁶]. Several studies have found that workload, leadership style, professional conflict, emotional cost of caring, lack of reward, shift working, a perceived increase in responsibility towards patients, role uncertainty, personal costs, and medical bureaucracy are the main sources of occupational stress in nurses and physicians [⁷-⁹]. Similarly, a relationship between work-related stress and burnout has been reported in Australian nurses, leading to absenteeism and nursing turnover and, therefore, deriving in staff deficiencies and work augmentation [¹⁰]. Among health workers, a high prevalence of obesity has been found associated with long working hours (more than 40 hours per week), shift work, and work-related stress [¹¹,¹²]. Moreover, an association has been reported between health-impairing behaviors (i.e., infrequent exercise, higher fast food and alcohol consumption, and more frequent painkiller use) with stress in health professionals from seven European countries [¹³].

On the other hand, promoting an active lifestyle is an essential element of a global public health policy, and the workplace is a critical location for primary prevention through public health initiatives [¹⁴]. The World Health Organization (WHO), in its 1997 document titled "Health-Promoting Workplace: Making it Happen" [¹⁵], succinctly defined workplace health promotion (WHP) as a diverse range of workplace policies and activities that have been implemented for the express purpose of supporting employers and employees at all organizational levels in the bolstering of their autonomy and the advancement of their physical and mental wellbeing. Thus, healthy work environments are crucial not only to the preservation and enrollment of health personnel and the sustainability of health systems [¹⁶], but they also can confer considerable individual and organizational advantages such as diminishing absenteeism and boosting productivity [¹⁷]. Previous studies [¹⁸,¹⁹] have shown that employer-driven workplace wellness interventions centered on employee weight management, enhanced individual health, and employer costs. Likewise, there is also an increasing awareness of the direct costs derived from mental illness and of the effects on workers who remain on the job [²⁰]. Only in 2017, mental illness had an impact on workplaces with depression and anxiety disorders costing US$1 trillion in lost productivity [²¹]. Additionally, it has been shown that presenteeism has a larger economic cost than absenteeism and employer health costs [²²]. In this sense, the relative returns from investing in worksite wellness programs are favorable: savings of US$35 on monthly healthcare costs and US$2.73 linked to absenteeism for each dollar paid [²³,²⁴].

Interestingly, regardless of the proven effectiveness of worksite health interventions in diminishing multiple health risk factors, increasing productivity, minimizing absenteeism, and decreasing health care costs [¹⁷,²⁵-²⁷] as well as the research efforts to improve the health and well-being of healthcare workers, the acute and long term sickness absence, in particular scenarios, remains high [²⁸]. Similarly, a recent systematic review of literature on worksite-based diet/physical activity interventions showed that the most effective methods tended to be the costliest in terms of both time and resources [²⁹], which is potentially problematic when it comes to implementing them in a wider range of work setups. Finally, it is worth mentioning that, although an increase in mental health promotion programs has been reported in the last few decades, just a small percentage (7) was workplace-based [³⁰]. Thus, additional research is needed to further establish the key aspects that determine the effectiveness of health activity interventions.

Therefore, this study aimed to identify the effect of workplace health promotion activities (WHPA) on the health status (both physical and mental) of health personnel by employing a systematic literature review. This information can help to make informed decisions and prioritize public health activities in the workplace.

Methodology

Results

Study selection

Figure 1 shows the flowchart of the literature search. In total, 558 potential studies were identified after removing the duplicates. Then, 528 titles were excluded for the following reasons: 434 were not related to the research topic; 59 did not include a health promotion activity; 13 were not implemented among health workers; 7 did not have an abstract available; 7 were systematic reviews; 7 were not articles; and 1 the full text was written in Chinese. Then, we did not grant access to one out of the 30 included papers; therefore, 29 articles were included for a full revision. After reading the full papers, 9 studies were removed because they did not incorporate any health promotion activity among health workers, and 1 did not include health workers as the target population. Thus, the final sample consisted of 19 papers that were included for methodological quality assessment.

Figure 1 Flow chart of the process for identification of studies via databases and registers 

Discussion

The purpose of this study was to determine the effect of WHPA on the health conditions of health workers by employing a systematic literature review. This review included 19 publications that reported changes in health outcomes associated with WHPA. Although quality assessment showed that publications’ quality was heterogeneous (from weak to strong) and the intervention designs were very different, the overall results suggest that WHPAs can improve physical and mental health, and wellbeing and encourage healthier behaviors in health personnel.

The fact that nine out of 19 studies utilized a randomized controlled design shows that RCTs are the most used methodological approach to studies aiming to determine the effect of HPAs on healthcare workers’ health status and well-being. This is certainly congruent when the objective is to assess the efficacy of a relatively standard intervention producing a discrete outcome [²⁰]. Nevertheless, in this review, there was no association between the study design with the type of HPA or the outcome. Now, knowing that RCT design can have some disadvantages such as logistics (power calculation might demand vast sample sizes, external validity may be threatened by factors such as atypical populations units, and long trial run time may result in the loss of relevance), statistics (allocation of participants may be expectable resulting in selection bias when the study groups are unmasked), applicability (trials which test for efficacy may not be broadly applicable, trials which test for effectiveness are larger and more expensive, and results may not always imitate real-life treatment situation), and ethical challenges (withholding potentially beneficial interventions from control population units) [⁵⁰,⁵¹], pre-post designs may also be appropriate to address this research topic.

Regarding health conditions, the majority of the papers reported interventions primarily focused on physical health conditions. This was followed by interventions addressing both physical and mental health aspects, interventions targeting solely mental health, and interventions addressing the social contexts in which health personnel work. Concerning health promotion activities, most interventions included three or more activities followed by the implementation of a single activity and, finally, the implementation of two activities. This result agrees with previous literature that has shown that mental disorders are not considered with the same importance as physical health and that the association between health and mental health is either overlooked or unrealized [⁵²]. This can be explained due to the evolution of the health concept, which only changed nearly 70 years ago when the WHO in 1948 defined health as “a state of complete physical, mental and social well-being, not merely the absence of infirmity or disease,” expanding the notion of health from a simple concern about the physical features of a disease to a contemplation of the social determinants of a patient’s health outcomes and quality of life. Moreover, it centered on the need to accomplish well-being, which diverges from the mere lack of disease by also incorporating psychosocial, behavioral, and environmental considerations [⁵³]. Nevertheless, although this definition was a step forward for health improvement, it was not practical due to being too fundamental and could not be reliably and equitably enforced [⁵⁴]. It has been only until recent times that in light of some of the shortcomings of the WHO definition, others have proposed broader definitions such as “a holistic state of physical, mental, emotional, and social wellness supported by an integrated and technologically sophisticated healthcare delivery system tailored to meet the entirety of a patient’s medical needs, including disease prevention and management of undesirable conditions, comorbidities, complications, and unique patient circumstances” [⁵³], p.7, allowing researchers and policymakers to truly transcend from the physical characteristics of health to a holistic perspective of it.

Based on this analysis, being mentally healthy should be given the same urgency by policymakers as maintaining physically fit [⁵⁵]. This is because there is substantial evidence demonstrating the association between physical and mental health and lifestyle choices, such as diet, exercise, smoking, and alcohol consumption [⁵⁶]. To achieve these goals, policies are needed to preserve good mental health instead of only caring for acute mental illness; there should be a larger emphasis on delivering effective services for individuals with common issues, such as depression and anxiety, and helping to keep people mentally well [⁵⁵]. Therefore, it is imperative to adopt a “whole person” perspective when it comes to providing healthcare services, otherwise the notion of having a fixed differentiation between “mental health professionals” and “physical health professionals” can create a reduced sense of responsibility, meaning that opportunities to improve outcomes are neglected [⁵⁷].

On the other hand, due to the heterogeneity of types of studies and measures used in the included articles, it is not possible to make meaningful comparisons between the studies. Nevertheless, we would like to draw particular attention to three results. First, only one study did not show any statistically significant difference after having implemented the HPA [³²]. As per the authors’ analysis, this result seemed to indicate that in that specific context, lifestyle improvements (healthier eating and increased physical activity) cannot be registered in the short term (12 months); however, we proposed an alternative explanation. The intervention on dietary habits focused mainly on making fresh fruit and vegetables available at least three days a week and placing campaigns to publicize the “Tuscan Dietary Pyramid” (Piramide Alimentare Toscana, PAT), the IARC guidelines, instructions for calculating BMI, and material regarding the project. These educational strategies have shown to be less effective than behavioral approaches for short-term weight loss [⁵⁸] as the one described in the study where no differences were found. Now, despite this, it is undeniable that at least in the field of health promotion, researchers must face issues regarding the selection of indicators and the timing of measurements that are often complex and controversial, in addition to having to manage anonymous data, which impedes the analysis of intra-subject variations in risk factors (considered as the major limitation of this type of investigation) [³²].

Second, most of the studies targeting mental health focused their efforts primarily on reducing healthcare workers’ perceived stress. This may be explained due to the growing recognition of multiple situations that challenge health personnel to meet work-related demands, leading them to illness, labor turnover, and absenteeism [⁴], as well as impeding organizations from recruiting new workers and retaining those already present in the workplace [⁵⁹]. It is worth mentioning that most of these interventions had a sustained effect over time that exposed two main elements: on the one hand, the efficacy of mindfulness-based stress reduction training as described in other studies [³⁶,⁶⁰,⁶¹]; and on the other hand, the effectiveness of using well-established problem-solving, emotion-regulation strategies, coping skills as well as approaches for improved communication skills to reduce stress in the long term [⁶²].

Third, HPAs that addressed both diet and physical activity behaviors were more effective in improving weight outcomes than those that used only one approximation. This finding is in agreement with previous studies [⁵]. Finally, we noticed that most of the interventions were centered on enhancing individual coping skills, rather than impacting the workplace environment such that it promotes healthier behaviors, which is something that has been reported in other studies as well [⁶³].

As with any research, this study entails certain inherent limitations that warrant consideration. Firstly, the restricted number of articles incorporated in our analysis curtails the extent to which our results can be extrapolated and applied to a broader context. Secondly, the substandard quality of most of these publications hampers the formulation of overarching conclusions. Nevertheless, although these limitations are evident, to the best of our knowledge, this systematic review is the first to assess the impact of at least one health promotion activity on healthcare workers in the workplace. This study offers valuable information to public and occupational health researchers on the impact of worksite-based health promotion interventions, including the effect of different strategies applied. Occupational health professionals should continue applying evidence guidance frameworks/tools, and developing multicomponent interventions that allow them to identify, reduce, and, if possible, eliminate work-related hazards that jeopardize workers’ health and well-being.