Design
An online, quantitative survey was organized. An email with an invitation to participate was sent to all sheltered and social workshops in Flanders (
n = 148). The social economy in Flanders comprises four types of companies, each with their own target population [
8]. In this study, two types were included which employ the largest group of disadvantaged people.
Sheltered workshops employ mainly people with disabilities (intellectual and physical).
Social workshops provide employment to people with physical, social or psychological problems (e.g. people with psychiatric problems, people reintegrating into society after prison, immigrants). The two excluded types of social economy companies were the local service economy who employ older people who are already long-term unemployed, and the insertion companies who provide a job for people with a low education level together with a history of long-term unemployment. The email-list was provided by the umbrella-organization for the social economy (CollondSe). The person who would normally be responsible for implementing HP interventions, completed the questionnaire. After two weeks, a reminder was sent. The study was executed from February to April 2013. The study was approved by the ethical committee of the Ghent University Hospital (2013/076). The respondents gave their informed consent for participation in the study by clicking on the link to the questionnaire.
Questionnaire
In the first part of the questionnaire, the current status of HP interventions and the characteristics of the workshop were questioned. The current status of HP was assessed by: “Does the company organize HP actions, besides the obligatory smoking ban at the workplace? Yes or no” and “If so, for which themes and how did the company organize HP?”. Examples were given for each HP action to make sure respondents knew what is understood under HP. The examples were: policy changes (e.g. an alcohol ban during lunch), environmental changes (e.g. providing fruit for free), education in groups (e.g. group session on healthy food), individual guidance (e.g. counseling at the social department), and short running actions (e.g. a smoke-free day). The themes were: nutrition, physical activity, smoking, alcohol use and mental health. Five new variables were constructed by recoding per theme the options ‘policy changes’ or ‘environmental changes’. The sum of these five variables was made and recoded into a new variable with categories ‘implemented an environmental intervention’ and ‘no environmental intervention implemented’.
Three characteristics of the workshop were assessed. First, the type of workshop (sheltered or social workshops) was asked. Second, the size of the workshop was asked and recoded into small (less than 49), medium (between 50 and 249) and large (250 employees or more) companies. Finally, the economical sector was asked including: primary (agriculture, retrieval of raw materials), secondary (industrial sector), tertiary (supplies commercial services) and quaternary sector (not-commercial service sector e.g. hospitals, education, social work, cultural sector).
In the second part, the personal opinion of the respondent about HP was questioned. This respondent was the person responsible for implementing HP in the company or the person that could have that task (if no HP was already implemented).
Being supportive towards implementing HP in the future, was asked by the question: ‘Are you a supporter to invest more in HP at your company in the future?’. A 5-point Likert scale was used ranged from ‘1-totally disagree’ to ‘5-totally agree’. Because of a skewed distribution, the variable was dichotomized into 0 ‘no supporter or neutral’ (scores 1–3) and 1 ‘being a supporter’ (scores 4 and 5).
A second question assessed the perception of the respondent on the statement if employees with a disability benefit from health promotion initiatives. The answer possibilities to that question were: 1) yes and there are enough suitable interventions for this specific group, 2) yes but the existing interventions are not adapted to people with a disability and therefore the results are limited, 3) no because the target group is not open for health messages, 4) no because the health and social issues of the target group are too big for the means that are available in the company.
The questions about the personal factors, derived from the Theory of Planned Behaviour, were based on the questionnaire developed by Downey and Sharp [
21]. To be in line with the other questions in the questionnaire, all answers were rated on a 5-point Likert scale, instead of the 7-point Likert scale used in the original questionnaire [
21]. The questionnaire was adapted to the Belgian situation, such as the inclusion of the trade union in the subjective norm scale and the exclusion of questions about discretionary spending on health care. Clarity of the questions and exhaustiveness of the questionnaire were tested in people working in the umbrella organization of the workplaces and some employees of the social department of the workplaces.
Attitude was measured by two constructs: behavioural beliefs (the perception of the respondent concerning the benefits of HP, e.g. investing more in HP will increase the moral of employees) and outcome evaluations (the importance the respondent gives to these benefits, e.g. trying to improve employees’ morale is desirable). Five different beliefs and their accompanying evaluations were assessed. The attitude-score was calculated by multiplying beliefs with the outcome evaluation and dividing them by 5 (see Table
1 for the 5 attitudes asked). The higher the attitude-score, the more likely the respondent beliefs that HP is beneficial and that the outcome is desirable. A total attitude-score was calculated by taking the mean of the 5 attitudes. The Cronbach alpha for the scale was 0.82.
Table 1
Mean and standard deviation of the personal factors of the respondent responsible for implementing HP in the company
Attitude: | Belief of HP outcomes (with ‘1-very unlikely’ to ‘5-very likely’) * Outcome evaluation (with ‘1-very undesirable’ to ‘5-very desirable’) | Mean (standard deviation) |
| - HP increases the moral of employees (0.20–5) | 2.72 (1.04) |
| - HP leads to an increase in productivity (0.20–5) | 2.64 (1.19) |
| - HP results in a longer life (0.20–5) | 2.28 (1.01) |
| - HP leads to a decrease in absenteeism (0.20–5) | 3.16 (1.11) |
| - HP results in a decrease of turnover (0.20–5) | 2.17 (1.07) |
| Total attitude scale (0.20–5) | 2.60 (0.82) |
Behavioural control: | How much control do you have on …(with ‘1–no control’ to ‘5–total control’) | |
| - the implementation of HP activities (1–5) | 3.54 (0.96) |
| - resources such as personnel and time (1–5) | 2.69 (1.24) |
| How extensive is your participation in securing budgets? (1–5) | 2.77 (1.30) |
| Total control scale (1–5) | 3.01 (1.04) |
Subjective norm: | Normative beliefs (‘How likely is it that following persons believe that you should invest in HP’ with ‘1–very unlikely to approve’ to ‘5–very likely to approve’) * Motivation to comply (‘How important is the opinion of following persons’ with ‘1–very unimportant’ to ‘5–very important’) | |
| - the person or committee above you (0.20–5) | 2.40 (0.93) |
| - colleagues (0.20–5) | 2.67 (0.91) |
| - clients (0.20–5) | 1.38 (0.89) |
| - co-owners (0.20–5) | 1.39 (0.95) |
| - employees (0.20–5) | 2.38 (0.96) |
| - other companies (0.20–5) | 0.96 (0.80) |
| - the community (0.20–5) | 1.78 (1.01) |
| - the trade unions (0.20–5) | 2.08 (1.19) |
| Total subjective norm scale (0.20–5) | 1.93 (0.66) |
Moral responsibility: | How much do you agree with following statements? (with ‘1–very disagree’ to ‘5–very agree’) | |
| - The benefits of HP exceed the costs of HP (1–5) | 3.39 (0.85) |
| - I have the moral obligation to ameliorate the health of my employees (obligation) (1–5) | 3.63 (0.94) |
| - As employees are spending a long time during the day in my company, it is fair that I invest in their health behaviour (fairness). (1–5) | 3.67 (0.89) |
| Total moral responsibility scale (1–5) | 3.56 (0.67) |
Behavioural control was measured using three questions on control over implementation, resources and budgets. For the total scale, the mean of the three questions was calculated. The Cronbach alpha for the scale was 0.87.
The subjective norm was measured by two constructs: normative beliefs (the perception of the (dis)approval of a reference group concerning HP, e.g. how likely is it that your colleagues believe that you must invest resources in HP?) and the motivation to comply (the importance of this reference group for the respondent, e.g. how much do you care whether your colleagues approve that you invest in HP?). Normative beliefs and motivation to comply were assessed concerning eight reference-groups: the seven reference-groups from the questionnaire of Downey and Sharp [
21], plus the reference-group ‘trade union’ (Table
1). As with the attitude scale, the scores of the normative beliefs and their accompanying motivation to comply were multiplied and divided by 5. The higher the score on the subjective norm, the more likely the respondent believes that HP should be implemented according to a relevant reference-group.’ A total score was calculated by taking the mean. The Cronbach alpha for this scale was 0.77.
Moral responsibility was measured using a scale developed by Hart [
22]. Three dimensions of moral responsibility were included (see Table
1 for the themes). The mean was used as total score on moral responsibility. The Cronbach alpha for this scale was 0.60.
Data analysis
To investigate the current status of the implementation of HP interventions (aim 1), percentages were given of the currently implemented HP themes and actions. Chi2-test were used to analyze if these results differed by the characteristics of the workshop.
To investigate which characteristics of the workshop and individual factors of the respondent were related to the implementation of environmental HP (aim 2) and to being supportive towards implementing HP in the future (aim 3), univariate logistic regressions were used. A multivariate logistic regression was performed with all significant factors from the univariate analyses.
SPSS 21 was used to analyze the data. P-values lower than 0.05 were considered to be statistically significant.