Assessed Coursework for Applied Psychology Postgraduate Courses
Module Title: The Promotion of Workplace Health and Wellbeing
Module Code: C84PWH
Grade Awarded: Merit
Application of the Transtheoretical Model to Workplace Interventions to Promote a Reduction in Sedentary Behaviour
Abstract
Sedentary behaviour is a significant burden on employers and a rapidly accumulating body of evidence has identified the relationship between sitting too much and negative health outcomes which include type 2 diabetes, cardiovascular risks, and premature mortality. A review of the literature revealed a lack of research on use of the Transtheoretical Model of behaviour change (TTM) to reduce sedentary behaviour in the workplace. There may not be one single ‘best’ concept or process for informing the design of workplace interventions, however the TTM model can provide a tangible and robust tool for reducing prolonged sitting time. It’s adaptability can provide a realistic benchmark, or frame of reference, to develop and assess alternative theories for improving health and wellbeing in the workplace.
Sedentary Behaviours and the Scale of the Issue
From an evolutional-biological perspective, the human anatomy has developed to effectively engage in consistent manual labour throughout the day since the period when humans were hunter gatherers. Compared with previous generations, people’s lifestyle behaviours are entirely distinct in terms of the amount of time we spend sitting. The physical, economic, and social environments in which we conduct our daily lives present circumstances which require prolonged periods of sedentary behaviour, for example watching TV, working on computers, playing computer games, and sitting in transit to work or home (Owen, Sparling, Healy, Dunstan, & Matthews, 2010).
The term ‘sedentary behaviour’ designates any waking behaviour that requires low levels of energy expenditure, specifically in the range of 1.0 -1.5 METs or metabolic equivalents (Thorpe, Owen, Niehaus, & Dunstan, 2011). One MET is defined as the energy expenditure of an adult sitting quietly for one hour. This equates to approximately one calorie per every 2.2 pounds of body weight per hour, while vigorous activities burn around 6 METs. (Measuring Physical Activity, 2017). Research literature does not present a consistent definition of the term sedentary. Some researchers describe participants as sedentary because they are not physically active, while others agree that engaging in low energy expenditure can be categorised at sedentary behaviour. Furthermore, the physiological consequences of these two separate entities are entirely distinct (Tremblay, Colley, Saunders, Healey, & Owen, 2010).
This poses a considerable dilemma for individuals and society at large, especially since it is likely that society has not yet reached the full possibilities for sitting because of technological advancements that do not stimulate physical activity. Surprisingly, epidemiologic evidence now suggests that the harmful consequences of sitting are entirely independent of whether adults meet the physical activity guidelines and inactivity results in unique detrimental physiological consequences such as obesity, diabetes, high blood pressure, and psychological problems (Hamilton, Healy, Dunstan, Zderic, & Owen, 2008).
This observation has been supported by numerous researchers including Owen, Healy, Matthews, and Dunstan (2010) who stated that “importantly, adults can meet public-health guidelines on physical activity, but if they sit for prolonged periods of time, their metabolic health is compromised”. The consequences of sitting for long periods is having a highly detrimental impact on the quality of life of the population. This is evident in the statistics published for 2016/17 by the Health and Safety Executive (HSE), which indicated that of 507 000 workers experienced musculoskeletal disorders, which accounted for 39% of reported ill health (HSE, n.d.).
Trends in the health behaviours of adolescents are extremely concerning with physical activities decreasing and sedentary behaviour increasing. Once these adolescents reach working age, employers will have to address the issue and absorb the related ill health costs (Brodersen, Steptoe, Boniface, & Wardle, 2007).
Introduction to the Concept of Workplace Health Promotion and the Business Case
In discussing the promotion of health and wellbeing at work, the European Network Workplace Health Promotion (2007) defined it as “the combined efforts of employers, employees and society to improve the health and wellbeing of people at work” and “can be achieved through improving the work organisation and working environment, promoting active participation and encouraging personal development” (p.1).
Workplace health promotion involves:
- Commitment from senior management to improving the health of the workforce
- Effective communication strategies that disseminate appropriate information to employees
- Involving and empowering employees to get involved and contribute ideas to the decision making process
- Developing a culture that encourages cooperation and community
- Providing working conditions, i.e. work tasks and processes that contribute to, rather than damage, health
- Developing and implementing policies and practices that positively contribute to employee health
- Recognising that the workplace has an impact on employees and that this is not always positive
(European Network for Workplace Health Promotion, n.d.)
It is imperative that strategies to improve health and wellbeing in the workplace integrate individual, social, political, and economic factors which all impede upon the health of workers in one way or another, and health promotion practitioners need to work with the relevant stakeholders in these areas to ensure a more holistic approach to tackling the issue (Leka & Houdmont, 2010).
The need for a robust and effective business case is essential for organisations. Baicker, Cutler, and Song (2010) attempted to place a monetary value on the benefits of utilising health and wellbeing programmes. They conducted a critical meta-analysis on the return on investment, or cost versus benefit, for employers who implement Workplace Wellness Programmes. By combining the results of 100 peer-reviewed studies over three decades they cautiously concluded that medical costs fall approximately $3.27 for every dollar spent and absentee costs decrease by $2.73 for every dollar spent. Limitations of the study included, but were not limited to, publication bias vis-à-vis programmes with the highest investment (which are more likely to be published) and almost all the studies were conducted by large employers who were more likely to have the resources to achieve their objectives. In fact, 90% of the programmes employed more than 1,000 employees while a quarter had more than 10,000.
This highlights the immensity of the issue society faces concerning small businesses who are far less likely to have the finances to implement workplace health programmes. For example, in the United Kingdom (UK) in 2017, of 5.7 million businesses more than 99% employed 0 to 249 staff while 5 million businesses employed 0 to 9 people (House of Commons Library, 2017). This is an area for future research to ascertain ways in which small business employers can implement low cost, high gain interventions.
The need for robust and effective business cases to justify expenditure on health and wellbeing programmes is nigh indisputable, as further evidence emerges, in this case regarding presenteeism.
In a study conducted at a large chemical company in the United States (US) with more than 10,000 employees using the Stanford Presenteeism Scale, information was collected from ‘self-reports’ at 5 locations on the prevalence of allergies and musculoskeletal disorders. Alarmingly, 65% of the respondents reported as having one of the conditions. Related absenteeism ranged from 0.9 to 5.9 hours in a 4-week period while on-the-job impairment ranged from a 17.8% to 36.4% decrement in ability to function effectively (otherwise referred to as presenteeism) (Collins et al., 2005).
It has been estimated that the cost of presenteeism to employers is $150 billion annually, but many researchers have cautioned against determining a monetary value because it is almost impossible to measure poor productivity. However, this estimate demonstrates the value of workplace health and wellbeing interventions for employers who are seeking to increase productivity and reduce operating costs (Schultz, Chen, & Edington, 2009).
The Transtheoretical Model of Behaviour Change
The stages of change, or Transtheoretical Model (TTM) of behaviour change as proposed by Prochaska (2013) evaluates an individual’s readiness to act and commence with a new behaviour. Six critical processes or milestones are defined which provide ‘benchmarks’ to the goal and can be applied at either the experiential or environmental level (Prochaska & DiClemente, 1982):
The core constructs are:
Precontemplation | At this stage the participant is not ready to change in the near future, or within 6 months. They are usually sceptical and less conscious regarding the benefits of change.
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Contemplation | The participant is getting ready to start the healthy behaviour within the next 6 months. There is still a degree of ambivalence, however they are becoming more mindful of the advantages of new ways of thinking and behaving.
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Preparation | The individual is ready to take action within the next 30 days. They are taking small steps to behaviour change and possibly communicating their intentions to friends and family.
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Action | The participant’s behaviour has changed within the last 6 months. However it is a period in which relapse is likely.
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Maintenance | At this stage the participant has engaged in the new health behaviour for longer than 6 months.
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Termination | The participant has no temptation and is confident of not returning to the old habit or behaviour. |
The TTM demonstrates that interventions to change behaviour are more effective if they are stage matched, i.e. corresponding to the individual’s mindset and readiness to commence with change, as opposed to the one-size-fits-all generic approach (Prochaska & Velicer, 1997).
Additionally, two cognitive constructs are associated with progress through the stages, namely self-efficacy (the extent of the person’s belief that the goal can be accomplished) and decisional balance or perceived positive and negative outcomes (pros and cons) for the behaviour change (Prochaska, 2013). It should be noted that the Health Belief Model (HBM) (Janz & Becker, 1984), a psychological health behaviour change model, also employs these two cognitive constructs, consequently their value in engaging with employees (and predicting future behaviour) in a health intervention should be emphasised when utilising TTM.
The Processes of Change
By applying the 10 principles/processes appropriately at different stages, resistance is reduced, progress is expedited, and relapse less likely. These include:
Cognitive and affective experiential processes. Consciousness raising, dramatic relief, environmental revaluation, self-revaluation, social liberation.
Behavioural processes. Self-liberation, counter conditioning, helping relationships, reinforcement management, and stimulus control (Prochaska et al., 1997).
Five critical assumptions are applied which help to understand the nature of behaviour and drive theory, research, and practice relating to TTM:
- Behaviour change, in all its complexity, cannot be explained by a single theory, however it is likely that a more comprehensive model will emerge as major theories integrate.
- Behaviour change is a process that unfolds over time through a series of stages.
- The stages can be constant or open to change.
- Traditional action-oriented programmes are not suitable for the majority of the population, who are not in the action stage, but still pre-contemplating or contemplating health behaviour change.
Within each stage, to maximise effectiveness, specific processes and principles for change should be applied to ensure that the individual’s unique situation is considered. (Prochaska et al., 1997)
The Strengths and Weaknesses of the Transtheoretical Model
The TTM was chosen for this paper following an examination of numerous research papers which focused on exercise as a solution to various adverse health behaviours. For example, of 31 stage matched interventions, 25 demonstrated success in motivating participants towards a higher stage which led to increased activity (Spencer, Adams, Malone, Roy, & Yost, 2006). The strength of TTM is that it treats behaviour as dynamic and identifies the stage construct as representing a temporal dimension. It has become one of the most widely used models in improving health and wellbeing and provides valid and reliable measures for promoting exercise (Prochaska et al., 1997).
The adaptability of TTM is most beneficial to practitioners since it can be used across a broad range of health-related behaviours. It can explain and predict an individual’s indicator of readiness to engage in a new health behaviour, which allows for tailored interventions at each stage with respect to timing and subject matter in learning materials (Sarkin, Johnson, Prochaska, & Prochaska, 2001). This was demonstrated by Noar, Benac, and Harris (2007) in a meta-analysis of 57 studies on the use of tailoring health messages in relation to each stage of change via printed media such as pamphlets, newsletters, and magazines.
However, as with all models, several criticisms have arisen of the TTM, via peer led reviews. In a scathing review, West (2005) stated that it was entirely flawed and suggested that explicitly defined stages do not consider the complexity and situational determinants of human behaviour. He argues that the dividing lines between stages need to be more coherent and that any successful outcomes cannot be determined on the model’s merits alone. West elaborated that the model assumed that individuals made coherent and stable plans when, in fact, they do not. The author of this paper suggests that this criticism is erroneous, taking into consideration the behavioural processes and five critical assumptions mentioned above, which account for unpredictable behaviours and the myriad of personalities which choose to engage in behaviour change.
In a published review of 23 randomised control trials, Riemsma et al. (2003) concluded that stage-based interventions are no more effective than non-staged based interventions. They suggested that the issue may not be the model itself, but that its effectiveness was dependent on the competency of the person/s using it. However, this criticism can arguably be applied to all health promotion/behaviour change models. Indeed, it is imperative that practitioners are fully competent in utilising the theoretical concepts of the TTM to benefit fully from its concepts and processes, including how to apply them within the workplace setting (Dawson et al., 2008). Spencer et al. (2006) explained the importance of utilising the whole model rather than aspects of it, with participants engaging fully in the processes of change relevant to each stage.
A Critique of the Transtheoretical Model
Leading philosophers of science agree that theories should fulfil certain criteria. Blalock proposed that they should be clearly articulated, testable, sufficiently complex to provide new insights, adaptable, and grounded in empirical data (Prochaska, Wright, & Velicer, 2008). The following evaluation criteria demonstrates why the TTM is applied so widely in health promotions (Prochaska et al., 2008).
Clarity. Terms and meaning are distinct and internally dependable. Assumptions, propositions and concepts are consistent while the measures used for each stage of change are reliable (Spencer et al., 2006).
Consistency. The essential factors do not contradict each other whilst definitions are logical and rational.
Parsimony. Testable “valid and reliable measures are available to assess stages of change, processes of change, decisional balance and temptations not to exercise, however more research is needed to refine these measures” (Spencer et al., 2006. p.9).
Empirical adequacy. It is possible to establish congruency between the theoretical claims and the evidence. For example, the model can explain why certain behaviour occurred in the past and whether behaviour will or will not occur in the future.
Productivity. The TTM reveals new relationships and ideas. It adds to the knowledge base by stimulating new ways of thinking and provides opportunities for future studies.
Generalisable. The flexibility of the model means it can be applied to different scenarios and disciplines.
Integration. The concepts can be organised and combined in systematic ways – conceptually, empirically, and ideally mathematically.
Utility. The constructs are suitable for application across many workplace health promotion programmes.
Practical and impact. The evidence has demonstrated significant success by producing behaviour change in intervention groups as compared to the control (or placebo) group (Glanz, Rimer, & Viswanath, 2008).
Alternative Theories of Behaviour Change
There are many theories of behaviour change, and each one tends to be more effective for particular units of practice, for example individuals, groups, or organisations. The choice of a suitable theory must be based on the issue, the desired outcome, and units of practice, and not because it is familiar or currently trending (Van Ryn & Heaney, 1992).
For example, the HBM is more suited to women who have personal resistance to obtaining mammograms, or people who are resistant to medical treatment or immunisation. This is because of the primary concepts being predictive, i.e. the reasons that people take action to prevent screening including susceptibility, gravity, benefits and barriers to behaviour, cues, and self-efficacy (Glanz et al., 2008). By encouraging the participant to focus on these constructs, self-awareness is developed which can lead to better informed decision making.
In conjunction with the TTM, the Theory of Reasoned Action (TRA) and the Theory of Planned Behaviour (TRB) is the most popular model currently being used in the workplace. TRA and TRB ise arguably more effective than the HBM since it can be applied more generally outside of the health sphere and help understand the relationships between attitudes, intentions, and behaviours. The model asserts that the key determinant of behaviour is behavioural intention, which is linked to the person’s inherent outlook on life and their subjective norm (Glanz et al., 2008).
For this paper, the TTM was chosen since it has been used extensively in health behaviour interventions. It is open to adaptation as new theoretical insights and concepts emerge around health behaviours, while authors have described it as intuitively plausible, since it matches needs across the constructs. The model’s flexibility can be demonstrated effectively in many settings, for example primary care, churches, schools, and worksites (Prochaska, Wright, & Velicer, 2008).
A Critical Literature Review of Previous Workplace Health Promotion Studies that Utilised the TTM to Improve Health Behaviours
A systematic search via Google Scholar was conducted using variations on the keywords ‘sedentary’, ‘workplace’, ‘TTM’ and ‘stages of change’. It revealed a lack of research on use of the TTM to reduce sedentary behaviour in the workplace.
Consequently, for the purpose of this paper, consideration will also be given to interventions in the workplace that focused on increasing physical activity.
In a study of 50 office workers in Perth, Parry and Straker (2013) established that sedentary behaviour accounted for 81.8% of time spent at work, which equated to 15.3% of light activity and 2.9% of moderate/vigorous physical activity. They concluded that more regular breaks (termed light activity) should be encouraged by the employer which can have enhanced benefits for health, for example pacing while talking on a mobile phone, lunchtime walks, and placing printers and water machines further away from work stations. However, future research needs to focus on optimum ways in which light physical activity can be integrated into the workday routine without affecting productivity. Additionally, there needs to be more clarity on the amount of light activity required to have health benefits. The study clearly established that the workplace encourages sustained sedentary behaviour and employers need to reconsider their responsibilities in terms of a ‘duty of care’ towards their workers.
The author implemented an intervention at a London University, the ‘Virgin Pulse Global 100 Day Challenge’, to increase physical activity over a period of 100 days, with 14 members of staff at a London university. It resulted in a decrease in sedentary periods, since participants were evidently eager to increase their steps throughout the day with lunchtime walks, walking meetings, and other activities that reduced time spent sitting. In fact, in a period of 100 days the participants walked a momentous 7,371 miles (monitored via step counters). We hypothesized that by increasing physical activity, sitting time decreased.
However Han, Gabriel, & Kohl (2017) suggested this assumption is incorrect, having engaged in a study to determine 225 college students’ motivational readiness to change their sedentary behaviour and the link to physical activity using the TTM constructs. Surprisingly, they found that sedentary behaviour reduction is not linked to increased physical activity. This has implication for health practitioners who ‘should consider physical activity promotion and sedentary behaviours reduction as two independent intervention goals instead of conflicting’ (p.1).
A randomised controlled trial was conducted by Proper et al. (2003) on three municipal services with an intervention group (n – 131) and control group (n – 168). Questionnaires, physical fitness tests, and structured interviews were used to gather data.
During a 9-month period, the intervention group was offered seven private counselling sessions which were based on each individual’s stage of change and the Patient-centred Assessment and Counselling for Exercise and Nutrition (PACE) programme was adopted as a framework for delivery. Despite there being no statistically significant changes in the control group, the study provided evidence that use of counsellors with the stages of change model helped to reduce sedentary behaviour among workers. Noteworthy improvements were made regarding cardiorespiratory fitness, blood pressure and cholesterol, and degree of body fat. Several limitations of the study were identified; contamination is likely to have occurred since both study groups worked in the same services and a number of inactive subjects or pre-contemplators were unwilling to change their activity. Consequently, the results were mainly limited to the people who were in the contemplation stage or action stages.
The benefits of utilising counsellors in workplace health programmes should not be overlooked since they have the skills to build rapport, demonstrate empathy, and help subjects to fulfil their goals. This was highlighted by Saliba and Barden (2017) when they integrated coaching and motivational interviewing based on the TTM. This approach ensured that participants were given tailored advice relative to the TTM model in areas such as decisional balance and self-efficacy (Prochaska & Velicer, 1997).
Not all employers have the budget to engage counsellors for one-on-one treatments, for example small businesses. Therefore, for a more cost-effective approach, a counsellor can utilise the TTM and simultaneously fulfil the role of facilitator in psychoeducation group work. This allows participants to share experiences in safe ‘classroom like’ settings. It can help to formalise learning and encourage a theoretical based approach (Saliba & Barden, 2017). This model encourages social interactions, which lead to supportive relationships and better states of mental health (Seeman, 1996). Consequently, it is reasonable to surmise that improved mental health can lead to better engagement with the programme
Alternatively, and in terms of cost savings, minimal contact, self-help programmes can be applied to much larger groups (Griffin-Blake & DeJoy, 2006). This was demonstrated in a randomised trial involving 208 participants in a TTM stage matched (n.115) vs. social cognitive (non-stage matched) (n.93) physical activity workplace intervention. At baseline, participants were given printed self-help exercise booklets of 12-16 pages with content that corresponded with either one of the above-mentioned interventions. One month later a follow-up assessment was conducted.
Surprisingly, both interventions were equally effective in moving participants to a higher level of activity or readiness to change. One-third of all participants – i.e. from both groups – demonstrated stage progression. This outcome illustrates that the TTM should not always be the preferred option for workplace interventions if the desired outcome can be achieved by use of key constructs from social-cognitive theory. Indeed, in an intervention to increase physical activity among 70 sedentary office workers at a Korean airline company, by developing self-efficacy as suggested by the social-cognitive theory, there was a positive change in behaviour. A total of 55% of participants completed the programme and daily steps increased from an average of 5,800 to 9,200. Additionally, fat mass, waist-hip ratio, and BMI decreased (Chae, Kim, Park, & Hwang, 2015).
The processes of change (as mentioned previously) are covert and overt activities that participants can utilise to progress through the stages of change. One could argue that to a large extent this encourages them to view their commitment, participation, and overall objective through a biopsychosocial lens (Santrock, 2007) which prevents narrow mindedness and augments an expanded view of the intervention.
For example, for someone in the pre-contemplation stage, consciousness raising can help to increase awareness about the cause and effect of unhealthy behaviours. Environmental revaluation can highlight the effect of personal choices on others and the environment, while helping relationships can provide moral and social support. Workers in the preparation stage should be encouraged to focus on the pros of changing while use of the self-efficacy constructs helps to alleviate fears of failure (Glanz et al., 2008). Additionally, by measuring the motivational and cognitive aspects of decision making, predictable relationships can be found across the stages. For example, pre-contemplators are more likely to be pessimistic about the benefits of change and resistant to taking the first step, whereas those in the action stage tend to be more engaging and positive about behaviour change (Prochaska, 2008).
Peterson and Aldana (1999) employed stage-based tailored messages, motivational resources, goal setting and relapse prevention material in an intervention to promote physical exercise among sedentary workers. Use of colour, clever titles, and process driven question and answer exercises aided in stimulating the participants’ thought processes in areas such as self-re-evaluation and self-liberation as proposed by Prochaska et al. (1997) in the processes of change framework. The results were very positive, with the stage based group demonstrating a 13% increase in activity while the generic message group reporting only 1% increase in movement from lower stages to higher stages.
Research is necessary to establish how to recruit more precontemplators and contemplators in interventions since, unsurprisingly, the majority of self-select participants are in the preparation or action stage. This was highlighted by Dawson, Tracey, and Berry (2008) who compared two activity based interventions, i.e. group-based and internet-based. By encouraging all employees to fill out the questionnaire regardless of whether they intended to participate, the researchers gained valuable information on the reasons that employees were reluctant to engage with the programme. This type of information can be helpful for health practitioners who are struggling to engage workers inclined to be couch potatoes.
Both groups were required to complete the stages of change algorithm (Marcus, Rossi, Selby, Niaura, & Abrams, 1992) and both interventions were as similar as possible in terms of information delivery and stage matched material. The results were positive only for the group-based participants who showed an increase in physical activity and self-efficacy.
However, the internet-based group showed improvements in life and job satisfaction scores, a fortunate outcome for their mental health and wellbeing. A limitation of the study was the low response rates to the pre-test and post-test questionnaires while a number of participants did not complete the intervention.
This flags up a concern regarding recruitment and retention, which is a consistent issue in health and wellbeing intervention programmes and an area for future research. This issue is experienced frequently by practitioners of workplace health programmes (Saliba & Barden, 2017) and (Peterson & Aldana, 1999). In a meta-analysis of 125 studies, Glanz et al. (2008) found that the average retention rate was 50% with few dependable predictors of premature termination. Despite this, they concluded that the best way to retain participants was to match the intervention to the stages of change model.
Conclusion
An emerging field of research continues to highlight the negative consequences of sedentary behaviour on the health of the population. Unabated technological advancements requires prolonged periods of sitting, and workers are suffering from the health consequences. While the issue affects society at large, the adverse implications for employers extends to financial losses relating to absences from work, presenteeism, and/or loss or productivity.
The author of this paper is aware of only one nationwide health initiative which seeks to reduce sedentary behaviour in the workplace, specifically the Get Britain Standing/Sit Less Move More campaign, which is insufficient to change perceptions and more resources are required to increase awareness around the issue. Solutions for reducing time spent sitting and increased physical activity needs to extend beyond lunchtime walks and include renewed ways of working which do not affect productivity and business objectives.
It is recommended that accelerometers become freely available to staff, which can track movement (other than vertical) during waking hours and provide valid measures of low energy expenditure. By providing tangible evidence on the amount of time spent sedentary, workers will be encouraged to reconsider their lifestyle habits and make healthier choices.
A search of the academic literature on the topic revealed copious amounts of workplace interventions that focused on increasing physical activity, but very few around reducing or breaking up sedentary behaviour, particularly in conjunction with the TTM. The adaptability of the TTM is ideal for shaping interventions that seek to reduce sedentary behaviour, however there is a dearth of evidence to conclusively prove whether such an approach is effective or not.
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