Attitudes to and perceptions of workplace health promotion amongst employees from ethnic minorities in the UK: A scoping review

2.1.1Identifying the research question

Scoping reviews enable a much broader view of the evidence base, yet Levac et al. [15] recommended the importance of combining this with a more detailed scope to focus the search strategy. The PICO framework introduced by Richardson et al. [17] supports this process when seeking both qualitative and quantitative literature. The research team determined the scope and formulated the research question, which was to ascertain what the evidence could reveal about the experience health & wellbeing of ethnic minorities at work, based on this framework (Table 2).

2.1.2Identifying relevant peer review studies and grey literature

Criteria for a full systematic search of relevant citations was decided upon by the research team. Anticipating a low number of relevant papers, the research team opted to include studies that either took place in a UK workplace or that had relevance to the UK workplace. Systematic searches were conducted using PubMed, SCOPUS, and The Cochrane Library. The search criteria are outlined in Table 2.

In addition, three journals highlighted as specifically relevant by the research team were hand searched via contents, title and abstract for further relevant studies. A further two journals were included in the hand search in response to the frequency with which articles from these journals appeared in the reference lists of other review articles on similar topics.

Furthermore, the research team developed a comprehensive list of websites from predominantly UK-based organisations that warranted an independent search for relevant grey literature (Table 3). These websites were searched for literature related to ethnic minorities in the workplace.

2.1.3Selecting studies

References were imported into Endnote and duplicates removed. Titles and abstracts were screened in Endnote, with relevant texts obtained for full text screening. The inclusion and exclusion criteria for screening are presented in Table 4.

Full-text screening was conducted by two researchers (ES, KP) working independently with any differences of opinion regarding inclusion discussed by a third reviewer (AC). The PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) flow chart was used to report results.

2.1.4Charting the data

A data charting form was created by the researchers undertaking full text screening (ES, KP) to enable data extraction, with any differences of opinion related to included content resolved by a third reviewer (AC). Key information extracted during this phase is outlined in Table 5. A quality appraisal of the included studies was conducted by a fourth reviewer (KG) using the CASP questions for qualitative literature [16].

2.1.5Collating, summarising and reporting the results

Following the conventions described by Levac et al. [15], a descriptive summary of the data was prepared, with careful reference to the original research questions and purpose of review, and implications for future research, practice, and policy were considered.

2.1.6Consulting knowledge users

The research team consulted with stakeholders at a UK-based private sector provider of workplace wellness solutions during the review process to ensure that the reported results and method of reporting had commercial relevance and were suitable and appropriate for organisational use.

3.1.1Identifying and selecting articles

3.1.1.1Academic literature

Initial database searches yielded 3,914 results, after duplicates were removed 3,689 were retained for title and abstract screening. Following title and abstract screening, 3,676 articles were deemed not relevant, with 13 retained for full-text screening. A further 21 articles were retained for full text screening from hand searched journals, leaving a total of 34 papers for full-text review. Only three articles met the criteria and were included in the final review. Results are outlined in Fig. 1 using an adapted PRISMA flow chart.

Fig. 1

Adapted PRISMA flow chart. *Journals hand searched: International Journal of Workplace Health Management (9 papers found), Journal of Occupational and Environmental Medicine (5 papers), American Journal of Health Promotion (5 papers), Ethnicity and Health (56 papers), Journal of Racial and Ethnic Health Disparities (18 papers).

3.1.2Charting, collating and summarising results

3.1.3Consulting knowledge users

The research team prepared a draft project report for the private sector collaborator, with a meeting arranged to disseminate, discuss, and interpret key findings via a presentation to key stakeholders from the business, prior to finalisation of the results.

3.2.1Cultural adaptation of health interventions in the community

Database searches yielded a total of 10 papers from the community literature and four papers from the cultural adaptation literature with relevance to the perceptions and attitudes of ethnic minorities to health and wellbeing interventions in the community (Table 8).

4.2.1Peer reviewed articles

Findings from the paper by Bertotti et al. [18] suggested that Chinese Employers in London had a reactive approach to health and wellbeing at work and would need a convincing business case to change practices. Views were affected by whether the business owners were first generation Chinese or British born, with the latter more willing to take on Western business approaches including workplace wellbeing policies and resources. Employees in this study were all Chinese, and problems highlighted included poor mental health and poor working conditions and wages –something the employers seemed unaware of.

This paper identified fundamental issues that needed to be addressed in Chinese-owned businesses that included basic health and safety, as well as a lack of workplace wellness engagement. Participants were from a limited business sector of English-speaking businesses, who volunteered to take part, so these results may not be generalisable to Chinese workers in other non-Chinese owned businesses. Indeed, other Chinese owned businesses who did not volunteer may have business environments that are more or less supportive of worker health.

Only the paper by Verburgh et al. [19] was based around an intervention ‘the Work-Life Program (WLP)’, which explored the impact of the programme on women’s health and work functioning in a Dutch medical centre. The programme demonstrated impact, with menopausal symptoms significantly improving following the intervention despite work-related parameters remaining unchanged. The qualitative findings suggest that female workers in low paid jobs experienced a positive impact from the WLP. The WLP was reported to empower them to make choices that benefit their health and wellbeing both at work and in their private lives, through a process of mental empowerment.

Although there is limited insight regarding reasons for engagement in the trial, participants highlighted that the WLP offered opportunities not usually available to them in their culture, specifically the discussion of menopause, midlife changes, and their own needs. Participants were not recruited based on any specific issues related to the topic of interest and came from diverse ethnic backgrounds preventing results from being representative across a particular population.

The second paper by Verburgh et al. [20] reported results relating to reaching and engaging women from ethnic minorities in workplace health promotion, although the minorities under study were categorised as ‘mixed’ and were not specified by ethnicity. The study design included many cultural adaptations, which may have aided recruitment and engagement. Recruitment activities, including personalised letters and an additional information meeting with a line manager of similar ethnic background present. This led to a diverse range of women from different ethnic backgrounds participating in the programme.

The key programme facilitators were reported to be: (1) accessibility of offering sessions in the workplace and in work time; (2) programmes tailor-made and both individual and group sessions available; (3) practical support for low literacy and language barriers; (4) female facilitators/professionals especially for women from non-western backgrounds. Barriers to participation were similar to those reported in non-ethnic minority groups and included: (1) creating time in the workday to attend sessions; (2) inconsistent time intervals between sessions; (3) availability/location of rooms for sessions.

Although the overall quality of the literature was reported as moderate to high, the strength of evidence is severely limited by the small number of papers and participants, with the included ethnic minorities of limited relevance to the dominant ethnic groups in the UK workforce (South Asian and Black). Direct evidence relating to perceptions and attitudes of minority groups to wellbeing interventions in American workplaces is similarly lacking. US-based research suggests that interventions should focus on proactively addressing the issues of discrimination and inclusion to support employee health, as these are the issues that individuals report to have the greatest bearing on sense of wellbeing at work [21, 42].

4.2.2Grey literature

Although there was a wealth of grey literature on workplace health and wellbeing, only a small amount of literature referred to race or ethnicity. However, this literature did not go beyond reporting data by ethnicity [22] and providing recommendations for future research based on the lack of evidence on specific needs and intervention effectiveness in different ethnic groups [23, 24, 42]. There was no direct information on the attitudes and perceptions of ethnic minorities in relation to workplace health and wellbeing or reports on intervention effectiveness.

4.3.1Dimensions of ethnicity

When looking at designing interventions to better support ethnic minorities it is important to understand that ethnicity has many dimensions. Liu et al. [12] outlined five overlapping components: physical features, ancestry, language, culture, and religion. Furthermore, even in individuals who have the same ethnicity there may be different needs depending on gender, age generation, migration history and socio-economic background [25].

4.3.2Cultural adaptations of health and wellbeing interventions

There is a lack of clear evidence in the research literature on how best to adapt health promotion interventions to better support people from ethnic minorities. Yet adaptations have the potential to increase the effectiveness of interventions, by improving uptake and acceptability across the whole population [12].

Cultural Adaptation is “the systematic modification of an evidence-based treatment (or intervention protocol) to consider language, cultural, and context in such a way that it is compatible with the client’s cultural patterns, meaning, and values.” [26]. One of the earliest studies to look at cultural adaptation was based on the development of psychosocial treatments with a Hispanic population [27]. Bernal et al. [27] identified eight dimensions for treatment interventions that could be adapted; language, persons, metaphors, content, concepts, goals, methods, and context. More specifically related to health interventions, Netto et al. [28] outlined five principles for adapting health promotion interventions in the community. These principles have potential use within the workplace, with potential examples for this context outlined in Table 9.

Liu et al. [12] used these five principles to set out a programme theory of adapted health promotion interventions (Fig. 2). These principles and theories were developed for use with community health interventions, yet few research studies have robustly tested the impact of implementing them in the community or workplace [12, 29]. In a recent review by Self et al. [30], 10 studies were identified as using culturally adapted motivational interviewing to promote behaviour change and reported that the culturally adapted intervention produced significantly better results for the primary outcome tested. However, data is still limited and has not been tested on health and wellbeing programmes in the workplace, yet they have the potential to provide a good starting point when designing or adapting health interventions for minority groups in the workplace.

Fig. 2

Programme theory of adapted health promotion interventions with examples of adaptations at each stage, reproduced from Liu et al. [12].

4.3.3Community health, wellbeing and lifestyle interventions targeting UK ethnic minorities

Data on wellbeing and lifestyle interventions to improve health for ethnic minorities are scarce. There is slightly more research across the US, but in Europe this is limited. Nearly all studies in Europe are with South Asian groups and are community based [2]. The South Asian population is the fastest growing minority in Europe [31]. Learnings from qualitative literature that has looked at perceptions and attitudes including barriers and facilitators to leading a healthy lifestyle is scarce. A summary of common findings is outlined in Table 10.

4.3.4Useful research methods for programme design

When designing research with any group of individuals, one of the most crucial things is to talk to those who are going to use the service. This is often classed as ‘people-centred’ design or co-design and at the very least should include patient or public involvement. Patient and Public Involvement and Engagement (PPIE) entails research being carried out ‘with’ or ‘by’ members of the public, rather than ‘to’, ‘about’ or ‘for’ them [32]. Key stages of co-design include exploring the problems, identifying priorities, ideating, and finalising solutions tailored to the local context, implementing these solutions with and for the people for whom it is designed, ensuring the results meet their needs and are usable [33]. Research methods suitable for developing interventions using a co-design approach include, patient/public involvement (PPI), focus/discussion groups, interviews, surveys, questionnaires.