Acceptability and feasibility of potential intervention strategies for influencing sedentary time at work: focus group interviews in executives and employees

Sedentary behaviours -any waking activity characterized by an energy expenditure ≤1.5 metabolic equivalents (METs) while being in a sitting or reclining posture [1,2]- have been identified as a potentially-unique health risk [3,4]. Cross-sectional and longitudinal studies have shown higher amounts of sedentary time, after controlling for moderate-to-vigorous physical activity, to be associated with obesity, metabolic syndrome, type 2 diabetes, cardiovascular disease (CVD), some cancers, mental disorders, and all-cause and CVD mortality in adults [5-16]. Breaks in prolonged sedentary time have been found to be associated beneficially with waist circumference, body mass index (BMI), triglycerides, and 2-hour plasma glucose, independently of the total time spent sedentary [17]. In summary, both the total amount of sedentary time and prolonged periods of uninterrupted sedentary time may have adverse health effects in adults.

Sedentary time occurs in a variety of settings: the domestic/leisure time environment; the occupational environment; and during transportation, with potentially different behavioural determinants at multiple levels in each of these settings [18]. Occupational sedentary time can be the largest contributor to overall daily sedentary time in white-collar workers [19]. An Australian accelerometer-based study for example revealed that full-time employed adults spent on average 6.8 hours/day sedentary at work [20]. In a review specifically focusing on sedentary time at work [19], the majority of prospective studies found occupational sedentary time to be associated with a higher risk of type 2 diabetes and mortality. Therefore, there is the need to develop and test public health intervention strategies focusing on reducing and interrupting occupational sedentary time. In the process of intervention development [21,22], an important aspect is testing the acceptability (are those likely to be affected by the intervention willing to receive the strategies?) and feasibility (is it realistic to consider implementing the proposed strategies?) of potential intervention strategies in particular contexts. This might prevent implementing an intervention that does not apply to the target population or is for example too costly to implement. A commonly used method to gain detailed insight into what, how and why strategies are found to be acceptable and feasible, is the focus group interview [22].

Only limited evidence is available on acceptable and feasible ways to influence adults’ occupational sedentary time. A qualitative analysis from the USA provided support for the acceptability and feasibility of health-promoting work breaks (Booster Breaks), however barriers were also identified, including a lack of variety in routines and a lack of management support [23]. In an Australian qualitative evaluation of an e-health intervention designed to reduce prolonged occupational sitting, some negative outcomes (disruption of work flow and work habits) were reported, in addition to positive outcomes [24]. Strategies suggested in focus groups with Australian office workers included workload planning (interspersing sitting and non-sitting tasks), environmental changes (e.g. stairwell access, printers away from desks), adding movement to some work tasks (e.g. walking meetings) and purposive physical activity (e.g. periodic breaks, exercise/walking groups) [25]. Enabling strategies identified were team leader involvement and manager support; the main barrier to their implementation was the possibly negative impact on productivity. Another Australian qualitative study with occupational health and safety practitioners revealed ideas for strategies including both offering choices to stand more (e.g. sit-stand desks) and obligating changes (e.g. centralising printers) [26]. Again productivity concerns were cited as a major barrier for change. Qualitative analyses in other (European) countries are recommended in order to generalise findings beyond Australia, [25,26] because workplace management practices, regulations, and cultures can differ between continents or countries [27]. In addition, the concept of sedentary behaviour is very new in Europe and not yet well-known to the general public, which is in contrast to what is the case in other countries, particularly Australia.

In the context of any workplace innovation, executives and senior managers are an important stakeholder group [26] and this is particular the case in relation to understanding the acceptability and feasibility of potential intervention strategies to influence occupational sedentary time. Therefore, qualitative data were collected via focus group interviews of employees’ and executives’ opinions on occupational sedentary time and on potential intervention strategies to reduce and interrupt sedentary time on a working day. The purpose of the present study was to test acceptability and feasibility of developing and implementing workplace interventions to reduce or interrupt sedentary time.

Focus group interviews with Flemish employees and executives identified several relevant sets of perceptions of occupational sitting and the acceptability and feasibility of workplace intervention strategies to reduce and interrupt occupational sitting. These findings have implications in European context for the development and implementation of interventions aimed at influencing sitting at work.

These employee and executive reflections on occupational sitting point out the potential lack of knowledge concerning the current evidence on sedentary behaviour, resulting in several questions about health-related sedentary behaviour (how long can we sit?, why should we interrupt?), doubts about the healthiness of standing, and linking sitting particularly with musculoskeletal health problems. The latter was also found in another study [25]. The European tradition of occupational health and safety regulations strongly focussing on ergonomics may be an explanation for the present way of thinking of employed adults [38,39]. The findings also point out that in Europe people are not familiar with the concept of sedentary behaviour and health and do not yet see this behaviour independent of physical inactivity, which is in contrast with Australian findings [25]. These results imply that more information or education is needed on the recent insights regarding sedentary behaviour, including the independent metabolic and chronic health risks of prolonged sitting. In previous worksite interventions promoting health-related behaviours other than sitting, (group) education was also part of the programs [40,41] and a review showed that the provision of education was an effective strategy to promote physical activity in the workplace [42]. Future studies will need to confirm the impact of educational aspects in workplace interventions aimed at influencing sitting, however a pre-intervention education session was found to be an effective mechanism for decreasing prolonged employees sedentary periods and increasing movement throughout the workday in Australian desk-based workers [43]. In practice, it might be convenient to add the current sedentary behaviour knowledge to existing ergonomic programs and to sensitize occupational physicians and workplace prevention coordinators to support this evidence. Present results also plead for the development of clear evidence-based health-related guidelines of (domain-specific) sedentary behaviour, next to those for physical activity [44,45], as these are not available in the literature at this moment.

The strategies identified for reducing and/or interrupting occupational sitting time correspond to the ecological model on sedentary behaviour, as strategies at the individual, social, organizational and environmental level were suggested [18]. Overall, the strategies found to be acceptable were mainly similar to those suggested in focus groups among Australian employees [25] and those implemented in a multicomponent intervention in Australian office workers [46]. Further research is needed to examine the actual influence of these suggested strategies on behaviour change in future interventions focussing on occupational sitting; however the evidence of effectiveness at this stage, while limited, is nevertheless promising [46,47].

The main barriers seen to be compromising the acceptability and feasibility of the strategies were comparable to those found in similar studies. In the focus groups of Gilson et al. [25], the potential loss of productivity and focus was the primary barrier for employees, followed by negative responses from management. Australian occupational health and safety (OHS) practitioners also had productivity concerns as a main influence for change [26] and a negative outcome reported in the evaluation of a workplace intervention to reduce prolonged occupational sitting was the disruption of the work flow [24].

Concerns about the practicality, cost and organization of several strategies were also reported in the focus groups of Gilson et al. [25]. The use of standing desks for example, implies a substantial perceived investment cost making this acceptable strategy less feasible. A qualitative evaluation of sit-stand desks in an Australian workplace showed, however, that sit-stand desks had high usability and acceptability and reduced sitting time at work [48].

The present findings have some practical implications for future interventions:

First, given the fact that sitting was recognized to be an easy habit which is hard to unlearn, continuous awareness raising seems needed. A study of Conroy et al. [49] indeed confirms that sitting is a daily process partly regulated by habits.

Second, simply asking people to stand up was perceived not to be acceptable by the study participants, suggesting that employees currently are not being autonomously motivated to change their sitting and stand up [50,51]. Alternatives to only standing as an alternative to sitting seem to be needed in order to promote change in sitting behaviour; and potentially a motivational intervention component might be needed to assist workers to formulate their own relevant alternative strategies.

Third, strategies should be simple and easy to implement, while not decreasing productivity and task focus. Employees’ perceptions of social support from management should be increased, which may happen if executives act as role models. The latter was also reported as an enabling factor by the present employees. In a study evaluating health promoting work breaks, a need for greater management support was also identified [23]. Having role models in the media, together with more media attention to workplace sitting, may also help to increase the perception of social support.

Finally, there is a need to take into account what has emerged from our study showing that employees and executives can think differently about some of the factors related to workplace sitting. Multiple approaches may be needed. For example, making some strategies obligatory was considered to be a facilitating factor for employees, while executives believed that employees should have the personal choice to decide about such matters for themselves. Such an apparent disjunction between providing employees with personal choices and making sitting-related changes obligatory was also identified from focus groups conducted with Australian OHS practitioners [26]. The fact that the participants in our study identified sitting as a strong habit that can be difficult to change may be related to employees identifying that some forms of organisational compulsion may be required. However, any suggestions about the use of a forced computer lock-out system were rejected immediately during these focus groups, while there were more positive reactions identified in Australian focus groups [25]. The present finding is also in contrast to what emerged among Australian employees of a professional workplace who were willing to accept a 26 weeks persuasive e-health intervention system with an element of compulsion [52]. Moreover, in this Australian study, the pop-up prompt, deactivating the screens every 45 minutes, was found to be effective in increasing non-purposeful movement at work [53]. Another aspect on which employees and executives did not fully agree was the intervention approach. Employees expected a top down intervention (with some obligatory strategies), while executives believed that intervening should be a shared responsibility. In Australian employees, workplace interventions were considered to be a joint responsibility of employees and the organisation [25].

The present study has some limitations that need to be considered. First, participation was voluntary, which may have resulted in recruiting employees and executives who potentially have unrepresentative perspectives. In addition, the sample of employees was mainly female. These weaknesses may compromise representativeness of the sample and generalizability of the findings. Furthermore, because of the open-ended recruitment approach that was used, information is not available on how many of those potentially eligible did not express interest in participating. Second, it cannot be assumed that participants have a comprehensive understanding and insight into the nature and extent of their own occupational sitting, nor of the causes and health consequences of sitting too much. These findings are perceptions of the participants and should not be interpreted as representing what is actually the case in their workplaces. However, we believe that these perceptions are of relevance and can be taken into account when developing intervention strategies to address occupational sitting. Finally, no participants used public transport to commute, resulting in the fact that this theme was not addressed during the focus groups. A unique aspect of our study is that our focus groups included executives, which is one of the major strengths of the present study. In addition, no other European qualitative study on this topic has yet been reported.

In summary, the present findings indicate that Flemish employees and executives were largely unaware of current knowledge about sedentary behaviour and health and the implications of this evidence for workplace policy and practice. Nevertheless, potentially relevant and plausible strategies mainly at the social, and environmental level were suggested to primarily interrupt sitting time during working hours. Overall, such strategies were perceived as potentially useful. However, the implementation of these strategies during working hours appeared to our participants to be likely to be unacceptable or unfeasible, as most strategies were perceived to be counteracted by barriers, such as concerns about productivity, practicality and costs, the awkwardness of standing, and the habitual nature of sitting. Overall, raising awareness, providing health-related alternatives for standing, providing some acceptable obligating strategies for employees, but also leaving the choice to decide and employees taking responsibility were considered to be facilitating factors and would increase acceptability of the intervention.

This study provides new perspectives with the potential to inform the development of workplace sitting interventions in a European context. However, additional research into the factors influencing occupational sitting time in different countries and in the different context of their workplace cultures and practices, is needed. At this stage, it seems likely that future programs need to be multi-component interventions focusing on informational, educational and motivational strategies on the individual, social, organizational, and environmental level. The effectiveness and sustainability of these strategies should be examined in further research.

The authors are grateful to all employees and executives who volunteered to participate in this study. This work was carried out as part of a study funded by the Department of Welfare, Health and Family, Flemish Government, Flanders, Belgium. KDC is supported by the Research Foundation Flanders (FWO) (postdoctoral research fellowship: FWO11/PDO/097).

Katrien De Cocker, Email: Katrien.DeCocker@ugent.be.

Charlene Veldeman, Email: charleneveldeman@hotmail.com.

Dirk De Bacquer, Email: dirk.debacquer@ugent.be.

Lutgart Braeckman, Email: lutgard.braeckman@ugent.be.

Neville Owen, Email: Neville.Owen@bakeridi.edu.au.

Greet Cardon, Email: greet.cardon@ugent.be.

Ilse De Bourdeaudhuij, Email: ilse.debourdeaudhuij@ugent.be.