Wellness Program for EAMC Personnel: Challenges to Effect Change in Perception, Behaviour and Attitude

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Abstract

The continuing rise in the prevalence of obesity calls for policies and strategies to address obesity and its resulting health- related problems. Implementing intervention programs on healthy weight management in the healthcare setting is challenging. Issues to consider are: management support to the program, physical and human resources to carry out the program, and the target group-the healthcare personnel-and their perception, and reception of the program. It is ironic that as healthcare personnel speak of and labour to prolong life and improve the quality of living between now and death, they themselves neglect to live a healthy life. The main concern here is the healthcare personnel, particularly their attitudes and behaviour, influenced by the organizational culture and individual beliefs, as one major challenge in the implementation of programs to address obesity. Among the lessons that could be learned from successful programs in the healthcare settings are: having clear plan of action, obtaining full support from management, creating a core team, innovating and maximizing resources, strengthening linkages, providing education, counselling, and a program of physical exercise. Following the causation pathway of weight problems- from environmental, lifestyle, and individual causes- obesity can be prevented through dedicated and concerted efforts to motivate behavioural change, and influence feelings and beliefs in an identified specific health concern, which is obesity.

Keywords

Obesity; East Avenue Medical Center (EAMC); Behavior and attitude

Background of the Study

This study narrates the experiences of the Public Health Unit’s initiative to start a wellness program for East Avenue Medical Center (EAMC) personnel. The program was conceptualized to address the observed problems of overweight and obesity in EAMC.

In an assessment conducted by the Public Health Unitin 2010, the need for a weight management program in East Avenue Medical Center came out borne by these statistics:

a- 61.62% of the doctors (61 out of the 99 respondents from the Medical Service) are obese.

b- 16.67% of the personnel (9 out of the 54 respondents from the Para- Medical Service) are obese.

c- 37.90% (130 out of the 343 nurses and nursing aides) from the Nursing Service are obese.

d- 40.32% (200 out of the 496 respondents) of the EAMC healthcare workers are obese.

e- 11.09% (55 out of the total sample population of 496) are obese males.

f- 29.23% (145 out of the total sample population of 496) are obese females.

g- 27.50% of the obese EAMC healthcare workers (55 out of 200 obese populations) are males.

h- 72.50% of the obese EAMC healthcare workers (145 out of the 200 obese populations) are females.

i- Among the obese males, incidence of obesity is highest in ages 46-50 with 23.64% (13 out of 55).

j- On the other hand, incidence of obesity among the obese females is highest in ages 56- 60 with 17.93% (26 out of 145).

The following tables show the frequency distribution and percentage of obesity rate, including obesity rate by gender and by age, among EAMC personnel (Tables 1-3).

It is important that healthcare personnel are healthy (or at least appear healthy), as they are considered credible authorities to talk about health and are being looked upon and trusted to be persons that are capable of carrying out health management and plan of care.

Health, as defined by the WHO, is a state of complete physical, mental and social well- being and not merely the absence of disease or infirmity. The main goal of healthcare therefore is not only to prolong life but also to improve the quality of life.

Statement of the Problem

The observed prevalence of overweight and obesity continues to rise in all sectors of the Philippine population, including the health sector [1]. This reality is a growing problem spelled out, calling for appropriate and committed actions.

Recognizing the fact that overweight and obesity is both a shortterm and long- term threat to the health and productivity of affected individuals, the East Avenue Medical Center, through the Public Health Unit, has conceptualized an integrated wellness program in the workplace, with the greatest attention on the weight management program.

Measures to prevent and manage obesity were initiated, but implementation of the program has faced a lot of challenges revolving around the health workers’ perception, behavior and attitude towards the program, to begin with.

Limitations of the Study

The content focus of the study is limited to the implementation of the wellness program in East Avenue Medical Center (2010 to present): the challenges in the initiation of implementations, and the revisions and modifications of strategies to effect change in the perception, behavior and attitude of the target group- the healthcare personnel. The core concept of the wellness program is to promote health through healthy lifestyles among the health workers.

Healthcare workers, as defined in this study, are the doctors, nurses, nursing aides, and the personnel in the Para- Medical Services.

Methodology

This is a comparative study of the EAMC personnel’s adherence to the Wellness Program when it was initiated in 2011 and when it was formally re-launched in June, 2013. As it narrates the experiences of the Public Health Unit’s efforts to start (and sustain) a program on wellness, it also identifies and analyses the challenges and difficulties that came along its implementation.

Obesity

Obesity is a leading preventable cause of death worldwide, with increasing prevalence in adults and children, and authorities view it as one of the most serious public health problems of the 21st century [2].

Before the 20th century, obesity was rare [3]. In 1997, the WHO formally recognized obesity as a global epidemic [4]. In 2008, 35% (more than 1.4 billion) of adults aged 20 and older were overweight, and 11% were obese [5]. In 2013, the American Medical Association has classified obesity as a disease.

In the Philippines, the nationwide nutrition survey conducted by the Food and Nutrition Research Institute of the Department of Science and Technology (DOST- FNRI) in 1993 showed that 14% of Filipinos 20 years old or older are overweight, while 2.6% are obese. When translated in absolute figures, there are 5.7 million Filipino adults who were either overweight or obese in 1993 [6]. In a survey by the National Statistics Coordination Board (NSCB) on 2008, data showed that 26.6% of Filipino adults are overweight, and 5.2% are obese [7].

Measuring Overweight and Obesity

Overweight and obesity is generally defined as having more body fat than is optimally healthy [8]. It is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/ or increased health problems.

Body Mass Index

Body Mass Index (BMI) is a simple index of weight- for- height that is commonly used to classify overweight and obesity in adults. It is defined as a person’s weight in kilograms divided by the square of his height in meters (kg/ m2) [9].

Where BMI ≥ 25 is overweight and BMI > 30 is obese

BMI provides the most useful population- level measure of overweight and obesity as it is the same for both sexes and for all ages of adults. However, it should be considered a rough guide because it may not correspond to the same degree of fatness in different individuals [10].

Weight-for-Height

Another method often relied upon to gauge obesity is the weightfor- height table, where the range of acceptable weights for a person of a given height is indicated.

A significant limitation of the weight- for- height table, however, is that it does not distinguish between excess fat and muscle. A very muscular person may be classified by the table as obese when he/ she, in fact, are not.

Hip-Waist Ratio

The hip- waist ratio (WHR) has been used as an indicator of the health of a person and the risk of developing health conditions, thereby making it as a reliable measurement of obesity. Calculation is as simple as by dividing the waist circumference by the hip conference of an individual.

As guided by the data gathering protocol of the WHO, waist circumference should be measured at the midpoint between the lower margin of the last palpable rib and at the top of the iliac crest, while the hip circumference should be measured around the widest portion of the buttocks, with the measuring tape parallel to the floor.

Where obesity is: WHR.0.90 (Male) and WHR > 0.85 (female)

For both measurements, the individual should stand with feet close together, arms at the side and body weight evenly distributed, and should wear little clothing. The subject should be relaxed, and the measurements should be taken at the end of a normal expiration. Each measurement should be repeated twice; if the measurements are within 1 cm of one another, the average should be calculated. If the difference between the two measurements exceeds 1 cm, the two measurements should be repeated [11].

Causes of Obesity

The fundamental cause of obesity and overweight is an energy imbalance between calories consumed and calories expended. Globally, according to WHO, there has been an increased intake of energy- dense foods that are high in fat, and an increased physical inactivity due to the increasingly sedentary nature of many forms of work, changing modes of transportation, and increasing urbanization.

Another cause of obesity is a person’s prevailing health condition, such as slow metabolism, hormonal imbalance, menopause (in elderly women), medical management and pharmaceutical substances used to treat physical and mental illnesses, and of course, genetics. Studies show that children born of obese parents are more likely to be obese and/ or will die early as adults.

Consequences and Implications of Obesity

Obesity is a public health and policy problem because of its prevalence, costs, and health effects. The WHO predicts that overweight and obesity may soon replace more traditional public health concerns (such as under nutrition and infectious diseases), as the most significant cause of poor health.

Health

A very significant implication of obesity in an individual’s health is the increased risk of many diseases and health conditions like coronary heart disease, type 2 diabetes, some cancers, hypertension, dyslipidemia, stroke, liver and gallbladder diseases, sleep apnea and respiratory problems, osteoarthritis, back problems, and gynecological problems. The fact that these conditions can cause or contribute to substantial disability and/ or premature death is a loud call enough to realize that obesity should never be taken for granted and efforts to arrest obesity should never been ignored.

Economics

The association of overweight and obesity to different health problems and conditions has a significant economic impact on health systems. The medical costs associated with overweight and obesity have both direct and indirect costs: direct medical costs may include preventive, diagnostic, and treatment services related to obesity, while indirect costs relate to loss of income from decreased productivity, restricted activity, absenteeism, and the income lost by premature disability or death.

Arresting the growing problem of obesity

The alarming results of the Public Health Unit survey (2010) to assess the need for a wellness program in East Avenue Medical Center engendered the Management’s committed support to promote healthy lifestyles and behavior in the workplace. It is meant to form part of the wellness program for the hospital’s workforce to prevent overweight and obesity, and the non- communicable diseases that are at risk when obesity is left unattended to or sidelined.

The Department of Health (Manila, Philippines) launched on June 6, 2013 the “Pilipinas G04Health”, a nationwide healthy lifestyle movement that aims to inform and engage the youth as well as adults in forming healthy habits and practicing a healthy lifestyle through promotion of four healthy behaviors: (1) physical activity, (2) healthy diet, (3) no smoking and (4) avoiding the harmful use of alcohol to prevent four fatal diseases: (1) Cardiovascular diseases, (2) Cancer, (3) Diabetes and (4) Chronic obstructive respiratory diseases. In 2008, the National Statistics Office reported that these four diseases were responsible for 54% of all deaths in the Philippines [12].

East Avenue Medical Center’s wellness program started early but the time to overcome its challenges and difficulties took long. Different strategies had to be conceptualized and modified according to how the target population, the healthcare workers, will adhere to the program.

Some policies formulated to promote wellness among EAMC employees included mandatory annual health assessment, promotion of physical activity and the use of traditional and alternative health care.

Mandatory annual health assessment

Policies were formulated to make the EAMC employees’ annual health assessment (total physical check- up and free medical and/ or dental services, as the needs may be) mandatory. In connection with this, an employees’ clinic was established at the Out Patient Department.

Fitness Gym

A fitness gym was put up (also in the Out Patient Department) to make facilities for body building and conditioning available for the employees right after work or duty hours, and even during breaktime.

Dance/Aerobic exercise class

A dance class with a fitness instructor was organized. Ballroom dancing for the “not so young” employees (Wednesdays, after office hours) and more extensive aerobic exercises for the younger adults (Fridays, after office hours) were scheduled.

Sports fest/summer olympics

Sports facilities like pelota court, tennis court and basketball court were made available for activities that require such. During summer, different services would compete for the Summer Olympics, while on the second semester of each year, sports fest would commence where different departments of different services compete in various sports activities.

Alternative health care

Programs on stress management like laughter class, movie time and video were put into place every last Fridays of each month. Stressed muscles can also have the best treatment with acupressure, acupuncture, heat therapy, and ventosa, whatever is preferred to.

Challenges

The wellness program in East Avenue Medical Center was designed to respond to the specific problems identified. Foreseen problems, primarily those that are Administrative in nature were salvaged even before they turned out to be deterrents for the program to kick off. Thus the most common problem in the initiation of implementing a program did not happen to become a problem after all. Management support was committed and extensive though there were difficulties in the physical, financial and human resources (to start with) efforts were more than enough to bridge the gaps. Surprisingly, the target population’s perception and reception of the program turned out to be the greatest challenge for the program implementer, the Public Health Unit. The healthcare workers may have had liked the idea of the program but they did not really care. The program and all its efforts were not maximized. Adherence to the program was very low and the objective to promote wellness through healthy lifestyles was not met.

Organizational culture and individual beliefs

The healthcare workers’ perception and reception of the wellness program is influenced or affected by the organizational culture and individual beliefs [13].

Organizational culture is the behavior of humans who are part of an organization and the meanings that the people attach to their actions. It includes the organization values, visions, norms, working language, systems, symbols, beliefs and habits that affect the way people (individual or groups) interact with each other and react to a stimulus.

Filipino culture is considered as a very rich culture for it is a blending of all cultures, so they say. East Avenue Medical centre is a small picture of the Philippines, and its culture that is strong can somehow make program implementations weak.

It is quite challenging, really to change the way people think, feel and behave over something when they already picked up a choice and have a variety of reasons to justify their course of action.

There are some beliefs unique to Filipinos that may be strong and helpful in many ways but may also have a negative effect if focused on a different perspective. Some of these beliefs that contributed to the low adherence of healthcare personnel to the wellness program include the “Bahalana” and the “Ningas Cogon” [14,15].

In quarterly program evaluation of the wellness program, other contributing factors why other healthcare personnel choose not to take part in the wellness program are the found hidden organizational culture that believes in the culture of excess, work in the health sector as exhausting, eating as a social event and compensation as merely monetary compensation.

Bahalana: Bahalana came from the phrase “Bathalana” meaning whatever the Supreme God wills. This defines the attitude that one is resigned to what will happen, asurrender to fate. The closest meaning to this phrase in English is come what may. It is a strong attitude with a negative connotation (most of the time) because it is like being knowledgeable of something and the risks and adverse effects it would bring and yet you dare not do something about it.

Ningas cogon: Ningas cogon is derived from two words: “ningas”, a Filipino word meaning flame and “cogon”, which refers to a tall, green, thin type of grass that grows through large fields and easily catches fire. This metaphor refers to the fact that people show fervent interest in a new topic (like the wild fire), but also lose interest just as quickly (like the cogon grass that burns out rapidly). Oftentimes, people describe ningas cogon as procrastination, as it refers to the fact that people tend to show immense interest in new topics, and then procrastinate by failing to follow through with the necessary means of solving the incident at hand.

The culture of excess: There is something for everyone, everywhere! The trapping of the good life is no longer the sole domain of the wealthy. Comfort and indulgence is never enough, as the “want” list gets longer and longer. Having things (food included) more than what one needs promotes a sense of living the good life and is perceived to be one’s reward for hard work.

Work in the health sector is exhausting: Every health worker believes that care giving is both physical and mental exhaustion, thus needs to be full- full of rest on off hours and a full stomach, of course!

Eating is a social event: Eating is considered a social event. It is a time when friends and colleagues get together, share stories and fun memories, and relieve stress on break time, off days, or “unscheduled vacations”.

Compensation is monetary compensation: Increased productivity means (extra) compensation. It is a reality that people often associate compensation with monetary compensation, or to others, simply material things in various forms.

Strategies and Modifications

To be able to make change acceptable, the Public Health Unit did some modifications on the programs, alongside with advocacy activities like awareness seminars and fun activities so as to promote healthy lifestyles. Efforts to realize that the wellness program is even more beneficial than just having a little extra (monetary speaking) were also initiated. Realizing the Filipinos’ love for excitement and entertainment, innovations were made to present to the EAMC workforce the fun side and social face of the wellness program. The matrix below presents the modified strategies, taking into consideration the challenges posted by the implementation of the wellness program in East Avenue Medical Center, to encourage and motivate the healthcare workers to take advantage of the program that is designed to prevent further risks of obesity among the personnel in the health workplace (Table 4).

Current Situation

Data show that there has been a positive effect on changing perception, behavior and attitude of healthcare workers on the wellness program for East Avenue Medical Center personnel. The once perceived as impossible program of activities to satisfy the complicated caprice of the implementers now turned out to be a pleasurable habit and a social event for the employees. It took a painstaking and tedious process to influence the target population- healthcare givers- on how they would think, feel and behave towards the wellness program. The Management proved justified in assigning a core group to handle the program from start- conceptualizing, implementing, revising and modifying- up to the point of acceptance and full implementation. To this writing, the modified EAMC wellness program is the GO for Health Daily:

Marching monday

This is a wellness strategy that encourages walking and not riding on Mondays. Car parks near the employees’ entrance are spared for other vehicles so the employees can start parking their cars 100 meters away from the entrance for the biometrics. The farther one parks his car, the longer the walking will be. Elevators are not for employees’ use on Mondays. As much as possible, the employees use the stairs. There are no sanctions if they don’t want to climb the stairs, but they have to use the patients’ elevator.

Traditional tuesday

This does not mean that PITAHC is available for employees on Tuesdays only. As mentioned earlier, there is a free pain management on Mondays. Traditional Tuesday is only to remind everyone that there is such thing as alternative healthcare. This includes awareness on detoxifying, relaxation, boosting the immune system, and the likes.

Wiggle it wednesday

It’s Zumba time! Wednesdays (3:00PM-4:30PM) are dedicated to move and shake the whole body. This is, actually, the favorite and most participated wellness activity of the week. Employee’s stucked in their office chairs for hours would express relief from tension and muscle pains after the Zumba. Yes, even the personnel from the Administrative Service are already into the habit of physical fitness.

Thoughtful thursday

This is a reminder to think of friends and go out together, or plan some weekend activities together, or make a project together, or simply “talk” once in every week. This is one way of keeping one’s social life healthy.

Fiber friday

This is a strategy to encourage everyone to eat fruits and vegetables. The cooperative canteen, as well as the food court will serve only vegetables and fruits on Fridays. No meat.

Solo saturday

Saturday is a time for the care giver’s self. It is like rewarding one’s self by indulging on the things one wants to do the most- rest is included.

Spiritual sunday

Sunday is encouraged to be a time for the Supreme Being. It doesn’t matter how one calls his God. What really matters is that the soul is nourished and the faith is strengthened. Now, the program is serving its purpose: reduce, if not prevent, incidence of obesity among the healthcare workers.

Recommendations for Further Actions

One of the proposed activities that will kick off on November 6, 2013 is a more structured weight loss program as part of the EAMC Weight Management Program. It consists of three phases, which includes (1) taking of baseline data of the participants, (2) an eight- week monitoring (inner body scan) and coaching (dietary and physical exercise) by the Department of Nutrition and Dietetics and the Department of Rehabilitation Medicine, and (3) a continuous program on weight management information dissemination by the Public Health Unit. The Weight Management Program aims to maintain a healthy weight through education on proper nutrition and improved eating habits and regular physical exercise. As an indicator of the program’s effect on the employees, weight loss will be measured every month. Programs that promote healthy lifestyles need collaborative efforts because wellness is a concern of all individuals, young or old, rich or poor, male or female. No bounds, no discrimination.

References

1. PASOO (2010) Declaration on Obesity Prevention II. Obesity Alert Newsletter 13.
2. http://en.wikipedia.org/wiki/Obesity.
3. http://www.who.int/mediacentre/factsheets/fs311/en/.
4. www.fnri.dost.gov.ph/index.php?option=content&task=view&id.
5. http://www.cohenlifestyle.com.ph/index.php/program/view/obesity-in-the-philippines.
6. Department of Health (2013) Healthbeat.
7. Sioksoan Chan-Cua PASOO President’s Message (for Obesity Alert Newsletter, 2012) Philippine Association for the Study of Overweight and Obesity.
8. Ramon F Abarquez Jr Don’t Judge a Book by Its Cover. Philippine Association for the Study of Overweight and Obesity.
9. Eduardo Gonzales (2012) The Growing Menace Called Obesity. Manila Bulletin.
10. http://exercise.about.com/od/fitnesstoolscalculators/l/blbmiwaistcircumferencechart.htm.
11. http://www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm.
12. http://news.pia.gov.ph/index.php?article=61346923521.
13. http://www.news-medical.net/health/What-is-Obesity.aspx.
14. http://mariaespievidal.com/obesity-a-serious-problem-overlooked-by-filipinos/.
15. http://en.wikipedia.org/wiki/Organizational_culture.

Tables and Figures at a glance

Table 1	Table 2	Table 3	Table 4