The imbalance between physical activity (PA) and nutrition is an important cause of overweight and obesity, which in turn are important risk factors for cardiovascular diseases (CVD), and other chronic diseases 1. The World Health Organization reported that, globally, there are more than one billion overweight adults and at least 400 million obese adults 2. In the primary prevention of obesity, a large variety of health promotion programmes are offered.

In the past decades the workplace has been identified as an important setting for health promotion, since it offers an efficient structure to reach large groups, and makes use of a natural social network 34. Research has thus far mainly focused on the effectiveness of these interventions. There are, however, several reasons to also investigate participation in health promotion programmes at the workplace. Firstly, the effectiveness of a worksite health promotion programme (WHPP) will be influenced by the characteristics of the target population and the proportion of the population that enrols in the offered intervention. As such, differences in participation levels may partly explain the large differences in effectiveness of WHPPs observed 356. Secondly, WHPPs have to deal with variable and often low participation levels 7. This may hamper the external validity of the findings, particularly when selective groups of individuals participate in the programmes. Earlier studies addressing participation in worksite health promotion 78910 presented participation levels varying from 8% to 97% 7. In a review, Glasgow and colleagues (1993) reported that men, blue-collar employees, and smokers appeared less likely to participate 9. In accordance with these findings, Dobbins and colleagues (1998) found a higher attendance in an at-work health risk assessment for women and those of higher occupational class. A lower participation was found among current or past smokers, but no differences were found for alcohol consumption, physical activity, and nutrition 8. Thirdly, low participation will result in low cost-effectiveness.

Since the last systematic review on participation in WHPPs in 1993 9, numerous worksite programmes aiming at physical activity, nutrition and overweight have been evaluated for their cost-effectiveness. Knowledge about programme characteristics that contribute to participation is required to increase the cost-effectiveness of the interventions, which may be crucial for companies implementing the programmes. In order to update and extent previous findings it is important to investigate (1) who are reached by means of WHPPs on physical activity and nutrition, and (2) when participation is more likely. Hence, we conducted a systematic review with the aims 1) to describe participation levels in WHPPs, 2) to evaluate underlying individual, health- and work-related determinants of participation, and 3) to analyse programme characteristics that influence participation levels.

Determinants of participation were reported in 10 studies with education or counselling as main component 13141516171819202122, 6 studies on the introduction of a fitness centre or exercise facilities 122324252627, and 7 studies describing a multi-component programme 12282930313233 (Tables 1, 2, 3). All 23 studies reported demographic factors 12131415161718192021222324252627282930313233, 11 (48%) health-related aspects 12131721232425263133, and 7 (30%) work-related determinants 14171822293031. The participation levels ranged from 10% to 64% 12, with a median of 33% (95% CI: 25%–42%).

The demographic determinants most often reported were sex (n = 22), age (n = 19), ethnicity (n = 10), education (n = 8), marital status (n = 7), and income (n = 3) (Tables 1, 2, 3). Most studies reported a higher participation among women (n = 16), of which 12 reached statistical significance 1214161819202930313233. In contrast, 6 studies found a higher participation among men 152122242526, of which 3 were statistically significant 152426. A higher participation among female employees was found for educational and multi-component programmes, but not for fitness centre facilities (Table 2).

Contradictory results were reported for age with both statistically significant higher by 1318283133 and lower 1220242732 participation levels among older employees. For marital status, five 1617182933 out of seven studies found a higher participation level among married or cohabiting employees (of which two were statistically significant 1633). Two out of six studies that reported a higher participation level among Caucasian or white employees found a statistically significant difference in comparison with black or Hispanic employees 1528. None of the four studies reporting a lower participation among Caucasian or white employees reached statistical significance 122629. Concerning education and income, both positive and negative associations were reported. Four positive statistically significant associations were found for a higher education level 26283233, and one study reported a higher participation level for those with a lower education level 12. One out of three studies showed a higher participation level among workers with a higher income 26.

A large variety of health-related determinants were addressed, most notably (over)weight (n = 6), physical activity level (n = 5), smoking (n = 3), cholesterol level (n = 3), general health/health risks (n = 3), blood pressure (n = 2), and nutrition (n = 1). For health-related determinants, there is no consistent evidence for a higher participation among healthier workers. Lewis (1996) reported contrary findings for the multi-component and fitness centre programme: a higher participation among employees with obesity and hypertension risk in the multi-component programme and a higher participation among those with a low fitness and obesity risk in the fitness centre intervention 12. One study reported a higher participation those with an elevated cholesterol level in a nutrition programme 13. Some studies reported a higher participation level among those with less health risks 2125, and those with less sick leave 24.

Work-related determinants studied were job type (n = 5), employment (full/part-time) (n = 3), company size (n = 1), and work shift (n = 1). The only statistically significant associations were a higher participation among white-collar or workers with secure contracts 3031, fulltime-workers 2231, and employees in smaller companies 14. A lower participation level was found for those with shift work 29.

In Table 4 the pooled ORs for the demographic determinants are provided. In accordance with the individual studies described above, a statistically significantly higher participation level among female workers was found (OR = 1.67, 95%CI: 1.25–2.27). After stratifying by programme type, no difference between male and female workers was observed in the fitness centre studies (OR = 1.02, 95%CI: 0.68–1.53) as compared to education/counselling and multi-component studies (OR = 2.00, 95%CI: 1.43–2.78). A significant higher participation level was found for married/cohabiting workers compared to other (OR = 1.25, 95% CI: 1.05–1.48). Age, education, and income had no effect on participation.

Table 5 shows higher participation levels in programmes offering incentives, and in multi-component interventions. No difference in participation levels was found between programmes requiring a fee and programmes with free participation. The difference in mean participation level between studies aimed at physical activity and studies aimed at multiple behaviours reached statistical significance.

In this systematic review, participation levels in health promotion interventions at the workplace were typically below 50%. A large variation in participation levels and determinants of initial participation in worksite health promotion was shown, and except for sex few statistically significant associations with initial participation were found. Female workers had a higher participation than men, but this difference was not observed for interventions consisting of fitness centre programmes. In addition, the review showed that programs that provide (1) incentives, (2) offer a multi-component strategy, (3) focus on multiple behaviours rather than on physical activity only have a higher overall participation level.

A major reason for choosing the worksite as setting for health promotion is the possibility to reach large groups 79. It is striking that the differences between participation levels were large, with mainly low participation levels, but also levels up to 64%. The large variation is comparable to the findings of Glasgow and colleagues (1993), who found participation levels ranging from 20% to 76%. The authors noticed that attending a single screening does not require much commitment 9. In our review, we included only studies evaluating interventions aimed at physical activity and/or nutrition, and therefore excluded studies evaluating only a single health risk assessment (HRA). The median participation level found in a review on 24 studies by Bull and colleagues (2003) was higher than the median reported in this review (61% versus 34%) 7. It is not clear if Bull and colleagues included studies evaluating a HRA.

The findings on determinants of participation are in accordance with the review of Glasgow and colleagues 9. The overall view is that female employees are more likely to participate in health promotion programmes than male employees.

After pooling, an overall higher participation level for married employees was found. All other demographic characteristics showed no consistent pattern. Only for age, there appeared to be a trend with a higher participation among younger employees, and lowest participation level among the oldest age group. As mentioned, just few statistically significant associations for health- and work-related determinants were found. Several studies have reported higher participation in smaller worksites albeit without providing quantitative information 3435. This finding is supported in this review by the included study of Blake and colleagues (1996) 14. No pooled ORs were calculated for the health- and work-related determinants due to the large variation in definition of determinants and programmes evaluated.

More than 80% of the studies evaluating a WHPP on nutrition or PA did not report any determinants of non-participants. In 1993, Glasgow and colleagues already recommended that future studies should report participation levels, the number of employees entering the programme, and demographic information 9. This information is needed to gain insight in potentially selective participation and external validity. Just few studies included information on educational level and income. Since unhealthy lifestyles are more common among lower socio-economic groups, it is important to get insight in the reach (and effectiveness) in these specific groups. Information on determinants should be an essential aspect of a process evaluation. In the RE-AIM framework for the evaluation of the public health impact of health promotion interventions, the 'reach' dimension is included which is measured by comparing records of participants and complete sample information for a defined population, in this case the worksite 36. In the recent CONSORT statements it is emphasized to include information on the eligible participants in order to increase the validity 37.

In total, 64 out of 130 (49%) associations between determinants and participation did not reach statistical significance. These null associations may be the result of a small sample size and lack of statistical power, and the presence of another risk factor or confounder 38. It is not likely that most null associations are explained by the sample size or confounding, because most studies had sample sizes larger than 500 subjects, and most ORs were calculated by means of univariate analysis. Thus, the lack of a clear health-related selection in participation suggests that WHPPs are able to reach those most-at-risk and, hence, provide a valuable setting.

After stratification of the demographic determinants by programme type, it appeared that fitness centre studies do not suffer from a lower participation among men. Further, no statistically significant differences in demographic determinants were found between programme categories. The finding that fitness centre studies do not favour female workers in comparison with other programme categories, suggests that the content of intervention programmes should be tailored to the population characteristics.

In addition to determinants that may play a role in the uptake of interventions in the context of work settings, several programme characteristics were associated with participation. First, this review and others 39 suggest that the inclusion of an incentive can have beneficial effects on reach, hence increasing the absolute number of people who engage in health-related activities. Second, the present finding that more multi-component interventions do not decrease the uptake is in itself reassuring. A potential explanation for this finding may be that these interventions offer a large choice for potential participants. It could be hypothesized that multi-component interventions may have bigger participation levels as it matches with a larger array of people, whereas a mismatch is more likely for single components whereby persons may not see the need or be ready to engage in a particular activity. Finally, in this review a fee for participation was not identified as a barrier to participate. The 4 studies reporting on interventions with a fee for participation included 1 very large study 28. Excluding this study showed among the remaining 3 studies a lower participation level (participation level: 24.3%; 95% CI: 22.7%–25.8%) as compared to studies not requiring a fee for participation (participation level: 31.7%; 95% CI: 31.5–31.9%). This indicates that the results of the pooled analysis should be interpreted carefully depending on the studies included.

Low participation levels will result in decreased (cost-)effectiveness of intervention programmes on population level and a potentially decreased generalizability of the results 40. Implications for raising participation levels in WHPPs are the provision of incentives, or a broad array of programme offers. To what degree these strategies affect also compliance to an intervention programme should be considered.

In this systematic review, participation levels in health promotion interventions at the workplace were typically below 50%. This will greatly influence the effects of these interventions. Few studies evaluated the influence of health, lifestyle and work-related factors on participation, which hampers the insight in the underlying determinants of initial participation in worksite health promotion. This insight is essential to develop tailored intervention programmes, to reach those who need it most, and to increase generalizability across all workers.

The authors declare that they have no competing interests.

SR carried out the design, literature search, data extraction, data-analysis and drafted the manuscript. FvL and PvE participated in discussing the paper, providing methodological input, and helped to draft the manuscript. AB conceived the study, and participated in its design, data-extraction and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.