A systematic literature review of workplace physical activity programs: an exploration of barriers and enabling factors

Abstract Physical inactivity continues to be a global issue with many adolescents and adults failing to meet the recommendations for daily exercise. Efforts to reduce physical inactivity in adults include the incorporation of strategies such as workplace physical activity programs, especially for sedentary workers. In this systematic literature review we examined current literature about the efficacy of workplace physical activity programs, as well as the barriers and enablers to these programs. Six EBSCO databases were searched (Academic Search Complete, CINAHL Complete, MEDLINE, APA PsycInfo, APA PsycArticles and SPORTDiscus with full text) between a ten year period (2011 to 2021). The search terms used were “physical activity”, “workplace” and “program” along with their variations. Following a systematic process, eighteen papers met the eligibility criteria. The authors analysed the findings using a narrative synthesis, in which four themes emerged from the data. These include Benefits to physical health, Benefits to mental health, Barriers to workplace physical activity and Workplace activity enablers. These findings provided several recommendations for organizations that endeavour to improve the health of workplace employees. Generalised workplace physical activity programs were viewed favourably by both employees and employers. Incorporating these practices into daily work structures may provide favourable outcomes such as increased work productivity and reduced physical inactivity.


Introduction
The World Health Organization (WHO) defines physical activity as "any bodily movement produced by skeletal muscles that requires energy expenditure" (World Health Organization [WHO], 2018, p. 14).Physical inactivity is recognized as a key modifiable risk factor for increasing rates of noncommunicable diseases, including coronary heart disease, stroke, type 2 diabetes and specific cancers (Lee et al., 2012).In 2013, the global cost of physical inactivity was estimated to be in the vicinity of $54 billion per year in healthcare costs, with an additional $14 billion lost due to decreased work productivity (Critical Appraisal Skills Programme, 2018).Physical inactivity continues to be prevalent on a global scale, with one in four adults and three in four adolescents aged between 11 to 17 years failing to meet the global recommendations for physical activity (Critical Appraisal Skills Programme, 2018).Current global guidelines recommend that adults engage in approximately 150 to 300 minutes of weekly moderate intensive physical activity or 75 to 150 minutes of vigorous exercise each week (WHO, 2020).As people age, robust efforts are promoting methods that integrate physical activity into daily life as a way to combat inert lifestyles and reduce chronic illness.
The Global Action Plan on Physical Activity 2018-2030(Critical Appraisal Skills Programme, 2018) encourages the incorporation of physical activity into multiple settings, particularly the work environment.Workplace group activities have demonstrated improved physical and mental health outcomes in employees, leading to increased work productivity (Commissaris et al., 2016;Jakobsen et al., 2015).Office workers spend approximately 89% of their working hours in a sitting position, placing them at increased risk of health consequences due to their sedentary behaviour (Gremaud et al., 2018).Employers have a responsibility to provide a healthy work environment for employees, which can lead to a reduction in overall absenteeism and improved productivity and performance (E.Taylor et al., 2017).The shared benefits between employees and employers indicate that physical activity programs may be advantageous to the work environment for all involved.
The evaluation of workplace exercise program efficacy can be complex due to influencing factors, such as program fidelity, mode of program delivery and the work population or program location (Lock et al., 2020).Evidence suggests that the use of wearable devices in conjunction with an activity goal or structured exercise sessions, were more effective when compared to sit to stand workstations (Lock et al., 2020).Previous studies have investigated workplace interventions to increase physical activity.A systematic review with a search range of 2000 to 2010 found that the use of pedometers, Internet based approaches and social and environmental interventions were more likely to report health improvements (To et al., 2013).This review also found that 7 out of 12 randomized controlled trials (RCTs) did not prove effective in any outcome.Another systematic review found that some workplace physical activity programs can be beneficial, however the overall results were inconclusive (Malik et al., 2014).Barriers and facilitators for implementing physical activity at work was explored through a scoping review in which 109 factors were identified via a Theoretical Domains Framework (GarneDalgaard et al., 2019).This review showed that the literature primarily describes employee perception.
The WHO recommends further research and evaluation into physical activity and sedentary behaviours to strengthen knowledge translation and policy implementation (Critical Appraisal Skills Programme, 2018).This systematic literature review aims to explore the contemporary literature pertaining to the overall efficacy of workplace physical activity programs with respect to overall physical, psychological; and social health outcomes.This line of questioning is relevant, given the low rates of global physical inactivity and health and work-related costs of physical inactivity.This review differs from other approaches in that it seeks to explore the barriers and enabling factors for both employees and organizations regarding these physical activity programs.

Aim
The research questions for this systematic literature review are: (i) What is known in the current literature about the overall efficacy of workplace physical activity programs with respect to overall physical, psychological; and social health outcomes?
(ii) What are the barriers and enabling factors for workplace physical activity programs?

Search strategy
This systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Page et al., 2021).The search was conducted using the following six EBSCO databases: Academic Search Complete, CINAHL Complete, MEDLINE, APA PsycInfo, APA PsycArticles and SPORTDiscus with full text.Databases were searched using MeSH terms and a Boolean search strategy, in which key concepts and their variations were entered into the databases (see Table 1).The search terms used were "physical activity", "workplace" and "program" along with their variations.The limiters applied to the search included peer-reviewed, full-text original articles and published in the English language within the last ten years (2011 to December 2021).The authors specifically selected this time period, as they were interested in reviewing current evidence in this field of study.The authors also conducted a search on Google Scholar and manually searched the reference lists of included papers.All citations from the database search were uploaded to Endnote.These records were transferred to Covidence, a software program that manages systematic reviews (Veritas Health Innovation, 2021).

Screening and eligibility
The authors collaboratively developed the inclusion and exclusion criteria.Studies were included if physical activity was the primary intervention, therefore studies were excluded if they consisted of environmental modifications such as sit to stand workstations to increase physical activity.Studies were also excluded if the primary intervention was technology-based such as the use of websites, mobile phone apps or health campaigns to promote general physical activity.Studies that incorporated pedometers were considered, as walking is the primary intervention in this context.The authors were specifically interested in physical activity programs conducted at the workplace during designated work hours.Studies were also excluded if they contained co-interventions such as dietary changes or stress-modification programs.All workplace settings were considered for inclusion, however studies that were geared towards specific diseases such as musculoskeletal conditions were excluded.The authors were specifically interested in generalised physical activity programs instead of specialised or tailored rehabilitation for known conditions.All types of study designs were considered for inclusion, however study protocols and non-original studies were excluded from this review.
After duplicated records were removed on Covidence two authors performed an independent title and abstract screen.A third author moderated the process in the event of uncertainty as required to achieve consensus.The records that passed the title and abstract screen were obtained in full text and further evaluated by the authors to determine if the study met the inclusion criteria.The approved full-text papers underwent quality appraisal before the final dataset was confirmed.

Quality assessment
The final papers underwent an independent quality assessment by two of the authors to critique the quality of the articles and assess the risk of bias.Qualitative studies were assessed using the Critical Appraisal Skills Program (CASP) Qualitative studies checklist (Critical Appraisal Skills Programme, 2018).Quantitative papers were assessed using the CASP checklist for randomised controlled trials (RCTs) and other study designs as applicable.The CASP checklists were applied to evaluate the methodology and validity of the research results, with papers scoring 80% or more included in this review.Mixed methods studies were appraised using the Mixed Methods Appraisal Tool (MMAT; Hong et al., 2018).All authors approved the final dataset for this review.

Data extraction and analysis
Following the quality appraisal, the authors extracted the data verbatim from the final studies.The data extracted from these papers included: author, year and country, study design, aim of study, study population, data collection tools and analysis and key findings.Other variables that were extracted included the type of physical activity intervention and program length/duration.These results are presented in two tables, in which two authors independently verified the data.
Data analysis consisted of a narrative approach, in which the authors summarised general key characteristics of the studies and physical activity interventions.Given the heterogeneity of the studies, the authors opted to use an inductive narrative synthesis in which common themes emerged from the extracted data.The authors agreed that the final themes are an accurate representation of the review findings.

Findings
The initial search produced 1624 papers and an additional three records from other sources.After de-duplication (n = 485), a total of 1139 records were screened based on title and abstract relevance.The authors assessed 123 full-text papers for their eligibility.Following this process 105 studies were excluded for various reasons: irrelevance to research aims (n = 42), physical activity was not the primary intervention (n = 28), wrong study design such as study protocols (n = 20), wrong population (n = 9), intervention was not at the workplace (n = 5), the study data is outside of our review date range (n = 1), non-English article (n = 1) and not an original article (n = 1).The final data set of this systematic literature review consisted of 18 peer-reviewed articles that met the eligibility criteria.A summary of the systematic search process is detailed in Figure 1.
The number of participants in this review ranged from 35 (W.C. Taylor et al., 2013) to 2206 participants (Mason et al., 2018).Participants were predominantly from office-based employment or sedentary duties.One study investigated intervention fidelity between various organizations (Lawton et al., 2015) and another consisted of warehouse workers (Hertting et al., 2020).Most workplace physical activity programs were designed to increase physical activity in employees, therefore it was unlikely that employment of a strenuous nature would require additional workplace physical activity incentives.

Physical Activity Intervention
Table 3 depicts the physical activity interventions and program details from each study.Walking was the most popular intervention (Gu et al., 2020;Hallam et al., 2018;Harding et al., 2013;Mason et al., 2018;Parry et al., 2013;Puig-Ribera et al., 2017) with one study incorporating treadmill workstations to increase physical activity at work (Bergman et al., 2020).Some studies preferred participants to choose the type of physical activity (Edmunds et al., 2013;Lawton et al., 2015;McEachan et al., 2011;Patterson et al., 2020), whilst one study assessed the impact of "Wellness Champions" on an eight week physical activity program for university employees (Ellis et al., 2021).Hertting et al. (2020) analysed the effect of ping pong on the health and wellbeing of warehouse workers, focusing on the social or enjoyment aspect of physical activity.Other studies focused on circuit training (Saavedra et al., 2021), computer-guided sprint interval exercise cycling (Metcalfe et al., 2020), a concurrent training program (Karatrantou et al., 2020), Booster Breaks (W. C. Taylor et al., 2013) and intelligent physical exercise training (one hour of intense activity; Dalager et al., 2017).The programs ranged in duration from six weeks (Metcalfe et al., 2020) to one year (Dalager et al., 2017).
Four themes were produced using Braun and Clark's (2006) six-step process for thematic analysis: from the findings: Benefits to physical health, Benefits to mental health, Barriers to workplace physical activity and Workplace activity enablers.The remainder of the findings will be discussed under these themes.

Benefits to physical health
Most studies identified in this review reported significant improvements to overall physical health in their participants.Findings included increased musculoskeletal strength in the treatment group (Dalager et al., 2017), increased aerobic capacity (Metcalfe et al., 2020)    • Surprisingly, significant reductions of generalised musculoskeletal pain occurred in both the treatment and the control group.

and increases in vigorous
• Participants who adhered to the intervention >70% had a significant betweengroup effects on neck pain in the past three months of the program.
(Continued) There was a small increase in the mental component of the HRQoL measure, however there was no change in the physical component.
• A limitation to this study is possible selection bias, in which participants had already met the PA guidelines at baseline.

•
The authors recommend a broad perspective of health to be used to implement and evaluate workplace PA programs.

Qualitative
The aim of the paper is to explore the participant's experiences of the intervention and how health and well-being were affected.
13 participants from the warehouse of a company within the retail sector One initial workshop baseline, a sport-based intervention, three group interviews, and a final workshop Hermeneutic phenomenology analysis • Three themes emerged: expressing positive individual effects, expressing improved work environment and the meaning of the workplace as a lived space. • The workplace as a lived space offers a valuable opportunity for sport-based interventions that improve health and well-being through physical activity, social relations and learning.

•
A possible disadvantage was an increase in workloads for other colleagues, whilst colleagues were participating in the intervention.
(Continued) • The local council was the only organization to show good intervention fidelity compared to the bus company and university (poor fidelity) and the hospital and government organization (moderate fidelity).
• Ideal conditions for the workplace intervention include facilitator commitment, support from management, employee receptiveness and engagement and the delivery of the intervention to a team within a physical space.
(Continued) There was a positive effect of the intervention on self-reported moderate/vigorous PA although it was non-significant.
• PA levels varied with social classes in that lower social classes reported higher levels of PA.
• There were significant benefits to systolic blood pressure and resting heart rate

•
The economic evaluation did not indicate that the intervention was effective.
(Continued) There was a significant increase in aerobic capacity in the exercise group compared to the control group.
• Shorter bouts of high interval exercise (10 secs) were tolerated better than longer bouts of 20 secs.
• Reduced-exertion high-intensity interval training could be implemented as a feasible, effective, and acceptable exercise intervention in a workplace setting.
• There were no changes to perceived stress in both groups after six weeks.• Effects were sustained two months after program completion.

•
The percentage of losses in healthrelated productivity was less compared to the comparison group at follow-up.
• There were no reported effects to employees' mental wellbeing from participating in the program.
(Continued) • Both programs improved cardiorespiratory fitness in participants and their reported mental health.

•
Neither program had an effect on lipid profile or blood pressure.

•
The circuit training intervention led to reductions in waist to hip ratio and body fat mass.Open-ended survey

Content analysis
• Three themes expressed the benefits of the Booster Breaks: reduced stress and promoted enjoyment, increased health awareness and facilitated behaviour change and enhanced workplace social interactions.
• Two themes described the barriers or areas for improvement to this program: a need for greater variety in the routine and for greater management support.
intensity physical activity levels (Dalager et al., 2017;Edmunds et al., 2013;Gu et al., 2020;McEachan et al., 2011).Physiological outcomes and measurements such as improved systolic blood pressure, waist circumference, body fat percentage and body mass index (BMI) were also statistically significant in the intervention group (Gu et al., 2020).An intensive six-month concurrent training program by Karatrantou et al. (2020) found improvements in participants' lean body mass, respiratory function, cervical, handgrip, back and leg strength, functional capacity, decreased body fat, blood pressure, heart rate and reported levels of musculoskeletal pain in office workers.This program was implemented over 120 supervised sessions incorporating flexibility, balance, strength and aerobic exercise.In contrast, Harding et al. (2013) found no changes  in the physical component of the health related quality of life (HRQoL) measures.This finding may be explained by selection bias, in that most participants had already met the physical activity guidelines at baseline (Harding et al., 2013).
Significant improvements were found in reported neck pain in the treatment group, compared to the control group in Dalager et al. (2017).Nevertheless, the between-group effect for neck pain was only significant for participants who adhered to the intervention >70%.Interestingly, Dalager et al. (2017) found significant reductions in generalised musculoskeletal pain in both the treatment group and the control group.Although these results in the control group are surprising, they could perhaps be attributed to the increased awareness of physical activity and health promotion in the workplace.
Reduced sedentary time was noted to be a benefit in Parry et al. (2013) and in Edmunds et al. (2013) who reported that physical activity levels were significantly higher at six months compared to baseline.The sustainability of the intervention was also noted in Mason et al. (2018), which found that the increased daily steps in participants remained above pre-intervention levels, with an estimated average cost of $65.52 USD per employee at the time of the study.

Benefits to mental health
Several studies included various psychological outcomes to assess the efficacy of the intervention on mental health and wellbeing.There was a small increase in the mental component of the HRQoL measure in Harding et al. (2013) and with reported mental health (Saavedra et al., 2021).Another study reported that simple, inexpensive physical activity programs such as the 10,000 step challenge may significantly improve mental and health wellbeing (Hallam et al., 2018).This study reported improvements in stress levels by 8.9% for participants, depressive symptoms by 7.6%, anxiety by 5% and wellbeing by 2.1% over baseline (Hallam et al., 2018).In contrast, the participants in Metcalfe et al. (2020) reported no changes in perceived stress between the treatment group and the control group, as was the case in Puig-Ribera et al. (2017).Similar feelings were also elias cited in Hertting et al. (2020) in which participants found increased enjoyment in learning a new skill (ping pong), as well as increased social connectedness and improved generalised wellbeing.The heterogeneity and various intensities of the exercise interventions indicate that regardless of the nature of the workplace program, positive effects to mental wellbeing are likely to occur.Similarly, Patterson et al. (2020) reported that group exercise programs may decrease depressive symptoms, leading to better work outcomes and productivity.

Barriers to workplace physical activity
Although the workplace physical activity programs were supported by employers and organizations, several barriers were identified in various studies.Barriers such as time and busy lifestyles were noted by participants in Metcalfe et al. (2020), in which they reported that the short interval training was easier to incorporate into their daily work schedules.The lack of motivation was also identified as a barrier, however participants reported exercising with a work colleague helped to overcome this barrier (Metcalfe et al., 2020).Participants in W. C. Taylor et al. (2013) reported the need for greater variety in the 15-minute physical activity Booster Break and the need for greater management support.
In Bergman et al. (2020) researchers from outside the organization to implemented the physical activity intervention of 13 months of access to treadmill workstations.The study identified the varying characteristics and motivation of participants to the intervention such as the convinced, the competitive, the responsible and the vacillating (Bergman et al., 2020).The authors identified that the behavioural change might be more sustainable if it was introduced from within the organization, denoting the importance of organizational support when implementing these programs.

Workplace activity enablers
The concept of fidelity was explored in Ellis et al. (2021), in which the voluntary Wellness Champions recruited employees and implemented the intervention for their team acting as enablers to workplace activity.As described by the Centres for Disease Control and Prevention [CDC], a Wellness Champion "provides expert training, technical assistance, and support to employers" and promote workplace health programs (Centers for Disease Control and Prevention, 2021).Participants reported higher program satisfaction and increased physical activity compared to teams that perceived low physical activity implementation by their team captain (Ellis et al., 2021).These results suggest the potential influence that a Wellness Champion may provide for their colleagues.This study differs from others given that the Wellness Champions offered peer support, and designed the physical activity intervention (Ellis et al., 2021).Although these Wellness Champions received instructions, they were not provided with formal educational sessions.Gu et al. (2020) reported using group captains within their physical activity intervention, however the outcomes of the physical activity were not discussed as a part of the article.The above information indicates that a team captain or Wellness Champion may have an important role in the delivery and implementation of workplace health and wellbeing initiatives.The ability of employees to be given the time, resources and motivation to participate greatly improved their ability to engage with structured workplace activity programs leading to a reduction in sedentary working time.
One study discussed how the physical activity intervention had a "ripple effect" on workplace culture (Edmunds et al., 2013).Another study reported that the ideal conditions for their workplace intervention included facilitator commitment, support from management, employee receptiveness and engagement and the delivery of the intervention to a team within a physical space (Lawton et al., 2015).Family support was also identified as key to program fidelity (Edmunds et al., 2013).

Discussion
The first research question for this review pertains to the overall efficacy of workplace physical activity programs.In general, studies supported physical activity interventions for improving general physical, mental and social health.Workplace group activities have been demonstrated to improve both physical and mental health in employees, which can be attributed to increased work productivity (Commissaris et al., 2016;Jakobsen et al., 2015).Our findings of improvement to mental health are in contrast to another systematic review, which reported that workplace exercise interventions seem to have limited effects on mental health (Bordado Sköld et al., 2019).The social benefits of exercise must also be considered with some studies linking the indirect benefit of physical activity with improved workplace culture (Edmunds et al., 2013) and positive enhanced social interactions (W.C. Taylor et al., 2013).As demonstrated in this review, studies incorporated various types of physical activity interventions.This is comparable to another project, the Sport4Health Network (SPORT4H) which identified a moderate to strong link between non-traditional physical activity programs in the workplace and several indices of health-related physical fitness (Todorovic et al., 2021).Implementing non-traditional physical activity programs may be an important strategy to reduce sedentary behaviour (Todorovic et al., 2021).This also signifies the importance of tailoring workplace physical activity interventions in accordance with both employees, managers and organisation policies to encourage participation.
The second research question explored the barriers and enabling factors for workplace physical activity programs.The use of treadmill workstations or active workstations were found to be a useful tool to encourage increased activity.Similarly, many studies utilised pedometers as feedback to evaluate the number of steps per working day.This is comparable to previous studies, which found that enablers also included the availability and accessibility of exercise equipment, including wearable devices (Lock et al., 2020).A number of barriers to participating in workplace activity were identified such as workload, nature of the activity, time and availability of exercise equipment.Given the decreasing participant adherence rates of some programs, such as 56% (Dalager et al., 2017) and 67.9% (Gu et al., 2020), it would be relevant to investigate the compliance rates in workplace physical activity programs and understand these influencing factors and barriers in order to improve the implementation of these programs.A fidelity analysis was conducted in Lawton et al. (2015) and investigated in Ellis et al. (2021), which highlighted the importance of a facilitator or champion to promote physical activity interventions and behavioural change.It is also essential to gain internal management support to promote physical activity interventions.A socio-ecological model such as the one proposed in Van Kasteren et al. ( 2020) could be a useful framework to incorporate broad changes to the workplace that address the various dynamic factors influencing behavioural change.It is essential that interventions are not solely reliant on individual motivation but address holistic elements to create opportunities for sustainable health change (Van Kasteren et al., 2020).Interestingly there were no studies included in this review which discussed the impact of COVID-19 on workplace physical activity.Future research could explore the influences of coronavirus on workplace behaviours regarding physical activity.

Implications for practice
In summarizing the outcomes and recommendations of this review: • The provision of a workplace physical activity program may provide important physical, psychological and social health benefits for employees with an emphasis on movement, irrespective of the type of exercise.
• The provision of workplace physical activity programs significantly reduce sedentary behaviour, especially in office-type jobs.
• Increased work productivity was identified by participants as an advantage of the workplace physical activity programs.
• Consider the allocation of a Wellness Champion or a team captain to promote the physical activity intervention and to motivate their fellow colleagues.
• Barriers to workplace physical activity programs include time, workplace culture, nature of work tasks and daily structure, motivation and public perceptions.
• Internal support within organizations was also recommended to encourage regular physical activity participation for employees.

Limitations
There are limitations to this review, which may have influenced the findings.This review considered papers in the English language, which may have excluded significant studies.Another limitation to this review is the exclusion of studies in which the intervention focused on specific conditions that required specialised treatment or care planning.While the authors acknowledge the importance of such studies in the workplace, the focus of this review was on generalised workplace physical activity programs.Some of the studies identified their own limitations such as a lack of information on dietary habits and physical activity outside the workplace (Gu et al., 2020) and small samples sizes (Metcalfe et al., 2020;Saavedra et al., 2021).The authors of this review identified that many of the studies excluded participants that had pre-existing conditions such as cardiac, cerebrovascular disease, mental illness or physical disorders.The findings of this review may not be applicable to participants with such health conditions.

Conclusion
This review aimed to identify the literature pertaining to barriers, benefits and enablers of workplace physical activity programs.Overall, generalised workplace physical activity programs were viewed favourably by both employees and employers.Incorporating these practices into daily work structures may increase work productivity, as well as reducing physical inactivity.Given the low rates of physical inactivity and subsequent links to chronic disease, finding ways to incorporate regular activity into daily life is essential to improve physical and mental health of employees.The significant healthcare costs of chronic disease and cost of lost productivity denotes the importance of a global effort in overcoming the modifiable risk factor that is physical inactivity.Workplace physical activity programs may be a valuable strategy to improve the physical activity statistics.You are free to: Share -copy and redistribute the material in any medium or format.Adapt -remix, transform, and build upon the material for any purpose, even commercially.The licensor cannot revoke these freedoms as long as you follow the license terms.
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Table 2 . Summary of key findings Author, Year & Country Study Design Aim of Study Study Population Data Collection Tools & Analysis Key Findings
The coding process revealed four ideal types or strategies that could be related to various behavioural models or theories: the Convinced, the Competitive, the Responsible and the Vacillating. •

Table 2 . (Continued) Author, Year & Country Study Design Aim of Study Study Population Data Collection Tools & Analysis Key Findings
•Participants had autonomy over the type and frequency of PA.•