A theory-driven evaluation of a wellness initiative

Orientation: By reporting on an evaluation of a wellness initiative, this article brings together an element of organisational development (employee wellness) with an approach to programme evaluation (programme theory-driven evaluation). Research purpose: Two questions were addressed: ‘What is the causal logic of the wellness initiative?’ and ‘Is this a plausible programme theory according to social science research and literature?’ Motivation for the study: A study that could demonstrate the usefulness of the theory-driven evaluation approach, especially in the local human resource (HR) domain, was considered to be valuable. In addition, this evaluation provided a careful consideration of how plausible it is for such interventions to achieve what they set out to do. Research design, approach and method: The evaluation relied mainly on qualitative methods (the examination of secondary data and interviewing) to extract programme theory, and on literature to assess plausibility. Main findings: The study had two main outcomes: the finalisation of a model of how the programme is supposed to work according to programme staff, and the conclusion that the model is plausible, provided it is implemented at full strength. Practical/managerial implications: Programme staff are advised to pay particular attention to implementation fidelity, especially to employee participation and involvement in the programme’s activities. A number of strategies are recommended to strengthen the effect of the model. Contribution/value-add: This evaluation showed the importance of conducting a theory- driven evaluation, not only in order to understand the programme and its context, but also to provide a basis for an implementation and outcome evaluation.


Introduction Key focus of the study
This article links an element of organisational development, namely employee wellness, with an approach to programme evaluation, in particular programme theory-driven evaluation. It uses the introduction of an employee wellness programme in a large brewery to illustrate how to go about conducting such an evaluation, and to provide a published example of how evaluation unfolds in 'real life'.

Background to the study: Description of the wellness model
This evaluation was performed in the Cape Town branch of a large brewery. Its international headquarters identified organisational health as a core characteristic of the industry, and the human resource (HR) department in each subsidiary company was tasked to develop a wellness programme for its organisation.
In the early months of 2008 the Cape Town subsidiary of the brewery commenced the development of their Wellness Model (WM). This model has been adopted by other subsidiaries in order to achieve a common, South African approach to wellness within different breweries. It is this model that is the evaluand, in other words, the object of the evaluation.
The main objective of this study was to extract the WM's programme theory, as the assumptions that guided it were all still implicit. In the process, we also wanted to show the usefulness of a theory-driven evaluation to understand any programme. Two questions guided the study: 'What is the causal logic of the wellness initiative?' and 'Is this plausible?'

Motivation for the study
A study that could demonstrate the usefulness of the theorydriven evaluation approach, especially in the local HR domain, was considered valuable. In addition, the evaluation provided a careful consideration of how plausible it is that such interventions could achieve what they set out to do.
The WM consists of six different plans, each with its own activities and aims, which are described in more detail below.

Alcohol policy
The brewery abides by the objectives as set out in The Liquor Act 2003(Act No. 59 of 2003, which aims to promote responsible alcohol use through the setting of norms and standards within the liquor industry. Three alcohol interventions are linked to these guidelines.
An alcohol policy document formulates an HR policy and procedure to maintain discipline and a healthy and safe working environment for employees through the setting of rules pertaining to the alcohol consumption of their employees. More specifically it states: • rules regarding the use and abuse of alcoholic beverages by employees • alcohol consumption of employees whilst on duty, reporting for duty, in company pubs or at social functions • the risks and issues related to alcohol dependency • the procedure for alcohol testing • the disciplinary procedures for staff not adhering to the regulations as set out in the policy document.
In addition to the policy, the company provides ongoing educational workshops, which provide employees with information on the implications and consequences of alcohol abuse. These workshops cover areas such as road and workplace safety, addiction risks of alcohol, early signs of alcohol dependency and information about a number of resources to assist employees with problems.
Finally, in order to promote safe alcohol use, the company provides treatment to employees who are alcohol dependent.
Where the employees themselves have indicated their problem, the company covers the costs for the necessary assessments, treatment and counselling services. Disclosure of alcohol dependency is kept confidential and reasonable time off is granted for rehabilitation.

Counselling service
An outsourced service provider, which employs qualified counsellors, provides a confidential, telephonic counselling service. The counsellors are on call at all times and can deal with: • personal, family or work-related concerns • financial, debt and legal issues • productivity and safety issues of staff (for managers) • emotional, behavioural and health concerns and issues of employees.

Financial skills
An annual educational workshop which aims to assist staff to manage their finances and plan for retirement, forms part of the model. The current economic recession in South Africa was the reason for implementing this plan.

Lifestyle management
An annual wellness week, which promotes healthy lifestyle choices to foster psychological, emotional, physical and nutritional balance in employees, is one of the six plans. Flexible working arrangements, which enable employees to attend the different activities, form part of the design: • Day one of the wellness week focuses on physical education. Employees take part in numerous exercises and activities such as yoga, Pilates and boot camp. Employees also receive information about the three gymnasiums located near the company premises. Discounted rates for employees have been organised at these gymnasiums. • Day two highlights the importance of HIV testing, and confidential testing and counselling are provided. Tests for other health risk factors, for instance high cholesterol, are also available. • On day three the focus is on mental health and well-being.
The counsellors from the outsourced counselling provider are involved in this during the day, and explain their role and services. • Day four deals with medical health management. Exercise experts and doctors educate employees about the different life stages and their associated health risks and prevention measures for these risks. • The fifth day focuses on nutrition and relaxation.
Nutritionists deliver presentations on healthy diets and various food stalls exhibit and sell healthy food. Massage and spa treatments are also available. • The final day of the wellness week is family day. On this Saturday employees are encouraged to spend quality time with their partners and children on the company premises. The plan includes activities suitable to all attendees and healthy catering. The aim is to promote a balanced lifestyle for all staff.

HIV and AIDS
The company explicitly acknowledges the high prevalence of HIV and AIDS in South Africa. It provides funding and donations to non-profit organisations working with this disease. However, as part of the WM it also includes an internally focused, two-pronged strategy. Firstly, the strategy is aimed at managing existing infections through the provision of treatment and, secondly, at preventing new infections by informing employees about these through educational programmes.
In terms of managing existing infections, the company launched the Awareness Counselling and Testing campaign (ACT) in 2003. This intervention allows all employees to receive free HIV and AIDS testing to make them aware of their status and, if necessary, to start early treatment. Test results are confidential and employees who are HIV-positive receive anti-retroviral therapy, lifestyle management and counselling services, all paid for by the company. Both staff and their dependants receive this benefit.
To prevent new infections, the company uses peer education, external experts, workshops, video, theatre and the provision of free condoms to focus on the behaviour and attitude change of employees. A special workshop on HIV and AIDS is presented on World Aids Day (01 December).

Life Threatening Diseases Policy
This policy and its procedures stipulate that all employees who have contracted a life threatening disease (cancer, heart disease, tuberculosis, chronic obstructive airways disease, hepatitis B or HIV and AIDS) are treated fairly and are informed of their rights. The policy document also provides managers with guidelines on how to deal with affected employees. All staff have access to education workshops, tests and counselling for these diseases.
Apart from these six plans, the company has also introduced flexible working arrangements for some positions in the brewery. With flexi-time, employees can stagger their starting and finishing work times, provided that they are at work from 09h00-15h00 and that they work the number of hours stipulated in their contract. This allows employees to spend time with their families or on leisure activities to achieve work-life balance.

Literature review: Programme theory-driven evaluation and employee wellness
A programme is an organised set of activities aimed to bring about a change for the better in the state of the problem or in the recipients. As such, programmes are based on a set of underlying assumptions about how they work to bring about this change. These assumptions are usually causal hypotheses, which propose how the inputs of the programme will result in the intended outcomes of the programme (Chen, 2005;Rossi, Lipsey & Freeman, 2004). The role of a theory-driven evaluation is to extract these assumptions from the programme stakeholders and to develop what Bickman called '… a plausible and sensible model of how a programme is supposed to work' (1987, p. 5). This evaluation used a programme theory-driven evaluation approach, to develop a model or programme theory for a wellness initiative offered by a large brewery. The main aim of this wellness programme was to enhance employee health. Donaldson and Gooler (2003) explain that theory-driven evaluation is a relatively new approach within evaluation practice. It was developed through the integration and synthesis of multiple ideas and tools from the different approaches, which existed in the earlier years of evaluation science.
Today, programme theory-driven evaluations are becoming increasingly popular despite the confusion about the exact nature of this type of evaluation (Donaldson, 2007).
This confusion is partly the result of the fact that many interchangeable terms are used to label this approach. Examples of these terms include: theory of practice, theorybased evaluation, theory-driven evaluation, theory of change, change model, logic model, and others (Donaldson & Lipsey, 2006). All of these terms have the common assumption that each programme is based on a particular set of beliefs or causal hypotheses. An evaluator conducting a programme theory-driven evaluation would aim to make these implicit assumptions (usually thoughts of various stakeholders, which are not recorded on paper) known, and formalise them as part of the programme's documentation.
The aim of programme theory-driven evaluation is twofold. Firstly, the evaluator extracts the programme theory from programme stakeholders and secondly, the evaluator investigates whether or not this theory is plausible and sensible. Thus, the central purposes of theory evaluation are, firstly, to understand fully the nature of the programme, including its purpose and design (Donaldson & Gooler, 2003) and, secondly, to determine its plausibility by assessing the model's alignment with previous empirical evidence and social science research (Reynolds, 1998). In other words conducting a theory evaluation would provide the evaluator and stakeholders with information about whether the programme could be expected to achieve its outcomes or not.
Programme theory-driven evaluation has received its fair share of criticism. Theorists like Scriven (1998) and Stufflebeam (2001) have argued that there is no need for this type of evaluation and that an outcome evaluation, which provides stakeholders with results on whether the programme is working or not, is more beneficial. Scriven argues that theory evaluations are often a waste of time and that the role of an evaluator is not to know how a programme's inputs produce outputs and how those outputs produce outcomes, but rather to provide data on the programme's effectiveness. He contends that it is possible to measure the success of a programme without having to investigate its programme theory. Rogers (2000) and Reynolds (1998) provided three reasons why evaluators may be apprehensive about conducting program-driven theory evaluation. Firstly, most programmes lack an explicit theory model because stakeholders have little understanding of the underlying assumptions of their programme. Secondly, programme theory models may become too complex and detailed for an evaluator to use as a guide for collecting and analysing data. Lastly, programme staff and stakeholders may have little interest in a programme theory, as their focus is mainly on the programme's success. Weiss (1998) responded to these arguments by noting that whilst a specific theory-driven programme evaluation would not allow evaluators to make inferences about other programmes, it could serve the need of the client to understand the programme design and improve it. It could also provide clients with a process by which to reach consensus about how the programme works. In turn, such consensus could lead to the commitment of stakeholders and staff, and their support for the programme. More carefully documented theory-driven evaluations could also contribute to evaluation science by providing programme designers with good programme theory on which to base a similar programme. A collection of fairly similar programmes could also be used for meta-analysis, to extract what works and what does not. Finally, a programme theory, which shows the causal relationships of a programme, could provide the evaluator with a framework for an impact evaluation.
Other evaluators such as Chen (2005), Donaldson (2007), Rogers (2000), Rossi et al., (2004) and Shadish, Cook and Campbell (2004) support Weiss' arguments. They contend that theory-driven evaluation results are not merely a list of programme components of an evaluand. Theory evaluations are able to provide details, explanations and propositions of the various programme components and, in so doing, they establish an underlying logic about the programme's operation (Donaldson, 2007). Donaldson also points out that in the case of an unsuccessful programme, a theory evaluation could provide reasons for programme failure. On the other hand, a theory evaluation of an effective programme could provide information on mediating and moderating variables, which could strengthen the programme effect.
Turning to employee wellness, researchers (Haviland, 1996;Matrone, 2008;Wilkinson, 1999) have used a number of terms to refer to programmes aimed at improving employee health, namely, employee assistance programmes, wellness programmes and initiatives, and health promotion. These programmes can all be described as long-term organisational activities adopted and implemented to promote employee behaviour that will enhance the physical, mental, psychological and emotional health and well-being of employees.
Employee assistance programmes have increased in size and popularity in the past decade (Haviland, 1996;Ilgen, 1990). According to Haviland, in the 1930s, the focus of such initiatives was on worker and workplace safety. However, in the 1950s, the focus changed to wellness as a lifestyle, which promoted physical and psychological well-being (Fogarty, 2008). Through education and feedback, employee health was encouraged and programme activities included changing undesirable behaviours related to drinking, nutrition, diet and exercise.
In 1970, the World Health Organisation (WHO) began to encourage health promotion and wellness within organisations in America and, in 1987, in European countries.
Since that time, researchers and employers postulated the relationship between employee health and worker productivity (Haviland, 1996). This perceived relationship prompted organisations to include psychological and emotional well-being components in their physical health interventions. These interventions utilised attitude and behaviour change to bring about employee wellness. This was evident in the intervention under evaluation, as reflected in the programme description above.
In the present case, although a full description of the WM existed, an explicit programme theory was not articulated in any of the relevant documentation. Therefore, the programme theory could be described as implicit (Rossi et al., 2004) or tacit (Weiss, 1998). We, therefore, decided to conduct a programme theory-driven evaluation to develop this programme theory, through various engagements with programme stakeholders and intended users of the programme (Patton, 1997).
In order to elicit the theory underlying the WM, the following questions, adapted from Rossi et al. (2004), guided the evaluation: 1. What is the causal logic of the programme (programme theory)? 2. Is this a plausible programme theory according to social science research and literature?

The potential value-add of the study
It could be concluded that, whilst the use of theorydriven evaluations is contested, potential benefits of such evaluations have also been documented. In South Africa there are not many documented instances of such evaluations. For example, in a virtual conference on methodology in programme evaluation, organised by the Wits Programme Evaluation Group, only one South African contribution came close to utilising such an approach (Hassett & Potter, 2010). In addition, papers on HR evaluation were completely absent. Thus, any study that could demonstrate the usefulness of the theory-driven evaluation approach would therefore be valuable, especially in the HR domain where very little has been done in this respect, and not only in South Africa. This evaluation details a programme theory-driven evaluation conducted on an HR wellness initiative, to contribute to the empirical evidence of the value of theory-driven evaluations in the HR domain.
As a result of the few evaluations like these in the local literature, we spend some time in the next section on how we extracted the programme theory, and how we built this theory through an interactive, iterative method of working with stakeholders. This resulted in a consensual model of how the programme is supposed to work. We were able to consider the plausibility of the theory in the light of existing literature. Although 'only' a theory evaluation was conducted, we were able to make recommendations to the organisation about improvements to the programme.

Research approach
An exploratory design was used for this evaluation.

Research strategy
The evaluation relied mainly on qualitative methods to extract programme theory and on a review of relevant literature to assess the plausibility of the programme theory.

Research setting
This theory evaluation was undertaken prior to the implementation of a wellness programme in a beer brewery.

Entrée and establishing researcher roles
The first evaluator was granted permission to evaluate the wellness model by the designer of the WM. She worked closely with the designer and the wellness coordinator.

Sampling
Two data sources were used for this evaluation, namely secondary data (programme records and document review) and key informant interviews with programme stakeholders. The two key informants were the designer of the WM and the wellness coordinator within the Cape Town brewery.

Data collection methods
Programme records and documentation, including corporate presentations, guides to managers, internal company policies, and newsletters were explored for information on the evaluand (for examples see http://www.sabmiller.com/ files/pdf/corporate_presentation.pdf).

Recording of data
The primary evaluator tape-recorded and transcribed the interviews with the two key informants.

Data analyses
We analysed the programme records in order to generate the description of the WM. Thereafter, the evaluators followed Donaldson's (2007) guidelines for developing a programme theory, namely: • We engaged the stakeholders. In this evaluation two key informants were interviewed. We intended to engage the wellness committee in this step, but time constraints rendered them unavailable for consultation. • We developed the first draft. Structured interviews with the two key informants explored what they thought the six plans of the WM would achieve, and encouraged them to expand on these outcomes in their own words. These key informants were then questioned about how they thought the specific activities within the six plans would lead to the outcomes they had formulated. • We presented the first draft to the stakeholders.
Information gathered from the two key informants in the previous step was then plotted as a box-and-arrow diagram by the evaluators. This causal map was discussed with the key informants to ascertain whether or not it represented, fairly and accurately, their conceptualisation of the programme. • We assessed the plausibility of the first draft. We assessed the definition of wellness and the plausibility of the links in the causal map by means of a literature review. The main search parameters were, firstly, 'employee wellness' and, secondly, an advanced search for 'employee wellness and evaluation'.
• We finalised the programme theory. Changes to the programme theory were first verified with the two key informants. Upon their agreement the theory was finalised.

Strategies employed to ensure data quality
In this study, very few real threats existed to the quality of the data collected. Nevertheless, steps were taken to ensure that the picture of the programme that emerged was accurate. Throughout the process of gathering data, careful notes were taken, and key informants were regularly consulted. The first evaluator produced drafts of the programme theory and presented these to the designer and coordinator of the programme in an iterative process, to remove possible misunderstandings. Additionally, the plausibility of the programme theory that emerged was cross-checked against existing literature on wellness models.

Reporting
The findings are reported as a plausible programme theory in the form of a diagram, which indicates how the programme will lead to changes in the life styles of the intended participants. Suggestions for good implementation practice were extracted from the literature and added to the programme theory.

Findings
The findings will be presented in terms of three of the strategies for the development of a programme theory, namely: engaging the stakeholders, developing the first draft, and assessing the plausibility of the first draft.

Engaging the stakeholders and developing programme theory
During interviews with the key informants, it became evident that they had difficulty in explaining their understanding of the programme's logic and that they had no formalised documentation, which reflected it. This was a puzzling observation, and it probably was a result of the top-down nature of the parent company's strategic focus on employee health as part of organisational health. Quite specific questions from the evaluators, and a review of the programme documents, resulted in a preliminary programme theory. This consisted of little more than 'there really is not a problem as such within the brewery, but as this programme was mandated by senior management, we had to implement it to enhance employee health'.
Further questioning of the key informants focused on how the WM would lead to enhanced employee health or other as yet unidentified outcomes. The key informants explained that the WM would encourage employees to adopt healthier lifestyle choices, which would then lead to enhanced health. In turn, healthy employees would enhance the image of the company. These additional insights were then presented in the form of a typical causal theory diagram (Figure 1).
When the draft was presented to the two key informants, they had difficulty dealing with the causal relationships of the whole WM. In order to overcome this obstacle, the evaluators divided the WM into sub-components and asked questions about each component. For instance, the question for the sub-component on HIV and AIDS was: 'What effect will the implementation of the HIV and AIDS initiative have for the employees?' Thus, a diagram was drawn up for each sub-component of the WM indicating this sub-component's short, medium and long-term outcomes. This helped the key informants to plot the causal relationships within the different components of the WM.
We used these sub-component theories to refine the previous draft, and develop and build the overall programme theory, as presented in Figure 2.
The diagram captures a more sophisticated understanding of the WM's impact model, in which two separate outcome lines can be ascertained. At one level, the wellness initiative encourages employees to make healthier lifestyle choices, which will lead to healthier employees who will benefit the organisation. At another level, the initiative is expected to increase job satisfaction, which will set a different outcome chain in motion.
This model was presented to the key informants. They agreed that it captured a more accurate and complete understanding of what the programme is supposed to achieve than they indicated previously. We therefore can agree with Donaldson (2007), that reaching consensus is often not particularly difficult, and that such an interactive process often leads to a common understanding.

Assessing the plausibility of the programme theory
We examined the literature generated by the literature search of wellness programmes for two aspects, namely the underlying philosophy, and the outcomes of the wellness programmes.

Individual's short-term outcome
These outcomes provide evidence supporting the assumption that implementing a wellness programme should bring about positive effects for employees and the organisation. Most of these outcomes are included in the WM's programme theory and, therefore, it can be assumed that this theory is plausible. However, it is important to note that no recent South African wellness programmes have been evaluated in order to determine whether or not these outcomes have been achieved in practice.

Ethical considerations
The Ethics in Research Committee of the Faculty of Commerce, University of Cape Town, approved the evaluation.

Potential benefits and hazards
There were no benefits or hazards for participants who took part in the evaluation.

Recruitment procedures
The designer of the wellness model and the wellness coordinator provided access to the programme documents and took part in the interviews to elicit the programme theory. They were identified by their role only.

Informed consent
The two key informants were aware of the scope and purpose of the interviews and agreed to provide the required information to the primary evaluator.

Data protection
The process by which the primary evaluator and the key informants agreed on the programme theory is described in the Findings section.

Trustworthiness Reliability
The key informants checked the programme theory at different stages of its development and agreed to the final theory. This process is described in the Findings section.

Validity
The evaluation focused on a specific programme theory and did not seek to generalise the findings to theories of other, similar programmes.

Discussion
The main objective of the evaluation was to provide a plausible programme theory for a wellness programme. This evaluation has demonstrated the importance of conducting a theory-driven evaluation, not only in order to understand the programme and its context, but also to provide a basis for an implementation and outcome evaluation. The finding, that employee participation is essential for the success of the WM, and the strategies to increase such participation, will be useful for improving the programme's effectiveness.
The main findings of this evaluation showed that, by using a process of consensus building with programme staff, the evaluator succeeded in producing a sophisticated programme theory for the brewery's wellness programme. Two strands of outcomes were identified, namely healthier lifestyle choices and increased job satisfaction for future participants in the programme. A review of the literature confirmed that the programme theory and its outcomes were plausible.
Whilst the programme theory of the WM was shown to be plausible, this does not guarantee the success of the programme. Researchers (Downey, 1996;Haviland, 1996;Ho, 1997;Wilkinson, 1999;Wolfe & Parker, 1994) agree that although a wellness initiative's programme theory may be feasible, implementation fidelity is imperative for its success. The relationship between programme activities and outcomes is specifically sensitive to the influence of the implementation variable, namely employee service utilisation.
According to Downey (1996) and Wolfe and Parker (1994), the desired outcomes of a wellness programme rely heavily on employee participation and involvement. Milano (2007) indicates that wellness programmes are often sporadic and randomly implemented and consequently do not succeed. She points out that multi-component programmes have low utilisation levels. Common barriers to programme success include: • lack of promotional materials • generic, non-individualised health messages • low motivation of staff to attend programme activities • target audiences not being reached • inconvenient scheduling of activities.
The involvement of top management and their attitudes toward the programme could create a culture of participation for all staff members, which may result in greater utilisation of services (Wolfe & Parker, 1994). Additionally, services provided on site, with convenient scheduling as well as time off to attend programme activities, all have positive effects on participation levels. In fact, the number of employees utilising the programme services determines the programme's success.
In order to strengthen the effect of the WM, it is suggested that some of the following strategies are considered. These are to: • gain top management's commitment, support and engagement in the WM (Downey, 1996;Ho, 1997;Wilkinson, 1999;Wolfe & Parker, 1994) • have strong promotional efforts and targeting of employees (Ho, 1997;Wolfe & Parker, 1994) • conduct a needs assessment of current employee health and preferences (Downey, 1996;Haviland, 1996;Ho, 1997) • allow for family involvement in the programme (Ho, 1997) • ensure the programme logistics are well organised and that the scheduling of programme activities is convenient (Downey, 1996;Wolfe & Parker, 1994) • develop policy documents outlining the organisation's commitment towards the WM and provide general information on the programme (Downey, 1996;Haviland, 1996) • provide supervisors with training on the WM to make them aware of the services (Haviland, 1996;Wilkinson, 1999).

Limitations
Initially, this evaluation was intended to be an outcome evaluation. However, the economic climate at the time halted the implementation of the wellness programme. The programme stakeholders then agreed to a theory evaluation.
This theory needs to be tested to see which outcomes are sustainable and which outcomes are unrealistic. It was not possible to complete this aspect of the evaluation.

Suggestions for future research
Ideally, the next step in a programme theory-driven evaluation would be to use the model to develop further evaluation questions and collect data to answer them. In other words, the theory-driven evaluation conducted would serve as a starting point for an implementation evaluation. The implementation evaluation could investigate how well those WM components, already implemented, were delivered and whether or not employees were using the services offered. A further focus could be on coverage (who uses the services), the quality of the services, and whether or not adequate resources were allocated to the programme.
Unfortunately, the brewery had to stop the full roll-out of the wellness programme and its evaluation because of various financial and organisational reasons. However, the programme theory remains useful and could be used as an evaluation framework once the obstacles to full implementation have been overcome.