Counting on Pedometers for Workplace Wellness

in Employee Wellness Programs, Uncategorized

Activity Trackers

[This post was first published back when analog pedometers were more common than accelerometer-based trackers like Fitbits. Most of the information about effectiveness and step counts still holds true.]

With all the chatter these days about whiz-bang innovations in employee wellness — mobile apps, body sensors, social media, and such — overshadowed is the lowly pedometer program. But why? I’d venture to guess that most employers running robust wellness programs, and even smaller employers just getting started, are offering some sort of pedometer-based program.

What are we to make of these programs, in which employees — usually in teams —  wear a pedometer for several weeks and record the total number of steps they take each day? Are they little more than the minor league of more hi-tech solutions?

Given my penchant for evidence-based approaches, you may assume I’d balk at pedometer programs. Not so.

The great challenge of implementing evidence-based employee wellness solutions is that there aren’t many of them. After reviewing the evidence, we frequently have to go with where it is strongest — even if it’s not very strong — as we factor in what’s most feasible and the best fit for our purposes. The “best fit” analysis may include employees’ needs, employees’ wants, resource availability, occupational factors (Do employees have internet access? Are they working on a manufacturing line? Are they in vehicles all day? What’s their educational level?), our organization’s goals and, of course, cultural fit.

I categorize pedometer programs as low-resource/modest-impact. As such, I believe they have a place in many, if not most, employee wellness programs, certainly compared to many of the high-resource/low-impact programs that have grown popular.

Here are some things we know:

  • Evidence is mixed regarding the effectiveness of pedometer programs. A limited meta-analyses of programs conducted in various settings — published in the Journal of the American Medical Association (JAMA) — found “significant increases in physical activity and significant decreases in body mass index and blood pressure.” (A 2012 Finnish study concluded that a pedometer intervention “was able to affect only modestly some of the outcomes of walking,” but acknowledged, “The intervention seemed safe, inexpensive and highly adoptable in worksite setting.”)
  • Pedometers can be crude instruments. Their accuracy depends on the quality of the unit. It can vary based on participant age, weight, and walking speed. But, generally, they are sufficiently accurate to be effective in promoting physical activity.
  • Employees enjoy pedometer programs, and team-based challenges using pedometers may help foster camaraderie and a culture of health at the workplace.

Pedometer programs are affordable, scalable, well received by participants, and work about as well as anything else.

One of the more interesting, unresolved questions, about pedometer programs has to do with the goal — number of steps — recommended to participants. Employee wellness programs commonly implore participants to strive for 10,000 steps a day. Is this based on evidence? Does it work as a motivational strategy?

The question of pedometer programs’ “step goal” goes to the heart of our understanding of motivation and behavior change. We’ll get to some answers in my next blog post.

♦♦♦♦♦

Much to my surprise, these little devices were shown to increase physical activity by just over 2,000 steps, or about 1 mile of walking, per day.

— Dena Bravada, MD, lead researcher of a Stanford meta-analysis

Health Risk Assessments: The Baby and the Bath Water

in Commentary, Employee Wellness Programs, Uncategorized

 

There may be some employees whose health has benefited based on some feedback they got on an HRA, but not enough to warrant the investment you are making in the HRA (that investment includes your organization’s money; your time; and, perhaps most importantly, your participants’ time, energy, and goodwill). But don’t listen to me. Your employees will also tell you that your HRA doesn’t make much difference to their health. That’s why some employers pay employees up to $500 just to complete an HRA.You wouldn’t have to pay employees to complete a simple form if they actually saw any value in it to begin with.

A series of blog posts about HRAs  has deconstructed HRAs with an eye toward better understanding their value or lack of value. Here are the cliff notes:

  • The conventional framework of employee wellness programs is predicated on the principle that improvements in the health risk profile of a population can lead to reductions in healthcare costs and improved employee productivity.
  • HRAs are techniques or processes of gathering information to develop health profiles, using the profiles to estimate future risks of adverse health outcomes.
  • HRAs are dependent on self-reported data, which is valid for effective use in population health management intervention, although its value at the individual level is questionable.
  • Importing clinical screening values — such as blood pressure and cholesterol — to an HRA does not add much validity to the HRA on an individual basis, but, like the self-reported data, should be sufficient to measure the health risk of a population.
  • HRAs may help steer individuals towards more intensive programs based on the position of the individual in the strata of the population’s health risk and predicted health care costs.

These findings point to the same thing: Health risk assessment is a population health tool. HRAs’ primary utility is in helping employers identify the health risks that deserve the most attention in order to achieve positive health and financial outcomes. The same tool can then be used to measure a program’s success in shifting the health risk of the population.

Unfortunately, employers have been using HRAs, a population health measurement instrument, as a behavioral intervention. No wonder you are disappointed. Be honest with yourself and with your employees: The HRA is for you — a potentially useful tool in the administration of your program. It’s not an employee benefit, and your employees know it.

Part of the reason employers have mistaken HRAs with a full-fledged health intervention is that vendors have marketed them as such. As a measurement tool, you should reassess whether your HRA is worth what you are paying.

But don’t rush to throw the baby out with the bath water. If you decide that your HRA’s capacity to measure risk in your employee population justifies its use, your next step is to reconsider whether you truly need to have all your program participants complete an HRA every year. Your vendor doesn’t want to hear it, but you may be able to realize the measurement potential of your HRA more cost effectively by having a sample of your employee population complete it every two or three years.

I’m not making a case for or against health risk assessments, just encouraging you to make a well informed and critical decision. What do you want your HRA to do? What does your HRA do? Is your organization getting its money’s worth?

[This article was originally posted on the InTEWN blog July 11, 2012].

Are Health Risk Assessments Effective?

in Employee Wellness Programs, Uncategorized

Are health risk assessments effective? Three systematic reviews have sought to answer this question.

One of the most rigorous and most recent analyses, Health Risk Assessment: Technology Report, conducted by McMaster University Evidence-based Practice Center for Agency for the Healthcare Research and Quality, examined 118 studies of health outcomes associated with HRAs. The report concluded:

Many HRA programs demonstrated improvements on intermediate health outcomes such as blood pressure, cholesterol, physical activity, or fat intake. However, only one article considered hard health outcomes (i.e., freedom from any of the following after 24-month followup: death, myocardial infarction, stroke, Class II-IV angina, or severe asymptomatic ischemia ). Also, followup periods were often shorter than 24 months. Therefore, we were unable to assess whether HRA programs produced health benefits over the medium to long term.

A previous, similarly comprehensive, review was conducted by RAND Corporation. RAND’s study endeavored to evaluate the effectiveness of HRAs for Medicare populations, but in order to do that their study focused on the evidence of HRAs’ effectiveness in any setting, especially worksites. Rand’s conclusions foreshadowed the AHRQ study, stating, “Interventions that combine HRA feedback with health promotion programs are most likely to show beneficial effects… It is not known if these effects persist over the long term.” But Rand also examined cost-effectiveness — importantly for corporate wellness programs — and added:

Current literature is insufficient to accurately estimate the cost effectiveness of programs using HRA. Limited evidence suggests that a carefully designed program that uses a systematic approach to implement HRA and subsequent disease prevention/health promotion interventions has the potential to be cost-beneficial. Considerable effort is needed to optimize program design, implementation, and evaluation.

Yet another study, conducted by the Task Force on Community Preventive Services and published in the American Journal of Preventive Medicine in 2010, suggested more positive outcomes for HRAs, but still with qualifications. The study concluded that HRAs with feedback “has utility as a gateway intervention to a broader worksite health promotion program that includes health education lasting at least one hour or being repeated multiple times during one year….Results of this review suggest that this intervention may be more effective for some outcomes (e.g., smoking behavior or cholesterol) than for others (e.g., change in body composition).”

(These three reviews, in addition to trying to measure the value of HRAs, also provide comprehensive background information about HRAs — their history, their intended purpose, their modes of delivery, their strengths and weaknesses. If you haven’t studied HRA methodology, I strongly recommend that you read at least one of these reviews.  Any of these three reviews will provide much-needed context. The AHQR review is the best place to start.)

Each of these reviews suggests that there is or may be some potential for HRAs in evoking positive health outcomes for individuals, but none of them are a ringing endorsement. In an upcoming post, I’ll offer my own opinion on why employers may want to hang in there with their HRAs.


[This post was originally published on the InTEWN blog on July 6, 2012]

The (Theoretical?) Framework of Employee Wellness

in Employee Wellness Programs, Uncategorized

tape measure, notebook, appleHow is employee wellness supposed to work?

For starters, here’s the prevailing rationale that serves as the framework of most employee wellness programs today:

  1. Most health problems, and their associated costs, are preventable.
  2. Modifiable health risk factors — such as tobacco use, sedentary lifestyle, and unhealthful eating habits — are precursors to many of these health problems.
  3. Many modifiable health risks are predictive of higher healthcare costs and decreased worker productivity.
  4. Employer sponsored wellness programs can reduce modifiable health risks.
  5. Improvements in the health risk profile of a population can lead to reductions in healthcare costs and improved employee productivity.

Important to this understanding of employee wellness are a few other learnings about health risks and their impact on health and productivity:

  • The number of health risks an individual has may have greater impact on financial outcomes than the severity of any one health risk. This is especially true for clusters of health risks related to heart disease, stroke, or psychosocial disorders (such as depression and anxiety).
  • Keeping low-risk employees low-risk may be a more direct route to health care cost containment compared to trying to improve the risk profile of high-risk employees. This focus on the low-risk, advocated by Dee Edington, is counter to a commonly accepted approach in which high-risk employees are targeted — based on the theoretical efficiency of targeting the 20% highest risk individuals believed to incur 80% of health care costs.
  • While it is unsurprising that risk is an indicator of future health problems, risk also is correlated — via mechanisms not fully understood — to near-term health care costs. In other words, one might expect that someone with cardiac risk factors is likely to incur higher health care expenses when they have, say, a heart attack, studies by Goetzel, Anderson, et al have shown that risk factors are associated with higher health care costs even in the near term, before the emergence of full-blown disease.
  • In employee wellness, absenteeism and presenteeism are the most common productivity metrics.

The model described by Goetzel and Ozminkowski is not the only rationale for conducting employee wellness programs. It may not even be the best rationale. But as we move forward in the next few posts to understand health risk appraisals — what they do, what they don’t do, and how they are perceived by wellness managers — it is essential to understand modifiable health risk and its role in the proliferation of employee wellness programs.


This post originally was published on Bob Merberg’s InTewn blog on May 27, 2012.

Health Behavior Change Program Mind Map

in Employee Wellness Programs, Uncategorized

health behavior change mind map I first tried mind mapping three years ago — to plan a family vacation to Oregon. But I’d jumped straight to the software without really understanding mind mapping, and I crashed into the mechanics…and burned. Then, last year, I tried using new mind mapping software to illustrate a project I was working on at work. That attempt may have helped me, but when I showed it to team members, it was greeted with profound silence, bewilderment, and polite smiles. I still hadn’t even tried to educate myself about mind mapping. But intuitively I knew that it’s important.

Now I’ve started to understand the Why and the How of mind mapping, and I see tremendous potential: For problem solving in the workplace, for communicating, and, personally, for learning, memory, and unlocking creativity.

I was fortunate enough to come across the work of Jane Genovese, of Learning Fundamentals in Australia. As part of her mission to make learning more effective and fun, Jane has created beautiful and engaging mind maps on a broad range of topics. She was kind enough to allow me to re-post here her mind map on Behavioral Change Programs. Click on the map [below] to open the full-sized version. Jane’s map is extraordinary in the thoroughness with which it depicts the elements of successful wellness programs, and I would recommend it to any health promotion professional — especially newcomers to the field. I hope you enjoy and learn from Jane’s mind map as much as I have. (And please be sure to visit her site. Lots of great mind maps and other innovative resources.)

health behavior change mind map

Health behavior change mind map for health promotion and wellness professionals.

I’ll be writing more about mind maps, and publishing my own, and hope to explore with you how we can use mind maps and other visual thinking tools to advance employee wellness (and, beyond that, human resources and organizations overall). I think we are just getting started and the possibilities are unlimited.

[A version of this article was originally published on my The Employee Wellness Network blog in October 2011 —  Bob]

Which is Better, Telephonic or Face-to-Face Health Coaching?

in Commentary, Employee Wellness Programs, Uncategorized

conversation

A recent Robert Wood Johnson Foundation study of workplace clinics included this:

“When it’s just a disembodied voice on a phone line in place of a face-to-face session, it’s not nearly as likely that [the employee] will form a connection with the health coach, or that the coach can figure out what makes [the employee] tick and what will drive behavior change that’s meaningful and lasting,” a benefits consultant said.

Certainly, when I’m seeking advice about human behavior, who better to ask than “a benefits consultant”?

What’s more, I’ve often heard decision-makers rush to judgement in favor of face-to-face coaching. One  benefits director, telling me about her new coaching vendor, gushed, “They only do in-person coaching, which we all know is the best!”

Well, we may all think it’s the best. It’s hard to argue with what appears to be a high-touch approach. But argue I will.

Here are 4 reasons why telephonic coaching may be at least as good as face-to-face coaching:

  1. Telephonic coaching overcomes one of the primary barriers to participation. Employees have limited time, and convenience is everything. With telephonic coaching, they can participate whenever and wherever they want.
  2. Telephone conversations are not “disembodied voices.” If you don’t believe people can communicate effectively via the phone, will you also stand in the way of work-from-home arrangements, mhealth and telemedicine, and even conference calls? To take full advantage of the technologies of the present and future, we’ll need to let go of our old ways of looking at them.
  3. Face-to-face coaching can be woefully expensive and inefficient. In most cases, face-to-face coaching simply is not feasible for employers that have employees dispersed over large geographical regions.
  4. Employees demand and deserve privacy. If you’re an employer with a lot of extra configurable space, you may be able to devise the level of privacy employees demand, in which they cannot be overheard by co-workers, nor will coworkers even see them enter or exit the coach’s workspace. But can you match the level of employees can establish when they call a coach from the comfort of their home or office?

I don’t want to go overboard and try to claim that telephonic coaching is better than face-to-face. Most likely, the situation differs depending on the organization and the individual employee, and the ideal is to offer multiple options to each. But, as employee wellness continues to drive most of its initiatives based on intuition and pseudoscience, I simply want to caution against assuming that telephonic coaching is in some way inferior to face-to-face coaching.

If you’re still not convinced, here are some studies that support the case:

Employee Wellness Programs: Beyond ROI

in Commentary

money puzzleWhen was the last time someone asked an insurer or an employer what their return-on-investment is for covering Viagra? Or back surgery? Prostatectomy? Probably never.

Yet we’re repeatedly asked to prove the ROI of wellness — partly because the role of wellness is misunderstood, and partly because we’ve oversold the ROI of wellness, as I outlined in a previous post.

Wellness is as much or more a part of health as those expensive medical procedures. It’s a double-standard to expect that wellness delivers a positive ROI when the same standard is not upheld for much more costly health expenditures.

Some may make the argument that CFOs will always demand ROI because their interests ultimately lie in the bottom line. But CFOs frequently approve expenditures that don’t have a documented ROI, including community service programs, facility maintenance, diversity initiatives, and go-green initiatives, not to mention numerous expenses more directly tied to business goals, such as those associated with creating a brand. All these activities, including wellness, may generate a positive ROI, but it hasn’t been well documented, in many cases because much of the “return” in “return on investment” is difficult or impossible to measure.

When your organization breaks free from what may be a misguided need to generate a numerical value — whether it’s 3:1 or 12:1 — to your wellness program, it will more readily see the full benefits of wellness, beyond the control of health care costs. These include:

  • Helping to keep employees healthy is the right thing to do. In fact, public health is dependent on having all sectors of society — employers as well as governments, schools, faith-based organizations, and so forth — working toward health improvement. Smoking cessation, reduced littering, and civil rights are just a few examples of how major changes in society require the broadest possible efforts. Ultimately, employee health is a component of an employer’s social consciousness.
  • Wellness programs may promote job engagement. A recent Well-Being survey showed that 40 percent of employees believe wellness benefits encourage them to work harder and perform better. Another survey, conducted by the World Economic Forum and Right Management, found that employees are eight times more likely to be engaged in their work when employers actively promote health and well being.
  • Wellness programs may enhance retention. The Well-Being survey cited above found that nearly half of Americans would stay at their jobs longer because of employer-sponsored wellness programs. The Right Management survey found that employers perceived as pro-wellness are 3.5 times more likely to be seen as encouraging creativity and innovation, and their employees are 4 times less likely to report that they plan to leave within the coming year (compared to employees who do not perceive their organizations as actively promoting wellness).

The United States is the only country where health care cost containment is the primary goal of wellness. “Keeping employees healthy and working” is the primary reason cited by most employers outside the U.S. and, notably, “improving workforce morale” is the primary objective in Asian countries, according to a survey by Buck Consultants.

Just as we all need to work on health improvement, we all do also neeed to work on a solution for spiraling health care costs, which requires strategies based on credible data that may include employee wellness ROI. But ROI is not the be-all-and-end-all of employee wellness, and the sooner we peek out from under the cloud of our single-minded focus on ROI, the sooner we can give our full attention to creating great programs that bring to fruition the full potential of employee wellness.