On a snowy winter day, as I listened on a conference call with a client, I watched through the window of my cozy home office as the curbside recycling truck lurched to a halt.
A burly guy jumped off the truck, where he’d been clinging in the blasting snow and arctic wind. In his orange reflector-striped parker, snow-dusted cap, and humongo gloves, he lifted my recycling bin out of the snow bank where it’d been half-buried by the city plow and in one swift move heaved the clinking and clanking contents into the backend of the truck.
He tossed the emptied bin onto my snow-covered driveway and stepped back onto the rear of the truck as it grinded away. With its amber caution lights flashing and sparkling in the icicles that hung off its rim like a damaged chandelier, the truck — its passenger clutching the back and ducking his head out of the wind — vanished into the whiteout.
“What kind of wellbeing program would appeal to this guy?” I thought. “What would be useful to him?”
On my conference call, the client was chatting about placing fruit-infused water stations in break rooms.
Would the recycling worker want a fitness challenge to track his steps? Would he like a health coach to call that evening to “nudge” him to eat fewer carbs? A work-life balance lunch-and-learn?
In the latest iteration of employee wellbeing, where all the buzz is about purpose, authentic self, mindfulness, and gratitude, would the recycling worker pick up what we’re throwing out there?
I don’t know what this individual worker wants and I won’t make assumptions. I haven’t spoken to him yet, but, like you, I chat with blue collar employees, manual laborers, and lower-wage workers every day. Some I meet in the course of my daily business, some are friends, some are family members. And I do ask what they want and how their workplace can support their wellbeing.
The above was originally the preamble to my LinkedIn post, “How My Dad Proved Steve Jobs Wrong About Loving What You Do…”, but I cut it because of length, relevance, and tone. Still, I’d love to hear from you. How can we serve employees in job classes like this recycling worker? How can we best support their wellbeing?
Richard Lazarus and Susan Folkman’s classic 1984 book,Stress, Appraisal, and Coping, defineddifferent kinds of stressors: challenges and hindrances. Jeffery LePine and his team at University of Floridaexpanded on thisand found that challenge demands are linked to improved job performance; hindrance demands lead to impaired work engagement and performance.
Opportunities and Obstacles
We’ll get to some examples, but for now know that:
Challenge demandscost energy but are viewed by workers as opportunities to grow, improve, advance, achieve.
Hindrance demandscost energy and are perceived as unnecessary obstacles, thwarting personal growth, wellbeing, and achievement.
(By the way, there also are different types of resources — for example, job resources and personal resources. Job resources include things like performance feedback, training, and autonomy; personal resources include self-efficacy (confidence in your ability to have an effect) and optimism. For a more detailed and expert analysis of different types of demands and resources, see Maria Tims and Arnold Bakker’s article, “Job Crafting: Towards a New Model of Job Redesign.”)
Demands-Resources Job Crafting
In job crafting with the JD-R model, employees
Seek challenge demands
Reduce hindrance demands
Some of what researchers point to as resources — like performance feedback and training — are sometimes viewed by employees as hindrances. And occasionally there’s a fine line between a resource like autonomy and a hindrance demand like role ambiguity.
In previous posts about the transition from wellness to wellbeing, I neglected to address the studies of wellbeing — including many attempts to define it — that were done before corporate America appropriated the term.
As legendary occupational psychologist Sir Cary Cooper says, “Define wellbeing? We can’t even agree on how to spell it Hyphen or no hyphen?” (I’ve paraphrased Sir Cary.)
“Wellness programs focus on physical health while well-being addresses ‘all things that are stressors in an employee’s life.’”
So far, so good.
Then they wrote:
“ Improving employee health was the most frequently mentioned (82%) reason for offering well-being programs, followed by: decrease medical premiums and claim costs…”
If those two quotes don’t have you scratching your head, you’re reading too fast. Please back up and keep rereading until you’re appropriately distressed.)
Gallup’s Essential Elements of Wellbeing
In recent years, Gallup describes wellbeing, based on their massive surveys, as consisting of (these are verbatim):
Purpose*: liking what you do each day and being motivated to achieve your goals
Social: having supportive relationships and love in your life
Financial: managing your economic life to reduce stress and increase security
Community: liking where you live, feeling safe, and having pride in your community
Physical: having good health and enough energy to get things done daily
In 2010, Gallup’s Tom Rath and James Harter published “Wellbeing: The Five Essential Elements.” The book served up the same five elements that Gallup advocates today, except the book used the label “Career,” whereas Gallup now calls the same element “Purpose.” Hmmm.
Gallup, with their partner Healthways (which eventually was acquired by Sharecare — creating the Gallup-Sharecare pair) argues that employers should address all five elements of wellbeing. For a price, they offer consulting services to help.
Employers faithfully adopted the five elements, depicting their wellbeing program goals with circles perfectly divided into equal parts — each representing one of the five elements — sometimes shoehorning in another element or two, like “emotional,” “environmental,” or “spiritual.”
But employers have not been well-served by their simplistic pie diagrams, which are used as virtual checklists to perfunctorily confirm that each element is addressed…
A fragmented effort to address what is in wellbeing, rather than a cohesive strategy to support what wellbeing is, may be one reason why, in practice, nothing but the name has changed.
Since his groundbreaking review, “Subjective Wellbeing,” first appeared in 1984, psychologist Ed Diener has probably published more wellbeing research than anyone. Though Diener evaluated the elements of what he calls “subjective wellbeing,” he defined it not by its elements but by the experience. To Diener, wellbeing is…
“…how people evaluate their lives — both at the moment and for longer periods… These evaluations include people’s emotional reactions to events, their moods, and judgments they form about their life satisfaction, fulfillment, and satisfaction with domains such as marriage and work. Thus, subjective wellbeing concerns the study of what lay people might call happiness or satisfaction.”
“Happiness or satisfaction.” Isn’t that what we always knew wellbeing to be, before we picked it apart?
I Feel Good!
With the various definitions of wellbeing circulating helter skelter, Uncle Sam (in the form of the CDC) played peacekeeper:
“There is no consensus around a single definition of well-being, but there is general agreement that at minimum, well-being includes the presence of positive emotions and moods (e.g., contentment, happiness), the absence of negative emotions (e.g., depression, anxiety), satisfaction with life, fulfillment and positive functioning. In simple terms, well-being can be described as judging life positively and feeling good.”
Rath and Harter’s description of wellbeing and other definitions of wellbeing emphasizes how you get there — the road to wellbeing. Diener and other psychologists emphasize how you are when you arrive.
Wellbeing and Burnout
Diener mentioned marriage and work, referring to domain-specific wellbeing. Here’s where that comes into play…
In job crafting research — as with a lot of organizational development research — “wellbeing” often is measured in the work domain only. Work wellbeing doesn’t just mean job satisfaction; it goes deeper to how employees are.
How do you measure how employees are at work?
For perspective, consider the symptoms of burnout:
A feeling of not making a difference
It’s not unreasonable to say that the opposite of burnout is work wellbeing — having energy, purpose, and optimism at work. This is why burnout metrics have, sometimes, been used to measure work wellbeing.
Focusing on work wellbeing — which, on the surface, seems to be just one domain — may be heresy to employee wellness leaders looking to check off their list each element of wellbeing.
But employee wellbeing programs risk getting in their own way if they try to do too much. Would it make sense to help employees thrive at work — the domain over which employers have most control — before trying to get them to thrive in, say, relationships, community, or even physical health?
On one hand, focusing on work wellbeing seems to contradict arguments against checking the elements off one-by-one. On the other hand, if the elements are interdependent, bolstering work wellbeing helps support the other elements. And if the others are supported at the appropriate time and place, work wellbeing will benefit.
To understand what job crafting has to do with employee health and wellbeing, it’s important to understanding the inner workings of job stress and motivation.
In a previous post — “I’ve Seen the Future of Employee Wellbeing: It’s Name Is Job Crafting” — I explained how, in 2001, Amy Wrzesniewski and Jane Dutton proposed that employees tweak their job tasks, workplace social connections, and perspective about their role to gain a greater sense of purpose and meaning, potentially leading to better job performance.
Around that same time, in the Netherlands, Evangelia Demerouti, Arnold Bakker, and othersintroduced their model of Job Demands-Resources(JD-R), which has since been fine-tuned and validated as relevant to a full range of occupations and outcomes in countless studies around the world.
If you’re familiar with job stress research, you know that job stress has causes, and shouldn’t be dismissed as a choice employees make.
Forget trendy notions that “stress is good.” It’s wishful thinking based on cherry-picked evidence. If stress is so great, why aren’t employees demanding more of it?
Forty years of research has shown thatharmful job stress is a result of jobs that have low levels of autonomy and high demands.
Job Demands and Autonomy Are Linked to Health Problems
Over the years, jobautonomy(or control) has been defined different ways, but can be broadly understood as limited flexibility (for example, with the tasks of the job) and limited decisional latitude, meaning the employee isn’t permitted or encouraged to make decisions in their work or about their work.
Jobdemandsoriginally meant the psychological intensity of work, but ultimately can be understood to include workload, time pressure, and physical demands.
Robert Karasekintroduced the theory of demands and control in 1979. He and others have shown that jobs in which workers consistently encounter high job demands with low job control — the combination of which is called jobstrain— are linked to a variety of health issues, especially high blood pressure and cardiovascular disease, as well as depression, anxiety, burnout, and metabolic disorders. Reducing job strain can improve productivity.
Karasek later learned thatsocial support “buffers” the negative effects of high-strain jobs. Social support originally meant supervisors’ and co-workers’ support for performing job tasks, but can be understood in all of the many ways it’s been defined: Having a sense of “belongingness” at work; having co-workers who are empathetic and confidantes; having supervisors who take a genuine interest in the personal and professional lives of team members; and having a best friend at work.
In sum, high demands and low control are an unhealthy combo.(High demands andhighcontrol are not necessarily bad.)
Effort-Reward Imbalance Is Linked to Health Problems
Unhealthy job stress has been framed in other ways. Germany’sJohannes Siegrist foundthat work in which the required effortis disproportionately high compared to the jobrewards— effort-reward imbalance — leads to the same kinds of health problems that result from job strain. “Rewards,” here, doesn’t just mean financial compensation, but also career opportunities and level of esteem within the organization.
The effort-reward imbalance model reminds me of an encounter I once had with a business analyst who transferred to another department because she didn’t feel valued in the department she was hired into. When I asked her, “What would have made you feel more valued?” her answer was not “better pay” or “someone saying ‘good job’”…
“I just wanted someone to listen to my ideas,” she told me.
A worker who doesn’t feel valued (i.e. esteemed) by being “listened to” is likely to have a higher level of disengagement and health impairment. This offers a glimpse into how management style, job design, organizational culture, performance, turnover, health, and wellbeing are all interconnected.
Overtime, Job Insecurity, Injustice, and More…
Several other causes of job stress have been identified, and most of them can in some way fit into the demand-control and/or the effort-reward imbalance model:
• chronic overtime
• job insecurity
• work-life conflict
• role ambiguity (not being clear of what’s expected, receiving contradictory direction, duplication with other workers’ roles, or not understanding how the work fits into the overall organization — all of which are among the most common complaints I’ve heard from employees who report high job stress).
• organizational injustice (being treated unfairly, which at the extreme includes bullying and harassment)
• lower levels of status within the organization
• sustaining high levels of vigilance (e.g. first responders, air traffic controllers, etc.)
Back to Bakker
The overlaps between and the nuances of these job stress theories makes them difficult to understand and apply. That’s where Bakker and Demerouti’s Job Demands-Resources model comes in. While building on the existing theories and expanding upon them, it also provides a simpler way of making sense of job stress and motivation. I consider it a comprehensible and practical unifyingtheory.
JD-R posits that all job traits can be categorized as either demands or resources.
• Demandsrequire sustained effort from employees. They’re an expenditure of personal energy.
• Resourceshelp fuel progress toward work-related goals. They’re restorative, buffering the effects of job demands —and activating personal development.
I interpret JD-R to mean that Karasek’s “demands,” Siegrest’s “efforts,” as well as role ambiguity, job insecurity, injustice, tedium, and work-life conflict aredemands.
Job autonomy, social support, rewards, recognition, feedback, task variety, and training are examples ofresources.
Side note: If you’re familiar withEdward Deci and Richard Ryan’s self-determination theory— popularized in the Daniel Pink bestseller,Drive— which tells us that motivation and flourishing depend onautonomy,competence, andrelatedness(i.e. social connection), you may recognize that job resources generally can be matched to the components of self-determination.
• Demandsregulate job stress.
• Resourcesregulate job motivation and engagement.
• And the two forces may act upon each other.
That’s enough theory for now. What I’ve come to appreciate about JD-R is how, according to research by Bakker and others, it serves as a foundation for a practical application: job crafting.
JD-R takes job crafting beyond meaning and purpose — which has received most of the public attention — and ties it directly into health and wellbeing.
I’ll spell this out further in a future post, and also draw the important distinction between positive and negative job demands. I’ll share what research shows about the effectiveness of job crafting interventions for improving employee wellbeing, work engagement, absenteeism, performance, and productivity. And I’ll offer evidence-based tips on how you can prime your organization for job crafting.
If you can find some downtime (or some treadmill time?), listen to “Dealing With Burnout” the Wisconsin Public Radio Morning Show. One of the guests wasMonique Valcour PhD CPCC, who has a gift for articulating, in super-practical terms, the connection between work and wellbeing. Monique explains what burnout really is, and delivers keen insight when the first caller makes a reference to the role of autonomy in addressing his own burnout. She talks about burnout as an “interpersonal phenomenon” and notes the supportive effects of mindfulness and emotional intelligence. And she provides practical tips for workplace leaders.
By the way, not only is it essential for us wellness professionals to address the burnout that occurs amongst employees, but I’m observing that it’s increasingly common within HR, Employee Benefits, and Employee Wellness teams. So if you don’t feel the need to learn about burnout for your organization, learn about it as an act of compassion for yourself.
I’ve had the pleasure of co-presenting with Rajiv on several occasions, and the conversations always take a turn toward the unexpected. I elaborate on my latest passion, job crafting, and how it may surpass other popular solutions for health-related job stress, burnout, and disengagement.
Rajiv brings his unique perspective as a community-minded entrepreneur, physician, and vendor. I’m always enriched by our conversations, and I think you will be, too.
The foundation of employee wellbeing isn’t employee behavior — it’s workplace exposure. Exposure to things like…
the physical environment,
the psychosocial environment,
the policies of the organization,
the work itself.
Designing jobs to optimize these exposures is a direct path to creating healthier work.
The employer that values employee wellbeing will design jobs that offer
well defined roles,
plenty of personal and professional support.
As the business world crams countless sections into its wellbeing pie charts, it persistently omits the core: For a sustainable workforce, healthy work comes first.
What Is Job Crafting?
In job crafting, employees tweak any combination of…
their workplace interactions,
the way they view their jobs.
One of the most commonly cited examples comes from Amy Wrzesniewski and Jane Dutton, who first coined the phrase job crafting in 2001. In their study of hospital housekeepers, some workers distinguished themselves by envisioning their role as part of the care team, taking the initiative to chip in where they could to make the environment more patient-friendly — adjusting a picture on the wall of a patient’s room, delivering a glass of water, or spending more time interacting with patients and visitors.
The researchers wrote,
When hospital cleaners integrate themselves into patient care functions, they are able to see their work as being about healing people and to see themselves as a key part of this process, thus enhancing work meaning and creating a more positive work identity.
A variety of workers studied, from machine operators to engineers to sales professionals, have been found to experience greater job satisfaction, better performance, less burnout, and enhanced wellbeing by bringing more meaning to their jobs via self-initiated or intervention-based job crafting.
I’ve come to see job crafting as the workforce sustainability intervention many of us have sought: An evidence-based, employee-centric methodology that can enhance employee wellbeing in a manner aligned with employers’ priorities.
Job crafting is not the solution, but it may be the keystone for employers that have their house in order. It’s one answer to the question, “Okay, we value autonomy, employee engagement, a supportive environment, and the rest… But what do we do about it?”
Job crafting is a tool — not a substitute — for good management.
If you may be interested in hosting a job-crafting beta workshop later in the coming year, touch base via the Jozito.com contact form.
Our major wellness conferences will connect their attendees with nonprofit (or under-resourced) employers in their host cities to model wellbeing interventions for employees who otherwise might not have access.
Last year, online media had a field day when a survey showed that one third of respondents who owned a “wearable” activity tracker stopped using their device within six months. The firm that conducted the survey referred to this as “the dirty secret of wearables.” But it’s premature to judge this disengagement rate, and there’s no secret to keep. Sixty-six percent adherence for wearables after six months may, in fact, be something to celebrate.
Is It Time to Disengage from Disengagement Rates?
We haven’t identified universally accepted goals for activity trackers (by “trackers,” we’re talking here about devices like Fitbits, Jawbone Ups, and the like). Is the purpose to increase activity? To lose weight? To (perish the thought) have fun? Without goals, there’s little we can say about effectiveness or the significance of disengagement rates.
The assumption behind the negative publicity for disengagement rates implies that users should wear their trackers indefinitely. But…Says who? Many consumers wearing a tracker for the first time will see, within a few days, that they aren’t as active as they thought. This may be a first step to modifying behavior, even if they ultimately rely on non-tracker strategies to make changes, and even if those strategies take place at a later date.
Business Insider writer Erin Brodwin recently published an article called, I Tried Fitbit for a Month, and Taking It Off Was the Best Decision I’ve Made. Judging from the title, we might think that Brodwin’s story is a testimonial to the transience of tracker engagement (or that she needs to make better decisions in her life). And it may be. But this observation she makes near the end of the piece may exemplify unexamined potential of wearables:
I still do some of the healthier things I learned to do with my Fitbit, like taking the stairs at work and going for a walk when I take a phone call.
In Brodwin’s case, sustainability of her Fitbit use would have been the wrong metric if her goal was to increase physical activity.
Do One Third of Users Disengage with Wearables after Six Months? Or Do Two Thirds Continue?
What benchmark are we using to judge sustainability of engagement with wearables? Do we compare it to the 20% of patients that drop out of psychotherapy early? Or to the attrition rate for Crossfit, physical therapy, yoga, walking groups, Weight Watchers, or gym attendance? What about mindfulness, our panacea du jour? What percentage of mindfulness practitioners sustain their efforts for more than six months?
I don’t have credible citations for disengagement rates on any of these potential benchmarks, because hardly anyone’s even asking the question. But, by most accounts, a 66% adherence rate after six months compares favorably to…well, just about anything that requires effort.
Previous research on pedometers and early-day accelerometer devices has shown they can be useful tools for increasing physical activity…when they’re integrated with a sound behavioral program. And this was the optimistic conclusion of the “dirty secret” survey — that use of wearables can be sustainable when integrated with behavioral approaches.
Through my job, I’ve overseen the distribution of thousands of pedometers and hundreds of modern tracking devices to people engaged in top-tier behavioral programs lasting several weeks, often offered periodically throughout the year. The pedometer users, I did indeed find, are usually eager to abandon their device in the junk drawer after a program ended. But those who stop wearing their pedometer after eight weeks tend to be perfectly happy to resume wearing it when the next program rolls around. And I’ve seen unpublished data showing that the effects of this intermittent participation on activity levels is sustainable for more than a year. Using it or not using it for the first six months of ownership doesn’t seem essential.
Our wearable technology is ahead of our research. Do we know what consumers expect from trackers? Not everyone wearing a tracker wants to change. Some may be quantified-self devotees. Some enjoy a tracker as an expensive toy.
As for me: I need to have an activity tracking device because I’m in the business, and I’m extra motivated to continue so that I can contribute my data as a subject in the Heart Study (which, I hope, may ultimately resolve some of our questions about wearables). If my job was unrelated, I doubt I’d pony up the bucks for a glorified pedometer.
Calorie-counting apps have come under similar criticism, but there’s no arguing that expectations of these apps are more clearly defined. Consumers come to these apps to lose weight, though research shows that attrition is high and that the apps, perhaps like wearables, are useful as a measurement tool and not a standalone strategy.
I use MyFitnessPal to track calories for 3 to 4 weeks each year. In the first three weeks I used it, I suffered the revelation that I consumed more daily calories in snacks than I did in meals. While I caution that n=1 — my experience may be irrelevant to anyone else’s — approximately three weeks was all it took to trigger a lasting change in my eating patterns. I consider that a win and, as of this moment, it’s no secret.
[This post was originally published on Medium.com on May 18, 2015]
Pay No Attention to the Magnate Behind the Curtain?
In 2000, a bunch of diet “gurus” were assembled to debate the pros and cons of different weight loss diets. Robert Atkins, Dean Ornish, John McDougall, the Sugar Busters guy, Barry Sears, and Keith-Thomas Ayoob from American Dietetics Association were in attendance.
At the time, the Atkins diet was booming in popularity. The low-fat guys demanded from Atkins data supporting his advocacy of high-fat, high-protein, low-carb diets. Atkins said he hadn’t been able to secure research funding.
Ayoob chided, “Excuse me, 10 million books in print and you can’t fund the study?”
Eventually, Atkins funded his own studies, which demonstrated that his’ conclusions about carbs and fats were not something to be ridiculed (they influences much of today’s emerging thinking about weight loss). Many of these studies were published in distinguished journals, such as the New England Journal of Medicine. Regardless, they were viewed warily because they were funded by Atkins.
In other words, skeptics belittled Atkins for not funding studies of his diet. Then, when he did fund them, they dismissed the results as biased…because he funded them.
Damned if you do, damned if you don’t.
Almost all employee wellness research is commercially funded, and I do believe bias and distortion are prevalent. On the other hand, I respect companies that endeavor to publish their results.
My job, as a consumer of science information is:
to be aware of the potential for bias;
to try to understand how bias may or may not influence outcomes;
to seek less biased sources;
…and then to use my own critical thinking skills to reach or reject a conclusion based on all the information I have at hand.
[This post was adapted from a reply I wrote in response to Ted Kyle’s blog post Head Spinning Bias About Funding Bias. Ted blogs prolifically about obesity on his ConscienHealth – website, and is uncommonly faithful to scientific evidence. He’s a voice that needs to be heard.]
I’ve compared, in a separate post, the terms health, wellness, and wellbeing.
But even “wellbeing” doesn’t go far enough. The term, as it’s typically used in employer circles, overlooks the interaction between an employee’s wellbeing and their work — the job conditions, the people they work with, the support they receive… indeed, all the way to the very way work is done. The consequences of a sustainable workforce are the very ones employers seek: work engagement, productivity, consistent attendance, and retention.
One of the best descriptions of workforce sustainability is offered by researchers Ellen Kossek, Monique Valcour, and Pamela Lirio in their chapter, The Sustainable Workforce: Organizational Strategies for Promoting Work–Life Balance and Wellbeing, published in the book Work and Wellbeing: A Complete Reference Guide:
“A sustainable workforce is one where the work environment is caring and supports employee wellbeing. Employees are not seen as primarily resources that can be deployed (and depleted) to serve employers’ economic ends. Their skills, talent, and energies are not overused or overly depleted. They are not faced with excessive workload nor with a relentless pace of work for weeks or years on end. During times of crisis (e.g., natural disasters, sickness), employees are given time to recover or seek the extra resources they need to be able to perform in the future. Burnout is avoided and workers are given time for renewal.
“When human resources are used in a sustainable way, employees are not only able to perform in-role or requisite job demands, but also to flourish, be creative, and innovate. Sustainable human resource management practices develop positive social relationships at work, which enhances business performance, including greater cohesion among organizational members, commitment to common purpose, hope for success, resilience, knowledge sharing, and collaborative capacity.”
There’s no secret sauce to achieving a sustainable workforce. But it’s important to understand the essential elements of workforce sustainability when implementing a wellness program, so that program offerings are crafted through a sustainability lens.
I recently read an article about business’s revolutionary transition from employee wellness to wellbeing. “Historically speaking,” the author wrote, “wellness has been thought of as strictly pertaining to physical health, usually measured by biometrics.”
But, accurately speaking, this is not so.
Of course, there’s no single arbiter who can proclaim what exactly health, wellness, or wellbeing mean, but it’s worth understanding some of the ways these words have been interpreted in order to fully appreciate the implications, or lack thereof, of the “transition” from wellness to wellbeing
“Health” was defined by the World Health Organization (WHO) in 1946 as
a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
WHO’s definition, incorporated into its constitution, remains unchanged to this day. But in 1986 the organization held an International Conference on Health Promotion in Ottawa, which resulted in the famous Ottawa Charter for Health Promotion that elaborated on the definition, stating,
An individual or group must be able to identify and realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities.
The Charter went on to list the conditions for health: peace, shelter, education, food, income, a stable eco-system, sustainable resources, and social justice. A far cry from biometrics.
In the late 1950s, the chief of the US Office of Vital Statistics — Halbert Dunn, MD — described a dynamic state-of-being he called “high-level wellness.” This is generally considered the founding of wellness, and Dr. Dunn’s sermon-like lectures reveal his concept to be anything but a simple embodiment of physical health. Dr. Dunn said…
The state of being well is…a fascinating and ever-changing panorama of life itself, inviting exploration of its every dimension.
I believe Dr. Dunn was amplifying — not refuting — WHO’s original definition, and the Ottawa Charter later adopted much of his take on wellness as a never-ending interaction with the environment.
But Dr. Dunn’s framework may have proven too cosmic for the mainstream. And many thought leaders have since distilled wellness into the sum of its various dimensions.
The National Wellness Institute adopted a model that incorporates six dimensions of wellness — occupational, physical, emotional, spiritual, intellectual, and social. Others have divvied wellness up into five, six, seven, or eight dimensions, sometimes tossing in a “relationship” dimension, sometimes “environmental,” “financial,” or “community.” A quick image search reveals a galaxy of multidimensional wellness models in the shape of pies, hexagons, prisms, Venn diagrams, concentric circles, and geodesic domes.
I don’t know exactly how “wellbeing,” in the last few years, worked its way into the hearts of employers and the wellness industry. But one catalyst probably was the bestselling book, The Five Elements of Wellbeing, by Tom Rath and Jim Harter. Both authors are workplace consultants with Gallup (a partner of wellness vendor Healthways) and entrepreneurial marketers with a track record of successfully persuading employers to their way of thinking.
Rath and Harter argue, based on Gallup findings, that wellbeing is more profound than health and wellness, incorporating career, social, financial, physical, and community wellbeing. Sound familiar?
In practice, employers are rallying around mindfulness programs and financial planning, and repackaging stress management as resilience, and using these incremental expansions of the status quo as markers to distinguish wellbeing from wellness. Ultimately, the transition amounts to little more than a name change.
I’m more than happy to dispose of the word “wellness.” I never cared for it — not because of its definition, but because it has failed to resonate with employees or the public at large. And I see no harm in calling it wellbeing instead of wellness. Certainly, while the employee wellness industry has been celebrating this “transition,” I doubt many employees have noticed a difference.
Besides, I’m open to the evolution of language, as long as it isn’t contrived to cover up a deception (like calling participation “engagement,” which I’m sure no self-respecting wellness professional would ever do).
Here’s my bottom line based on this incomplete and superficial exploration of the terms health, wellness, and wellbeing: Some people are inclined to see connections, whereas others are more drawn to compartmentalize. Maybe surgeons and benefits directors are more likely to see what’s tangible and quantifiable, while artists and farmers see the whole and the dynamics it contains. Both points of view probably deliver value.
Either way, I’m guessing that anyone who views health and wellness as only physical phenomena is likely to see wellbeing the same way. Others who view these concepts holistically are likely to do so regardless of the labels we attach to them.
Health, wellness, wellbeing: In the end, what we call it won’t matter as much as how we think of it…and how we act on it.
It may be too late for employee wellness professionals to adjust their plans for holiday-season programs this year, but now is an ideal time to rethink the holiday stress programs we typically offer.
Every December, wellness program managers promote programs about managing “holiday stress.” These commonly take the form of lunch-and-learns or communication campaigns. They have the usual catchy titles like Holiday Stress Less and Take the Hassle Out of the Holidays.
The holiday season is stressful for many employees — no doubt about it. And it’s distinct from other sources of stress in the workplace in that the conditions that cause holiday stress can, indeed, be modified with behavioral approaches.
But I suspect that our holiday stress programs add to employee stress. They contribute to a culture that considers stress the primary mental state in which we experience the holidays and, as such, comprise a self-fulfilling prophecy.
May I suggest a new approach to promoting mental health during the holidays, even if some of the content may be the same? Let’s offer programs that promote happiness and joy, rather than just trying to remediate stress. Next year, instead of teaching people to manage holiday stress, why not teach them how to nurture their holiday happiness? Why not publish newsletter articles like “How to Share Holiday Joy”?
Instead of “5 Tips for Managing Your Holiday To-Do List,” how about “101 Reasons to Enjoy a Holiday Vacation”? Rather than “Balancing the Burdens of Work/Life During the Holidays,” how about “Focus on Family this Holiday Season!”
[Originally posted by Bob Merberg in May 2010 on the In TEWN blog.]
Photo: The Teaching Kitchen Collaborative evolved out of the Healthy Kitchens, Healthy Lives® conference, shown here. Photo creative commons copyright courtesy Culinary Institute of America Leadership Programs. Acquired via Flickr.
A study investigating the feasibility of workplace teaching kitchens, and the outcomes that might result from integrating them with other types of health behavior interventions, may herald a new and important movement for employee wellbeing programs.
The Teaching Kitchen Collaborative — led by the Culinary Institute of America and Harvard TH Chan School of Public Health — endeavors to promote teaching kitchens as “catalysts of enhanced personal and public health” across a variety of settings, including workplaces.
The study — led by Dr. David Eisenberg, Director of Culinary Nutrition at Harvard TH Chan School of Public Health and published in the Journal of Lifestyle Medicine — set out to determine the feasibility of an interdisciplinary teaching kitchen curriculum that includes…
hands-on cooking instruction
encouragement and resources to promote physical activity
mindfulness training, and
personalized health coaching
… and to measure the program’s behavioral and health outcomes.
At the completion of 14- and 16-week interventions participants showed statistically significant decreases in body weight, body mass index, waist circumference, systolic and diastolic blood pressure, and total cholesterol.
Participants who completed the program also were more likely to engage in positive behaviors, such as cooking meals from scratch at home more often, relying on ready-made meals less often, reading nutrition labels on purchased foods more often, and feeling more confident in cooking.
The study had several limitations, as the researchers noted in their published article. The number of participants was small (40 all told) and the pool of potential participants was comprised of (non-culinary) employees of the Culinary Institute of America, which meant they had state-of-the-art teaching kitchen facilities available to them. The intervention was expensive, and many of the results weren’t statistically significant or sustained over 12 months of follow-up.
Models for teaching kitchens, in the workplace and in other settings, will continue to be refined and studied. The pilot study described here represents an encouraging first step. As Harvard wrote in its summary of the findings:
With dramatic increases in obesity and diabetes, the search is on for innovative strategies to change the paths of those living with, or at risk for developing these and other lifestyle-related chronic diseases. In conjunction with good medical guidance, holistic strategies are needed.
Dr. David Eisenberg may have tapped into one winning strategy with Teaching Kitchens—a kind of cooking laboratory that combines culinary instruction using healthful whole ingredients, nutrition education, exercise, mindfulness, and personalized health coaching.
Summer’s here, and it’s time to unstrap the Fitbit and track some physical inactivity — the kind, for example, that takes place while reading. Pictured here is a pile of books that I’d recommend, or almost recommend, to wonky wellness professionals who have been at it for a while and are still searching.
You may think it weird that some of these books are old or even out-of-print. What good does an out-of-print book recommendation do you? Well, sometimes the story of a book is worth telling just as much as the story inside it.
Starting at the bottom of the pile…
Making Health Communication Programs Work.
Can you imagine there was a time — from 1989-2004, to be exact — when the US government gave this health communication book away for free? All you had to do was call and ask. This was the authoritative source on health communication — with more of a public health bent rather than employee wellness — affectionately known to health communicators as “The Pink Book.”
The good news is that you can get the final version of the book as a pdf. Who cares if it doesn’t include the last 13 years of developments? Who cares if the last entry in the glossary is a definition of “World Wide Web”? The book still covers an evidence-based approach to health communication theory and practice, with some behavioral change theory thrown in to boot. Get on it.
I’ve been studying the Hawthorne experiments for the last couple of years, and have assembled quite the collection of yellowed, musty, out-of-print books, this being one of the most important and, published in 1993, the most recent. At the heart of the matter is the field study of workers, supplemented with detailed interviews of 23,000 workers, under different conditions at Western Electric’s Hawthorne plant outside Chicago, in the 1920s and early 1930s. It stands as one of the most important studies of workers, management, and productivity ever.
While the Hawthorne researchers weren’t committed to worker wellbeing as we think of it, they did recognize wellbeing as relevant to productivity. And much of what we believe today about management styles, leadership, employee engagement, and teamwork was rooted in the Hawthorne research. Forget the fact that it started as a study of lighting, or that it had an entire category of bias named after it. Most experts today believe that if there is such a thing as the Hawthorne effect — in which research subjects change their behavior simply as a response to being observed — it didn’t occur at Hawthorne.
Let’s get real… You’re not going to read an old book about a 90-year-old study. So take 9 minutes to listen to this peppy BBC podcast on the topic. Regardless of the Freakonomics interviewee drawing an unfounded explanation of the Hawthorne findings, the podcast may start to give you a sense of how important the Hawthorne experiments are to our understanding of work, motivation, and even research design.
Yup, out-of-print — I don’t know why, as this is a seminal classic about the relationship between work and health, in which Robert Karasek, one of the most important worker health researchers of our time, lays out the case for the demand/control model of job strain.
Healthy Work may be too technical for a lot of people, but if you can get your hands on a copy, it’s great to keep around and skim through whenever you have a chance. Healthy Work changed how managers, health agencies, and labor organizations around the globe think about worker health.
Health Behavior and Health Education.
Get the 2015 version (5th edition), which is called Health Behavior: Theory, Research, and Practice. Health behaviors aren’t the foundation of employee wellbeing. (Exposures are.) But whether you agree with me or are convinced that, like people always say, “it all comes down to behavior,” isn’t it important to understand what makes health behavior tick?
This book was published in 2000 predominantly for clinicians and other wonks. It gets highly technical — so it’s not something you’ll want to read at the beach. But I keep it handy on my desk. It’s a collection of evidence documenting the relationship between work, psychosocial job stressors, and health, and suggesting a causal relationship — that is, bad jobs lead to poor health. The rigor of the studies contrasts with the vendor- and employer-fueled quasi-science to which wellness professionals are customarily subjected.
Amazon usually sells The Workplace and Cardiovascular Disease, used, for less than 10 bucks. If you want something cheaper and more current, you can try to access the article, “Globalization, Work, and Cardiovascular Disease,” published in 2016 in the International Journal of Health Services. Two of the article’s authors, distinguished researchers Peter Schnall and Paul Landsbergis, were among the editors of the book.
The only thing I find more painful than hearing our industry called the “ignorati” is noticing that we often do ignore criticism. Sure, we’ve all been paying the price for Al Lewis’s book ever since it was published, but we can be thankful that someone cast skepticism on the claims of the wellness industry. I don’t know if this is Al’s goal, but it is mine: To get better at supporting the wellbeing of the American workforce. In order to achieve this, we need to be able to assess our practices critically, and this book rallies us to do just that.
Former Washington Post reporter turned work-life balance hunter, Brigid Schulte, endeavors to wake up America to the mess we’ve gotten ourselves into by putting obsessive “busyness” and profits ahead of our kids, our spouses, and ourselves. Schulte deconstructs an American culture driven by a destructive sense of individualism and machismo that puts us on a never-ending treadmill — the unhealthy kind — as well as the policies and gender inequality that keep us there. She draws upon the experience of her own work and family life, and visits Denmark where the possibility of a better way reveals itself to her.
Health is influenced by social status — specifically, our position in the spectrum of autonomy and of full participation in society. The workplace is a microcosm for this “social gradient.” Epidemiologist and author Sir Michael Marmot, who has devoted his career to spotlighting the social determinants of health, led the Whitehall studies — investigations into the work lives and the health of thousands of British civil service workers. Whitehall II is among the most important studies of worker health, but — as with much of the excellent research from Europe and other countries around the globe — is noncommercial and, consequently, infrequently discussed at American wellness conferences. Sir Michael once wrote in Lancet,
Healthy behaviors should be encouraged across the whole of society. More attention should be paid to the social environments, job design, and the consequences of income inequality.
Of all the books in my pile, this is the one I most enjoyed reading. If it’s nothing else to you, it’s a heart-wrenching story well told. Triangle also is filled with historical detail about working life that, for many, will continue to resonate today. The importance of the Triangle Factory fire — along with the events that preceded it and those that ensued — remind us of the context for worker wellbeing, and how it represents something more profound than lower health care costs or even improved morale.
Worthwhile reading, but not in my pile:
Workplace Wellness That Works, by Laura Putnam. At this point in my career, I learn most by delving into topics that are unrelated or only somewhat related to wellness. I don’t own Laura’s book, but I flipped through a co-worker’s copy and found it to be thorough and well-researched. This is the book I’d recommend to someone who’s looking for wellness ideas or trying to assess the evidence basis for employee wellness.
Quiet: The Power of Introverts in a World That Can’t Stop Talking, by Susan Cain. Quiet raises consciousness about what life is like for the large segment — perhaps the majority — of employees who consider themselves introverts. This is relevant as we plan our wellness programs and events and target our communications. Quiet isn’t on my pile because I lent it to someone and never got it back. I’d like to think that’s some sort of endorsement.
Any text on occupational health psychology. I like The Handbook of Work and Health Psychology, but others will do. Just as we should understand health behavior if we want to influence employees’ exercise and eating habits, we need to learn the science behind stress, burnout, adjustment to change, resilience, depression, motivation, and engagement.
Even if we don’t always understand the science of worker health, we benefit from recognizing that there is science to worker health.
For those interested in evidence-based approaches to wellness, reading these or similar books will be a breeze this summer.
Resistance to offering healthy workplace food options — whether it’s raised by cafeteria operators, vending machine operators, or company leaders — is often based on a myth that assumes employees demand unhealthy food, and don’t want healthy unprocessed food.
A new survey provides some evidence that it’s time we toss this myth down the garbage disposal. According to the 2017 Food and Health Survey, conducted by the International Food Information Council Foundation:
73% of college educated consumers and 51% of non-college educated consumers use nutrition information when eating out.
76% are trying to avoid or limit sugars in their diet.
Healthfulness, along with taste and price, is a top driver of food purchasing decisions.
Women favor foods and beverages with no artificial ingredients.
60% of those who regularly use nutrition info when eating out say it’s important that their food contains only natural ingredients.
The length of an ingredient list affects the perceived healthfulness of nutritionally identical products.
Overall, Americans say they take steps to eat healthy and understand the importance of expert nutrition guidance.
Undoubtedly, the Foundation brings food-industry bias to its positions. But that doesn’t necessarily invalidate its findings about increasing consumer demand for healthy food.
Other market surveys have had similar findings. A 2015 Workplace Food Insights survey by Sodexo, for example, found that eating healthy is “extremely” or “very important” to nearly 80% of surveyed workers.
I brought this point home in an article just published by Carol Harnett — employee benefits visionary — in Human Resources Executive Online…
Good food isn’t something you’re trying to convert employees to eat. It’s a need you’re seeking to accommodate.
Check out the article to get a taste of how the need for whole, fresh, well-prepared food has been met by at least one employer.
As an employee wellness manager for a large company, I was given responsibility for dining services — cafeterias, catering, and vending machines — with the express goal of accelerating our commitment to providing healthier options.
Easier said than done.
A slew of challenges ensued, but most perplexing were those instances in which food service operations directly conflicted with wellness goals.
Converting Brown Baggers
We were hosting finalist meetings for food service vendors, and it came to light that our “participation rate”— the percentage of employees who regularly use our cafés for breakfast or lunch — wasn’t up to par. The standard in our region is about 35%, and we were well below that.
We attributed our low participation to our homebody culture and demographics that include a lot of likely “brown baggers” — employees who bring their lunch from home. Our facilities don’t have competition from nearby eateries that could’ve been drawing business away.
The vendor’s sales guy told us, “We can convert a lot of those brown baggers to café customers, so that they’re buying their lunch instead of bringing it.”
There was a long silence as our wellness-focused team conjured images of employees leaving their brown bags — with their simple sandwiches in zip-lock baggies, or leftover lasagna in Tupperware — sitting on their kitchen counter as they headed out to work in the morning with a pocketful of cash to spend at our café.
I looked at my boss and asked, “Do we want to convert brown baggers to café customers?”
The Other Side of “Nudging”
Our company needs to generate revenue in our cafés in order to keep them operating affordably for employees. On the other hand, research tells us that food prepared at home is likely to be more aligned with healthy eating compared to eating out (notwithstanding our efforts to offer plenty of healthy menu options). Eating home-cooked food is better for financial wellness, too.
We’ve faced other dilemmas: Several years ago, before it was fashionable, we started diverging the prices of “healthy” foods from the prices of foods considered unhealthy. The idea was to “nudge” customers to buy the more favorably priced healthier food. Each year, we raise prices, on average, according to the Consumer Price Index for Food (about 3% or 4% in recent years). We’d achieve the average increase by raising prices more for the so-called unhealthy food and less (or not at all) for the healthy food.
We were victims of our own success. Sales shifted from soda to bottled water, from fried food to salads, and from beef burgers to turkey burgers (this harkens back to a simpler time when experts agreed that lean meat was healthier than red meat).
The problem was that our margins decreased. We were making less “profit” because we’d nudged people to buy the least profitable food menu items. Don’t get me wrong, we hold true to the belief that we are not in the business of making money from employee cafeterias. But we all have budgets to meet.
Advocating for the Opposite
One more example: We have trays in most of our cafeterias, but for some reason they’re rarely used. A consultant observed this, noting that it was unusual. More importantly, he advised us that we could increase our “check average” (the amount of revenue earned on each purchase of a meal) by encouraging the use of trays.
Customers are limited by what they can hold in their hands, and using trays would allow them to pile on the food well beyond what their hunger level actually demanded.
Did we want to encourage trays, so that employees would buy more food than they wanted or needed? In most companies, the wellness manager would advocate for the exact opposite: Making trays less convenient in order to “make the healthiest choice the easiest choice.”
I’m proud to report that we’ve consistently opted for whatever we determined to most effectively serve the best interests of employees. Sometimes it served their nutritional wellbeing and sometimes their financial wellbeing. And sometimes it served their career wellbeing by assuring sustainability of good food at work. Sometimes it was all of the above.
Organizations are complex. It’s easy for consultants, vendors, and academics to sit in their home offices hollering at you about what you should do. But real jobs have real people, with real goals, real pressures, real personalities, real challenges, and real conflicts.
Seeing the big picture, and recognizing that it can be viewed from different angles, sometimes is the first step to success.
Wellness experts emphasize the importance of sleep, and vendors promote sleep-tracking devices, apps, and programs. But little is said about the job conditions necessary to assure workers have the opportunity to get the sleep they need.
It’s hard to get eight hours of sleep if you’re only home for five or six hours between your evening shift and your morning shift. And that’s where “clopening” comes in. The term commonly applies to schedules in which part-time retail and fast food workers are required to close the store late in the evening and open early in the morning.
Clopening gained notoriety in a 2014 New York Times story about the life challenges a Starbucks employee faced as a result of “just in time” (last minute) scheduling that included clopening. In the minds of activists, unpredictable scheduling and insufficient rest periods between shifts have been linked ever since — appropriately so, as both practices tend to coincide and threaten employee wellbeing.
These scheduling practices also go hand-in-hand with schedule fluctuation (like working eight hours one week and 40 hours the next) and inflexibility. According to a report by the University of Chicago, unpredictable, fluctuating, and inflexible scheduling undermine almost every dimension of workers’ wellbeing, including the physical, mental, family, occupational, and financial realms. The report’s author, Susan Lambert, was quoted in a follow-up Times article as saying:
This particular form of scheduling — not enough rest time between shifts — is particularly harmful.
Through literature review, original data analysis, and focus groups, we find that the health and well-being of workers is undoubtedly compromised by unpredictable work schedules.
Even prior to the original New York Times exposé, and increasingly after it, municipalities have considered “secure scheduling” legislation to limit schedule unpredictability, fluctuation, and, yes, clopening.
In 2014, San Francisco enacted the Formula Retail [i.e “chain store”] Employee Bill of Rights, which requires covered employers to provide employees with two weeks’ notice of work schedules, advance notice of schedule changes, and additional pay for schedule changes made on less than seven days’ notice and unused on-call shifts.
Employers inevitably resist regulation. But if we are as committed to employee wellbeing as we say we are, we should evaluate and address scheduling practices proactively.
Leadership sometimes emerges where it’s least expected — in this case, Walmart. The mega-retailer recently phased in new processes — on the heels of improvements it made to compensation and occupational development — in order to make scheduling more flexible and predictable for workers. The Washington Post reported that, based on early results, workers with access to the new scheduling system experienced an 11% decline in absenteeism and a 14% drop in turnover, “which comports with what academic research has shown is possible with greater predictability and worker control.”
[This post is adapted from one originally posted by Bob Merberg on September 19, 2016 on the Healthshifting blog.]
As the article mentions at the end, community cookbooks are still alive…
Community cookbooks are worth flipping through if you come across a boxful at a garage or used book sale… You may find a current self-published book from a group connected to your own community.
Employee recipe books are a form of community cookbook. They help employees build community at the workplace and — in the context of the type of cookbooks Gig Goodies will produce, they help workplace health seekers rally around a more hospitable work environment.
Make-your-own fruit cones (photo, below) are the perfect fresh-food option for workplace meetings and events.
They’re easy to serve, and attendees will love the novelty, the choices, and the refreshing sensation. And, unlike what may be served at, say, an ice cream social, your attendees will feel energized and ready to go after this delicious treat.
But Berkowitz is more captivated by the social norms candy bowls reveal. Why do people have candy bowls? What’s the personality profile of those willing to snag the last morsel? Was Forrest Gump’s mama right about life?
Check out the Post article for life-changing answers to these and other questions about office candy bowls.
Employees at many workplaces have a big role in shaping their environment. Sometimes those environments can be harmful. Nowhere is this more clear-cut than in the environments employees — in many offices — shape via their nutritional and food-sharing practices.
I’m not talking about employee cafeterias and vending machines — food provided by employers. They’re important, but receive due attention.
This is about employee-provided grub — a harder nut to crack.
As wellness professionals, it’s tempting to overlook the less-than-wholesome food shared at workplace birthday celebrations, the candy passed around at meetings, the treats at trainings, the potlucks, the chocolate that co-workers sell for their kids’ fundraisers, the “food days,” the desktop candy bowls, munchable business gifts and giveaways, breakfast donuts for the staff, leftover halloween candy, Friday ice cream socials, and so on. In fact, with a wink and a nod, we may sometimes enable this culture in our desire to buddy-up to co-workers.
Speaking of buddying up, let’s not forget sugary rewards doled out by managers — a demeaning ploy applied to school-children, and no better with workers.
My awareness about shared-food has been raised after listening to employees’ complaints about it or overhearing those who indulge while engaging in self-talk about lack of willpower, excess body weight, or plans for self-punishment. Unhealthy eating environments foster a culture of guilt. And guilt is fundamentally incompatible with wellbeing.
As I’ve chatted with employees and employers, my mention of the overabundance of indulgent food at work is met with knowing groans.
As a manager responsible for cafés, catering, micro markets, and vending machines at my own workplace, I’m fully aware of the behavioral economics manipulations we can use to make the healthy choice the easiest choice and the policies we can create to support healthy eating via the food channels under an employer’s control.
But I also know these efforts are for naught if candy, pastries, soda, and pizza are dangled in front of workers in every break room, displayed on credenzas along every aisle of cubicles, served at every event because “people will always come for free food,” and generally tempt employees everywhere they turn.
I’ll post more on this topic in the coming days and weeks, and explore strategies to understand and influence the pervasive sharing of unhealthy food. Throughout, I’ll challenge some of my own assumptions — and perhaps some of yours. For now, mine include:
A lot of workers want to make healthier food choices.
Acting as “food police” always backfires.
No food is bad when consumed occasionally.
More choice is rarely a successful strategy to support healthy eating goals.
Employers aren’t obligated to provide unhealthy foods.
Workplace eating touches multiple dimensions of wellbeing.
Workers should never be shamed regarding their body weight, food choices, or anything else.
Different channels of food at work — cafeterias, vending machines, food brought from home to share, treats and celebrations, catered events, farmers’ markets or local produce delivery — interact to create a nutritional milieu.
Habits like desktop dining, skipping lunch, eating alone, and brown-bagging vs. buying are vital pieces of the workplace eating puzzle.
A couple of years ago, I wrote that partnering with local farmers — via community-supported agriculture — could be the best wellness thing an employer can do. Based on the experience of at least one employer with 10,000+ office workers nationwide, I may have found my next best thing.
A survey completed by employees at this firm showed “healthier food at meetings, in cafeterias, and in vending machines” to be the second most requested wellness offering (after gym membership discounts). And 30% of employees who reported having unhealthy eating habits said they were actively engaged in trying to improve them. Some employees want to eat healthier.
The employer had, years ago, dug into a bag of age-old merchandising tricks that had become trendy when some bestselling author dubbed them “behavioral economics”: pricing healthier food more attractively than unhealthy food and making the healthiest choices the easiest choice.
The behavioral economics nudges had some success, but there was another obstacle afoot for employees who wanted to make healthier food choices…
Eating healthy is not always easy for consumers during the work day, with a little over half finding it only “somewhat” to “not at all” easy…Most attempt to eat healthy, but encounter challenges along the way. Some backslide the rest of the day and continue to indulge and eat less healthy as a part of a more emotional cycle of guilt and reward.
Free food is everywhere in offices and call centers. Sometimes it’s provided by employers, like not-so-refreshing refreshments served at long meetings and special events, or sweet treats used to reward workers the way you might use Milk Bones to reward a paper-trained labradoodle.
But much of it is introduced and shared by co-workers. I’ve previously described workplaces flooded with cakes, candy, and other treats, and cited studies that coined the terms “food altars” (where leftovers and treats are reliably displayed) and “cake culture.”
Navigate around the 'food altars' & head to the water cooler – Avoiding the high calorie office snacks https://t.co/Yk3bXG7IR9
The challenge this employer faced was how to meet the needs of employees seeking healthier choices and a healthier environment — without taking on the role of “food police.”
A pulse poll found that, when co-workers brought in treats, 23% of this company’s employees ignore them because they don’t fit into the respondents’ eating style, diet, or health concern; 9% sample some to be polite but “wish it wasn’t there”; 8% tend to overindulge and “feel gross after.”
Did I mention that some employees want to eat healthier?
When asked what type of foods they are most likely to bring to an office potluck, 32% of respondents from a separate poll of the same employees said they’d contribute an indulgent dessert; 15% said they’d bring “pizza and wings, or something like that”; only 16% said they’d bring a healthy dish; and 12% said it depended on their co-workers’ dietary concerns.
Not much can be concluded from informal poll data, but at first it may seem like there’s a reasonable match between employees that bring treats and those who consume treats. That’s not a problem if workers are only bringing in food, say, once every week or two.
But “cake culture” isn’t about what happens once every week or two. It’s about what happens every day. That’s what makes it cake culture… and not just…you know…cake.
If the majority want to have their next slice of cake within arms’ reach all day every day.…what about those who don’t?
Remember that “choice” thing? Does it only apply to those who fall into a narrow majority?
Some will argue, “Who cares?! It’s a matter of personal will. Employees who don’t want unhealthy food don’t have to eat it!”
Did I say “some will argue”? Nix that. Most will. But this stance reflects an unfounded belief in willpower, which has little to do with behavior (or obesity, in case you’re interested), a lesson even many wellness professionals have not yet learned.
Research has shown that people who demonstrate what might appear to be a high level of willpower generally are not exercising willpower at all, but in fact craft their environments in a way that supports specific behaviors. If anything, some researchers have said, naive faith in willpower reduces your chance of adopting a healthy behavior.
This employer endeavored to support the normalization of healthy food, so that the needs of employees seeking healthier choices, even if they weren’t a majority, were not drowned in a sea of cake, candy, cookies, pizza, and chips.
In an upcoming post, we’ll see how this employer leveraged a feel-good crowdsourced tactic to support employees when their own workplace food culture sometimes failed to do so.
I recently celebrated ten years at my current job.
I started in the thick of the holiday season. My first day, a co-worker came over to my cubicle to offer me a gooey chocolate confection she was serving off a piled-high tray. “Wow, what a classy holiday treat!” I thought.
Another co-worker left a tray of Italian cookies on the long credenza down the aisle. Then a couple of gifts came in from vendors — caramel-dipped popcorn from one, mixed nuts from the other — and they also were put on the credenza to share.
We had a big meeting where I was introduced, and a giant bowl of candy was passed around, for reasons unknown to me. It reminded me of my orientation the day prior, when the facilitator did an ice-breaker by asking us trivia questions about the company, and if you answered correctly he threw you — threw you! — a packet of M&Ms.
After the candy-bowl meeting, I was taken to lunch at the company cafeteria, where I enjoyed a good-sized serving of pork tenderloin with a side of fries. For a beverage, I stuck with water — you know, to keep it all healthy.
Holiday feasting and food-sharing are wonderful and important social traditions. Little did I know back in those days that the feasting had little to do with the holidays, and would ebb and flow — but mostly flow — for the next ten years.
It surprised and saddened me back then that, as I was introduced to co-workers as the new wellness manager, they sometimes felt the need to make an awkward joke about whatever food they had around at the time, assuming I was judging them for the muffin on their desk or the McDonald’s bag they were carrying.
But I wasn’t judging and never have. I’ve observed an abundance of edible goodies pervasive in the workplace — my workplace and others — and I’ve learned that it’s a force employees quietly contend with daily. But, indeed, it’s a force that challenges me — I like food, too — so far be it from me to judge anyone else.
Congratulate me! This week, I celebrated ten wonderful years at my current job.
Yes, I started in the thick of the holiday season. I remember my first day, a co-worker came over to my cubicle to offer me a gooey chocolate confection she was serving off a piled-high tray. “Wow, what a classy holiday treat!” I thought.
Another co-worker left a tray of Italian cookies on the long credenza down the aisle. Then a couple of gifts came in from vendors — caramel-dipped popcorn from one, mixed nuts from the other — and they also were put on the credenza to share.
Then we had a big meeting where I was introduced, and a giant bowl of candy was passed around, for reasons unknown to me. It reminded me of my orientation the day prior, when the facilitator did an ice-breaker by asking us trivia questions about the company, and if you answered correctly he threw you — threw you! — a packet of M&Ms.
Anyhow, after the candy-bowl meeting, I was taken to lunch at the company cafeteria, where I enjoyed a good-sized serving of pork tenderloin with a side of fries. For a beverage, I stuck with water — you know, to keep it all healthy.
Holiday feasting and food-sharing are wonderful and important social traditions. Little did I know back in those days that the feasting had little to do with the holidays, and would ebb and flow — but mostly flow — for the next 10 years.
It surprised and saddened me back then that, as I was introduced to co-workers as the new wellness manager, they sometimes felt the need to make an awkward joke about whatever food they had around at the time, assuming I was judging them for the muffin on their desk or the McDonald’s bag they were carrying.
But I wasn’t judging, and never have. I’ve observed an unbridled abundance of edible goodies pervasive in the workplace — my workplace and others — and I believe it’s a force in wellbeing that employees quietly contend with daily. But, indeed, it’s a force that challenges me — I like food, too — so far be it from me to judge anyone else.
Here are some of my observations and thoughts — optimistic, skeptical, and neutral — about the promise of this new player on the employee wellness scene:
Giving a keynote presentation at a small conference last April, I speculated that burnout will be the next employee wellness trend — on the heels of mindfulness, sleep, and financial wellness.Thrive Global positions “burnout” front and center. Their announcement states,
Thrive Global’s mission is to change the way we work and live by ending the collective delusion that burnout is a necessary price for success
Thrive Global currently has seven employees. In light of recent consolidation in the wellness industry, we may expect that the company’s plans include significant partnership (possibly including acquisition or merger) with an existing wellness vendor.
Thrive Global already is partnering with basketball players Kobe Bryant and Andre Iguodala, and football coach Pete Carroll… (…because, when employees struggle with their physical and mental vitality as a result of working multiple jobs, being torn between the demands of their family and their employer, enduring long commutes to a workplace where they’re overwhelmed with responsibilities that aren’t clear or meaningful to them, being subjected to unfair or hostile environments where their efforts aren’t rewarded, feeling alienated, and/or being anxious about the possibility of losing their job altogether — the variables known to be drivers of employee wellbeing and burnout — who better to help than a pro basketball player and a football coach?)
A seat on Thrive’s Board of Directors is held by Aetna CEO Mark Bertolini, de facto czar of the mindfulness-industrial complex. Time will tell whether this relationship leads to Thrive Global having ready access to Aetna’s 23 million members or its 50,000 employees (who often serve as test subjects for the insurer’s innovations).
The announcement states that Thrive Global will partner with “thought leaders including Adam Grant… to measure the impact of its services on employee retention, wellbeing, and productivity, as well as organizational culture.” Grant is an organizational psychologist — a field conspicuously absent from the US wellness scene — with a track record of insightful research and a knack for contributing to marketable content. Possibly to Mark Bertolini’s chagrin, Grant authored the New York Times article “Can We Stop the Meditation Madness?“
On the consumer side, Thrive Global is planning an e-commerce strategy that includes products like “sleep kits,” pillows, beds, candles, supplements, “food products” and “lines of product and subscription boxes specially curated by celebrities and athletes.” This is one of the biggest red flags. Is Thrive Global a serious company “aimed at changing the way we work and live’’ as they say in their announcement? Or a celebrity-fueled new-age bazaar “capitalizing on this growing market opportunity” (as the investor pitch explains)? Or both?
Arianna Huffington is a former feminist-bashing “Republican Revolutionary” metamorphized into a liberal self-help guru. The investor pitch says Thrive Global “leverages the brand and success of Arianna Huffington as the face of the platform to drive adoption.” For more about how the brand was built and about the twists and turns of Huffington’s activism, check out the 2008 New Yorker article, The Oracle: The Many Lives of AriannaHuffington
We’ve had one of our [startup] partners say to us: ‘Everyone here does three jobs.’ There has been this hero mentality and sometimes in that culture companies want to change that so they can do right by their employees…
Levy has described Thrive Global’s corporate offering as a consultancy. The investor pitch envisions, “Organizational Design consulting to establish structures and systems that support Thrivers, eg. workspace design, (including nap and quiet rooms), healthy snack offerings, team communications design and more — all within an educational framework that encourages healthy choices.”
In an interview conducted by Benz Communications, published last week, I called for the convergence of independent wellness research with wellness product. Though it may be agonizing to see employee wellness take a turn toward celebrity-worship, health fads, and opportunism, Thrive Global may be just what this convergence inevitably looks like in real life.
What do you think? Visit the LinkedIn version of this post and chime in with your opinion.
The Robert Wood Johnson Foundation, as well as the Harvard T.H. Chan School of Public Health and National Public Radio, may have given a boost last week to advocates of employee wellbeing. Here, I refer to what I consider authentic wellbeing — based on workers’ exposure to harmful job conditions and environments — not the store-bought imitation based on wellness websites, apps, incentives, and medicalized interventions.
To promote the findings of their Workplace Health poll of 1,601 workers, these sponsoring organizations waged a publicity blitz that brought the “healthy work” perspective to a broad new audience. A Health in the American Workplace panel, streamed live on the web, served as a centerpiece of the campaign.
Workers’ Views on Jobs and Health
Poll results, according to panelists, revealed that many workers view their jobs as impediments to their wellbeing.
43% said their job has a negative impact on their stress level
28% said their job undermines their eating habits
27% reported that their job interfered with the ability to get a good night’s sleep
22% said their job has a negative impact on their weight.
Panelist Marjorie Paloma, director of RWJF, explained how job stress and health are influenced by workplace policies:
If you think about the stress a person feels whether because of their day to day work routines, or the stress they feel because of caring for a loved one while working a full time job, or workers who feel as if they have to go into work despite being sick…These are all stressors that influence health.
Succinctly describing the relationship between behaviors and the environment, Paloma stated:
The choices we make are as good as the choices we have.
She summarized this position with the catchy phrase:
Health shapes work, and work shapes health.
“Human Resource Failures”
Harvard Business School professor John Quelch described how workforce management and the intensification of work have been shown to influence health. Quelch bemoaned…
…the sheer overload that comes from downsizing and outsourcing and asking someone to do two jobs when previously they had to do one.
He cited an often overlooked source of stress:
It can also come from job ambiguity — the requirements of the job are not being clearly articulated by supervisors.
Quelch characterized these workforce management patterns as “fundamental human resource failures.”
Gloria Sorensen, from Harvard Chan, cited her team’s studies of health care workers, whose job conditions have been linked to health problems:
Risk of injury or musculoskeletal pain or accidents on the job increase…when we look at harassment on the job, inadequate staffing, bullying at work, high job demands, lack of control, and poor supervisor support.
Sorensen went on to say that these job conditions also have been linked to fatigue, sleep problems, and risk of obesity. She concluded…
The point is these conditions of work are critical when we look at a range of health outcomes for workers.
The panelists’ remarks revealed mixed feelings about conventional worksite wellness programs that focus on behavior change. The poll results showed that only half of workers have access to wellness programs, which at times the panelists, such as Harvard’s Robert Blendon, seemed to cite as an indictment of employers:
Almost half of people who work are at a workplace that has no workplace health program.…People go to work every day, and this is something they read about in a magazine, but they don’t see in their own job.
On the other hand, Paloma remarked…
Worksite wellness is insufficient if it’s not going hand in hand with efforts to improve the health of communities.
Blendon, director of the poll, said that the findings changed his mind about stress. He led an uncomfortable laugh at the expense of conventional stress management strategies, and noted…
Employers should have some responsibility for lowering the level of stress.
NPR’s Joe Neel, the panel’s moderator, summarized…
It’s all about conditions of the workplace and stress.
Kudos to Harvard Chan’s Sorensen, who introduces the audience to the study of job stress in San Francisco transit operators, in which changing the work — such as modifying schedules, training, staffing changes, and equipment upgrades — succeeded in reducing worker stress, whereas, according to Sorensen, previous efforts to change the workers (for example, with stress management programs) failed. For the curious: The research Sorensen cited has been incorporated into an in-depth analysis of stress prevention for bus drivers, available from the International Labour Organization.
The disconnect between the “healthy work” approach and the behavior change emphasis in the panel’s videos, if anything, highlights the need for an acceleration of credible worker health research, which is exactly what NIOSH’s Total Worker Health initiative has set out to do .
In the interim, watch the full one-hour panel here:
Your mother always told you life wasn’t fair. In few places did her words ring truer than workplaces where favoritism, bullying, discrimination, or broken promises rule the day.
But if life’s not fair, it may be no small consolation that, when facing an unjust and uncivil work environment day in and day out, life may not be very long either.
One study has shown that workers who felt they were treated unfairly at work — compared to well-treated workers — had a 55% greater risk of heart disease, even after controlling for other risk factors.
Organizational unfairness, or injustice, refers to a pattern of exposure to inequitable conditions that undermine workers’ dignity and self-respect. It runs the gamut from being ignored… to being spoken to rudely… to being bullied… to being assaulted.
In addition to its link to heart disease, which includes documented cases of heart attack and angina — organizational injustice has been associated with a variety of physical and mental health problems.
In one study, 8% of workers reported being harassed within the previous 12 months. These workers were significantly more likely to be obese; sleep less; smoke more; and experience psychosocial distress, pain disorders, and lost work days.
Another study showed that men who felt their workplaces had a high level of justice had a 25% lower risk of developing metabolic syndrome than those working in unfair conditions. And a review of several studies revealed a consistent association between organizational justice and mental health.
The exact definitions may differ depending on which expert you talk to, but generally workers experience unfairness via four categories of organizational injustice:
Procedural injustice — Processes for the employer to interact with employees aren’t created or conducted in an equitable manner. For example, effective systems are absent to assure that workers in comparable circumstances are treated equally when decisions are being made about job performance issues, schedules, promotions, and transfers.
Interactional injustice — Workers aren’t treated respectfully and their value isn’t recognized. Bullying and hostile work environments are examples of interactional (also called relational) injustice.
Distributive injustice — Benefits, compensation, and other rewards aren’t extended equally to employees doing comparable work, or generally aren’t appropriate for the demands and expectations of the job. Workers who earn less due to discrimination based on race, gender, or religion experience distributive injustice.
Psychological breach — Promises are broken. This includes the expectations the organization sets — including those related to pay, responsibilities, job demands, opportunity, and job security — when workers are hired or assume a new role. This category isn’t always included in classical definitions of organizational injustice, but is a process that may amplify the other categories.
Failure to communicate accurate, timely information to workers and to offer conduits for meaningful input are common denominators of organizational injustice.
Manage Fairness for Better Health
A 2011 meta-analysis confirmed that organizational injustice is associated with physical health problems and mental health problems, especially depression, anxiety, and burnout. Interestingly, the study also found that the strength of the association with specific kinds of health problems depended largely on the type of organizational injustice:
Workers experiencing procedural injustice were most likely to have physical health issues
Those encountering distributive injustice mostly reported mental health problems.
Psychological contract breach was associated with burnout.
Reviewing the meta-analysis, the online publication I/O At Work proposed strategies employers can consider if they genuinely want to promote worker health:
Organizations have a great deal of control managing fairness (and unfairness) perceptions. To increase feelings of distributive justice, organizations should strive to make policies with outcomes that are the same for all employees regardless of gender, race, and tenure. Increasing perceptions of procedural justice can be accomplished by insuring that decision-making processes treat all employees equally. Finally, to increase perceptions of a sturdy psychological contract, openly and clearly communicate to employees, provide them with information, direction, and support in times of change, and treat employees with respect.
Your mother may have been right: Life’s not fair. But that doesn’t mean the workplace can’t be.
Our society of hard knocks may scoff at the notion of fairness at work — dismissing it as the product of a self-entitled workforce. And it may be hard for traditionalists to believe that justice and other organizational strategies are an avenue toward improved workforce health.
But sometimes it’s the employer that feels entitled or plays the victim. And the observational evidence that connects the dots from fairness to health is no less solid than that cited by the wellness industry to sell behavioral change.
Ultimately, organizational change and individual change are likely to complement each other in cultivating a healthier workforce. Of the various solutions to choose from, a combination of organizational and behavioral strategies may be the fairest of them all.
Like many industries, we in the wellness biz tend to run with the herd. A few years ago, all we could talk about was mindfulness. Then we veered toward resilience. Last year, financial wellness was the buzzword. This year, the herd must be getting tired, as we switch direction toward…sleep.
New sleep program providers are cropping up, and existing wellness vendors are waking up to the opportunity to hop on the bandwagon.
Don’t get me wrong. Mindfulness, resilience, financial wellness, and sleep are important.
And I’m not saying that none of us have run against the herd by addressing these topics before they got trendy or supporting employee wellbeing in innovative ways. But, in general, our industry flits from one topic to another, from one tactic to another, falling in line with our herd’s stampede. The risk is that workers get trampled in the process.
One key to sustaining established wellness efforts, rather than letting the sun set on last year’s program as dawn breaks on this year’s, is to strategically scale up the size of the team that operationalizes these efforts. In other words — to use the term HR has eerily adapted from cattle ranchers — “add headcount.” Expand resources in proportion to demands? What a concept.
Despite my earlier acknowledgment that our herd mentality is comparable to other industries’, there is a difference: Other industries — especially those that are consumer-oriented — respond to changes in demand: Cold-pressed juice with chia one day, probiotics the next. Fuel-efficient cars one year, technology packages the next.
What drives our wellness herd?
As our newfound devotion to employee sleep takes hold this year, I suspect our herders may be revealed to us if we keep an eye on who is sponsoring the events, the publications, and the research that promotes it. There, the presence of vendors and pharmaceutical companies, for example, wouldn’t invalidate sleep as an important issue for employees, but it seems unlikely to serve as a sustainable driver of a successful long-term employee wellbeing strategy.
By this time, most of us are well-versed in how sleep — more accurately, the lack of it — affects work. Injuries, errors, accidents, and health care costs have all been linked to sleep loss and shown to affect business results.
What’s more, as reported by McKinsey in the article “The Organizational Cost of Insufficient Sleep,” there’s a host of psychosocial and cognitive problems that have been linked to sleep loss, including impaired attention, concentration, creativity, learning and memory, decision making, and relationship formation. Some studies have even shown that lack of sleep is associated with unethical behavior and have proposed specific pathways in the brain that may explain the connection.
Just as important, however, as how sleep affects work — maybe more important — is how work affects sleep, points out Canadian researcher Julian Barling, author of the forthcoming book Work and Sleep.
Chronic overtime, excessive workloads, shift work, expectations to be “always on,” and a culture that diminishes sleep all have been shown to contribute to the widespread problem of worker sleep loss.
The average person needs 7-9 hours of sleep per night. When surveyed, about 29.9% of Americans stated that they had gotten less than 6 hours of sleep the previous night.
Okay, we get it. Lack of sleep is widespread and undermines the wellbeing of workers and organizations. What can we do about it?
Typically, well-meaning employers wheel out their usual wellness strategies to get employees to change their sleep habits:
Education about sleep hygiene, with tips like
Don’t eat large meals before bed
Establish a consistent schedule for going to bed and getting up
Limit nighttime use of lit devices, like phones and computers
Use your bedroom exclusively for sleeping and sex
Apps and web-based modules, like the cognitive behavioral therapy-based Sleep.io
Behavioral change programs that include goal setting, tracking, and rewards
But employers should first look at themselves, and how they create or facilitate the conditions that lead to sleep loss. These are the factors the employer can control, and only once they’ve committed to organizational changes as a primary solution can the benefit of behavioral change strategies be fully realized.
What changes should employers consider? The McKinsey authors also published an article in Harvard Business Review, in which they suggest some ideas for starters:
Evaluate and rework company policies to ensure that they encourage — or at least don’t discourage — a good night’s sleep. Look at policies covering travel, email (e.g., blackout time on email, after which no emails can be sent), team working (creating tag teams that enable employees to hand work to each other across time zones), work-time limits (setting limits on hours or creating blackout periods), mandatory work-free vacations, predictable time off, napping rooms, and smart technology that improves sleep management.
Flexible schedules might seem like a slam-dunk solution, but University of Washington researcher Christopher Barnes found they often backfire, according to a BBC article. Due to cultural biases that favor early risers, flexible schedules prompt workers to start their days too early for their own natural sleep and wakefulness rhythms. One of the sources cited in the article estimates that 70% of workers typically wake up too early to achieve optimal performance during their work day.
Multiple studies, the BBC reported, have found “that workers who adjusted their work schedule to their individual biological clocks were more productive, healthier and less tired both at work and in their free time.”
Nominal, short-term sleep loss — like the kind many of us experience in the days following the switch to Daylight Savings Time — can lead to big problems. According to one study, for example, workers sleep on average 40 minutes less, compared to other days, on the Monday after turning clocks an hour forward. An accompanying study found 3.6 more mining injuries each year on these Mondays, with absenteeism data indicating that these injuries tended to be especially severe.
How much sleep did you get last night? How alert and well rested do you feel right now?
Job loss is associated with a 73 percent increase in mortality risk — the equivalent of adding 10 years to a person’s age, according to a 2014 study from Drexel University. Yet the same study found that each percentage-point increase in state unemployment rate reduced the mortality risk of a resident of that state by 9 percent, about the equivalent of being one year younger.
In other words…
Joblessness strongly increases the health risk for people who are jobless.
Periods of higher unemployment rates, such as recessions, moderately decrease health risk among the entire population.
What at first seems paradoxical may not be. The significant increase in mortality risk for the jobless is limited to a relatively small population — say, 9% in a typical recession. The improvement in mortality for the population is based on a small improvement spread across a much larger population, which can easily be misinterpreted, if someone were to oversimplify it, to mean that everyone’s health is getting better. (In fact, there undoubtedly are other subpopulations for whom health deteriorates during economic downturns. These may include those living in poverty, people with less access to health care, senior citizens, and less educated people.)
The researchers did not investigate the question of why risk improves for employed people during economic downturns, but they offered a hypothesis:
During economic expansions, work is done at a faster pace, more employees are commuting, workers have less average sleep, and so on — all of which can be linked to higher risk of heart attacks, vehicle crashes, industrial injuries and enhanced circulation of germs. All of this reverses in recessions.
Of course, this leaves us with a damned-if-you-do-damned-if-you-don’t scenario. Joblessness is harmful to your health — but hard work is also harmful and less work is the cure? This wouldn’t even begin to explain the bi-directional changes in mortality risk for the employed and the unemployed. And it neglects to factor in how job insecurity — which presumably increases across a wide swath of the population when unemployment rates spike — factors into population health shifts.
We still have a lot to learn about where the sweet spot lies for employment, productivity, and worker health. Ultimately, we get on the right track by asking the right questions.
You look to your job not only for income and benefits, but also for purpose, social interaction, and daily routine. These influence your health, and the loss of them — or the threat of losing them — can suck the life right out of you.
Every day, millions of Americans either look for work or go to work. Their success at finding and/or maintaining a decent job with good benefits will, to a large degree, determine their current and future health.
Job loss, long periods of unemployment, and job insecurity have all been linked to deteriorating health. Yet, even companies that profess to support employee well-being have been known to contradict themselves by executing mass layoffs as a first line of financial defense rather than a last resort.
The Netflix exec who masterminded the vaunted slide deck about the company’s do-or-die culture boasted about the workers she’d laid off and fired. After being let go in 2015, she “doesn’t like to talk about it.”
Of course, layoffs aren’t the only source of unemployment and job insecurity…
Workers get fired due to performance problems.
Businesses go belly-up.
Some employers foster job insecurity as an ill-fated method to drive productivity.
But mass layoffs — regardless of whether they are euphemistically called reductions-in-force, redundancies, right-sizing, down-sizing, or all-around-the-town-sizing — are responsible for the majority of job loss that is out of workers’ control.
Job Loss and Health
Compared to employed workers, people who have recently lost a job are…
According to Gallup, Americans who have been unemployed for a year or more are more likely to be obese than those unemployed for a shorter time. The obesity rate rises from 22.8%, among those who have been jobless for less than three weeks, to 32.7% among those unemployed for a year or more. Those who have been jobless for more than 26 weeks are twice as likely to have high blood pressure and high cholesterol compared to people who have been unemployed for shorter periods.
Gallup also found that 20% of people unemployed for a year or more suffer from depression — about twice the prevalence compared to people unemployed for less than six weeks.
The Robert Wood Johnson Foundation points to several pathways from unemployment to deteriorating health:
Reduced income, which leads to inadequate nutrition, shelter, and health care.
Increased stress and limited access to the physical, mental, and social activity that are underpinnings of well-being.
Increased likelihood of engaging in unhealthy behaviors, like alcohol consumption, smoking, and drug use.
Job Insecurity and Health
The jury is still out on whether job insecurity — the threat of involuntary job loss — causes measurable declines in health status, but plenty of studies suggest a connection.
Job insecurity harms health, even more than unemployment.
One of the largest investigations of job insecurity and health analyzed data from more than 174,000 workers who were studied for nearly 10 years. It found that workers with job insecurity were 20% more likely to experience life-threatening heart disease compared to others who felt their jobs were a lock.
Job insecurity can lead to unhealthful behaviors like smoking, a Canadian analysis concluded, and avoidance of healthy behaviors like exercise and taking needed vacation and sick time off. It may even increase the risk of work-related injury and illness.
The relationship between job insecurity and health may depend on job type, economic conditions — how readily a laid off worker can land a new job — and workers’ attitudes about their employment and health. Case studies suggest that availability of social support and services for laid off workers may be differentiators for wellbeing.
Honeywell CEO Dave Cote doesn’t have a perfect record when it comes to worker well-being, but his decision to favor furloughs over layoffs during the Great Recession serves as a Harvard Business School case study on how to maintain competitive edge during economic downturns and recoveries. Cote’s process should be required reading for execs who succumb to arguments that layoffs are inevitable.
The benefits of using layoffs to manage costs during a recession didn’t make economic sense…
For workers in America, if you worked at a company like General Electric it’s more like you get a month’s salary and go. They lock the doors on the day you are fired. At Nokia there were people who knew they were going to be laid off in six months and were able to stay at Nokia with a Nokia email address with the Nokia laptop and spend time applying for new things, and Nokia helped them.
— Ari Tulla, laid off Nokia employee, now co-founder and CEO of BetterDoctor (quoted by BBC)
In a separate post, we’ll explore what we know about the relationship of health and on-demand or “gig” economy jobs, like Uber drivers, Airbnb hosts, Postmates couriers, and TaskRabbit taskers.
[If you’d like to comment on this post, please head on over to the LinkedIn version.]
Half of What I Know About Employee Health
I Learned from Concussion
Concussion is a movie about employee health as much as it’s about anything.
In the movie, the National Football League goes to great lengths to cover up the harm it allows to be inflicted on its players. The league is motivated by fear of liability and its unquenchable thirst for ever-increasing revenue.
Medical examiner Bennett Omalu, MD, a trained neuropathologist played in the movie by Will Smith, determines that several ex-players who died of unnatural causes suffered from chronic traumatic encephalopathy — CTE. The disease is characterized by long-term damage to specific sections of the brain, where tau proteins surround and choke off brain cells. The damage affects memory, agitation, and anger, and leads to dementia and, reportedly, Alzheimer’s disease. Brain studies were conducted on numerous players who died, including several who committed suicide. Ann McKee, a neuropathologist at Boston University’s CTE Center, reported in 2013 that she’d examined the brains of 46 former football players and found CTE in 45 of them.
Professional football players are employees of their respective teams, and the NFL serves as a sort of trade association for its member teams. For years, the NFL deflected blame for CTE, sometimes onto the players themselves. They pointed their finger to substance abuse (including steroids and alcohol), past history of concussion, and genetics. They downplayed the role of concussion, insisting that “mild traumatic brain injuries are not serious” and that players could safely return to the same game after suffering a concussion.
Ultimately, the NFL agreed to pay $765 million dollars in a settlement with more than 4,500 retired players who sued the league for concealing the issue. Speaking about the settlement, NFL Commissioner Roger Goodell said, “There was no admission of guilt. There was no recognition that anything was caused by football.”
The settlement included a provision that the NFL would never again compensate players or their families for CTE, which is why, as one example, the family of hall of famer Frank Gifford, diagnosed with CTE post-mortem in November 2015, cannot take action against the NFL.
Joe’s brain cloud and black brain mass, which viewers are led to believe result from job strain, are the stuff of satire. But is there really a chance that average workers exposed to prolonged job stress suffer brain damage — structural changes in brain tissue with accompanying symptoms?
Yes, there is.
Repetitive stimulation of the amygdala — a result of prolonged job stress — releases chemicals to the medial prefrontal cortex and may cause thinning of the cortex, enlargement of the amygdala and, consequently, a cycle of deteriorating stress modulation, cognitive symptoms, and impaired fine motor function.
In 2014, Ivanka Savic, MD, PhD of Sweden’s Karolinska Institute, published a study that used brain MRIs and showed that prolonged job stress — which included chronic overtime and a cycle of distorted perceptions regarding job demands, abilities, and control — leads to structural changes in the brain.
Compared to the MRIs of demographically matched control subjects, the patients who reported debilitating job stress — and exhibited burnout symptoms like impaired memory and concentration, sleeplessness, achiness, fatigue, and emotional exhaustion — showed abnormalities in the parts of the brain involved with the processing and perception of stress, specifically the prefrontal cortex and the cortex (which were abnormally thin) and the amygdala (abnormally large). These findings were consistent with Savic’s hypothesis that “repeated, chronic stress could lead to damage of the brain areas which modulate stress perception, leading to a vicious cycle with impaired ability to cope with stress.” The MRI findings were supported by documentation of reduced fine-motor skills and emotional regulation in the stressed group compared to the control subjects.
Finally, Dr. Savic concluded, “This condition needs to be considered as a stress illness, whose sufferers deserve proper and swift treatment.”
While a worker suffering from stress-related ailments may feel, as they go about their business, like they metaphorically are banging their head against a wall, the analogy between job-stress and football concussions is somewhat tenuous. Here are some ways the two phenomena differ:
The research on job-stress-related brain damage is still preliminary.
CTE is a result of smashed brains. Job-stress-related brain damage is more subtle, resulting from interactions between an individual’s job and their perceptions, and the resulting chemical activity in the brain.
There is no “cover-up” of job-stress-related brain damage that we know of — if for no other reason than most employers don’t know about it.
Job-stress-related brain damage has not been linked to behaviors that are as aberrant as those linked to repeated football concussions, nor has it been linked to death (though job stress has been found to be a significant risk factor for cardiovascular disease and death).
But there are some similarities, too:
Football concussions cause brain damage. Prolonged job stress also appears — based on preliminary research — to cause brain damage.
Just as football’s CTE was originally blamed on players (their drug use, history of previous head injury, or genetics), job stress in the United States has commonly been accepted to be solely a consequence of employee perception and coping skills, with employers turning a blind eye to their own role in creating job conditions that cause stress. Instead of empowering you with more control over your workflow, your employer adds a resilience program to your to-do list. In the absence of a broader preventive strategy, resilience programs are for job stress what football helmets are for concussions: Tools to help you endure more pain.
NFL players and everyday workers — as well as the enterprises that employ them — will benefit from having these neurological conditions identified and treated as early and effectively as possible.
Ultimately, symptoms of job-stress-related brain damage may prove to be less severe than CTE. But its burden to society — in terms of economics, well-being, and productivity — may be far greater simply due to the vastly larger population at risk.
In 2013 the LA Times quoted Dr. Anup Kanodia serving up the catchphrase, “Sitting is the new smoking.” Ever since, you’d have to be an epidemiologist to separate the fact from hype. And you and I are no epidemiologists.
Personally, I’ve resisted the phrase “sitting is the new smoking,” except to use it mockingly. In equating sitting and smoking we diminish the 50 years of investigation, social change, and sacrifice committed to understanding and addressing an insidious chemical dependency — tobacco use — that remains the world’s leading preventable cause of death.
But I get it. Prolonged sitting puts us at risk for future disease and premature death, inducing harm that can’t be undone even by regular exercise. The research suggests that interrupting prolonged periods of sitting is essential to health.
No one is surprised to hear that lack of physical activity is a health risk factor. The unique finding in the sitting research is that there is something deadly specifically in the act of prolonged sitting — the position itself — and that standing (or breaking up periods of sitting with standing) has health benefits. The recommendation from a landmark study in 2010 was:
Public health messages should include both being physically active and reducing time spent sitting.
seated-based work should be regularly broken up with standing-based work, the use of sit–stand desks, or the taking of short active standing breaks.
For starters, the panel advised sedentary workers to accumulate two hours of standing or light activity (such as the type of low-speed walking you do on treadmill workstations, which usually have top speeds of 2.0 mph).
The 2010 study and others like it catapulted the popularity of standing workstations, which already were on the rise as a potential solution to ergonomic back pain. In my experience, however, enthusiasm for standing workstations was quickly eclipsed by a preference for sit-stand workstations, which offer workers the option to change position at will.
“Sitting Is No Worse Than Standing”
In recent weeks, however, we’ve seen a slew of studies that offered new perspectives — some refuting previous research about standing, some expanding on it:
be cautious about placing emphasis on sitting behaviour as a risk factor for mortality
Next… Hold the phone. Acknowledging that there’s “insufficient evidence specifically focusing on the public health and medical implications of increasing daily standing,” researchers set out to identify the relationship between standing, metabolic syndrome (a cluster of risk factors), and obesity. They found that people who spend 25% of their day standing are less likely to be obese compared to more sedentary counterparts.
The plot thickens: Much of the earlier research was based on subjects’ total time spent standing or sitting. An employer may well question why they should invest in a sit-stand workstation if Joe-The-Knowledge-Worker goes home and spends hours on the couch at home. Why not encourage people to stand while watching TV or eating? Is the idea of a standing dining room table or a raised counter in front of the TV really so far-fetched?
Sitting at Home Is the New Sitting at Work
Along comes a small study that evaluated the outcomes of workers outfitted with sit-stand workstations. Data was collected via self-report and via instruments that monitored the workers’ position. The conclusion: Workers using sit-stand workstations spent significantly less time sitting at work…but significantly more time sitting while they were home. (Interestingly, previous work showed that workers with sit-stand workstations spend more time standing at work, but was not able to correlate this difference to health outcomes.)
That employees with sit-stands spend more time sitting at home is entirely plausible. Consider our tendency to overcompensate for a workout by overeating afterward. Another explanation may be that people standing more during the day experience fatigue that leads them to sit more at home.
Speaking of fatigue from standing, read on…
Standing Is Linked to Problems with Pain, Cardio Health, Pregnancy
For me, an irony of our newfound penchant for standing is the long and hard-fought battle workers previously waged to sit more. This came to my attention when I researched my blog post about the workers who ultimately perished in the Triangle factory fire. Seamstress jobs at the Triangle factory were considered cushy at the time, because the workers sat all day, in contrast to the more common manufacturing jobs in which workers toiled on their feet for hours on end.
Prolonged standing was identified as an epidemic health risk long before cigarette packages even existed to put warnings on. In the 17th century, Bernardino Ramazzini, the “father of occupational medicine,” called for shorter periods of standing and more frequent breaks during work.
A recent analysis confirmed that prolonged standing at work increases risk of low back pain, fatigue, cardiovascular problems, and adverse pregnancy outcomes. Most modern-day experts favor a mix of sitting and standing rather than prolonged periods of either.
At this point, the body of evidence remains a labyrinth, with important variables — sitting at work vs. away from work; the role of standing vs. physical activity — not fully teased out. In the interim, we need to be wary of the “sitting is the new smoking” hype and learn more about the problem and the solutions.
In my opinion, pending further research, sit-stand workstations are a reasonable solution to attenuate problems associated with prolonged sitting at workstation desks. They give the worker more control over the work, which, all things being equal, is always a good thing for employee well-being.
I also have come around to supporting treadmill workstations, though I sacrifice a piece of my soul in doing so. Some physical activity is better than no physical activity, just as shifting positions is better than prolonged sitting or standing. But treadmill workstations seem just a step away from succumbing entirely to absurdity and putting workers in a hamster wheel.
There’s another approach that may be more sensible, well articulated in the quasi-satirical New Republic piece, “Screw Your Standing Desk!”
Of course the long, stationary workdays of most Americans are unhealthy. The solution should not be to sit less, but to work less. If sitting is as bad as the doctors say—and I’m sure it is!—then why not prescribe longer lunch breaks, shorter hours, and more vacation? You can still be chained to a standing desk.
On June 19, 2015, while the U.S. federal government was determining how much employers should be allowed to fine workers for high blood pressure and cholesterol, the United Kingdom’s quasi-governmental National Institute for Health and Care Excellence (NICE) was doing something beneficial for employee wellness. NICE issued evidence-based guidelines for management practices and policies that support employee health.
In the U.S., where we lean on behavioral programs and medicalized approaches to try to manipulate worker health, NICE’s focus on workforce management and policy may seem…um…foreign. But as often mentioned in this blog, much of the rest of the economically advanced world long ago realized that management practices — especially those relating to job design and work environment — are the foundation of employee health. Voluntary behavioral programs play a potentially important but supporting role.
In fact, a recent Stanford study, described in a previous post here, determined that low job control, unemployment, long work hours, and work-family conflict had a greater affect on mortality than second hand smoke. And more than 120,000 deaths per year and approximately 5% to 8% of annual healthcare costs may be attributable to how U.S. companies manage their workforce.
The NICE guidance includes recommendations like…
“Encourage employees to be involved in the design of their role to achieve a balance in the work demanded of them. Allow them to have a degree of control, appropriate to their role, over when and how work is completed.”
“Value and acknowledge employees’ contribution across the organisation. If practical, act on their input and explain why this action was taken.”
“Create a supportive environment that enables employees to be proactive to protect and enhance their own health and wellbeing.”
“Ensure any unfair treatment of employees is addressed as a matter of priority.”
“Proactively challenge behaviour and actions that may adversely affect employee health and wellbeing.”
“If possible and within the needs of the organisation be flexible about work scheduling, giving employees control and flexibility over their own time.”
In the U.S., we seek “disruption” in the form of new wellness programs, gizmos, and websites. But these aren’t disruptive and in some cases they aren’t even improvements. They’re just new tricks for old dogs.
Even if behavior is the underpinning of health, as we insist on believing, employers have little influence over it, and may do some damage in the process of trying.
Employers do influence the workplace and the work, and that’s where they can have the most impact on wellness. Hence the tagline of this Health Shifting blog…
It may be hard to get your brain around abstract models of stress, especially when they don’t line up with the usual fright-or-flight illustrations or seem remediable by the relaxation tips commonly sold as solutions. But if we care about workers, and how employers may be able to help them, we can’t ignore the harmful effects of effort-reward imbalance.
Think back to Psych 101 and you’ll remember that most human transactions are based on our expectation of an even exchange, or social reciprocity. It’s like an unwritten contract. We’re hard-wired for evenhandedness, and when we get — or believe we’ve gotten — a raw deal, we suffer from physical and emotional stress.
In the workplace, employees trade their currency — effort — for the employer’s currency, rewards, which include:
job security and prospects for promotion
respect and prestige within the organization
The balance — or imbalance — of effort and reward may be influenced by an employee’s motivational style, especially for employees who are intrinsically driven to overextend their effort independent of rewards, often to fulfill their underlying longing for approval. This surfaces as “overcommitment” in the effort-reward imbalance model.
When physical and or mental job effort outweigh the reward — or employees perceive the balance to be out of whack — the result is chronic stress and, over time, the physical and mental problems that stress can lead to.
This understanding of work stress was first conceptualized by medical sociologist Johannes Siegrist.
The model of effort rewards imbalance claims that lack of reciprocity between costs and gains (i.e., high-cost/low-gain conditions), define a state of emotional distress with special propensity to autonomic arousal and associated strain reactions.
Siegrist’s theory was put to the test in Britain’s classic “Whitehall II Study,” which followed more than 10,000 civil service workers for 11 years. Results showed that effort-reward imbalance led to increased risk of cardiovascular disease, as well as declines in overall physical and mental health. Study subjects who were lower on the organizational chart and those with less workplace social support had the highest levels of risk among those with effort-reward imbalance. Since then, research has shown even more pronounced effects of effort-reward imbalance, especially on the risk of heart disease and depression — based on rigorous studies of employees in a wide range of occupations working in countries across the globe.
The Whitehall researchers, led by social determinants of health pioneer Sir Michael Marmot, felt their results showed that cardiovascular disease and other stress-related illnesses could be prevented by improving work conditions. Their work led to a campaign to encourage employers to:
Improve rewards by recognizing good job performance
Encourage job-skill and professional development
Foster social support at the workplace
Siegrist has proposed additional solutions:
Leadership development among supervisors, emphasizing the importance of esteem, recognition and appropriate feedback.
Building upon non-monetary rewards, like flexible work options, more effectively matching job status to achievements, and fostering job security.
Effort-reward imbalance is one of the two most influential frameworks for understanding job stress, alongside the demand-control model of job strain. In fact — despite our preoccupation with other models that push accountability for stress solely on workers — regarding both demand-control and effort-reward imbalance, Siegrist wrote in 2014:
Empirical evidence on their health-adverse effects is far broader than is currently the case for any other stress-theoretical model related to work and employment.
Ultimately, most elements of the psychosocial work environment can be plugged into one or both of these models.
Whether effort-reward imbalance is a product of employee perception or actual work conditions remains a topic of debate. Most likely, both play a role. Certainly, job demands and job control have been validated as causes of cardiovascular disease and high blood pressure, in contrast to trendy notions that stress is a mindset or is a good thing and that employees are on their own to address it. The role of personal interventions is to help employees with problem-solving skills that can help them advocate for themselves, assess their level of effort as objectively as possible and, in some cases, moderate overcommitment. Stress management and resilience programs may play a supporting role.
Last summer, I offered up my family as guinea pigs for a local Community Supported Agriculture program (CSA). As the leader of an employee wellness program, I was considering creating a partnership with the CSA to have shares of their harvest delivered to employees directly at work, and I wanted to check it out myself, first. If you’re not familiar with how CSAs bring together residents and farmers to support local agriculture and promote fresh food, find out more about them here.
My family started getting our weekly deliveries of vegetables and fruit — eagerly checking-in with the earthy young workers at the local pick-up spot and collecting our garlic scapes, bok choy, berries, broccoli, peas, greens, corn, chard, melon, and so forth.
My epiphany occurred around week two of the 14-week summer season. We’d received a bunch of green peas in that week’s harvest. The pods were plump and firm and seemed ready to burst. Like I said, I’m no foodie, and I wasn’t sure whether to eat the pods. So I did. Raw. I had about six or seven, and soon felt like I was digesting an electric sander. The next night, we cooked them, which I thought might soften them up but instead just seemed to toughen the fibers. So I went to the CSA’s Facebook page and asked whether the pods were edible.
“All that hot weather,” they wrote back, “followed by the thunderstorms made those peas really GROW in the last week. So, although typically delicious and tender. if you don’t enjoy the shells a bit more fibrous, the peas themselves are still delicious…”
That muggy weather. Those storms! I remembered them from just five or six days earlier. As I held a plump pea pod in my hand, I was thunderstruck by how it had been affected by the same storm clouds that had flash flooded the roads during my commute and overflowed the roof gutters of my house. There was a direct line from the weather into the ground through the pea and into my body. We were connected.
Of course, this realization isn’t that novel — even for a city kid like me. After all, I’d planted gardens that were influenced by the environment. But something about this direct experience of it in my core food supply brought it home and made it real. And I related to those pea pods, and all the veggies that came after, in a way that I’d never related to food before.
At work, we went on to pilot delivery from the CSA to employees at four worksites. One hundred co-workers out of about 2500 participated. That may not sound like a lot, but we chose not to set participation goals and didn’t push the pilot aggressively. We weren’t trying to change anyone; we were providing employees with a convenience they’d been asking for.
I considered subsidizing employees’ purchases. In today’s world of wellness, however, a subsidy functions like an incentive — and health incentives are deadly to the success of employee wellness programs. But I may rethink this.
The primary objectives of the program were:
To support employees who seek convenient access to whole, fresh food.
To support local agriculture.
But what I hope may be a bonus, and the reason this small program might be the most important wellness program I’ve ever offered, is because it has the potential to help employees experience their relationship with food in a whole new way — just like I did with the peas (Caution, however: n=1!).
Most healthy eating promotions used today — calorie labeling and nutrition education, merchandising tactics like those promoted by the Cornell Food and Brand Lab, and behavioral interventions like Weight Watchers— haven’t been a match for the proliferation of unhealthful food, oversized portions, and appetites that, for whatever reason, are insatiable. Conventional approaches have their place, but none have achieved good results on their own. And, with the possible exception of mindful eating strategies, none get to the root of the matter by a change in folks’ relationship to food, potential that exists with a CSA partnership.
I believe we also experienced an unintended consequence: A social effect that stands to bolster an employee community that rallies around well-being. Not only do some participants choose to split their shares, teaming up to divvy their bounty and exchange recipes, but on the day the large boxes filled with each week’s share were delivered, there was a heightened level of energy, curiosity, and camaraderie amongst co-workers.
We expect participation to double this year. Our next step is to source some of our employee cafeteria menu items from the CSA. This will, of course, support local agriculture in an even bigger way. More importantly, it will make high quality food available to a larger population, and it will integrate with our CSA purchase program — cross promoting and allowing prospective participants to experience how local crops can be transformed into delicious meals.
And a little transformation can go a long way.
(My wellness colleagues needn’t fret about the usual… ROI, outcomes, and definitions of terms. We’re helping get fresh veggies onto the tables of employees and their families. No vendors, no registration, no incentives, no behavior change, no contracts. The simplicity makes it sublime.)
The workplace demons that threaten employee health include long work hours, job insecurity, low job control, high job demands, shift work, effort/reward imbalances, role ambiguity, work-family conflict, inadequate workplace social support, and unfair treatment. These can be bucketed in various ways, but whatever you call them, they are the work conditions — controllable by employers — that research has consistently shown to influence employee health and well-being.
Now, along comes a study out of Stanford University that not only endeavors to quantify the burden — in terms of health outcomes, cost, and mortality — of these demons (what the researchers called “stressors” and I sometimes refer to as the workplace determinants of health), but also puts it into context relative to other, more commonly recognized, health issues.
Spoiler alert: More than 120,000 deaths per year and approximately 5% to 8% of annual healthcare costs may be attributable to how U.S. companies manage their workforce, according to this analysis. The mortality rate for these stressors, plus another the researchers found to have significant impact — lack of health insurance — was on par with the fourth and fifth largest causes of death in the U.S.: heart disease and accidents. It was greater than mortality resulting from diabetes, Alzheimer’s, or influenza.
Exposure to the following stressors was found to be more harmful than secondhand tobacco smoke:
Lack of health insurance
Low organizational justice (fairness)
High job demands
And — again, using secondhand smoke as a benchmark — the conditions that had a greater affect on mortality are:
Low job control
Long work hours
Lack of health insurance
The Stanford researchers concluded,
Employers may not make appropriate decisions concerning workplace management if they are unaware of the link between management decisions and employee health and healthcare costs. Our analysis suggests that for such organizations, paying attention to the structure of the workplace and the associated job stressors experienced by their employees may be a fruitful way to reduce unnecessary healthcare costs.
But they acknowledge that employers may have limited motivation to address these issues if, indeed, they’re not on the hook for the costs of health care — for example, in the cases of employees who have been laid off or who are not offered health insurance. The study didn’t delve into associations between stress and productivity.
The analysis was conducted by Joel Goh, Jeffrey Pfeffer, and Stefanos A. Zenios and published in Management Science. Goh is now on the faculty of Harvard Business School.
The researchers are conservative yet insightful in their expectations regarding the implications of their work:
While we stop short of claiming that employer decisions have a definite effect on these outcomes and costs, denying the possibility of an effect is not prudent either. Analyzing how employers affect health outcomes and costs through the workplace decisions they make is incredibly important if we are to more fully understand the landscape of health and well-being.
And what of our current approach to employee well-being, with its slaphappy embrace of screenings, health risk assessments, health coaching, apps, wearables and incentives? How does it jibe with the real determinants of worker health? Not very well, according to study co-author Jeffrey Pfeffer. In his YouTube interview for the Stanford Graduate School of Business, he says,
Employers worry mostly about individual decisions: eating, exercise, smoking, drinking…things like that. Or about policy issues like how we pay for health care. A lot of their excess health care costs come from what happens to people every day in the work environment… Things that employers could fix, if they wanted to.
Only about half of employers evaluate their employee wellness program’s effectiveness, so it may be time to own up to the possibility that you have no idea whether your program is helping or hurting, or whether anyone even knows you have a program. Or whether your company even knows it has you. That’s okay. You’re okay.
Here are 15 Do’s and Don’ts to help you rise out of the abyss of employee wellness mediocrity:
Don’t:Expect your program to reduce health care costs. Most likely, it won’t. Do: Strive to support your employees’ wellness aspirations. Positive outcomes originate with your good intentions.
Don’t: Encourage your employees to get annual screenings. Screenings are probably one of the least cost-effective components of your program. Do:Offer your employees paid time off and good health insurance so they can get the care they need, when they need it.
Don’t: Get caught up in language: “Wellness” vs. “well-being”; “return-on-investment” vs. “value-on-investment”; “health risk appraisal” vs. “health assessment.” Not only are these sideshows, but in most of these debates, the wellness industry is settling for the less specific — hence, less measurable — option. That said… Do: Distinguish between “participation” and “engagement.” To use them synonymously is downright fraudulent. Especially: If you have incentives, you have unengaged participation.
Don’t:Call your health surveillance program an “outcomes-based wellness program.” It gives a bad name to those of us, and those employers, who truly care about worker wellness. Do: Speak out — in professional networks, on social media, at conferences, in journals, and in your company — against the scourge of “outcomes-based wellness.” If you don’t stand up to protect employees from mercenaries trying to pass off discriminatory tactics as “wellness,” who will?
Don’t: Try to address all the dimensions of wellness. Do: Pursue those dimensions of wellness that employees want addressed, that they will respond to, and that are actionable by and meaningful to your organization. (The dimensions of wellness — physical health, emotional health, spiritual health, financial health, occupational health, environmental health, relationship health, and so forth — are interdependent. When you influence one, you’ll influence others.)
Don’t: Rely on wellness committees to do the work. You don’t use committees to run your other employee benefits or your total rewards programs, do you? Do: Hire qualified professionals to do the work.
Don’t: Do something just because you heard about it at a conference. Do: Avoid insularity by attending wellness conferences and conferences focusing on unrelated industries.
Don’t: Obsess over obesity in the absence of population-based solutions. Do: Provide employees with delicious, fresh, whole food, when it’s necessary to provide food, and with opportunities to move.
Don’t: Get preoccupied with employees’ families. They don’t want you messing in their business. Do: Get preoccupied with the health of the community you are in. They do want you messing in their business, and you’ll stand to affect employees and their families in the process.
Don’t: Take it from me… Do: Seek diverse sources of evidence and opinion, and draw your own conclusions.
[15 Do-This-Not-Thats to Transform Your Wellness Program Into a Recruitment, Retention, Engagement, and Productivity Health-a-Palooza was originally published on the InTEWN blog, April 2015. Some of the links have been updated]
Napo raises awareness of the drivers of workplace stress.
The psychosocial and environmental interplay of stress at work are foregone conclusions among regulators, thought leaders, and many employers across the globe, especially in Europe. In the United States, with the exception of NIOSH’s Total Worker Health strategies, the drivers of stress at work remain largely ignored. In the US, we take the reactive viewpoint that an individual’s response to stress is more important than the causes of stress. In doing so, employers grant themselves license to put the onus for solutions on employees, too. Whereas the rest of the industrialized world endeavors to address stress by balancing employees’ job control and demands, offering scheduling flexibility, limiting overtime, addressing bullying, and so forth — even the most caring American employers take pride in addressing stress merely by offering stress management programs or uber-trendy resilience training. “Yes, we’ll stress you out,” we seem to be saying, “but we compensate by training you how to live with it.”
Reflecting their dedication to furthering employers’ understanding of workplace wellbeing and encouraging action, a small group of European organizations commissioned French company Via Storia to develop a series of videos promoting employee health and safety. The result is a lighthearted collection of culturally non-specific, animated vignettes featuring an endearing main character, Napo. Consistent with the European viewpoint, these videos include — in addition to episodes about slips and falls, workplace transport safety, skin protection, noise control, and the rest — a full series about the psychosocial and environmental causes of stress at work.
The Napo videos aren’t intended to be scientific documentaries or instructional tools. They’e an intentionally simple means to raise awareness about worker health and safety and, in this case, the ingredients — like role ambiguity, untenable work schedules, and job strain — of workplace stress. I’ll share some of these Napo videos, as well as other invaluable resources readily available to European employers — here on the Health Shifting blog.
To complement my previous post, which addressed NIOSH research suggesting a connection between hostile work environments and obesity, I’m pleased to share the following Napo video — a segment from “When Stress Strikes.” In this 56-second video — probably the simplest of these episodes — Napo’s co-worker, Napette, is subject to repeated incidents of disrespect from a workplace bully. The Boss intervenes.
The exterior of the Asch building remained intact after the fire (above). The Triangle Shirtwaist Factory occupied the top three floors. (Photo courtesy of the Kheel Center, Cornell University.)
Years ago, in lower Manhattan, flames burst through the windows of a skyscraper. Cornered by a fast-moving fire, employees clung to the window frames until the heat, the flames, and the terror became too much to bear. They leapt from the windows to their certain death, their burning hair and clothes leaving a smoky trail, and crashed smoldering to the ground with an unearthly thud.
This is not an account of a terrorist attack. This is the scene of what, for 90 years prior to 2001, had stood as the worst workplace disaster in New York City history. Like 9/11, this tragedy changed the world — especially the world of work.
This is the story of the Triangle Shirtwaist factory fire, in which 146 employees — mostly young immigrant women — perished on March 25, 1911.
Shirtwaists were a kind of trendy women’s blouse, and the Triangle factory, which occupied the top three floors of the 10-story Asch building, could barely make them fast enough to keep up with demand. Each floor of the crowded Triangle factory had two exits. But the Greene Street exit, the one that workers were herded through at the end of each day so that bosses could search the workers’ handbags for stolen goods, was blocked by flames after the blaze exploded near the end of the workday that Saturday.
The only remaining exit, the Washington Place exit, was locked — a huddle of desperate workers burned to death trying to open it. Fire escapes led nowhere and eventually collapsed in a mangled mass of heat-compromised iron. Workers jumped down the elevator shaft into a heap of corpses on top of the elevator, which had shuttled many panicked workers to safety until the heroic elevator operator, Joseph Zito, knew it could run no more.
The fire department responded quickly, but their ladders weren’t tall enough to reach any of the victims. The factory owners, Max Blanck and Isaac Harris, managed to escape the inferno. (Later, Blanck and Harris were found not-guilty of wrongdoing in a contrived court case, and had to escape the courthouse undercover as the families of the victims cried for justice. They went on to have additional scuffles with the law over suspicious fires and illegally locked factory doors).
Several days after the fire, a funeral procession of 120,000 workers marched in the pouring rain, as 300,000 grief stricken New Yorkers looked on in a demonstration of unity. Marchers pledged never to forget the fate of the young women and men of the Triangle Shirtwaist factory.
We need not sully the memory of this tragedy by comparing the plight of the Triangle workers to the work conditions that most Americans enjoy today. But nor should we dishonor the memory by neglecting to apply the lessons we can draw from it.
Bestowed with a broad charge and powers to investigate the Triangle fire and the work conditions of factory employees throughout the state, the New York Factory Investigating Commission in 1912 argued that the “human factor is practically neglected in our industrial system,” and reported that employers had “shown a terrible waste of human resources, of human health and life.”
Foreshadowing current events, in which government intercedes where employers fail to regulate themselves, the Commission spelled out the true significance of worker health:
Health is the principal asset of the working man and the working woman… Aside from the humanitarian aspect of the situation, economic considerations demand from the State the careful supervision and protection of its workers. Failure to perform this obligation will produce serious results in the workers of the future. It will affect the working capacity of the future generation.
The Commission recognized that worker health had implications for society as a whole, in the present and in years to come.
Indifference to these matters reflects grossly upon the present day civilization, and it is regrettable that our State and national legislation on the subject of industrial hygiene compares so unfavorably with that of other countries.
Other industrialized nations continue, more than 100 years later, to surpass the US in the protection of total worker health. They emphasize psychosocial health at the workplace, regulate limits on overtime, require paid sick time, and encourage workers to take needed leave to care for newborns and for ailing family members.
The work of the Commission set the tone for widespread changes in labor practices, without which the comfort many of us enjoy in today’s workplace likely would not exist. (Many of us enjoy comfort, but not all.)
And, yet, today, when employee health is discussed in journals, in lay media, and at conferences, we persistently neglect the “human factor,” which the Commission identified as the core of worker wellbeing.
The question, “Does employee wellness work?” is posed consistently with an assumption that “wellness working” is measured in employer cost savings or increased output. This commodification of human life stands in marked contrast to the social consciousness, the compassion, the empathy, and the vision that swept the nation after the Triangle fire.
Rosaria Maltese was 14 years old. Bettina Maiale and her sister, Frances, were 18 and 21, respectively. Ida Brodsky was 15. Fannie Rosen, an immigrant from Kiev who had worked at the Triangle factory for only two days and was one of the last six victims identified — a century later — was 21 years old. These girls were among the 146 employees who perished in the Triangle Shirtwaist factory fire on March 25, 1911.
Fannie Rosen, age 21
With a unified voice, Americans pledged that we would never forget these girls and their courageous young coworkers who fought to be treated humanely, who suffered and endured, and left a legacy from which most of us now benefit every day of our lives. Just as we now pledge to always remember the victims of the 9/11 terrorist attacks, we once gave our word that we would remember the sacrifice represented by the charred remains of 146 Triangle factory workers.
But every time we argue, or simply assume, that the primary purpose of employee health is not the human factor but is, instead, simply to save an employer money…we harden ourselves against the memory of Rosaria, Bettina, Frances, Ida, Fannie, and the others.
As former Secretary of Labor Hilda L. Solis wrote in her commemoration of the 100-year anniversary of the Triangle Shirtwaist factory fire, “We must always be a nation that catches workers before they fall.”
Job strain is a particularly insidious form of stress that goes far beyond overflowing inboxes or tight deadlines. It is characterized primarily by organizational environments and job structure in which employees have high levels of demands placed on them and limited control over those demands (that is, low “decisional latitude”). This is the demand-control model that was originally described and measured by Robert Karasek. Other organizational and job-related factors that contribute to unhealthy job-related stress are effort-rewards imbalances, long work hours (sometimes including long commutes), job insecurity, and lack of social support on the job. Some researchers have categorized all of these stressors as job strain, others differentiate them. But most agree that these stressors — all related to organizations and job design and not to individual behavior — lead to negative health outcomes.
How unhealthy is job strain?
Job strain has been linked to hypertension and to heart disease. This is not a simple matter of people who have other risk factors, like pre-existing hypertension or what used to be called Type A personality, being drawn to stressful jobs. Research suggests a causal relationship between job strain and both hypertension and cardiovascular disease. (Some studies also have linked job strain to depression, musculoskeletal disorders, dyslipidemia, physical inactivity, obesity, and adverse birth outcomes.)
Blue collar workers are more prone to the effects of job strain compared to white collar workers, but no one is immune.
Not every study of job strain has confirmed this relationship, but most have. A 10-year prospective study of 22,086 female health professionals, published in 2012, revealed that women with active jobs (high demand, high control) and high levels of job strain (high demand, low control) were 38% more likely to experience a cardiovascular disease event (such as heart attack or diagnosis of atherosclerosis) compared to women reporting low job strain. During the study, there were 170 myocardial infarctions, 163 ischemic strokes, 440 coronary revascularizations, and 52 cardiovascular-disease-related deaths, reaffirming that cardiovascular disease is a major concern for employers and for public health.
A Finnish study of 812 employees, followed for more than 25 years, found that employees with high demands at work and low job control had a 2.2-fold increased cardiovascular mortality risk — independent of other risk factors — compared to their colleagues with low job strain.
Earlier this year, an Israeli study confirmed a link between job burnout and coronary heart disease. Job burnout was defined as physical, cognitive, and emotional exhaustion that results from stress at work. Factors contributing to burnout included most of those typically associated with job strain or job stress: heavy workload, lack of control over job situations, lack of emotional support, and long work hours. Over the course of the study, 8,838 male and female employees were followed for an average of 3.4 years. Each subject was measured for burnout, which, as it turned out, was associated with a 40% increased risk of developing heart disease. Of greatest concern, the 20% of participants with the highest burnout scores had a 79% increased risk of heart disease.
A British study of 6,014 workers, followed for an average of 11 years, found that three to four hours of overtime per day is associated with a 1.6-fold increase in coronary heart disease risk, independent of other risk factors. (More about overtime in a future post.)
Countless research studies have demonstrated the relationship between job strain and health.
Unlike many other countries (again…especially Scandinavian countries), American employers continue to insist on offering employees behaviorally based stress management programs, such as relaxation programs and time management seminars, rather than trying to address the program where the employer actually has the most control: the structure of the organization and the jobs within it.
Even the National Institute for Occupational Safety and Health declares, “Working conditions play a primary role in causing job stress” and it advises,
As a general rule, actions to reduce job stress should give top priority to organizational change to improve working conditions.
Check out the NIOSH page for some ideas about the type of organizational change that is needed.
Emphasis on the organization’s role, rather than the employee’s role, may have applications beyond stress. Fitness challenges, biggest loser contests, tobacco-free campuses, incentives, health risk assessments, coaching, health screenings, yoga classes, and even culture-of-health have limited potential to evoke meaningful population health improvement…as long as the roots of the problem persist.
[A version of this post was first published on Bob Merberg’s Health Shifting blog on December 20, 2014]
Recently, I chatted with the Human Resources director from an employer known for encouraging “fun at work.” The company had the usual symbols of a fun workplace: foosball tables, slides, Xbox, pie-eating contests, and parties for every occasion. The HR director boasted about parades, in which employees construct floats, dress up in costumes, and march around the office to mark company milestones. I asked, “What if you don’t want to join the parade?” No problem. If you’re not the parading type, you can work on building a float. “Everyone is expected to participate in some way,” she told me. “Our employees know what kind of place this is when they accept a job.”
Fair enough. But count me out. When the data reconciles, when I have that eureka moment of identifying a creative solution to a work-related problem, when a team member rises to a new challenge or lights up when recognized for a job well done… That’s what I call fun. Some employees enjoy the fun of work, and don’t depend on adding fun to work.
Much of what passes for “fun at work” — parties, games, playground apparatus, contests, dress-up, etc. — represents little more than workplace tyranny of extroverts over introverts. And studies show, according to author Susan Cain, that one third to 50% of employees are introverts. So consider that half of your workforce may experience fun by setting their minds to their work, and they may be put off by someone else’s brightly colored and boisterous version of fun.
Lately, the social web has shone a light on “surface acting” in the workplace and the body of research, albeit thin, which suggests that being compelled to demonstrate positive emotions — like when service workers are required to smile and chirp to customers, regardless of what they are actually feeling — leads to emotional exhaustion, stress, and reduced productivity.
While most research demonstrating the negative effects of surface acting is based on studies of frontline workers such as customer support reps, food servers, hair stylists, clinicians, and first responders, blogger Mike Pearce — in a post called Surface Acting: Bad for Business and Your Health — points to a study suggesting that expressing inauthentic emotion in meetings is linked to employee burnout and turnover. Indeed, it’s not unheard of for supervisors to warn office workers — even those who have no exposure to customers — to smile more, a directive that serves no purpose other than allowing the supervisor to perpetuate their own delusion of leading an energized team.
In a LinkedIn post called The High Cost of Acting Happy, Time magazine contributing writer Annie Murphy Paul proposed well-founded alternatives to forced happiness:
Train workers well, so that they satisfy their customers with good service. Offer them congenial working conditions, so that they’re glad to be at work. Allow them more personal control over how they do their jobs (research shows this can buffer the stress imposed by surface acting). And provide them with opportunities to develop genuinely warm relationships with managers, coworkers, and customers—so that employees have something real to smile about, and so that when they tell someone to “be well,” they mean it.
Paul’s advice is rooted in evidence that maps how employee well-being is a product of healthy organizations and job design rather than employee behavioral change.
Do employers’ attempts to foster fun at work actually promote surface acting and its unwelcome outcomes? Do employees really want fun at work? Does contrived fun serve any purpose whatsoever? We’ll need more evidence to know for sure. In the interim, here are six tips for keeping the fun fun, and for keeping the surface acting at bay:
Genuine fun arises effortlessly. It may come organically to some workplaces whose culture is well suited for it. If you try to have fun, you’re not likely to.
Allowing people to bring their individual authentic personalities to the workplace, to express them freely, and to socialize according to their own desires, may be more fun than so-called fun-at-work events, campaigns, or games.
Not all employees seek fun in the workplace, and not every organization needs it. Tune in to employee demographics and organizational culture.
Fun in the workplace efforts may not be the only employer contrivances that promote a culture of surface acting. Be on the lookout for unintended consequences of the increasingly popular resilience and positive psychology initiatives so that stress, sadness, depression and even everyday introversion are not stigmatized.
What employees and employers sometimes perceive as a need for more fun may actually be a need for something else — gratification, camaraderie, satisfaction, purpose, hope, inspiration, or self-expression.
Based on studies of surface acting, expecting employees to act like they are having fun may lead to burnout, job dissatisfaction, turnover, and absenteeism. And that’s no fun for anyone.
I’ve previously mentioned that Scandinavia has pioneered research about job-related stress. Now, we learn that Scandinavian countries — specifically, Norway, Sweden, and Denmark — are the only ones that have a word for “happiness at work.” The word is arbejdsglaede. And, no, that’s not a typo.
Below is a video about arbejdsglaede.
The video is oodles of fun, but I have one beef with it: It advances the conventional American notion that employers are not responsible for employee happiness, and that your happiness is entirely in your hands.
Certainly, you have some accountability for your own state-of-mind. But Scandinavian research has shown repeatedly that organizational structure and job design are the primary drivers of employee well-being. So go ahead and grab yourself some arbejdsglaede — happiness at work — if you can find it. But don’t be too hard on yourself if you can’t.
[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.]
I don’t advise pedometer program participants to strive for 10,000 steps per day.
Having each individual aspire to an identical goal flies in the face of everything I’ve learned — or is it assumed?– about behavioral change. But participants have heard the 10,000-step mantra, and sometimes adopt it as a goal. Ultimately, many report getting discouraged when they clip on their pedometers and realize they only walk a baseline of 2,000 or 3,000 steps per day, at which point a 10,000-step goal can be a real motivation crusher.
Where did this 10,000-step goal come from? What are the alternatives? And what’s been shown to work? Pedometer programs are reasonably effective, but solving these mysteries may lead toeven greater effectiveness and may even influence how we think about goal-setting and self-tracking.
Back in the 1960s, a Japanese pedometer manufacturer dubbed one of its products manpo-kei, which translates to “ten thousand steps meter.” There was no known reason the company settled on 10,000 for its product name, but shortly thereafter, Japanese researchers did determine that habitually active walkers typically accumulate something in the neighborhood of 10,000 steps per day.
Since then, evidence has shown that it takes approximately 3,000 steps over and above the average steps taken by typical sedentary people to meet the standard recommendation for physical activity — namely, getting at least 30 minutes of moderate-intensity activity each day. Anything less than 5,000 steps a day is considered sedentary. So a daily recommendation for physical activity — 3,000 steps over and above a baseline of 5,000 — would be 8,000 steps.
The Institutes of Medicine, however, advises that 60 minutes of daily activity is necessary to maintain a healthy weight. This would be equivalent to 6,000 steps, which, when added to the baseline 5,000, means participants should accumulate 11,000 or so steps per day to prevent weight gain.
This establishes that 8,000 to 11,000 steps, a guideline subject to individual variation, is equivalent to the minimum amount of physical activity people should get to maintain good health. The question remains: How do you motivate sedentary employees to achieve this level?
An alternate to the 10,000-steps-per-day goal has been popularized by one of the first widescale pedometer programs, America On the Move, founded by obesity researchers James Hill and John Peters. AOM encouraged participants to wear their pedometers for three days prior to the program, then to set a goal 2,000 steps above their average for these three days. When they achieve this goal, they can set a goal 2,000 steps higher. It’s individualized and incremental.
But research has not shown individualized, incremental step goals to be more effective.
One randomized, controlled study compared participants who had 10,000-step goals to participants who had individualized goals. It found that, although previously sedentary participants rarely reached their goal of 10,000 steps per day, they increased their steps as much as those with the more modest, individualized goal.
Referring to this study, the authors of a 2007 meta-analysis concluded, “Given the relatively similar increases in physical activity among those pedometer users given the 10,000-step goal and users given other goals, we conclude that the relative benefits of setting different goals remains unclear.”
The specific goal didn’t make a difference. What about people who didn’t have any goal whatsoever? The authors of the meta-analysis reported:
“Pedometer users who were given a goal, whether the 10,000-step goal or an alternative personalized step goal, significantly increased their physical activity over baseline, whereas pedometer users who were not given a goal did not increase their physical activity.”
“…It may be premature to make firm conclusions about the efficacy, effectiveness, or appropriateness of any specific step-based goal in terms of behaviour change…Regardless of the number of steps per day, effective programs, informed by the best research on critical moderators and mediators of behaviour change (i.e., what works best for whom under what conditions and at what cost) remain implicitly necessary in terms of increasing individual and population levels of ambulatory activity.”
In the end, it may not be the ambitiousness of the goal, but the existence of the goal — any goal — and a behaviorally sound program, that make the difference.
The significance of this conclusion may go beyond employee pedometer programs. For example: with all the talk these days about the quantified self movement — and people strapping on accelerometers, body sensors, and all sorts of biometric devices — we should not assume that tracking organically leads to improved behavior.
We all know that goals don’t amount to much without measurement. Now we also know that measurement — in this case, step tracking — may not amount to much without goals.
[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
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? 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]
For starters, here’s the prevailing rationale that serves as the framework of most employee wellness programs today:
Most health problems, and their associated costs, are preventable.
Modifiable health risk factors — such as tobacco use, sedentary lifestyle, and unhealthful eating habits — are precursors to many of these health problems.
Many modifiable health risks are predictive of higher healthcare costs and decreased worker productivity.
Employer sponsored wellness programs can reduce modifiable health risks.
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.
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:
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.
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.
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.
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 tocaution 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:
When 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.