The BJ’s Wholesale Club study wasn’t the most important employee wellness research published last month. Let’s look at the Workplace Health in America Survey conducted by the Centers for Disease Control and Prevention.
The CDC asked about companies’ employee health promotion programs. 2,843 respondents completed surveys — targeting whoever in the company was most knowledgeable about its wellness offerings — from a variety of employers.
What wellness vendors sell, and what employers buy, often contrasts with what employees want. Over the course of my career, I’ve heard directly from more than 100,000 employees via surveys and face-to-face interactions, and this is one of the most valuable lessons I’ve learned.
Using an unscientific approach, I’ve summarized some of the differences below. Continue reading »
When skillfully incorporated into a broader strategy, external recognition for wellness programs has the potential to be a win-win, serving both the employer and the employees.
In keeping with my recent theme of providing practical tools and tips for wellness managers who do the hard work of creating and operating employee wellness programs in complex corporate environments, I’m pleased to share this post I wrote for one of my clients.
I’m pleased to provide these practical tips for wellness vendor management, one of the most demanding roles of employee wellness managers. Some of these — six tips for implementation and oversight, eight for selection and contracting — may be more relevant to larger corporations, but many are applicable to a spectrum of organizations and a variety of non-wellness vendors. They can help make a manager’s job easier, while eliciting higher levels of performance from vendors. Continue reading »
This was a randomized controlled study of an employee wellness program. To date, the study results have shown no improvement in health behaviors, health care costs, or productivity. To date.
You can read the full study paper published on the Bureau of Economic Research website. But if you’re not one to wade through a swamp of statistics, check out the study’s very own website for info, updates, and bar charts galore.
Does Feeling Valued Count?
Rather than cherry-picking the facts, allow me to just suggest questions to consider as you learn more about this study:
What does “doesn’t work” mean, anyway? Work to do what?
The study found that the number of program participants who believed their employer was committed to their health and safety increased significantly as an effect of the intervention. Is this important?
In the study paper, how many times do the researchers make the claim that has captured the imagination of Dr. Carroll and many others in the business and health care media, that “wellness doesn’t work”? (You can cheat by using your browser’s “Find” function. Or take a guess. It’s somewhere between -1 and +1.)
Was the study published in a peer-reviewed journal?
How many employers, and how many different kinds of wellness strategies, were included in this study of the University of Illinois wellness program (called iThrive)?
Let’s say you’re running a program for a global manufacturing company or a tech start-up. How comparable is your employee population to the employees at University of Illinois?
A Comprehensive Wellness Program
iThrive is said to be a “comprehensive” wellness program. In my mind, a comprehensive wellness program might include some behavioral programs, cultural strategies, environmental strategies, and, most importantly, organizational strategies that promote healthy work.
Is this a comprehensive program? You be the judge. The core activies and strategies of iThrive:
Biometric health screenings
Health risk assessments
Participation in “one of several activities in the fall and then again in the spring.” Activities included classes on chronic disease management; weight management; tai chi; physical fitness; financial wellness; healthy workplace habits; a tobacco cessation hotline; and an online, self-paced wellness challenge.”
A “Post-Intervention” Time Warp?
Screenings were conducted from August 15 to September 16, 2016.
Health risk assessment was conducted from September 8 to October 4.
Fall wellness activities were held October 10 to December 16.
Spring wellness activities were held January 30 to April 25, 2017.
“Post-intervention” healthcare utilization was measured for the period August 1, 2016 through July 31, 2017.
Thinking carefully about this timeline, what changes in healthcare utilization patterns would you expect during the first year of the program?
Keep these questions in mind. And I hope you’ll pose a lot more of your own when you read about future findings from this and other studies.
There’s been a lot of talk lately about how to take wellness past well-being and into the future. Specifically, how can we expand beyond physical health and, as wellness professionals, deliver maximum value to our organizations.
Check out the milestone 100th episode of Jen Arnold‘s Redesigning Wellness podcast.
As a result of all the interviews she’s conducted, combined with her own experience and insight, Jen has her finger on the pulse of employee wellness more than just about anyone.
In this solo episode, Jen — with her characteristic candor — systematically lays out a case for a new vision of wellness and previews exciting opportunities she’s creating for wellness professionals who want to make good things happen.
Listen to “Celebrating 100 Episodes” on the Redesigning Wellness podcast wherever you usually get podcasts, or stream it here…
Big thanks to the folks at Lumity, Inc. for inviting me to present the webinar “Wellness, Wellbeing, and Workforce Sustainability: 3 Routes to Employee Wellness and Optimal Performance.” If you missed it, check out the recording.
In this orderly mash-up, I present about 40 years of work in 33 minutes (plus Q&A). It has something for everyone — from the HR generalist who’s been assigned to wellness but may not know much about it, to veteran managers of comprehensive programs trying to figure out what does and doesn’t work. I cover
the premise of health risk costs and risk reduction;
the distinctions between wellness and wellbeing;
ROI vs. VOI;
typical wellness program components;
work, stress, and health;
Without being overly prescriptive, I offer my own interpretations of evidence and practices, some of which you’ll find immediately applicable and some of which will irk you to no end. This link, exclusively for my blog readers, takes you directly to the recording.
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?
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.]
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.]
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.
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.)
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]
[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: