Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Monday, December 10, 2007

Blurring the Lines between CEO and MD: A Psychosocial Critique on the Healthy Worker Discount Program – Lia Cross

Obesity is a growing global public health burden. Increased consumption of energy-dense, calorie-packed, high sugar and high saturated fat foods, combined with reduced physical activity, has led to an increase in obesity rates by three-fold or more since 1980 in some areas of North America, the United Kingdom, Eastern Europe, the Middle East, the Pacific Islands, Australasia, and China (1). More specifically, in the United States, between 1980 and 2002, obesity prevalence doubled in adults aged 20 years or older (2). Data obtained from the National Health and Nutrition Examination Survey (NHANES) indicated that in 2003-2004, 32.2% of adults were obese (BMI ≥30) (2). It was found that the age-adjusted prevalence of obesity in adult men and women had increased from 22.9% in the 1988-1994 NHANES to 30.5% in 1999-2000 (3). The prevalence of overweight (BMI ≥25) increased over this period as well, from 55.9% to 64.5% (3). These alarming statistics have catapulted the problem of obesity and overweight into the limelight in recent years and have been the subject of discussion in multi-disciplinary journals, conferences attended by health professionals and government agencies, among key players in the food industry and professional marketers, as well as on the radio, television, internet, and other mainstream media outlets.
Now that everyone is talking about it, the big question is – what can be done? While a variety of interventions have been proposed and implemented with solutions aimed at individuals, parents, government, and public institutions, many have not been completely successful because they often ignore specific social conditions that must be in place to realize the potential to change public health (4). In public health there is a heavy reliance on behavior change models which limit our ability to examine the influence of various social systems on obesity and overweight issues. There must be political and public will to institute these changes necessary to prevent and reduce the problem of obesity and overweight in the US. To do this, there must be a full understanding of the barriers to change as well as an analysis of the factors that promote change (4).
One controversial public health intervention that relies heavily on individual-based behavior change models is a healthy worker discount program. It attempts to stem the tide of rising obesity and overweight in the workplace and to shift rising health care costs (5). It is offered by HMOs and hospital systems and rewards healthy employees with lower insurance deductibles, but imposes higher insurance rates for those who do not maintain a healthy lifestyle. Though the intervention brings attention to the problem of obesity and overweight in the workplace, people will invariably react differently to it, and without considering the environmental factors that influence an individual’s lifestyle, the tools necessary to promote self-efficacy, or the potential for negative labeling, this intervention fails to adequately address the nature of the obesity and overweight problem, and may actually be making people less physically, mentally, and emotionally healthy than they were before.
The healthy worker discount program’s reliance on the Health-Belief Model ignores multi-level environmental influences on unhealthy behavior
Many, if not the majority, of public health interventions rely on the Health Belief Model (HBM), which was designed by social and behavioral scientists to explain health-related behavior at the individual level (6, 7). The HBM consists of a rational balancing act whereby the perceived benefits of adapting a healthy behavior change are weighed against the perceived costs, and assumes that if an individual has the intention to carry out a healthy behavior change that they will in fact execute that behavior. However, this model is inadequate in explaining health behavior because having the intent to behave in a specific way does not necessarily mean that an individual will in fact engage in that behavior. Additionally, health decisions are not always the result of rational decision-making, and it assumes that people have adequate self-efficacy and will therefore feel competent to make the necessary changes in behavior.
The healthy worker discount program relies heavily on the principles of individual behavior theory models like the HBM, assuming that all employees will jump on the chance to get healthier because by doing so they can be rewarded with lower insurance rates. This program is essentially perpetuating the idea that being obese or overweight is a matter of personal responsibility. Some programs do not call for environmental changes, such as access to fitness equipment and providing an office environment designed to protect health, that could have a greater impact in helping people to lose weight and live healthier lifestyles. This is the problem with individual level health psychology as it focuses on the psychology of individual health behavior without regard to the social, economic, environmental, or political contexts that play a very large role in individual behavior (8). The interventions that rely on these paradigms, as we see in the healthy worker discount program and in many other obesity programs, focus strictly on the ability of individuals to manage their own health and ignore the wider social context within which the individual circulates (9). This is a significant downfall for the healthy worker discount program. Another issue illustrating the shortsightedness of the program is that the insurers and executives who back the plan may just be looking for a way to shift exploding health care costs, and are not focusing on designing meaningful interventions to combat the real problem of how to help people make healthier decisions, which in turn makes the plan less effective. Indeed, “The discounts give insurers and companies an incentive to put pressure on employees to mind their health in a decade when medical costs have soared” (10).
Many people who are unable to meet the healthy requirements due to specific social conditions which have not been taken into consideration will have to pay more insurance or have money taken out of their paycheck at their own will. For example, Clarian Health, an Indianapolis-based hospital system, will institute a policy starting in 2009 that will fine employees $10 per paycheck if their BMI, blood pressure, or glucose levels are too high (5). Suppose that, in certain situations, employees may live in an unsafe area where there are congested highways and high numbers of fast food restaurants. This situation would make it very difficult for someone to feel that they have the self-efficacy to eat healthy and exercise on a regular basis.
What is needed in the design of the healthy worker program is an understanding of the social conditions that expose people to individually-based risk factors, and interventions must be directed at changing the social condition or fundamental social cause itself to alter the effects of the determinants of disease (11). One way to do this is to “contextualize” individually based risk factors. Basically, the goal would be to “(1) use an interpretive framework to understand why people come to be exposed to risk or protective factors and (2) determine the social conditions under which individual risk factors are related to disease” (11). The question that needs to be asked is - what is it about people’s life circumstances that influences their exposure to certain risk factors? The healthy worker discount program could have been more effective if it incorporated such an analysis of the context that leads to exposure. Some of the questions in this analysis could ask about what type of neighborhoods people live in and how safe they are; what, if any, community-based programs or workshops are available; whether people have access to grocery stores or shops that sell fresh fruits and vegetables; the attitudes people have toward working out and eating healthy in a specific area etc.
The healthy worker program may also have been more effective if it had relied less on the HBM and more on social theories like the Theory of Social Ecology. Originally proposed by McLeroy et al. (1988), this theory does take into account the relationship between the individual and the environment and considers both of these influences as possible explanations for unhealthy behaviors, rather than laying the blame solely on the individual for failure to change (9).
The healthy worker discount program does not provide the tools necessary to promote self-efficacy
Self-efficacy plays a significant role in complex human behavioral processes and is a useful factor in evaluating the effectiveness of the healthy worker discount program. According to Albert Bandura’s Social Cognitive Theory and concept of self-efficacy, an individual’s decision to engage in a particular behavior is influenced by his or her own expectation of personal mastery and success (6, 12). Two types of expectancies strongly influence behavior: outcome expectancy, which is the belief that certain behaviors will lead to certain outcomes; and self-efficacy expectancy, which is the belief that one is capable of executing the behavior and thereby achieving the desired outcome (6). Perceived self-efficacy will determine how much effort an individual will put forth and how persistent they will be in the presence of obstacles (6). For example, people with high levels of self-efficacy are more likely to try new behaviors and to be highly persistent in achieving the outcome. Personal self-efficacy expectations are further influenced by performance accomplishments (success in performance), vicarious experiences (modeling others successfully/unsuccessfully engaging in a behavior), verbal persuasion (encouragement or discouragement from others), and emotional/physiological arousal (response to stress) (6).
The healthy worker discount program only provides company-administered tests each year to check cholesterol, blood pressure, BMI, and smoking status, among other health indicators. This information alone is not enough to provide employees with the means to promote long-term healthy decision-making and self-efficacy. Further, these tests by themselves are not accurate indicators of how healthy or expensive an employee will be. The program is emphasizing a risk-elimination or an “all or nothing” approach, as opposed to a risk-reduction approach that focuses more on the steps to achieving the goal rather than the end point itself. Rather than “forcing” people to become healthy or else face the consequences, there is a need to educate people about the health risks associated with being obese and overweight and providing them with a supportive environment which will allow them to make long-term healthy decisions. This can be combined into a normative-reeducative approach which attempts to change people’s attitudes or social norms about the benefits of physical exercise and eating healthy (13).
Many changes can be instituted that can help to change social norms, including discount gym memberships and access to fitness equipment, lunchtime walks, healthy cafeteria food, wellness workshops, employee sports team tournaments, signs to encourage taking the stairs, health counseling services etc. An environment such as this can allow employees to feel that they can successfully engage in behaviors and it also provides them with the tools to become healthier not necessarily because the company is mandating it but more importantly for their own well being and dignity. Employees will have more opportunities to increase their success in physical activities, which in turn can increase perceived self-efficacy. If other people in the workplace are engaging in healthier activities successfully (going to the gym, walking during lunch), the more that people observing them will want to enhance their expectation of mastery in engaging in the same behavior (learning through vicarious experiences) (6). Without the necessary tools in place to promote self-efficacy and reduce the risk of long-term health problems, overweight employees may feel helpless and unable to do anything to improve their situation.
The healthy worker discount program may promote negative labeling
The purpose of the healthy worker discount program is to identify employees who are overweight or at risk so that they can take steps to improve their health and reduce insurance costs. The problem with this is that it may have the effect of separating the “healthy” people who meet company-mandated health indicator guidelines from the “unhealthy” people who don’t, and therefore may risk labeling these “unhealthy” employees as “fat.” The impact of negative labeling in this situation is that it poses a psychological burden for overweight employees that may hinder them from taking on healthy behaviors.
According to labeling theory, the behavior of an individual is influenced by how others “label” him in society (14). Societal labels that are negative or stigmatizing, in particular, can promote negative behavior. Other people’s perceptions about being overweight or fat and unhealthy in the workplace could promote a sense of victimization and low self-esteem among overweight employees, especially in a western society where the tendency to overstate the impact of the individual on health strongly plays into the “victim-blaming ethos” (8). Essentially, an individual may feel that he or she is being blamed and singled out for being overweight or unhealthy, which is a reason that many people believe the program is a form of discrimination (5). Some people have voiced their frustration over this issue: “What’s to say that tomorrow you don’t start discriminating against people who have venereal disease or AIDS?” asked Donna de Sanctis of the Health Insurance Association of America, which represents health insurers (10).
The negative stereotype of being overweight or fat could become a self-fulfilling prophecy, which is a characteristic of labeling theory, where the individual begins to internalize these public perceptions of not being healthy, and assumes the qualities and behaviors of a negative label. For example, perhaps an individual will choose not to work out because they may assume that other people think that the very reason they are overweight to begin with is because they do not exercise. Having this attitude would make them less likely to want to engage in healthy behaviors. The negative health impacts of labeling therefore render the program ineffective for the overweight population, and may also lead to unintended negative health consequences in already healthy employees. In this case, for fear of being socially labeled as fat, many non-overweight employees may adopt unhealthy dieting behaviors. The program may also cause weight to become an increasingly popular topic among employees, which puts normal weight and overweight employees at greater risk for unhealthy behavior. Overall, it would appear that the healthy worker discount program is actually making people less healthy than they were before its inception.
Implications/recommendations for future public health interventions in improving employee health
A more appropriate intervention for improving health in the workplace would be one that focuses on the intermediate steps needed to achieve a healthier lifestyle rather than on health indicator targets, which, by themselves do not necessarily indicate an individual is completely healthy. This program design should focus on educating people about the disease risks associated with being overweight or unhealthy and positively promoting healthy eating and exercise habits, which can improve self-efficacy. Rather than enforce policies that shoulder the burden entirely on the individual and risk negative labeling, employers should identify barriers to achieving a healthy lifestyle in the work environment and from that assessment develop the changes needed to encourage physical activity and healthy eating habits among employees. Promoting these behaviors can help to encourage employees to speak with their primary care physician or other health professional about the ways to achieve a healthier lifestyle, which is a much more private and appropriate setting for assessing one’s health, as opposed to getting health checks at work. Making positive changes to the wider social context of the work environment that can change social norms are important initial steps in combating the problem of obesity and overweight in the workplace.
Overall, the healthy worker discount program is ineffective in reducing the problem of obesity and overweight in the workplace. The program’s reliance on the Health Belief Model limits its ability to take into account the multi-level environmental influences on people’s behavior, and only focuses on the role of the individual in managing behavior. The requirement to undergo company-mandated tests for blood pressure, cholesterol, BMI and others does not provide people with the tools to promote self-efficacy. Also, the fact that the program is basing whether one is healthy or not on a few health indicators may present the risk of negatively labeling employees as fat. This perpetuates unhealthy behaviors among overweight individuals as they begin to take on the qualities of this negative label. A more appropriate approach to address obesity and overweight problems in the workplace which provides an empowering and supportive environment for improving physical activity and healthy eating habits may be a more effective mechanism to promote self-efficacy and long-term healthy decision making.
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