Challenging Dogma - Fall 2007

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

Monday, December 10, 2007

‘Show Me the Money’: A Critique of Incentive-Based Workplace Wellness Programs – Megan Halmo

Employers are listening: a healthy workforce translates into a more productive workplace. According to a survey by the Midwest Business Group on Health, of 160 employers, 95% believe in the relationship between employee health and productivity in the workplace (1). Legitimizing employer beliefs, a number of new studies indeed suggest the truth of this association. A study recently released by Duke University Medical Center found a relationship between the body mass index (BMI) of employees and the number of workers compensation claims filed. On average, employees who were defined as “obese” according to their BMI filed twice as many claims as “healthy” employees (defined as employees whose BMI fell within the recommended range). In addition, these obese employees were found to have medical costs that were seven times higher than healthy employees, and also missed thirteen times more workdays (2). A study by the Centers for Disease Control (CDC) found that the combination of absenteeism and medical costs for obese workers resulted in an extra $460 to $2,500 cost increase per employee to their employers (1).
Heeding the research, a number of companies are taking the relationship between employee health and workplace productivity quite seriously. But, at what cost to employees? In order to cut high health care costs to the company, employers are offering more opportunities for their workers to “get healthy.” Often, these benefits take the form of discounts on gym memberships or even the construction of a gym area within the workplace, and/or workplace smoking cessation programs. These types of programs are called workplace “wellness” programs, and are defined as “any program designed to promote health or prevent disease” (3). These initiatives aim to create healthier workers, and perhaps happier workers, in the larger effort to save cash for the company by decreasing the cost of employer-provided health insurance. Many employers maintain that wellness programs are voluntary, and offer no incentives or only minor incentives to employees to participate. However, as a result of new federal regulations outlining exceptions to the HIPAA Nondiscrimination Act (3) some companies are taking workplace wellness programs to a new level, by financially rewarding, or even financially penalizing employees who do not achieve specified measures of health, such as BMI and cholesterol levels. Proposed financial penalties have generally come in the form of docking employee paychecks, or increasing health insurance premiums for the “unhealthy” employee. Says Garry Mathiasion, a partner at Littler Mendelson (a law firm consulting with companies considering initiating mandatory wellness programs) “The demand for [curtailing health care costs] is so great that [employers] are willing to take the next step. It’s tough love.” (4) But, is it too tough? This paper will argue that workplace wellness programs that penalize employees are a flawed public health intervention for their failure to take into account basic concepts of the social and behavioral sciences.
Failure One: Neglecting Social Cognitive Theory
Workplace wellness programs aimed at creating a healthier workforce by financially encouraging workers often measure health in terms of indicators such as BMI and cholesterol levels. For example, Clarian Health, a hospital system based in Indianapolis and a previously outspoken advocate of its newly designed wellness program, proposed to dock $10 from the paycheck of each employee if their BMI exceeds 30, $5 each if their cholesterol levels, glucose levels, and blood pressure are classified as high, and another $5 if they are smokers (4). In this public health intervention then, the intended health behaviors are those activities that help lower BMI, cholesterol, glucose, and blood pressure levels. These activities include healthy exercise, diet, and possibly adherence to a medication regimen (i.e. statins for lowering cholesterol).
According to one social science model of behavior change, in order for an individual to perform a behavior that individual must have a reasonable expectancy of individual agency, or self-efficacy – “the conviction that one can successfully execute the [health] behavior to produce the [intended] outcomes” (5). First posited by the behavioral theorist Albert Bandura, the concept of self-efficacy has evolved into Social Cognitive Theory (SCT), a popular model of health behavior (6). As described by Edberg, SCT incorporates individual characteristics, comprised of self-efficacy based on an individual’s behavioral capacity, expectations, emotions, and self-control; and environmental factors, which provide an opportunity for “vicarious learning.” Vicarious learning sometimes leads to modeling, via observation of the behavior of others, and observations of corresponding conditions of positive or negative reinforcement. These factors interact through reciprocal determinism, a process by which an individual adjusts behaviors gradually based on internal and external reactions to behavior and behavior outcomes.
The role of self-efficacy in determining the behavior of an individual is of utmost importance, according to SCT. Applying SCT to workplace wellness programs with financial penalties, it is clear the degree to which they are flawed as a public health intervention. By setting uniform health benchmarks that must be achieved in order to avoid penalties some employees, namely those who are in the poorest of health, will consider the health goals out of reach, diminishing feelings of capability and expectations of self-efficacy. In this manner, the desired health behaviors (i.e. diet and exercise) are discouraged from the outset for their perceived impossibility, greatly lessening the chance that wellness programs will achieve the ultimate goal of improving employee health and saving company costs.
In order to be effective, workplace wellness programs should be designed in such a way that increases the self-efficacy of employees. Employers might do this by encouraging even the smallest levels of improvement in individual physical health, as opposed to intimidating employees with uniform and lofty health benchmarks. A good wellness program should also take a holistic approach to health by focusing on all areas contributing to the overall well-being of an individual, not only the physical aspects. These strategies surely will heighten feelings of self-efficacy in employees by discouraging competition, and by allowing and helping them to focus on improving a wider range of health parameters, thereby presenting an opportunity for personalization of the wellness program experience. Finally, wellness programs should certainly not implement financial penalties, for they only have the potential to further lower feelings of self-efficacy. By introducing financial consequences for physical and emotional health failures not only do these programs impart some employees with little self-efficacy to change their health, but they may also demote feelings of self-efficacy to control individual finance and income.
Failure Two: Heavy Reliance on the Health Belief Model
Workplace wellness programs that impose financial penalties to motivate employees, such as Clarian’s, rely heavily on the Health Belief Model (HBM) of health behavior. Unfortunately, this is largely to the detriment of wellness programs. While the HBM remains one of the most influential models in the designing of public health interventions, it is rarely adequate in producing an effective, comprehensive program. The HBM posits that all individuals weigh perceived susceptibility to severity of a particular health outcome against perceived barriers to action (the health behavior). This presumed “rational” balance results in the individual’s intention to perform the health behavior, which, in turn, dictates behavior (7).
Studies exposing the shortcomings of the HBM shed light on the inadequacies of workplace wellness programs in their attempt to improve the health status of employees. One fault of the HBM that is especially destructive to workplace wellness programs is the assumed link between intention and behavior. In following the HBM, if an employee intends to perform the desired health behavior then they will, in fact, perform that behavior. However, according to studies examining the connection between intentions and behavior (for example, the intention to exercise as it relates to actually performing the intended exercise) intention accounts for only 20 – 50% of performed behavior (8,9). The wellness programs under scrutiny here even provide behavioral cues to action, in the form of financial penalties, in the effort to strengthen the intention-behavior connection. Despite this, the link remains weak. Accurately dubbed the “intention-behavior gap” (10), this flaw in the HBM leads to persistent problems in many public health intervention that rely upon it for its design, including workplace wellness programs.
In addition, the HBM excludes any proposition of the relationship between health behavior and outcomes – and so operates in ignorance of the well-researched position that good health behaviors do not always result in desired health outcomes. Illustrating this flaw of the HBM are studies suggesting that socioeconomic status (SES) is a primary cause of negative health outcomes (11-13). In a study of the relationship between SES and health, Lu et al. found that health insurance status and health behaviors only account for a small portion of the difference in health status (10-16%) between poor populations and wealthy populations (11). This implies what the HBM does not account for: the reality that there are factors beyond actual health behaviors that have a major influence on health status. If SES and health status are so persistently linked regardless of intention or health behavior, it seems ludicrous to impose pay cuts or to increase health insurance premiums for those employees whose health status is poor. By punishing employees in such a manner, workplace wellness programs simply perpetuate the cycle linking low SES and poor health. In addition to and in corroboration with SES, other confounding factors might include familial, social, and genetic characteristics of an individual. The failure of the HBM, and therefore of workplace wellness programs, to incorporate or at least consider the range of extenuating factors that affect health behaviors and health outcomes embody key flaws in this intervention.
Failure Three: Inappropriate Use of the Power-Coercive Approach
In developing a public health intervention with the goal of changing health behaviors, a power-coercive approach can sometimes be the most effective method. According to Benne and Chin, “When a person or group is entrenched in power in a social system, in command of political legitimacy and economic sanctions, that person or group can use power-coercive strategies in effecting changes, which they consider desirable, without much awareness on the part of those out of power in the system…” (14). Power-coercive strategies for effecting change include the use of nonviolence, the use of political institutions and legislation, and the manipulation of power-elite members of society (14). By conceptualizing companies or workplaces as microcosms of larger society, it is evident that some of these organizations have indeed employed the power-coercive model in planning and instituting workplace wellness programs based on financial penalties to employees by mandating health “requirements” that are enforced by financial penalties. Despite its occasionally unique effectiveness, an examination of the occupational psychology literature exposes here the inappropriate and even counterproductive application of the power-coercive approach in the context of a public health intervention to improve employee health.
Employee health and well-being appear to be related to organizational productivity, and this conclusion is supported by the relevant occupational literature and research (1, 15-19). As previously noted, health and well-being of employees, however, does not only imply physical health, which is largely the target of the workplace wellness programs that are presently at issue. Wellness in the workplace is truly a more all-encompassing concept, and includes feelings and conditions of motivation, job satisfaction, morale, empowerment, and stress (15,16,20). Research shows that psychological empowerment, for example, influences employees’ feelings of job strain and satisfaction (20), which can in turn influence organizational outcomes such as productivity (15). As a component of individual empowerment, employee involvement is identified as an important factor in determining employee outcomes, and in a study by Grawitch et al. is shown to be significantly positively associated with employee commitment and employee well-being, and significantly negatively associated with emotional exhaustion and turnover intentions (16).
Consequently, a power-coercive approach to workplace wellness seems antithetical to promoting employee well-being. Employees at companies such as Clarian have little role in informing the planning of such programs, and as noted, many will be unable to participate due to physical, social, and/or economic reasons, even when they wish to participate or intend to participate. Some employees are in fact angered by the bodily incursion perpetrated by workplace wellness programs, which may involve extra medical exams, or peeping into employee medical records. One Clarian employee exclaims, “How dare you? This is my personal space.” (4). Surely, the exclusion of employee input and financial coercion of employees by powerful superiors does little, if anything, to increase employee empowerment, and therefore may have a negative effect on the well-being of employees and the productivity of the company.
Furthermore, the use of a power-coercive approach may perpetuate new, exaggerated hierarchies of power amongst coworkers based on attractiveness and a magnification of personal responsibility for health. Employees who cannot participate in workplace wellness programs might encounter feelings of social isolation from “healthy” coworkers, may find themselves being labeled by their coworkers and superiors as unfit or even “fat,” and might feel discriminated against. Commenting on workplace wellness programs, Barbara Weltman, a small business specialist says, “Any program that you adopt can’t be discriminatory… You have to encourage all employees to take advantage of it” (2). The problem is, however, that many workplace wellness programs using financial penalties are inherently discriminatory, as it seems impossible that every employee will be able to participate. Ultimately, the use of a power-coercive model to promote health in the workplace will likely result in lower self-esteem and higher emotional stress, only compounding upon the financial stress felt in the pocketbooks of employee “victims” of such workplace wellness programs. Moreover, in the aggregate, the physical health of employees will see little to no improvement.
In their 1987 article, “When health means wealth,” Gettings and Maddox conclude,
“Regardless of the program itself, a firm that makes a commitment to improve the emotional and physical health of its employees can enhance both performance and productivity. A corporate wellness program is an explicit statement to employees that ‘we care about you.’ Such concern enhances employee cohesiveness and contributes to a spirit of teamwork. At the same time, the company promotes a positive climate within the organization.” (17)
Clearly, an examination and application of the social and behavioral sciences to the world of workplace wellness programs exposes the illegitimacy of this claim. Arriving at quite the opposite conclusion, J.H. Browne argues that human resource practices “are only progressive if the concern for organizational-level outcomes is matched by a concern for the well-being of employees who are directly affected by these practices” (15). In the case of workplace wellness programs that impose financial penalties, this comment is truly on the mark. By promoting the goal of improving employee health in service of the larger goal to save money for employers, companies proposing these wellness programs are transparent in their true financial motivations, and even in this pursuit they may find themselves unsuccessful.
On November 1st, 2007, lamenting that their wellness program was “ahead of its time,” Sheriee Ladd, the Vice President of Human Resources at Clarian Health announced that they have rescinded the plan to penalize employees (21). Clarian will continue its program on a reward only basis. While some companies continue to push wellness programs that rely on financial penalties, the reasoning of the social and behavioral sciences exposes flaws that appear to condemn this brand of public health intervention a failure.
1. Farnsworth D, Kemker F. Final Wellness Program Regulations Offer One Piece in the Health Care Cost Puzzle. Tampa, FL: ABA Health eSource, June 2007.
2. Schweitzer, T. Obese Employees Cost Company More., May 2007.,3566,274978,00.html.
3. U.S. Department of Labor. FAQs About the HIPAA Nondiscrimination Requirements. Washington, D.C: U.S. Department of Labor: Employee Benefits Security Administration, December 2007.
4. McGregor, J. Being Unhealthy Could Cost You – Money. Business Week, August 2007.
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6. Edberg, M. Social, Cultural, and Environmental Theories (Part I) (pp. 51-64). In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, Inc. 2007.
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9. Rhodes, RE. Understanding Action Control: Predicting Physical Activity Intention-Behavior Profiles Across 6 Months in a Canadian Sample. Health Psychology 2006; 25(3):292-299.
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13. Bosworth HB et al. Racial Differences in Blood Pressure Control: Potential Explanatory Factors. American Journal of Medicine 2006; 119(1):70.e9-70.e15.
14. Chin R, Benne KD. General strategies for effecting changes in human systems (pp. 22-45). In Bennis WG, Benne KD, Chin R, Corey KE, eds. The Planning of Change: Third Edition. New York, NY: Holt, Rinehart and Winston, 1976.
15. Grawitch MJ, Gottschalk M, Munz DC. The Path to a Healthy Workplace: A Critical Review Linking Healthy Workplace Practices, Employee Well-being, and Organizational Improvements. Consulting Psychology Journal: Practice and Research 2006; 58(3):129-147.
16. Grawitch MJ, Trares S, Kohler JM. Healthy Workplace Practices and Employee Outcomes. International Journal of Stress Management 2007; 14(3):275-293.
17. Gettings L., Maddox NE. When health means wealth. Training & Development Journal 1988; 42(4):81-86.
18. Spreitzer GM, Kizilos MA, Nason SW. A dimensional analysis of the relationship between psychological empowerment and effectiveness, satisfaction, and strain. Journal of Management 1997; 23(5):679-705.
19. Industry News SHP. Stress rise leads to productivity drop. The Safety & Health Practitioner 2003:70.
20. Spence Laschinger HK, Finegan J, Shamian J. Promoting Nurses’ Health: Effect of Empowerment on Job Strain And Work Satisfaction. Nursing Economics 2001; 19(2):42-52.
21. Lee, D. Clarian won’t dock workers who fail to meet health standards. Indianapolis, IN: The Indianapolis Star, November 2007.

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