worksite health promotion: the social context

Sm. Sci. Med. Vol. 26, No. 5, pp. 485-489, 1988 Printed in Great Britain. All rights reserved

0277-9536/88 S3.00 + 0.00 Copyright 0 1988 Pcrgamon Journals Ltd

WORKSITE HEALTH PROMOTION: THE SOCIAL CONTEXT

PETER CONRAD Department of Sociology, Brandeis University, Waltham, MA 02254, U.S.A.

Since the mid-1970s an increasing number of Ameri- can corporations and businesses have introduced health promotion or ‘wellness’ programs into the workplace [l]. Worksite health promotion can be defined as a “combination of educational, organizational and environmental activities designed to support behavior conducive to the health of employees and their families” [2, p. 131. In effect, worksite health promotion consists of health education, screening and/or intervention designed to change employees behavior in a healthward direction and reduce the associated risks. It differs from the traditional occupational health mission in that wellness programs are interested in general health promotion among employees, rather than focusing on health protection, i.e. preventing occupational diseases or insuring safe working conditions.

Worksite health promotion ranges from single interventions such as hypertension screening to comprehensive health and fitness programs. Comprehen- sive programs, which are being adopted by a growing number of companies, may include health risk assessments, hypertension screening, aerobic exercise and fitness, nutrition and weight control, stress manage- ment, smoking cessation, healthy back, cancer risk screening and reduction, drug and alcohol abuse prevention, accident prevention, self-care and health information. While few programs include all of these features, the orientation of the wellness programs is to facilitate changing people’s behavior or lifestyle to prevent disease and promote health. Participation is voluntary, although many programs make efforts to reach ‘high risk’ employees and provide incentives (from T-shirts to cash) to encourage participation.

Programs vary in scope and orientation. Variations include whether they are onsite (e.g. with a staffed fitness center) or offsite (e.g. a company contracting with a local health club); managed by the company or a ‘private vendor’; at no cost or at some cost to the employee; on or off company time (or some combination); available to all employees or some limited segments or with worksites; or operating on a continuous basis or intermittent modules.

The idea of doing health promotion in the workplace has captured the imagination of many health educators and corporate policy-makers. Since workers spend more than 30% of their waking hours at work, the workplace is considered to have great potential for health education and promotion. Cor- porate executives and managers are attracted by the broad claims made for worksite health promotion which include: improving employees’ health and fitness; decreasing medical and disability costs; mduc-

ing absenteeism; decreasing turnover; improving employee mental altertness, morale and job satisfaction; increasing productivity; and enhancing the corporate image [3,4]. While most of these benefits have yet to be demonstrated by scientific research, there is a widespread belief among wellness advocates that these programs have significant positive effects for employees and corporations.

Many major American companies have already developed health promotion programs, including Lockheed, Johnson & Johnson, Kimberly Clark, AT&T, Tennaco, IBM, Metropolitan Life, Pepsico, CIGNA Insurance and the Ford Motor Company, among probably thousands of others. Studies in the early 1980s reported between 20 and 38% of surveyed companies had some type of health promotion program, with larger companies and worksites more likely to offer health promotion [S]. While these percentages are hard to interpret because of varying definitions of what constitutes a program, nearly all surveys report an increasing number of companies considering introducing health promotion activities. Estimated employee participation rates range from 20 to 40% for onsite to lO-20% for offsite programs [6], but accurate data are very scarce [7l.

In many ways worksite health promotion is still a uniquely American phenomenon. Several years ago I wrote letters to sociologists and occupational health professionals in several European and Pacific coun- tries. In this informal survey I could not locate any worksite health programs like those found in the United States. In Europe there are some cardio- vascular risk reduction programs, with a few in- volving worksites (run by unions), but no wellness programs as described here. There is also some concern with ‘humanizing’ the workplace, but this does not involve health promotion. A number of Japanese companies offer general fitness programs but they seem to have only a minor interest in health.

THE CONTEXT OF WORKSITE HEALTH PROMOTION

Why has worksite health promotion developed in the United States? While I cannot fully address this question here, I can point to a few conditions that have been important in its emergence. For the sake of analysis we can separate them into corporate, health and cultural factors.

In terms of health care, the corporate context in the United States is rather unique. Because there is no national health insurance, corporations pay for a large portion of the national health bill, primarily by

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providing medical insurance as an employee benefit. Eighty percent of the workforce has some private group health insurance and much of this coverage extends to dependents as well. Business and industry pays an estimated 30% out of the national health care bill and its costs have been rising rapidly. In 1984 corporations paid about $90 billion in health insurance premiums. To give one example, in the early 1980s S500 of each Chrysler car produced went for health costs [8]. General Motors health bill in 1982 was five times what it was in 1970 [9]. Corporate health costs in the late 1970s were rising as much as 20-30% a year [lo] and became an issue of consid- erable concern to corporate executives.

In the 1980s American industry has adopted ‘cost containment’ as a key to corporate health policy. The incentives are substantial, for if companies can reduce their medical insurance and disability claims they may be able to lower their health costs and poten- tially reduce their insurance premiums, which in turn would reduce their operating costs. Corporations and their insurers have developed multi-pronged plans to control health costs, including more cost-sharing (of deductibles and premiums) with employees, second opinions for many elective surgical procedures, incentives for out-patient surgery, encouragement of ‘alter- native’ health providers such as Health Maintenance Organizations (HMOs) and Preferred Provider Or- ganization (PPOs), and worksite health promotion. Thus worksite wellness programs, with their goal of keeping employees healthy and reducing medical care utilization, are a part of this cost containment strat- egy. Perhaps equally important, a wellness program may be seen as a symbolic exchange for employer cost-shifting and reductions in other benefits.

There are also other corporate rationales for devel- oping health promotion programs. In the competitive international marketplace, employee productivity is a crucial concern. Wellness advocates claim, and many corporate executives seem to believe, that health promotion programs can improve employee morale and productivity and reduce absenteeism. In any case, evidence suggests that these programs are very popular with employees and are a relatively low-cost benefit. They are upbeat, positive and good for the corporate image. Their existence may LX seen by employees as tangible evidence that the company cares about its workers and therefore may indirectly affect job satisfaction and loyalty.

A second general condition underlining the rise of health promotion has been the emergence of the lifestyle-risk factor paradigm in medicine. To the extent there is a scientific justification for imple- menting health promotion, it resides within this paradigm. The basic assumption of this paradigm is that individual behaviors or lifestyles, in terms of risk factors, are central in the development of chronic disease. Because these risk factors are behavioral they can be modified and thus risks to health can be reduced. This paradigm is epidemiologically based and has its origins and initial scientific support in research like the 1964 U.S. Surgeon General’s Report on Smoking which implicated cigarette smoking with the development of lung cancer [I I], The Framing- ham Heart Study [ 121 which linked cholesterol, smoking and hypertension to the risk of heart disease, and

research which showed that certain behaviors and habits can make substantial contributions to health status and longevity [13]. There is a dominant perspective in the medical world that individual lifestyle factors can have a major impact on health and disease [14]. Government policy makers have amplified and endorsed this approach in influential documents like the Canadian Lelonde report [ 151 and the U.S. Surgeon General’s Report, Healthy People 116). Although the risk factor-lifestyle approach has been criticized for overstating individual responsibility for health, blaming the victim and providing a justification for the reduction of medical services [17], it is a reigning paradigm for medical research and practice.

The third condition supporting the development of worksite health promotion in the United States can be termed ‘cultural wellness’. For nearly two decades interest and participation in fitness and ‘wellness’ have been booming in America, especially among the middle classes. This is manifested in health foods, health clubs, jogging and exercise, holistic health and so forth. These health interests seem to result primarily from changes in cultural and social values rather than scientific advances.

The increase in jogging and aerobic exercise is a prime example of cultural wellness (181. Estimates of the number of Americans engaged regularly in stren- uous exercise range from 37 to 60 million, with the vast majority of them being middle class and between 20 and 50 years old [ 19,201. Millions are spending at least several hours a week jogging, running or engag- ing in aerobic exercise. This has happened without any breakthroughs in medical research and with limited scientific justification; indeed the extant research is supportive of mild health benefits but is not without contention [21). While the individual mo- tivation for exercise may not always have to do with health [22], the extent of participation reflects a clear change in American culture.

Wellness is something of a populist movement that has been amplified and fueled by the media and the commercial marketing of products touted to have health benefits. A consciousness about wellness in the culture has created for some individuals a readiness to participate in worksite wellness programs. One might even say worksite health promotion is riding the crest of cultural wellness.

POTENTIALS AND PITFALLS

Even if worksite health promotion cannot live up to all the enthusiastic claims of its advocates, its potential employee health and corporate benefits may still be significant. There is some evidence for the health effectiveness of specific worksite interventions like hypertension control and smoking cessation programs [23]. In the past few years extensive research has begun on some major health promotion programs. Most of the results thus far available are from pilot programs that are only a few years old. In general the results show health improvements in terms of exercise [24], reduced blood pressure and cholesterol [25,26], although the findings are not entirely consistant. Most of the studies are short-term and cost containment benefits are likely to be longer-

Worksite health promotion 487

term, but the early data on cost control are interesting. One study tracked the medical claims of 2400 employees for five years and found the average payments for wellness participants was generally lower [26,271. The ‘savings’ per employee was about $143 compared to a program cost of $98. Recent studies also have found a significant reduction of insurance claims at worksites that had implemented health promotion programs [28) and among fitness program participants [29]. While these data are prom- ising, they all come from wellness programs where companies have made unusual and intensive commit- ments to health promotion; it is unclear how well these findings would be replicated at run-of-the-mill programs in garden variety companies. While actual cost saving remains contentious, the programs may well be a cost-effective benefit.

The lifestyle-risk factor approach to worksite health promotion has some pitfalls [30]. For example, social scientists and health educators have very limited knowledge about how to change people’s (healthy or unhealthy) habits. Education is helpful, but not sufficient. Most people are aware of the health risks of smoking or not wearing seatbelts, yet roughly 30% of Americans smoke and, when not required by law, 80% don’t regularly use seatbelts. Worksite weliness programs focus on individual ‘risk’ and emphasize individual responsibility for health- yet, can we really say how much individuals are responsible for their high blood pressure, elevated cholesterol or stress? And what of the dangers of crossing that thin line from individual responsibility to blaming the victim? Some evidence suggests that people who come to wellness programs may be healthier than those who do not [7]. Thus programs may miss some of the most ‘at risk’ employees. This may in part be a result of the middle class bias of the programs. They ignore issues like social deprivation and social class, and have not been attractive to blue collar workers. Moreover, it is possible that health promotion may dilute corporate attention for health protection (i.e. occupational health and safety). Well- ness advocates shift attention from the environment to the individual. They have put very little energy into modifying the work environment and generally have ignored the health effects of working conditions. Finally, there is always the potential that corporations will become more coercive about promoting health and, for example, make wellness a condition of employment. This could lead to new and subtle discriminations on the basis of health.

SOCIOLOGICAL PERSPECTIVES

Most of the published research on worksite health promotion has been in the areas of public health, health education and occupational health and has focused largely on outcomes, especially in terms of health behaviors, medical utilization and corporate health costs. By contrast, the papers in this collection are less interested in specific outcomes per se and focus more on the social organization of health promotion in the workplace. We use the term social organization broadly here, highlighting the social, organizational and interactional factors that create

and affect worksite health promotion. Thus the authors raise some new questions: What are the features of companies that adopt worksite health promotion programs? How do corporations define their ‘health problem’ and select worksite health promotion as part of the solution? What are the social boundaries of wellness programs in the workplace? What types of employees are most likely to participate? What brings employees to programs and encourages their participation? How do participants perceive the health promotion? What are the effects of gender and other social characteristics on participation and change? Can programs have impacts that affect the participants’ family members? These papers represent first forays into sociological analysis of worksite health promotion; there are of course other sociological questions that don’t get addressed here. Future research can examine such issues as the relationship of worksite health promotion to the wellness movement in general, the conditions that facilitate corporations’ develonment of weliness uro- grams, the hmits and benefits’of social structuril as well as behavioralllifestvle interventions. the effect of the vast entrepreneuraf industry that has grown up around wellness, the role of corporate cultures in health promotion, the effects of workplace social networks on health promotion, the potential of health and fitness centers in creating informal networks in otherwise hierarchical organizations, the relations of wellness to traditional occupational health, and the impact of wellness programs on the meaning of work. Research on worksite health promotion has the potential to contribute sociological knowledge of organizations, preventive health behavior, social change and social control.

The papers in this special issue focus on worksite health promotion programs as their unit of analysis. Wherever possible the authors use sociological theory to illuminate on the problem they are examining or bring the worksite health promotion data to bear on existing sociological theory. The ordering of the papers progresses from the national-scale macro surveys of programs in corporations to the more micro studies of participants’ perspectives on actual program participation.

Roberta B. Hollander and Joseph J. Lengerman’s “Corporate characteristics and worksite health promotion programs: survey findings from Fortune 500 companies” examines selected characteristics of For- tune 500 companies that affect the existence and extent of corporate health promotion. Corroborating other recent surveys [S], Hollander and Lengerman found a high degree of worksite health promotion activity among these large corporations, although it seems clear that only a few have comprehensive wellness programs.

Worksite health promotion is not the first ‘health oriented service to appear in work organizations in recent years. With the encouragement of federal funding, in the early 1970s many companies introduced Employee Assistance Programs (EAP). EAPs had their origins as occupational alcoholism programs, but have expanded to include a variety of mental health and substance abuse problems. In their paper “Formal intervention in employee health: com- parisons of the nature and structure of employee

488 PETER CONRAD

assistance programs and health promotion programs” Paul M. Roman and Terry C. Blum examine the conceptual, organizational and programatic simi- larities and differences between the more established EAPs and the newer wellness programs. While the programs are similar in certain ways, and even occasionally have organizational overlap, it is the differences that shed the most interesting light on worksite health promotion.

The next five papers report studies of specific worksite health promotion programs. These range in size from a major corporate initiative (AT&T) to a local fire department. Although each site has specific features, the papers address some general issues around worksite health promotion. “Changing health practices: the experience from a worksite health promotion project” by Jennie J. Kronenfeld, Keith E. Davis and Steven N. Blair draws on data from a study of health promotion among government employees in South Carolina. The authors examine who, in terms of demographic and social characteristics, are the ‘changers’ and ‘nonchangers’ of health practices one year after the program intervention.

M. A. Spilman’s “Gender differences in worksite health promotion” focuses on one of the more interesting and uninvestigated issues in health promotion. Drawing on data from a large and comprehensive study of AT&T’s “Total Life Concept” program this paper examines the effect of gender on predicting participation in specific worksite wellness interventions. Aligning with some previous research on preventive health behavior, Spilman found that women participate differently than men.

The control of health costs is often presented as an important incentive for introducing employee health promotion. Yet two thirds of employer health costs are paid for spouses and dependents who are not part of most worksite health promotion programs. Rick S. Zimmerman, Terence A. Get-ace, John C. Smith and Julio Penezra’s article, “The effects of a worksite health promotion on the wives of fire fighters,” asks whether a worksite health promotion program can permeate into the family and affect healthward changes among spouses. Attention to this issue is critical if wellness programs are to be successful in reducing health costs.

Participants’ perspectives on programs and health have been overlooked in most research on worksite wellncss. Occasionally, employees opinions have been solicited for needs assessments or program evalu- ations, but these are usually relegated to numerical summary statements appended to larger reports. The next two papers are ethnographic in nature and focus directly on how employees come to participate in wellness programs and what that participation means to them. Peter Conrad, in “Health and fitness at work: a participants’ perspective”, contends that participants have a “fitness” as opposed to “health” orientation and discusses what consequences this may have for promoting health and for the future of wellness programs. In “Worksite health promotion and the becoming of self”, Joseph A. Kotarba and Pamela Bentley explore the subjective meaning of wellness participation and adherance, especially in terms of the role of perceived competence and self- actualization. They emphasize how participation may

be effected by and in turn affect conceptions of self and personal identity.

The final substantive paper takes a critical look at the corporate perspective on health promotion. In “The ideological construction of risk: an analysis of corporate health promotion in the 1980s” Jacqui Alexander argues that the theoretical knowledge about health promotion is more of an ideological construction than a scientific fact. Specifically, she shows how the corporate construction of the health problem-in terms of medical costs, individual ‘risk’ of disease and employee overutilization-may affect and limit the types of solutions sought.

Since the sociological study of worksite health promotion is a new topic for study, this volume helps set the angle for future sociological work in the area. With this in mind, I asked Diana Chapman Walsh-a longtime specialist on industry and health who has sociological training-to reflect on these papers’ strengths and limitations and use them as a spring- board for proposing further directions for us to go. I asked Dr Walsh to engage the papers critically and to encourage debate. Her paper “Toward a sociology of worksite health promotion: a few reactions and reflections” outlines some of the challenges that lay ahead as we try to better comprehend the worksite wellness phenomenon.

Rcknowledgemenf-This symposium was developed whiie the editor was a Visiting Fellow at the Department of Social Medicine and Health Policy at Harvard Medical School where he was supported by NIMH National Research Service Award (IF32MH0333-01).

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worksite health promotion: the social context

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