Why do some workplace wellness programmes work while others do not? Dr Bridget Juniper analyses a survey that reveals some of the answers.
A recent survey on workplace wellness programmes by researchers at the RAND Corporation is as depressing as it is revealing. Depressing because the authors conclude that the effect of such programmes is only modest, and revealing because these findings blow a big hole in some of the wild claims made by providers of health promotion programmes on what they can deliver in terms of enhanced performance.
RAND was commissioned to carry out this sizeable study by the US Department of Labor and the Department of Health and Human Services, and therefore focused on the activities of US companies. However, the conclusions it draws can apply to the UK just as much and highlight a question that I have asked for a long time: why is it that our wellness industry continues to thrive but the UK workforce is getting sicker?
In the US, there are an estimated 7,500 wellness vendors with roughly £2 billion spent by companies every year. Despite this, chronic disease is on the rise.
There are two fundamental challenges with current workplace health programmes. First, they do not attract those employees who are at greatest risk. Second, they are not linked to business outcomes that affect the bottom line.
So, if these are the problems, what steps can companies take to make sure their investment in workplace wellness delivers real benefits?
First, let’s be clear what we mean by health promotion in the workplace. This term references all kinds of corporate programmes that are offered to staff that encourage them to adopt more healthy behaviours. They are accessed on a voluntary basis and include the usual staples such as health-risk assessments, health screening, smoking cessation, weight-loss plans, mental resilience, health education and fitness. On-site vaccination plans and healthy food options are also popular. In wellbeing parlance, workplace wellness programmes are primary interventions; that is – they are targeting employees with various health measures now to try to prevent chronic disease later. Many wellness promotions just seek to spread the word about healthy lifestyles. Specific medical conditions that are most commonly targeted include diabetes, heart disease, lung disorders, depression and cancer.
Why stage a health promotion programme?
One of the main stumbling blocks to an effective programme is the fact that most organisations fail to articulate why they are entering into this kind of initiative. Is it part of their corporate social responsibility policy? Is it to reduce absence and, if so, what kind of absence? Short term? Long term? What particular medical conditions are they wishing to tackle? What about retention? Or productivity? If an organisation can specify the main business objective(s) that underpin its wellness programme, it will stand a far better chance of delivering something that has an impact.
Aligned to this issue is where exactly does health promotion sit within the wider health and wellbeing offer? Is it a bolt-on extra that sits on its own as one of many “health du jour” activities or is it a more strategic programme that complements other initiatives in this space?
Who is the target?
If an employer can articulate why it is promoting health, it should also be able to define the profile of those staff it would like to take part. Many wellness programmes I have come across simply preach to the converted. They attract those who already eat well and exercise regularly but singularly fail to reach those who avoid healthy foods and have never seen the inside of a gym. It is clear that an organisation that can stratify the group(s) of employees it wants to reach will be better placed to shape wellness programmes that appeal directly to these factions.
The basic principles of marketing can provide a useful framework for an effective health programme. These are sometimes referred to as the four Ps of the marketing mix, and a brief description of each follows.
In marketing speak, this refers to the work involved to provide the product at a place that is convenient for consumers to access. Applying this to health promotions, this looks at how easily the offering can be used/acted on by employees. This does not just cover physical space; it also means online programmes and other remote services. The bottom line is that the promotion must be totally convenient to those whom the organisation is wishing to switch on.
[Many wellness programmes] fail to reach those who avoid healthy foods and have never seen the inside of a gym.”
A recent example of how the wrong place can influence engagement levels concerns a leading retail store. The OH manager was surprised at the lack of uptake among her shop-floor staff of a free health screen. On the face of it, this sounded odd. However, when it became apparent that these employees – mostly women – who were not allowed to sit or slouch while on the shop floor and had to wear heeled footwear, were being required to walk to another building and climb three flights of stairs – all within their lunch break – in order to take advantage of this offer, it became clear why utilisation rates were as low as they were. Had the site been located at a more convenient spot, take up could have been better.
As the name suggests, this element is all about what the health promotion contains. Does the health programme satisfy what the employees need or want? There is a lot packed into this question for health promotion sponsors. Do employees need this product? How do you know they need it and perhaps, more to the point, how do they know they need it? If employees are of the view that they neither need nor want what is being offered, the project is doomed.
In order to counteract this scenario, employers are advised to do two things. First, amass some decent data to justify there is a need among their staff. There are too many instances of programmes that are dreamt up in the HR/OH teams because someone somewhere thinks it is a good thing without any evidence to back things up. Second, test the product directly with some of the employees for whom it is designed. Ask them what they think. Are they likely to engage with it? If not, why not? How can the offering be improved perhaps to make it more attractive?
A case in point is a rail company that I have recently done work for. The HR team was entertaining ideas of health education around nutrition and exercise for its train staff. Following some research we conducted into the health and wellbeing needs of those working on the trains, it became clear that these staff were not interested in nutrition and exercise. Much more important, was some waterproof clothing, helping them cope with angry passengers when train services were disrupted, and preventive exercises to protect lower limb damage from standing on moving trains for long periods of time. These needs and wants became the “product” and there was a 1,600-day reduction in absence last year. Nutrition and exercise programmes were shelved.
If you are thinking about buying an off-the-shelf product, it is a good idea to research the vendor’s claims about the benefits of their particular solution. I see a lot of bold assertions about the results that health promotions can bring about that cannot always be corroborated when you delve behind the proposition a bit further.
Pricing is about the amount a customer – or employee in this case – is prepared to pay for the product or promotion. Generally speaking, the cheaper the programmes are to employees, the more chance they have of succeeding, especially in today’s harsh economic climate. Initiatives such as health education programmes are usually made available free of charge. Other options such as fitness programmes, for example gym memberships, and health screening, are often subsidised by the company.
The price an employee is prepared to pay goes back to the earlier point about product. If it meets their need or want, they are likely to part with cash. If they see no benefit, it will be a different story.
In order to alert people to the merits of the health programme, staff need to be made aware of it through promotional channels. This covers all methods of communication that a promoter may use to provide information to different parties about the product. Different people respond to different mediums, so mix up the channels to appeal to as wide a number of employees as possible. The younger staff will prefer social media perhaps, while older members of the workforce may be more receptive to more traditional communications such as posters and flyers. The support of line managers should also be galvanised.
Carrot or stick?
As part of the promotion, employers may consider offering incentives to boost participation rates. This is more popular in the US than it is in the UK and beware the issues it might create with the Equality Act’s provisions for disability discrimination, which have subsumed the Disability Discrimination Act. Incentives are typically framed as rewards and tend to fall into one of two categories – financial rewards, for example gym discounts or cash, or novelty items, for example t-shirts.
Mostly, incentives act as carrots. They reward good behaviour that requires staff to change their lifestyle habits on the promise that this will pay dividends in the future. This is fine for those individuals who are motivated to engage in healthy behaviours but not the case for those who are not healthy and do not respond to incentives. This problem is known as time-inconsistency and references those people who tend to give less weight to the “pleasure” they will receive in the future – being healthy in old age – over the pleasure they can receive today – pursuing an unhealthy lifestyle now.
Any evaluation should track the change in work-related outcomes, such as absenteeism or health insurance claims.”
This gets to the root of the problem with health promotion programmes. Using disincentives and penalties as a stick to encourage participation might be more effective.
The work in behavioural economics by the likes of Tversky and Kahneman (1979) lends support to this type of approach. These researchers, at Stanford University, showed that people’s attitudes towards risks concerning gains may be quite different from their attitudes toward risks concerning losses. For example, when given a choice between getting $1,000 with certainty or having a 50% chance of getting $2,500 they are likely to choose the certain $1,000 in preference to the uncertain chance of getting $2,500, even though the mathematical expectation of the uncertain option is $1,250. This is a perfectly reasonable attitude that is described as risk aversion. But Kahneman and Tversky found that the same people, when confronted with a certain loss of $1,000 versus a 50% chance of no loss or a $2,500 loss, often choose the risky alternative.
This is called risk-seeking behaviour. For corporate wellness programmes, this carries important implications. People respond to the chance of a gain – a positive incentive in workplace health promotion – differently to when there is a chance of a loss – a disincentive or penalty. People tend to act in a manner that minimises the chances of a possible loss and are more willing to forgo a potential gain. So, for wellness programmes, the use of disincentives – a potential loss – to encourage participation may be more effective than incentives. The desire to avoid the potential loss will be a greater motivating factor than the desire to obtain a potential gain. From the employer’s point of view, incentives add to the costs of a programme, which is another reason to explore the viability of introducing penalties and possible losses.
RAND suggests that just 46% of employees undergo screenings or complete health-risk assessments, 21% take up fitness programmes and only 10% participate in weight-loss initiatives. Even more worrying is the finding that of those identified for an intervention based on screening, for example increased physical activity, only one-fifth or less chose to take this up. Perhaps the subtle employment of disincentives may nudge these participation rates in a more favourable direction.
The final consideration for any health promotion is how to determine whether it has been successful or not. Curiously, very few employers conduct any sort of formal evaluation. According to the RAND study, the 600 employers were overwhelmingly confident that their programmes were effective, although only half stated that they had evaluated programme impact and only 2% reported actual cost-savings estimates.
Employers are encouraged to elect as priority the criteria for judging the impact of health promotions. Some companies may be satisfied simply with utilisation rates. However, utilisation rates are not a reliable indicator of gains in health and wellbeing. Instead, any evaluation should track the change in work-related outcomes such as absenteeism, health insurance claims and other proxies for performance. After all, these are the main levers for bringing in workplace health initiatives in the first place so why not test their impact? How else will you know that what you are doing is having the desired effect?
Dr Bridget Juniper is head of Work and Wellbeing Ltd, which specialises in the measurement of employee wellbeing. Juniper has conducted award-winning research on employee wellbeing at Cranfield University. She publishes regularly in scholarly journals and frequently presents to academic and corporate audiences.
Mattke S, Schnyer C, van Busum KR (2012). “A review of the US workplace wellness market”, sponsored by the US Department of Labor and the US Department of Health and Human Services. Conducted by RAND Health, a division of the RAND Corporation.
Kahneman D, Tversky A (1979). “Prospect theory: An analysis of decision under risk”, Econometrica, vol.47, no.2, pp.263–292.