Culture of Health: A New Perspective
One thing is clear, simply instituting a health and wellness program does not mean your employees are participating or that your business is benefiting. In order to drive employee engagement and ultimately realize business impact, a more robust approach must be taken.
This includes establishing organizational best practices and taking the employees' perspective into consideration. In this paper, we argue that establishing a Culture of Health (COH) is a critical component of realizing the full benefit of health and wellness programming. We have three aims:
(1) to define what a culture of health is and how it influences employee engagement,
(2) present data from our "Landmark Study" on the importance of employee perceptions of COH in the workplace, and
(3) draw conclusions on how to approach COH in employer organizations.
Individuals play a crucial role in maintaining and improving their own health or, conversely, driving up healthcare costs and contributing to morbidity; the current healthcare crisis is ample evidence. As such, participation is a key factor in any health and wellness programming. This is true for both the individual and the organizational level.
From the business case, this is most evident in studies that ascertain return on investment (ROI). (1, 2, 3) These studies clearly show that increased participation affects major outcomes in an ROI calculation. For example, as participation, increases (1) program costs per member decrease and (2) incremental health risk reductions accumulate on a population level; hence, return on investment is quite sensitive to participation rates.
Although participation has historically been a formidable challenge, it is one of the highest priorities in the current climate of the continuing rise of healthcare costs across the country. A wide variety of interventions has been used to address this issue, including the use of incentives, social networking, game mechanics, the infusion of behavioral economic principles, and monitoring devices as a source of feedback.
None, however, has yet established superiority in the field.Building a COH is growing in prominence as a valued strategy to increasing and sustaining participation. Although not a wholly new idea, recent data provide new insight into the importance of employee perception of that culture and how perception correlates with participation in health and wellness initiatives.
Culture of Health (COH)
Culture can be understood as what is "learned, shared, transmitted inter-generationally and reflected in a group's values, beliefs, norms, behaviors, communication and social roles." (4) In other words, when people are part of a culture, they are part of a system that fosters the learning; sharing and generational transmission of the group has combined mission and values, which in turn shapes behavior.
Scientific models such as the Social Ecological Framework suggest that human development, behavior and learning, along with their biological and genetic composition, are influenced by the entire ecological system surrounding an individual. This model most closely aligns with our conceptualization of an organizational Culture of Health and how employees learn and engage in health and wellness behaviors.
Employees are working in a cross section among the dimensions of culture. No one could argue that work environments do not have a substantial effect on people's lives. When employed, we spend most of our waking hours engaged at work. As such, creating a COH in the workplace is a viable approach to influencing health-related behavior.
So, what is a Culture of Health? William Baun, President of the National Wellness Institute states,"In a culture of health, employee well-being and organizational success are inextricably linked. It aligns leadership, benefits, policies, incentives, programs and environmental supports to reduce barriers to active engagement and sustainability of healthy lifestyles across the healthcare continuum."(5)
There are many ways to assess and implement a COH, but no standard methodology exists. Hence, companies continue to look for help in building a COH. (6) This state of affairs mainly reflects the level of difficulty in the task. For example, anthropologist Clifford Geertz claims that culture research is not easily subject to experimentation and is best interpreted by those embedded in the culture. (7)
Edgar Schein defines organizational culture not as a scaled rating of items, but instead as a collection of shared, learned employee assumptions that are so well ingrained in an organization they are hard to identify.(8) We believe that COH is a social phenomenon that exists in a company only when employees know and act according to customs for engaging in healthy behaviors.
So then, how can organizations really know when they have a COH? What can they do to establish a COH? Moreover, how does it actually work to impact engagement and the bottom line? Can a strong enough COH do more than impact only the bottom line? Is it worth all the effort?
The Landmark Study
In an attempt to answer some of these questions, we completed a comprehensive "Landmark Study" during October and November 2009 among a sample of 3,007 employees, age 25 - 60. All were employed full time (30+ hours) across a spectrum of companies with more than 300 employees per company (as reported by the employee).
All received health insurance through their employer. Employees completed a 60-minute online questionnaire addressing health and wellness status and beliefs, behaviors, and barriers to activating healthy practices (e.g. eating nutritious diets).
Employer engagement and the desired role employers play in health and wellness was addressed. Questions were asked about company commitment, specific attitudes toward employees, and what the employer most recognizes and rewards.
What we found:
Perception of COHData from our qualitative open-ended item about COH revealed some interesting findings. It provided information used to develop a measure for perceived COH that relies on authentic employee language to interpret and describe ingrained assumptions that operate among employees in an organization.
Moreover, employees told us that a COH was not a yes/no proposition but instead operated on a continuum, akin to degrees of temperature. This variation or intensity of strength could describe where organizations lie in realizing a strong COH.
As such, employees were asked to describe their perceptions about the existence of a COH. The group provided answers to finish the statement: "The culture of health at my particular company can best be described as..."
While 72% of respondents reported that their employers offered wellness programs, only 25% perceived that health and wellness programs were strongly promoted supported or were integral to the company mission, which demonstrates that employees clearly distinguish programming as separate from a COH.
COH 1: about 1 in 10 employees believes programs are not visible or evident
COH 2: 14% of employees believe programs are talked about but not put into practice
COH 3: about 1 in 5 employees believes programs are offered but not supported
COH 4: about 3 in 10 employees believe programs are somewhat supported
COH 5: 19% of employees believe programs are strongly promoted and supported
COH 6: 6% of employees believe programs are integral to the company mission and goals
Even when companies make investments in wellness and leadership professes support for a strong COH, efforts may not be realized. If these efforts alone are not enough to create an environment conducive to employees practicing health and wellness behaviors, when and to what degree is it necessary to intervene? Utilizing this measurement with employees might be a simple and effective way to get that information.
Motivation and Confidence
Motives are a major driver of human behavior. People typically go through life with some balance of both intrinsic and extrinsic motivations. In this context, intrinsically motivated employees are self-driven to improve their health behaviors, while extrinsically motivated employees may act on incentives.
Despite the natural dichotomy, we found that motivation to work on health goals increased significantly when the COH was strongly promoted or perceived as integral to the company's mission. Employees reported higher levels of confidence in their ability to make progress toward their health goals when a COH was strongly supported, and, similarly, confidence was significantly higher when the COH was integral to the company mission or culture.
In a strong COH, employees tend to respond favorably to health promotion programs. (9) We found this to be the case in that employees reported greater gratitude and loyalty to the company when the COH was strong. Perhaps the presence of a COH helps employees perceive the company as caring for their well-being.
Furthermore, a type of psychological contract may be in play where employees feel some kind of reciprocity toward their organization. (10) This finding can support the case to build a strong COH and thusly many employers are looking to wellness programming to improve the employee/management relationship, increase employee morale, or be recognized as a "good employer." (11)
Conversely, employees in lower COH organizations were more skeptical about both their ability to participate in wellness programs without repercussions to their career as well as the likelihood of their company maintaining such programs. Skepticism was highest when report of a COH was minimal, even when program elements were robust.
However, organizations have been able to change employee assumptions from skepticism and resistance to acceptance and enthusiasm. Again, taking a view of the broader organizational landscape can help sharpen the focus of change efforts.
Job Satisfaction and Performance
Employees reported higher levels of job satisfaction in companies with a stronger COH. Job satisfaction could be a proximal indicator for turnover and employee engagement, and engagement is found to be on a decline in the US. Therefore, while wellness program sponsors may not be able to lay direct claim to improving job satisfaction, they can argue that a strong enough COH likely contributes to job satisfaction and, perhaps, retention.
While we could find no empirical evidence proving a stronger COH increases aspects of organizational performance, claims are made that companies with effective health and productivity programs are also seeing reduced turnover. (12)
Increased Participation / Utilization and Decreased Absenteeism
Employees with higher levels of motivation and confidence were more likely to utilize on-site facilities and physical fitness supports in workplaces with a high COH. In addition, respondents in companies with a stronger COH reported lower levels of absenteeism. When a strong COH is established, there appear to be meaningful effects on engagement in offered on-site supports as well as reductions in absenteeism levels.
This paper shares some new perspectives gleaned from our proprietary Landmark Study where we sought to learn more about employees' perspectives about their company's COH. We believe a perspective that includes understanding the psychological underpinnings of employee behavior as well as the larger organizational context provides a richer understanding to better target efforts unique to the company needs.
The study has multiple implications. First, this promising and simple measure based on qualitative data provided by employees can be used to assess the level of COH in an organization. Survey results demonstrated that employees recognize the difference between a COH and wellness programming, and show how a COH might work to influence employee behaviors across multiple domains.
Having this understanding can help in building unique organizational strategies to increase and sustain participation. The motivation data suggest that in a company with a strong either COH, extrinsically motivated people become more intrinsically motivated or respond to naturally occurring external cultural incentives. (13)
In addition, the COH can remove barriers by providing "permission" to behave in healthy ways. Employees of a company with a strong COH could be influenced to report higher levels of motivation because it is easier and more acceptable for them to engage in healthier acts (e.g., it's easy to jog at lunch at our company gym and I see my supervisor doing it every day), or because there is enough choice to suit varied preferences found across populations.
Many companies have recognized the need for programs aligned to employee preferences and have reported interest in customized programs and employee input in their design.(14) When it comes to confidence, we know people learn through observation, and within organizations peer modeling or social recognition can influence employee behavior.(15, 16)
Employees can observe colleagues and understand how to engage in healthier behaviors or feel more confident in their ability to do so, gaining more self-assurance through practice and repeated attempts.
A New Perspective - What Does It All Mean?
We believe that not only is a strong COH important in realizing higher engagement, but that there is a strong value proposition in that it contributes to a number of benefits including improved organizational performance. Taking a different perspective and asking questions of employees about the larger organizational context can help sharpen the focus for any change management strategies.
First, is there a need to move from the present state? Take a pulse check of employees' perceptions about the COH. Then, look to grow employee motivation and confidence: What are the barriers for employees and where do they learn and practice healthy behaviors?
Then look to grow receptivity: How does the larger culture help or hinder perceptions about wellness programming? Is the organization ready and able to focus on a COH? Finally, do all the leaders see the value of a COH and know their roles to support it?
What we know is that employees "know it when they see it" and so it is important for wellness programming sponsors or owners to have a clear perspective as well. Seeing things clearly can make all the difference in establishing a strong COH, and it is evident that the benefits are worthwhile.
1. Schwartz, S., Ireland, C., Strecher, V., Nakao, D., Wang, C., Juarez, D., The Economic Value of a Wellness and Disease Prevention Program. Population Health Management, 2010, 13(6), pp. 309-317.
2. Schwartz, S., Day, B., Wildenhaus, K., Silberman, A., Wang, C., Silberman, J., The Impact of an Online Disease Management Program on Medical Costs Among Health Plan Members. American Journal of Health Promotion, 2010, 25(2), pp. 126-133.
3. Allen, J., Achieving a Culture of Health: The Business Case. Health Enhancement Systems, 2008. Available at http://www.healthyculture.com/ Articles/HES%20Culture%20White%20Paper.pdf.
4. Kreuter, M.W. & Haughton, L.T. (2006) Integrating culture into health information for African American women. American Behavioral Scientist, 49(6), 794-811.
5. Baun, W., Creating a Culture of Health. Total Value of Worksite Health Promotion 2010 Executive Summit, 2010. Available at http://www. acsmiawhp.org/files/DOCUMENTLIBRARY/Exec_Summit_Baun.pdf
6. Cramer, S., Parrack, C., Davis, B., Logue, T., Building a Culture of Health, Differentiating Real and Perceived Value. Health Management Corporation, 2009, p.5 Available at http://www.worldcongress.com/events/HR10000/pdf/thoughtleadership/HMC%20BACH%20White%20 013009.pdf
7. Anthropologist Biographies: Clifford Geertz http://www.indiana.edu/~wanthro/theory_pages/Geertz.htm. Accessed May 31, 2001
8. Nellen T. Organizational culture & leadership by Edgar H. Schein notes. 1997 http://www.tnellen.com/ted/tc/schein.html Accessed August 1, 2011.
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10. Psychological Contract , Janet Smithson Ph.D., and Sue Lewis, Ph.D., Department of Psychology and Speech Pathology, Manchester Metropolitan University Accessed at http://wfnetwork.bc.edu/encyclopedia_entry.php?id=250
11. Cramer, S., Parrack, C., Davis, B., Logue, T., Building a Culture of Health, Differentiating Real and Perceived Value. Health Management Corporation, 2009
12. The Health and Productivity Advantage, 2009/2010 North American Staying@Work Report, p. 2 Accessed at http://www.watsonwyatt. com/research/render_research.asp?id=NA-2009-13844
13. Social Determinism Theory http://www.psych.rochester.edu/SDT/theory.php#MetaTheory1 Accessed July 22, 2011
14. Cramer, S., Parrack, C., Davis, B., Logue, T., Building a Culture of Health, Differentiating Real and Perceived Value. Health Management Corporation, 2009
15. Social Learning Theory http://www.learning-theories.com/social-learning-theory-bandura.html Accessed July 22, 2011
16. Golaszewski T., Allen J., Edington D. Working Together to Create Supportive Environments in Worksite Health Promotion, The Art of Health Promotion in Am J Health Promotion March/April 2008
17. Keup, J. Walker, A., Asin, H., Lindholm, J., Organizational Culture and Institutional Transformation, http://www.ericdigests.org/2003-1/ culture.htm Accessed July 21, 2011
About the Author
Joe Alexander is currently Director of Insights and Market Research for Ortho Clinical Diagnostics, Inc., a Johnson & Johnson company. Prior to that, Joe had been Director of Insights and Market Research for Wellness & Prevention, Inc., a Johnson & Johnson company.
Joe joined Wellness & Prevention, Inc. soon after it was formed in 2009. He was responsible for all insight work at W&P including Portal research and development, participant messaging campaign studies, consumer segmentation studies, program choice studies, as well as consumer attitude and behavior studies.
Prior to joining W&P, Joe was Director of Market Research within the J&J Pharmaceutical Group Strategic Marketing Group, where he oversaw market research for a variety of therapeutic areas including insomnia, diabetes, pain, sexual dysfunction, and schizophrenia.
Before that, he was a Director of Market Research within the J&J Consumer Group heading up OTC market research and, later, Nutritionals. Joe has also worked at Kraft General Foods, Leaf Confectionary, and Quaker Oats.
He has a M.M. from the Kellogg Graduate School of Management at Northwestern University, an M.A. in Sociology and a B.A. in Psychology from the University of Rochester.
Dr. O'Day is a member of Wellness and Prevention, Inc., a Johnson & Johnson company. She is part of theScience and Innovation team and has primary responsibility for deepening participation and engagement practices and analytics, designing and executing research initiatives, and contributing to data analytics and publication efforts.
Raphaela comes from the Department of Psychiatry at the University of Michigan where she worked on NIH, NIDA and Robert Wood Johnson Foundation funded grants in addiction research and serious mental illness prevention.
Prior to her tenure at the University of Michigan, she worked in basic science research focusing on the areas of immunology and cancer prevention and treatment at Wayne State University. Additionally, she has provided both clinical and assessment services to children, adolescents, adults and couples.
She received her Bachelor of Science degree in Human Physiology, with an additional focus in Psychology from Michigan State University, her M.A. in School and Community Psychology, specializing in Marriage and Family Therapy, and her Ph.D. in Educational Psychology, with a concentration in Neuroscience from Wayne State University.
Dr. Mason manages data analytics and outcomes, as well as research study planning and design across multiple organizational and customer platforms. He is a licensed Clinical Psychologist and Assistant Professor, adjunct at the Johns Hopkins University School of Medicine.
Previously, he was lead for risk, resilience, and recovery outcomes at the US Army Southern Regional Medical Command Warrior Resiliency Program. Dr. Mason completed his doctoral degree in Clinical Psychology at Eastern Michigan University, internship at the Henry Ford Hospital in Detroit, Michigan and fellowship at the Johns Hopkins School of Medicine where he spent the majority of his effort in the Johns Hopkins Burn Center in collaboration with the National Institute on Disability and Rehabilitation Research Burn Model Systems Grants