Archive: Bob Merberg's info, tips, and tricks for employee health and wellness leaders, 2011-2019

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Oct 11, 2015

The following are old posts — some outdated — written for employee wellness leaders who sought to meaningfully support the wellbeing of workers. The posts are not displayed in order. A table of contents is provided, below, to simplify finding what you’re looking for.

Waking Up to How Sleep and Work REALLY Interact

Created on 2016-03-09 23:51

Published on 2016-03-10 00:11

By this time, most of us are well-versed in how sleep — more accurately, the lack of it — affects work. Injuries, errors, accidents, and health care costs have all been linked to sleep loss and shown to affect business results.

What’s more, as reported by McKinsey in the article “The Organizational Cost of Insufficient Sleep,” there’s a host of psychosocial and cognitive problems that have been linked to sleep loss, including impaired attention, concentration, creativity, learning and memory, decision making, and relationship formation. Some studies have even shown that lack of sleep is associated with unethical behavior and have proposed specific pathways in the brain that may explain the connection.

Just as important, however, as how sleep affects work — maybe more important — is how work affects sleep, points out Canadian researcher Julian Barling, author of the forthcoming book Work and Sleep.

Chronic overtime, excessive workloads, shift work, expectations to be “always on,” and a culture that diminishes sleep all have been shown to contribute to the widespread problem of worker sleep loss.

Researchers from the University of Washington and University of Michigan recently published a whitepaper, Why it Pays to Ensure Adequate Sleep for Your Employees. The authors point to the prevalence of the problem:

The average person needs 7-9 hours of sleep per night. When surveyed, about 29.9% of Americans stated that they had gotten less than 6 hours of sleep the previous night.

Okay, we get it. Lack of sleep is widespread and undermines the wellbeing of workers and organizations. What can we do about it?

Typically, well-meaning employers wheel out their usual wellness strategies to get employees to change their sleep habits:

Education about sleep hygiene, with tips like
Don’t eat large meals before bed
Establish a consistent schedule for going to bed and getting up
Limit nighttime use of lit devices, like phones and computers
Use your bedroom exclusively for sleeping and sex
Apps and web-based modules
Behavioral change programs that include goal setting, tracking, and rewards

But employers should first look at themselves, and how they create or facilitate the conditions that lead to sleep loss. These are the factors the employer can control, and only once they’ve committed to organizational changes as a primary solution can the benefit of behavioral change strategies be fully realized.

What changes should employers consider? The McKinsey authors also published an article in Harvard Business Review, in which they suggest some ideas for starters:

Evaluate and rework company policies to ensure that they encourage — or at least don’t discourage — a good night’s sleep. Look at policies covering travel, email (e.g., blackout time on email, after which no emails can be sent), team working (creating tag teams that enable employees to hand work to each other across time zones), work-time limits (setting limits on hours or creating blackout periods), mandatory work-free vacations, predictable time off, napping rooms, and smart technology that improves sleep management.

Flexible schedules might seem like a slam-dunk solution, but University of Washington researcher Christopher Barnes found they often backfire, according to a BBC article. Due to cultural biases that favor early risers, flexible schedules prompt workers to start their days too early for their own natural sleep and wakefulness rhythms. One of the sources cited in the article estimates that 70% of workers typically wake up too early to achieve optimal performance during their work day.

Multiple studies, the BBC reported, have found “that workers who adjusted their work schedule to their individual biological clocks were more productive, healthier and less tired both at work and in their free time.”

Nominal, short-term sleep loss — like the kind many of us experience in the days following the switch to Daylight Savings Time — can lead to big problems. According to one study, for example, workers sleep on average 40 minutes less, compared to other days, on the Monday after turning clocks an hour forward. An accompanying study found 3.6 more mining injuries each year on these Mondays, with absenteeism data indicating that these injuries tended to be especially severe.

How much sleep did you get last night? How alert and well rested do you feel right now?

Job-Crafting Intervention: What Works

Created on 2018-04-20 20:34

Published on 2018-04-20 23:53

We wellness professionals are drawn to intervention. Once we come to see that job crafting "in the wild" enhances wellbeing, reduces burnout, boosts performance, and eases adaptation to change, we'll ask how we can facilitate it while clinching a win-win for both the employee and the employer.

And if we're going to offer job crafting interventions... We want to know what the evidence says about what works.

I'll keep this from becoming a wonky diatribe about research design and statistics and just give you the basic lowdown. There'll be links to the studies so you can dig in further, if that's how you roll. As you know, I'm just a glorified gym teacher -- not a social scientist or statistician -- so I'm giving you a practitioner's-eye view.

Let's look at interventions based on two branches of job crafting:

• What I call Job Crafting Classic -- as I described in I Have Seen the Future of Employee Wellbeing. It's Name is Job Crafting -- in which workers tweak the tasks, the personal interactions, and their perception of their job in order to experience a greater sense of meaning and purpose, and to increase work engagement, satisfaction, resilience, and thriving.

• What I call Job Demands-Resources Job Crafting -- as described in my article The Good, the Bad, and the Crafty: Challenges and Hindrances in JD-R Job Crafting -- in which workers seek resources, seek challenges, and ratchet down "hindering" demands in order to achieve much of what's achieved in Job Crafting Classic, with more emphasis on well-being and, theoretically, health.

Job Crafting Classic

In a controlled study at a large tech company, participants were happier and more effective in their jobs six weeks after completing the Job Crafting Exercise™. Here's a 90-second video describing this Job Crafting Classic intervention and some outcomes...

Skeptics: Take note that these outcomes weren't based exclusively on self-report, but also on observations of managers who didn't know which employees were in the intervention group versus the control.

As far as I can tell, outcomes from this particular intervention, which was spearheaded by Amy Wrysznewksi, Jane Dutton, and Justin Berg, weren't published in a peer-reviewed journal.

A Japanese study delivered a modified version of The Job Crafting Exercise to 54 manufacturing managers and 25 psychiatric hospital workers. The intervention led to moderately improved levels of work engagement, reduced stress, and an increase in job crafting behavior.

Increasing job crafting behavior -- Wrzesniewski et al describe a job-crafting mindset -- is important. You see, the intention of these programs is not to have participants abruptly modify their jobs at the intervention workshop and then go about their merry way; it's to have them re-envision their jobs as malleable and to bolster their skills and their sense of empowerment...so they can establish and continuously improve their person-job fit.

Interventions and evidence for JD-R Job Crafting are more plentiful and more complex, so let's take a break and dig into that in another post. At that time, I'll also tell you how I'd grade the evidence, on the curve and off the curve.

Calm Down, Everyone. WHO Didn't Call Burnout a Disease.

Created on 2019-05-29 09:29

Published on 2019-05-29 10:56

Yesterday, the media was abuzz about the inclusion of burnout in the World Health Organization's ICD-11. Most of them got it wrong.

CBS News, CNN, and other major outlets blared headlines and articles — most featuring photos of office workers plotzed face-down on their desks — about a new diagnostic class, with many saying it represented acceptance of burnout as a medical condition or a disease.

Drunk with long overdue validation, those of us who do work related to burnout neglected to check primary sources and overlooked the fact that the media reports were almost completely unfounded.

ICD-11 — the International Classification of Diseases — lists burnout in its section of "factors influencing health status or contact with health services," separate from its sections on diseases. It's no more a disease than other factors in this section like "low income" or "dependent relative needing care at home."

(View burnout in context, in the ICD-11, here.)

What's changing? WHO is defining burnout more specifically as an occupational phenomenon characterized by exhaustion, cynicism about one's job, and reduced professional efficacy, compared to ICD-10 in which burnout was defined simply as a "state of vital exhaustion."

To stop this viral outbreak of misunderstanding, WHO issued a special statement, replete with UPPER CASE and bold letters, pinned yesterday to its Twitter page:

(They should have used the ICD's full name: The 11th Revision of The International Statistical Classification of Diseases and Related Health Problems.)

Under any circumstances, note WHO's caution:

A critical point in engaging with the ICD is that inclusion or exclusion is not a judgement on the validity of a condition...

What Is ICD?

The ICD is a tool for gathering data and monitoring health and disease. In some environments, especially in the US, it's used to classify and validate healthcare financial transactions. (Learn more about ICDs from CDC information published during the transition from ICD-9 to ICD-10 and/or from the WHO video, below.) I suspect that outside research settings, a typical American primary care physician is unlikely to use the ICD codes for "factors influencing health status" (I'd love to hear from some clinicians or medical office personnel about this). Consequently, it remains to be seen whether QD85, the new ICD-11 code for burnout, is any more likely to be used than Z73.0, the old ICD-10 code for burnout.

I hope yesterday's brouhaha evokes meaningful discussions about burnout. I think it already has. But, ultimately, the lesson for many of us is to approach with skepticism media reports related to health science, to do our own due diligence, and to resist sacrificing our sensibility to whatever's trending that day.

Food Nudger Gets Caught with a Hand in the Cookie Jar

Created on 2018-11-30 22:16

Published on 2018-12-01 16:42

First of My Top 10 Wellness Stories from 2018

Brian Wansink, author of bestsellers like Mindless Eating and Slim by Design, recently had 13 of his research articles retracted and was nudged right out of his job as director of Cornell Food and Brand Lab, earning a spot on my list of 2018's biggest wellness stories.

Even if you’ve never heard of Brian Wansink, you’ve probably been affected by his research. His studies, cited more than 20,000 times, are about how our environment shapes how we think about food, and what we end up consuming. He’s one of the reasons Big Food companies started offering smaller snack packaging, in 100 calorie portions. — Vox

Wansink led many headline-grabbing studies of eating behavior, showing, for example, that people eat less when food is served on smaller plates and that pre-ordering lunch leads to healthier choices. His work unleashed many employers' nutritional wellness strategies, especially “making the healthy choice the easy choice.”

The media ate up Google’s implementations of Wansink’s "tricks" at their employee eateries, and wellness managers, like the rest of America, were sold, stocking the healthier vending machine options at eye level, featuring more nutritious foods near cafeteria entrances, serving on smaller plates, shutting down buffets, and changing the name of the daily special from “Tilapia” to “Succulent Italian Seafood Filet.” (Ask me why the “succulent, descriptive menu-item names trick" backfired when I tried it in an employee cafeteria).

According to the Cornell provost, Wansink’s academic misconduct included “the misreporting of research data, problematic statistical techniques, failure to properly document and preserve research results, and inappropriate authorship." — Vox

(Also see: Here’s How Cornell Scientist Brian Wansink Turned Shoddy Data Into Viral Studies About How We Eat — BuzzFeed news investigative report.)

Dr. Wansink’s fall from grace is first on my list because it sounds a clarion call to our industry and to business leaders: Be wary of gimmicky research and employee wellness fads. It's a lesson, as you'll see in the other stories on my 2018 Top 10 list, that bears repeating.

Job Demands and Resources Shed Light on Stress and Motivation

Created on 2018-02-26 18:14

Published on 2018-02-26 18:47

To get a handle on what job crafting has to do with employee health and wellbeing, it’s important to get a fresh take on job stress and motivation.

In a previous post — “I’ve Seen the Future of Employee Wellbeing: It’s Name Is Job Crafting” — I explained how, in 2001, Amy Wrzesniewski and Jane Dutton proposed that employees tweak their job tasks, workplace social connections, and perspective about their role to gain a greater sense of purpose and meaning, potentially leading to better job performance.

Around that same time, in the Netherlands, Evangelia Demerouti, Arnold Bakker, and others introduced their model of Job Demands Resources (JD-R), which has since been fine-tuned and validated as relevant to a full range of occupations and outcomes in countless studies around the world.

If you’re familiar with job stress research, you know (or you may have heard me blabbing about) how job stress has causes, and mustn’t be dismissed as a choice employees make.

Forget trendy notions that “stress is good.” It’s wishful thinking based on cherry-picked evidence. If stress is so great, why aren’t employees pleading for more of it?

Forty years of research has shown that harmful job stress is a result of jobs that have low levels of autonomy and high demands.

Micromanagement: An Occupational Health Hazard?

Over the years, job autonomy (or control) has been defined different ways, but can be broadly understood as limited flexibility (for example, with the tasks of the job) and limited decisional latitude, meaning the employee isn’t permitted or encouraged to make decisions in their work or about their work. (Contrast job control with micromanagement, and you may come to see that micromanagement can be an occupational health hazard.)

Job demands originally meant the psychological intensity of work, but ultimately can be understood to include workload, time pressure, and physical demands.

Robert Karasek introduced the theory of demands and control in 1979. He and others have shown that jobs in which workers consistently encounter high job demands with low job control — the combination of which is called job strain — are linked to a variety of health issues, especially high blood pressure and cardiovascular disease, as well as depression, anxiety, burnout, and metabolic disorders. Reducing job strain can improve productivity.

Karasek later learned that social support “buffers” the negative effects of high-strain jobs. Social support originally meant support from a supervisor, but can be understood in all of the many ways it’s been defined: Having a sense of “belongingness” at work; having co-workers who are empathetic and confidantes; having supervisors who take a genuine interest in the personal and professional lives of team members; and having a best friend at work.

In sum, high demands and low control are an unhealthy combo. (High demands and high control are not necessarily bad.)

“Listen to My Ideas”

Unhealthy job stress has been framed in other ways. Germany’s Johannes Siegrist found that work in which the required effort is disproportionately high compared to the job rewards — effort-reward imbalance — leads to the same kinds of health problems that result from job strain. “Rewards,” here, doesn’t just mean financial compensation, but also career opportunities and level of esteem within the organization.

The effort-reward model reminds me of an encounter I once had with a business analyst who transferred to another department because she didn’t feel valued in the department she was hired into. When I asked her, “What would have made you feel more valued?” her answer was not “better pay” or “someone saying ‘good job’”…

“I just wanted someone to listen to my ideas,” she told me.

A worker who doesn’t feel valued (i.e. esteemed) by being “listened to” is likely to have a higher level of disengagement and health impairment. This offers a glimpse into how management style, job design, organizational culture, performance, turnover, health, and wellbeing are all interconnected.

But Wait. There’s More!

Several other causes of job stress have been identified, and most of them can in some way fit into the demand-control and/or the effort-reward model:

• chronic overtime

• job insecurity

• work-life conflict

• role ambiguity (not being clear of what’s expected, receiving contradictory direction, duplication with other workers’ roles, or not understanding how the work fits into the overall organization — all of which are among the most common complaints I’ve heard from employees who report high job stress).

• organizational injustice (being treated unfairly, which at the extreme includes bullying and harassment)

• lower levels of status within the organization

• sustaining extremely high levels of vigilance (e.g. first responders, air traffic controllers, etc.)

Back to Bakker

It's hard to sort out the variations on job stress theory. That’s where Bakker and Demerouti’s Job Demands-Resources model comes in. While building on the existing theories and expanding upon them, it also provides a simpler way of making sense of job stress and motivation. It's a unifying theory that’s not too hard to understand and informs the actions we can take in the workplace.

JD-R tells us that all job traits can be categorized as either demands or resources.

• Demands require sustained effort from employees. They’re an expenditure of personal energy.

• Resources help fuel progress toward work-related goals. They’re restorative, buffering the effects of job demands —and activating personal development.

I interpret JD-R to mean that Karasek’s “demands,” Siegrest’s “efforts,” as well as role ambiguity, job insecurity, injustice, tedium, and work-life conflict are demands.

Job autonomy, social support, rewards, recognition, feedback, task variety, and training are examples of resources.

Side note: If you’re familiar with Edward Deci and Richard Ryan’s self-determination theory — popularized in the Daniel Pink bestseller, Drive — which shows how motivation and flourishing are dependent on personal autonomy, competence, and relatedness (i.e. social connection), you may recognize that job resources generally can be matched to the ingredients of self-determination.

So...

• Demands regulate job stress.

• Resources regulate job motivation and engagement.

• And the two forces may act upon each other.

JD-R takes job crafting beyond meaning and purpose — which has received most of the public attention — and ties it directly into health and wellbeing.

*************

For an excellent overview, see Bakker and Demerouti’s 2016 article: Job Demands-Resources Theory: Taking Stock and Looking Forward

"The Health of the Worker, as a Worker"

Created on 2016-05-02 01:36

Published on 2016-05-02 12:21

The National Institute of Occupational Safety and Health (NIOSH) just published its Total Worker Health Agenda for 2016 - 2026. Total Worker Health (TWH) is the most credible approach to comprehensive employee wellbeing. Regrettably, TWH, with its employee-centric approach and de-emphasis of return-on-investment has not drawn great interest from employers, to date.

Stakeholders had several opportunities to give input on a preliminary version of the TWH Agenda. While I encourage you to read the complete Agenda and NIOSH's published Responses to Stakeholders' Comments -- one section of the responses so eloquently articulates the distinction between TWH compared to "traditional wellness" that it warrants being excerpted here, in its entirety:

"Stakeholders’ Comments regarding the relationship between TWH and wellness programs
"Stakeholders cautioned that current wellness programs focus on individual health-related behaviors and that such approaches effectively 'blame the worker' for health-related choices, coerce workers into participation, and disproportionately impact lower-income workers.
"NIOSH Response
"NIOSH agrees that some current 'wellness' programs lack scientific support, focus solely or heavily on individual behavior change appraised almost exclusively by biometric data, can be punitive and discriminatory, and/or are designed with short-term economic savings for the employer as the primary goal. Some place far too much emphasis on individually focused behavior change and fail to address the nature, risks, and challenges of work itself on worker health. NIOSH considers typical 'wellness' programs to be inadequate because they ignore the contribution of work on health and, as the commenters suggest, focus largely on medical cost savings. NIOSH agrees that integrating these types of 'wellness' programs with occupational safety and health protection programs does not ensure the types of worker health interventions TWH seeks to promote. A program that considers the workplace as just a platform (as opposed to being a risk factor itself) to improve employee health can be successful only if it makes the health of the worker, as a worker, the centerpiece of its efforts.
"The NIOSH goal is to integrate high-value safety and high-value health programming in a holistic, efficient way. We believe NIOSH plays a unique role and has a sentinel voice in shining a light on the shortcomings of these wellness-program-only approaches while simultaneously championing their value in a more integrated, worker-centered approach to health interventions.
"NIOSH believes TWH is the example to follow, not a 'wellness' program. The TWH Program has never advocated or advanced unproven, coercive, disrespectful, or punitive interventions. The NIOSH Essential Elements of Effective Workplace Health Programs and Policies for Improving Worker Health and Well-Being, a document developed with labor and management input, still serves as the central core of recommendations that guide the TWH program.
"NIOSH reiterates its commitment to the position that it is the primary responsibility of employers to create safe, healthful working conditions for all of its workers. First-dollar investment must be directed toward safer work that does not endanger workers.
"For employers who are meeting and exceeding industry safety standards in their industry, additional gains in injury and illness prevention hinge upon using a broader, holistic view of worker safety, health, and well-being. By not doing so, we rob workers of access to high-quality, evidence-based programs and we leave the program environment to traditional employee wellness practitioners who do not consider the nature and hazards of work in their program design or implementation."

[Note: Total Worker Health is a registered trademark. I have no affiliation with TWH or with NIOSH, and my own comments should not be construed as representative of their positions. -- Bob]

Sitting is the New Smoking. Smoking is the Old Standing. The Old Standing is the New Sitting.

Created on 2015-11-09 22:59

Published on 2015-11-09 23:21

In 2013 the LA Times quoted Dr. Anup Kanodia serving up the catchphrase, "Sitting is the new smoking." Ever since, you'd have to be an epidemiologist to separate the fact from hype. And you and I are no epidemiologists.

Personally, I've resisted the phrase "sitting is the new smoking," except to use it mockingly. In equating sitting and smoking we diminish the 50 years of investigation, social change, and sacrifice committed to understanding and addressing an insidious chemical dependency -- tobacco use -- that remains the world's leading preventable cause of death.

But I get it. Prolonged sitting puts us at risk for future disease and premature death, inducing harm that can't be undone even by regular exercise. The research suggests that interrupting prolonged periods of sitting is essential to health.

No one is surprised to hear that lack of physical activity is a health risk factor. The unique finding in the sitting research is that there is something deadly specifically in the act of prolonged sitting -- the position itself -- and that standing (or breaking up periods of sitting with standing) has health benefits. The recommendation from a landmark study in 2010 was:

Public health messages should include both being physically active and reducing time spent sitting.

[emphasis added.]

A group of international experts commissioned by Public Health England recently obliged, publishing a consensus statement that recommends:

seated-based work should be regularly broken up with standing-based work, the use of sit–stand desks, or the taking of short active standing breaks.

For starters, the panel advised sedentary workers to accumulate two hours of standing or light activity (such as the type of low-speed walking you do on treadmill workstations, which usually have top speeds of 2.0 mph).

The 2010 study and others like it catapulted the popularity of standing workstations, which already were on the rise as a potential solution to ergonomic back pain. In my experience, however, enthusiasm for standing workstations was quickly eclipsed by a preference for sit-stand workstations, which offer workers the option to change position at will.

"Sitting Is No Worse Than Standing"

In recent weeks, however, we've seen a slew of studies that offered new perspectives -- some refuting previous research about standing, some expanding on it:

First: An analysis of the Whitehall II study data (which I've described elsewhere) determined that sitting is no worse than standing. Reporting in the International Journal of Epidemiology in October 2015, the researchers found no association between sitting time and mortality. Their recommendation:

be cautious about placing emphasis on sitting behaviour as a risk factor for mortality

Next... Hold the phone. Acknowledging that there's "insufficient evidence specifically focusing on the public health and medical implications of increasing daily standing," researchers set out to identify the relationship between standing, metabolic syndrome (a cluster of risk factors), and obesity. They found that people who spend 25% of their day standing are less likely to be obese compared to more sedentary counterparts.

The plot thickens: Much of the earlier research was based on subjects' total time spent standing or sitting. An employer may well question why they should invest in a sit-stand workstation if Joe-The-Knowledge-Worker goes home and spends hours on the couch at home. Why not encourage people to stand while watching TV or eating? Is the idea of a standing dining room table or a raised counter in front of the TV really so far-fetched?

Sitting at Home Is the New Sitting at Work

Along comes a small study that evaluated the outcomes of workers outfitted with sit-stand workstations. Data was collected via self-report and via instruments that monitored the workers' position. The conclusion: Workers using sit-stand workstations spent significantly less time sitting at work...but significantly more time sitting while they were home. (Interestingly, previous work showed that workers with sit-stand workstations spend more time standing at work, but was not able to correlate this difference to health outcomes.)

That employees with sit-stands spend more time sitting at home is entirely plausible. Consider our tendency to overcompensate for a workout by overeating afterward. Another explanation may be that people standing more during the day experience fatigue that leads them to sit more at home.

Speaking of fatigue from standing, read on...

Standing Is Linked to Problems with Pain, Cardio Health, Pregnancy

For me, an irony of our newfound penchant for standing is the long and hard-fought battle workers previously waged to sit more. This came to my attention when I researched my blog post about the workers who ultimately perished in the Triangle factory fire. Seamstress jobs at the Triangle factory were considered cushy at the time, because the workers sat all day, in contrast to the more common manufacturing jobs in which workers toiled on their feet for hours on end.

The UK's Hazard Magazine, which covers health and safety issues -- from a decidedly pro-labor perspective -- chronicles the history of European workers seeking the right to sit at work. But let's not dismiss the right to sit as a relic of European history... In 2014, AT&T Mobility settled a complaint by workers and agreed to redesign stores with “learning tables” that gave retail staff the option to sit if customers also chose to do so. (The settlement also required AT&T to pay approximately $250 per eligible retail employee.) In 2007, Safeway -- self-anointed prophet of all that is righteous about employee wellness -- was unmoved when a customer took sympathy and gifted stools to cashiers.

Prolonged standing was identified as an epidemic health risk long before cigarette packages even existed to put warnings on. In the 17th century, Bernardino Ramazzini, the “father of occupational medicine,” called for shorter periods of standing and more frequent breaks during work.

A recent analysis confirmed that prolonged standing at work increases risk of low back pain, fatigue, cardiovascular problems, and adverse pregnancy outcomes. Most modern-day experts favor a mix of sitting and standing rather than prolonged periods of either.

At this point, the body of evidence remains a labyrinth, with important variables -- sitting at work vs. away from work; the role of standing vs. physical activity -- not fully teased out. In the interim, we need to be wary of the "sitting is the new smoking" hype and learn more about the problem and the solutions.

In my opinion, pending further research, sit-stand workstations are a reasonable solution to attenuate problems associated with prolonged sitting at workstation desks. They give the worker more control over the work, which, all things being equal, is always a good thing for employee well-being.

I also have come around to supporting treadmill workstations, though I sacrifice a piece of my soul in doing so. Some physical activity is better than no physical activity, just as shifting positions is better than prolonged sitting or standing. But treadmill workstations seem just a step away from succumbing entirely to absurdity and putting workers in a hamster wheel.

There's another approach that may be more sensible, well articulated in the quasi-satirical New Republic piece, "Screw Your Standing Desk!"

Of course the long, stationary workdays of most Americans are unhealthy. The solution should not be to sit less, but to work less. If sitting is as bad as the doctors say—and I’m sure it is!—then why not prescribe longer lunch breaks, shorter hours, and more vacation? You can still be chained to a standing desk.

┏(-_-)┛┗(-_- )┓┗(-_-)┛┏(-_-)┓

Yes, a New Wellness Study Does Shed Light on What Works

Created on 2019-04-26 19:32

Published on 2019-04-30 16:05

The BJ's Wholesale Club study wasn't the most important employee wellness research published last month. Let's look at the Workplace Health in America Survey conducted by the Centers for Disease Control and Prevention.

When you put the CDC survey together with BJ's Wholesale Club research, as well as last year's University of Illinois worksite wellness study (both employers found that 1-1.5 years of wellness programming failed to reduce healthcare costs or improve productivity) we get a more complete picture of relevance.

The CDC, with support from a variety of experts and stakeholders (including a few of the usual industry insiders) asked about companies' employee health promotion programs. After a winnowing process, 2,843 respondents completed surveys — targeting whoever in the company was most knowledgeable about its wellness offerings, with about a third being HR or benefits professionals — from a wide range of employers.

Here's some of what the survey found:

Larger employers love health risk appraisals...

Not many wellness professionals publicly admit using health risk appraisals — those burdensome health-habit questionnaires from yesteryear — but many (about 68.7% of large employers) fessed up on the survey. Ruh-roh: A quick scan of the raw data reveals that 18% of respondents "don't know" if their program uses HRAs.

"A committee is a group of the unprepared, appointed by the unwilling, to do the unnecessary." — Fred Allen

I'm glad 41% of employers don't have wellness committees. I'd like to see that number grow. Committees have long been considered a "best practice" in wellness, mostly by employers who haven't learned about participative processes or who don't believe in wellness enough to actually hire professionals to do the work. How's your company's sales committee doing? How about its merger and acquisitions committee?

Wellness Budgets: Are we going for broke?... Or just plain going broke?

More than a third of organizations with wellness programs have no budget. The survey's raw data reveals that about 6% of all respondents had budgets greater than $100,000, including the 1% that have budgets greater than $500,000. Compare these figures to the findings of a Fidelity and NBGH survey also published last month. Their news release leads with: "Companies across the country are expected to spend an average of $3.6 million on well-being programs in 2019." Geez, for 3.6 mil, you'd think employers wouldn't have to rely on committees. I'll do their committee work for half that amount.

Oooh... We "use data" to evaluate programs

Most often cited from the info in this chart (above) will be the finding that only 50% of companies with health promotion programs "use data" to evaluate their program (as opposed to those pesky "non-data" evaluations). In fact, companies don't evaluate a lot of what they do, especially what they do to employees. How many companies evaluate their performance management strategy? Their compensation strategy? Their EAP? Heck, a lot of companies don't even evaluate their marketing practices.

Be that as it may, the takeaway here is that, of those that "use data" (no, I won't stop putting that in quotes) to evaluate the program, 73% use health care claim costs and 57% measure ROI. More on this, later.

Incentives: The good times roll for vendors selling them and employers using them to camouflage cost-shifts...

Most wellness incentives are ill-conceived, but tying incentives to a health standard (like BMI or blood pressure) is a practice that pushes some programs over the edge from naive to nefarious. But we won't let that stop us.

Is there safe quarter from employee health screening?

Based on the survey's weighted estimates, above, more than 25% of worksites currently offer screening programs. (In the unweighted data, the percentage of respondents offering health screenings was 38.4%, up from 23.5% in 2004.) You'll see why this is important. [<— Foreshadowing!]

What's old is new

"Comprehensive" programs, which offer screenings, integration of health promotion, health education, linkages, and positive environments are on the rise! Can I get an amen? (Don't like the way the CDC defined comprehensive worksite wellness programs in 2010? Get involved with other policy-making decisions that influence the direction of wellness research.)

Y'know what's fat? The mistake of obesity management programs. They're a big, fat, hairy mistake.

Give it up for those savvy kids at the CDC. In other slides, they specified "evidence-based" physical activity strategies and "evidence-based" nutrition strategies, but they held back from labeling obesity programs as evidence-based, because they know there aren't any (with the possible exception of the Diabetes Prevention Program which, go figure, is spearheaded by the CDC). Anyhow, evidence-baseless obesity programs sit high atop the wellness hit parade, with more than two thirds of companies sticking 'em to employees.

In an "Opportunities" section of its summary report, the CDC wrote, "Worksites may want to consider their nutrition and physical activity initiatives when they are planning weight management programs." Yeah. Worksites may.

When it's time to fire your wellness manager...

In the absence of a well-equipped and -staffed onsite clinic, I have no idea why an employer is doing most of these screenings. But that's not even the wackiest part. Look, for example, at the cancer screenings in the bar chart: 11.3% of employers provide mammography, but only 6.2% include referral to treatment and follow-up education? What sort of deviant screening sorcery is this? How do you screen for cancer and not refer people for follow-up? "You've got a lump. Have a nice day. Next!"

Total Worker Health

About 1,255 respondents opted-in to answer questions that were deemed less "critical to the survey’s objectives" and relegated to a Supplementary Survey. These asked mostly about Total Worker Health — an evidence-based arm of employee wellbeing — and other (ahem) non-critical topics like support for nursing mothers and mental health. The Supplementary Survey included Yes/No questions and the data indicates some responses were "logically assigned a no." I'm not sure what that means, but here are a few of the questions and the percentage of respondents, based on my own calculations, that replied, "Yes":

• 13% provide dedicated quiet space where employees can engage in relaxation activities.

• Only 20% provide training for managers on reducing stress-related issues.

• 23% offer opportunities for employees to participate in organizational decisions that affect job stress.

• 28% provide safe places and/or opportunities that encourage social connectedness.

Read the (presumably) peer-reviewed study results in the American Journal of Health Promotion. Explore the CDC's summary report, glossary of terms, and data files on the CDC's website.

What does it have to do with BJ’s Wholesale Club?

Here on LinkedIn, wellness leaders have lamented the BJ’s Wholesale Club and University of Illinois studies — which, over a short period of time, yielded no meaningful improvements in health care costs or productivity — and the way the study outcomes were generalized and sensationalized in the media. "It's like we've always said," we complain. "Programs focusing on biometrics, obesity, and ROI won't amount to much, and these programs aren't comprehensive or typical."

But the CDC study suggests that in the LinkedOut world, biometrics, health risk assessments, weight loss programs, incentives, and expectations of healthcare cost reduction not only are cornerstones of wellness programs, but uptake of these types of programs skyrocketed between 2004 and 2017. This confirms what many of us know from our daily exposure to various employers.

To hear it on LinkedIn — and at our wellness conferences — you'd think that today's wellness program is all about getting employees to bring their authentic selves to work; discover their why; ooze empathy, companionate love, and compassion; and arrive at humanized workplaces every day in blissed-out states of mindful gratitude.

The CDC survey doesn't ask about authentic-self and gratitude programs, so we don't know how common they actually are, but we know they're not putting conventional programs out of business. Indeed, I've found that most employers, once you get past a wellness coordinator who is sincerely committed to doing good, continue to promote biometrics, HRAs, weight loss, and incentives, and ultimately are motivated by the hope of healthcare cost reduction. (Or they just do wellness for show and don't expect or care about results.) If you have doubts, go to a conference of your local SHRM chapter and ask some HR directors about wellness. Most will pledge their allegiance to using health insurance premium discounts and penalties to promote behavior change. The new CDC study verifies that the types of programs featured in the BJ's and Illinois studies are alive and well. As such, the studies are relevant to a broad segment of employers.

Call to Action

HR departments' practices are catching up with their long-held promises about the use of analytics, and the wellness industry's claim that its new objectives are hard to measure will be exposed as a ruse as soon as the next fad comes along. (Remember VOI?) "You can't measure what doesn't happen" is not a sustainable evaluation strategy. And complaining about fake news won't get us far, either.

When headlines blare, "wellness doesn't work," it's not enough to say, "Oh yes it does. You're just doing it wrong."

Measure. And show what does work.

The Wellness Industry Sleeps Thru the Predictable Scheduling and Clopening Debate

Created on 2016-09-19 23:01

Published on 2016-09-19 23:19

For a group that purports to be committed to wellbeing and helping employees get a good night's sleep, the wellness industry sure is quiet about the issue of "clopening."

Wellness experts harp on the importance of sleep, and vendors hawk sleep-tracking devices, apps, and programs. But nary a word is spoken about the job conditions necessary to assure workers have the opportunity to get the sleep they need.

It's hard to get eight hours of sleep if you're only home for five or six hours between your evening shift and your morning shift. And that's where "clopening" comes in. The term commonly applies to schedules in which part-time retail and fast food workers are required to close the store late in the evening and open early in the morning.

Clopening gained notoriety in a 2014 New York Times story about the life challenges a Starbucks employee faced as a result of "just in time" (last minute) scheduling that included clopening. In the minds of activists, unpredictable scheduling and insufficient rest periods between shifts have been linked ever since -- appropriately so, as both practices tend to coincide and threaten employee wellbeing.

These scheduling practices also go hand-in-hand with schedule fluctuation (like working eight hours one week and 40 hours the next) and inflexibility. According to a report by the University of Chicago, unpredictable, fluctuating, and inflexible scheduling undermine almost every dimension of workers' wellbeing, including the physical, mental, family, occupational, and financial realms. The report's author, Susan Lambert, was quoted in a follow-up Times article as saying:

This particular form of scheduling — not enough rest time between shifts — is particularly harmful.

The Economic Policy Institute has delineated how "irregular scheduling" influences employee stress, work/life balance, and financial health -- all issues we in the wellness industry prattle on about ad nauseam.

In July 2016, Human Impact Partners published an analysis, Scheduling Away Our Health, concluding...

Through literature review, original data analysis, and focus groups, we find that the health and well-being of workers is undoubtedly compromised by unpredictable work schedules.

Even prior to the original New York Times exposé, and increasingly after it, municipalities have considered "secure scheduling" legislation to limit schedule unpredictability, fluctuation, and, yes, clopening.

• In 2014, San Francisco enacted the Formula Retail [i.e "chain store"] Employee Bill of Rights, which requires covered employers to provide employees with two weeks’ notice of work schedules, advance notice of schedule changes, and additional pay for schedule changes made on less than seven days’ notice and unused on-call shifts.

• Seattle's City Council passed on September 19, 2016 secure scheduling legislation that, in addition to protections similar to those offered under the San Francisco bill, addresses clopening by requiring employers to schedule employees no less than 10 hours apart. Costco, Starbucks and the Washington Retail Association reportedly opposed the measure, whereas Safeway/Albertsons expressed its support,

• New York City's Mayor Bill deBlasio has launched, as a centerpiece of his re-election campaign, a law affecting fast food workers that would limit unpredictable scheduling and clopening in a manner similar to Seattle's law.

Employers inevitably resist regulation. But if they are as committed to employee wellbeing as they say they are, they should evaluate and address scheduling practices proactively.

Leadership sometimes emerges where it's least expected -- in this case, Walmart. The mega-retailer recently phased in new processes -- on the heels of improvements it made to compensation and occupational development -- in order to make scheduling more flexible and predictable for workers. The Washington Post reported that, based on early results, workers with access to the new scheduling system experienced an 11% decline in absenteeism and a 14% drop in turnover, "which comports with what academic research has shown is possible with greater predictability and worker control."

Earlier this year, a group of large employers, led by a prominent wellness vendor, reportedly launched a bizarre initiative to persuade publicly held businesses to disclose aggregate data on the health status, including body mass index, of their employees.

In recent years, the Business Roundtable, an association of CEOs from the largest corporations in the U.S., lobbied aggressively against the EEOC's efforts to curb discriminatory cost-shifting strategies cloaked as "wellness incentives."

Hopefully, these business leaders will channel their commitment to employee wellbeing toward more effective efforts, leading the business community on issues that matter to employees and that employers are in a position to do something about -- like predictable scheduling and clopening.

As wellness professionals, our job is to anticipate these issues, study them, and propose evidence-based action plans, and to keep these employee wellbeing needs at the forefront of the business agenda.

Below is a video from a Seattle City Council meeting in which stakeholders testify about how unpredictable scheduling and clopening affect employee wellbeing. Note that none of them are lobbying for tracking devices, apps, or programs.

Not-So-Great Expectations Land Yale Wellness In Court

Created on 2019-07-21 23:13

Published on 2019-07-22 14:53

"57% of participants with BMI ≥ 30 have lost an average of 13 pounds." Allow this factoid to sink in as we learn about the latest wellness program to get hauled into court.

Once a wellness program finds its way into the headlines, we owe it to ourselves to understand how it got there -- good or bad -- and what we can learn from it.

Yale University, the latest newsmaker, is the defendant of a class action lawsuit filed by the AARP Foundation on behalf of 5400 union employees who, AARP says, are "forced to pick either privacy or penalties."

Required Requirements

The basics of the program, based on a program brochure:

• Employees follow their "screening requirements." These are preventive health screenings, including physical exams, mammography, cervical cancer screening, lipid and glucose screening... generally in line with evidence-based standards.

• Employees "participate in the Yale Health coaching program, if required." Risks that may require coaching include failure to get preventive screenings, blood work biometrics, and certain health care utilization patterns. Conditions that "may require coaching" include COPD, diabetes, heart disease, heart failure, hyperlipidemia, and hypertension.

The program also offers some health education programs and a web portal to track progress.

Cough Up the Opt-Out Fee to Opt for the Opt-Out Option

Forget the required requirements. Yale emphasizes that employees can "choose" not to participate: "You also have the option to opt out of the Health Expectations Program on a quarterly basis. By opting out, you agree to pay the $25 fee per week. The opt-out fee will be payroll deducted on a weekly basis."

So the required requirements are cancelled out by the choice of options to opt out of... for a nominal "opt-out fee" of 25 bucks a week, which adds up to $1300 a year. (The plaintiff's court papers note, "In New Haven, Connecticut, where Yale is located, $1,300 is equivalent to nearly five and half weeks’ worth of food, four months of utility costs, nearly a months’ worth of housing, or a month’s worth of childcare.")

The program is directed at Local 34 with about 4,000 clerical and technical workers and Local 35 with approximately 1,400 cafeteria, maintenance, and physical plant workers. (The union that represents Yale police officers balked at the prospect of the $25 per week fine, according to the Yale Daily News, and negotiated their way out of it.)

One of the plaintiffs named in the complaint is "a 56-year-old part-time service assistant at Yale. She makes approximately $25,600 per year." The 2nd named plaintiff is a 57-year-old cook and the 3rd is a 46-year old locksmith.

The lawsuit states: "The $25 per week fine imposes a significant burden on certain members of the Class; so much so that paying the $25 per week fine is not a viable option. These members of Local 34 and Local 35 are forced to disclose sensitive medical information and undergo invasive testing to avoid the weekly fine."

The suit argues that the program violates employees' civil rights and federal legislation: "The Americans with Disabilities Act and the Genetic Information Nondiscrimination Act prohibit employers from extracting medical or genetic information from employees unless that information is provided voluntarily."

See the post written by Al Lewis, who first brought this case to my attention, in which he retells from the court papers a story of an employee who'd previously undergone a double mastectomy, but allegedly was being hassled by one of Yale's vendors to get a mammogram.

Yale's Health Expectations Program relies on two vendors: one that sifts through employees' personal health data to find risks and disease, and another (with an intriguing history we'll get to in the next section) that is then given that data in order to deliver health coaching. The coaching vendor, according to the lawsuit, required employees to waive their confidentiality rights granted under HIPAA and, the the suit suggests, did not have a Business Associates Agreement in place with the first vendor or with Yale. "[Vendor 1] accesses and transfers employees’ and their spouses’ insurance claims data to [Vendor 2] even when employees do not participate or refuse to sign the HIPAA waiver," the lawsuit claims.

The lawsuit seeks to stop Yale from imposing the fines; prohibit Yale from having health data shuffled around by vendors without employee consent; purge data previously collected; award economic and non-economic damages; and declare the university in violation of ADA and GINA.

Let's Learn!

There are a lot more details to the program, and in the plaintiff's complaint more testimonials of hardship and accusations of impropriety, but let's see if there are some insights, commentary, and analysis, that may help us improve our own programs. (You can opt out of reading the rest of this article by paying me $25.)

• Yale's promotional material emphasizes that its Health Expectations Program was developed in partnership with unions. Initially, I was excited to hear this. Absence of employee voice may be the number one cause of wellness program failure. But in the Yale Daily News article, the "partnership" seems more like an ultimatum: "The University presented the [police union] with two options: a cost-shifting coverage model in which officers face annual premium increases, or a preventative treatment-oriented system called the Health Expectations Program." So much for employee voice.

• When I first heard the name "Health Expectations Program," I spit up a little in my mouth. Whose expectations? As there's no mention of helping employees meet their own expectations, Yale implies that it has expectations of employees' health. This is common benefits-think: "We pay for most of your health care and therefore have the right to tell you what to do with your health." It's overreach based on a distorted interpretation of the social contract between employer and worker. Employers aren't purchasing shares of each employee's health -- health insurance is part of a compensation package provided in exchange for the employee's productivity. We want employers to support and encourage all aspects of wellbeing -- especially those that contribute to productivity and corporate citizenship -- but employers have no place wielding "expectations" of employee health. "Health Expectations Program" announces from the outset that this program is developed to satisfy the employer and not the employee. Least. Inspiring. Program name. Ever.

• The program reeks of behavioral economics, especially the scheme known as loss aversion, popular amongst benefits directors who may have once read — or gone to a conference where the keynote speaker read — Nudge, a bestselling treatise on how to manipulate people who you think aren't as smart as you are. The idea is that people will be more motivated to take an action to avoid the loss of something (such as an annual amount equal to the cost of five and a half weeks worth of food?) compared to gaining a reward. These tactics have valid applications, but bludgeoning employees' financial wellbeing isn't one of them.

• HEP's objective is to reduce health care costs. Yale's labor negotiator says as much in the Yale Daily News: "Employees must engage to improve the status of their health outcomes. If that happens, overall health care cost would go down." Employees must. Then, cost goes down! (Wellness programs are still driven by this fairy tale -- regardless of the stories we like to spin about workplace connectedness and purpose. So, when new studies show that costs don't go down, let's not dismiss them as no longer relevant. Benefits directors, understandably, are obsessed with health care costs, and they favor programs focused on physical health. As long as wellness programs are tied to benefits, they'll be over-medicalized and dedicated to perpetuating the cost-reduction delusion.)

• The Yale vendor's alleged dismissal of HIPAA and employee confidentiality are beyond credulity. I hope there's another side to the story that will come out in the legal wrangling. As a general rule, I encourage wellness programs to think of HIPAA and GINA as minimum levels of security for employee data. We have a responsibility to be vigilant stewards of personal health information, which means collecting and transmitting as little of it as possible -- and then only with employees' fully informed consent.

• Around January 9, 2015, Yale's health coaching vendor was acquired by a large health insurer as part of the insurer's turnaround strategy. At the time, the insurer's CEO -- who later resigned due to "unspecified misconduct" -- touted the coaching company as "an effective and attractive tool for employers to help employees improve their health, but it is also one with excellent potential for lowering health care costs.” There go those pesky health care costs, again! (Oh, yeah, and that whole "improve their health" thing, too.)

The insurer boasted that in 2018 (the year after Yale's program was launched) it reversed its flagging financial fortunes, thanks largely to the coaching company generating higher-than-expected revenue.

What Does This Average Mean?

This statement on the coaching vendor's Proven Outcomes web page demands our attention: "57% of participants with BMI ≥ 30 have lost an average of 13 pounds." No additional information supporting this factoid is provided.

There are reasons (often, bad reasons) to present outcomes of less-than-the-full population, e.g. only people who completed the program; only participants who respond to a follow-up survey; etc. But those would be spelled out.

I can't think of any reason to provide an average of 57% of participants, except to deceive people by "averaging" only the data from the most successful participants (a percentile). For all we know, the other 43% gained an average of 20 lbs. and the average outcome for all participants could've been increased weight. Is an average of 57% of the program population -- especially with no info about how this group was selected -- really an average?

The coaching company says many right things on their lovely website. But, those of us who are purchasers or who advise purchasers have to hold our industry's feet to the fire when a vendor features screwy data. If there's a good explanation... Great, let's all learn from it. Otherwise, we should be skeptical about anything else they say, because they've exposed their willingness and their need to mislead. We can only hope that Yale, as a major client of this coaching company that earned greater-than-expected revenue and helped reverse the fortunes of an entire health care organization, demanded something better -- if not for its own benefit, then on behalf of the union workers it forced into the Health Expectations Program. Is that too much to...expect?

As for Yale's program overall... It's important to note that Yale has not commented on the class action lawsuit, so we don't have the full story yet. I look forward to hearing their side. HEP seems like it was developed with some positive will and high regard for evidence-based approaches ... that ultimately were undone by out-of-touch behavioral economics group-think, awful communications, and disregard for the real needs of employees.

Wellness Far Gone: Banking on Two-Bit Stress Management Programs

Created on 2016-11-15 03:01

Published on 2016-11-15 03:32

Consider the plight of workers caught in the middle of the Wells Fargo scandal. You know the one: Bank workers were pressured into “selling” unneeded and unauthorized accounts and services to existing customers. The workers were damned if they did and damned if they didn’t: Threatened with termination if they fell short of unachievable sales goals; fired — 5,300 of them — when they were caught creating phony accounts to meet those goals. Whistleblowers were subject to retaliation.

Research has shown time and time again that job demands and job control — in addition to a host of other psychosocial factors at the workplace like effort-reward imbalance, organizational injustice, work-life conflict, and chronic overtime — lie at the heart of worker wellbeing.

Wells Fargo workers, given voice via the New York Times and CNNMoney, bear witness to the reality of how systemic "job strain" compromises physical and mental health.

A worker told the New York Times:

One morning, before meeting with a customer, in which I knew I was going to have to sell unneeded services, I had a severe panic attack. I went to the bathroom and took a drink of some hand sanitizer. This immediately reduced my anxiety. From that point, I began drinking the hand sanitizer all over the bank. In late November 2012, I was completely addicted to hand sanitizer and drinking at least a bottle a day during my workday. In December, I was confronted by management about my behavior. I decided to seek treatment and went on leave.

In the same article, a Wells Fargo worker who had been scolded for not conning an elderly woman into a credit card by telling her she could use it as identification, reported:

There were numerous days where I would hide in the men’s bathroom crying. It got so bad that one day I left work to go to the emergency room because I thought I was having a heart attack. It turns out it was an anxiety attack.

CNNMoney, in a report from an insightful series by business journalist Matt Egan, told of one worker who said that “trying to balance the bank's aggressive sales goals without doing something illegal and sacrificing her morals pushed her into deep depression.” The employee alleged the “constant pressure” and ethical conflict led to migraines and other physical and psychological problems.

CNNMoney reported:

The experiences recounted by these employees underscore the human toll inflicted by a work culture that many former Wells Fargo employees said forced them to cheat and even break the law. Some described migraines and severe anxiety. Several complained of stomach ailments because they were denied bathroom breaks.

A branch manager who had been pressured to have workers open unauthorized accounts “said she suffered ‘severe depression and anxiety’” as a result and had to “take medical leave and resigned in 2008 due to the stress.”

According to Wells Fargo workers, these practices may have been going on for nearly 10 years. A recent CNNMoney article about the aftermath of the scandal says problems persist, with many employees being treated for mental health problems resulting from a toxic culture.

The issue of workers being denied bathroom breaks is a troubling one that came up often during CNNMoney's conversations with employees. It's unclear how widespread the practice is now, but former and current employees say it resulted in stomach-related ailments in the past.

As for wellness… Wells Fargo claims, “Our culture supports team members wherever they are on their health and well-being journey.”

“Wherever they are.” Unless they are in the bathroom, apparently.

In addition to the usual wellness offerings — health risk appraisals and screenings — Wells Fargo offers stress management programs, according to the company’s Benefits Book. Not only are workers offered an opportunity to take part in online wellness modules and telephonic health coaching that aim to fix health risks including — among other things — stress, the bank offered workers a $400 incentive to complete one of the programs.

-- “Hello, Mr. Health Coach?”

-- “Yes, how can I help you?”

-- “My job at the bank is a living hell. I have impossible sales quotas. I work 14-hour days to try to meet them. My boss insists I sell illegally, and bullies me if I don’t. My stomach is in knots, but I’m not allowed to go the bathroom. My heart is constantly pounding, my head hurts, and my family and finances are falling apart.”

-- “I see. Have you tried mindfully counting your breath? Relaxing your muscles from your head to your toes? How about coloring books — that’s a new thing that helps with stress. Or I could send you a link to a time management module.”

To be fair… Wells Fargo offers robust employee benefits that can genuinely help employees address psychosocial stress and other hardships. Eligible workers are provided with paid family leave, generous tuition reimbursement, adoption assistance, and 401(k) match up to 6%. If anything, the bank exemplifies how even the best well-being initiatives don’t amount to a hill of beans when the cost to workers is a brutal job.

Lest you think that these workers are fat cat bankers getting their comeuppance, the affected group reportedly included mostly frontline bank workers earning $10 to $14 per hour.

On the other hand, Fortune reported that the exec in charge of the “phony accounts unit” was granted a $7.4 million bonus in 2015, partly in recognition of her achievement of “strong cross-sell ratios.”

Wells Fargo may be an extreme case, and we don’t know the validity of all the workers’ anecdotes (many of them are participating in a class action lawsuit).

But a principle holds true: Stress management programs may offer some relief to workers caught in insufferable circumstances — just as a Tylenol may offer some relief to your co-worker being brutalized with a two-by-four.

The most readily achievable, the most business savvy, and the most meaningful solution, however, is not to hold employees accountable for their stress, or to trivialize their stress, or to try to manipulate them into modifying stress-related behaviors by dangling financial incentives in front of them.

The primary solution is to change the conditions that cause their pain.

Good News (and Bad News) About Employee Wellness!

Created on 2015-11-02 13:23

Published on 2015-11-02 13:49

I’m a steadfast proponent of employee wellness. I seek, and try to steer us toward, a path to evidence-based solutions. I'd like nothing more than to see employers double down on their wellness investment.

…

The organizational and psychosocial factors that influence employee health include:

• job design

• work schedules

• job security

• organizational justice

• social support

• effort-rewards balance

• work-life fit

My Eight Employee Wellness Flip Flops

Created on 2017-02-12 19:18

Published on 2017-02-12 22:41

I'm opinionated, but I like to think I approach wellness with an open mind. Consequently, throughout my career I've reversed many of the opinions I've held.

Some of my flip-flopping is based on evidence; some is based on my own experience. [Insert gratuitous #AlternativeFacts comment here.] If my flip flops seem jaded and this distresses you, be sure to read through to the list of things about which I have not changed my mind.

Here, in no particular order, are my top eight employee wellness flip flops:

I used to think health risk appraisals have value. Now, not so much.
I was once proud of conducting lipid screenings for 30 employers in 30 days. Now I regret the time and resources I've wasted on screenings.
I once taught an extension class at UC Berkeley. It was all about worksite wellness and behavior change. Today, I believe behavior change is a trifling element of the employee wellness equation. Our inability to see past it holds us back.
Ugh... I once thought that incentives could help employees overcome inertia, and that their intrinsic motivation would kick in from there. This is an intuitive belief. But it's wholly unfounded.
The comments the EEOC received regarding their wellness rules exposed the underbelly of wellness. There are not as many well-meaning employers as I once thought. Many, at best, have been passive accomplices in cost-shifting schemes disguised as wellness. One prominent wellness tycoon went so far as to submit into the record the suggestion that the EEOC should stop fretting about discrimination -- the EEOC! -- and let us behavioral change whizzes do our job.
Like all of us, I got excited about the prospects of technology -- apps, portals, and trackers -- providing more engaging, scaleable, and customizable wellness experiences that could lead to better outcomes. Thus far, they've failed to deliver. I have never, ever, ever had an employee ask me for yet another website or app.
I've seen de-light. There was a time when I was offended by those who might lump wellness programs in with activities like employee sports leagues, events, or outings. Now I think they go well together. Delight, in any form, delivered into employees' lives aligns with wellbeing.
I've stopped crowing about "culture of health," or culture in any context. I still believe organizational culture is important -- and there are positive cultures and not-so-positive cultures. But purposefully changing an organization's culture is an unsolved mystery, and the sort of manipulations it requires generally create just another stressor in workers' lives.

Things I have not flipped flop on:

The key to employee health lies in the nature of the work itself. The evidence on this is profound. The most promising recent development in wellbeing is not financial wellness or sleep wellness or artificial intelligence. It's the NIOSH-funded research that Harvard and Sodexo recently announced, studying the connection between the work environment and health for frontline service workers and applying the research to improve the lives of workers.
At a presentation by David Kessler in a Washington, DC hotel on a dreary day, I witnessed the then-FDA-Commissioner passionately proclaim, "Those smokers you passed at the entrance of the hotel are huddled in the rain and the cold because tobacco companies preyed upon them when they were kids and they didn't know better!" After finding confirmation of this in the Truth Tobacco Documents, my commitment to tobacco cessation has been unwavering.
I've never believed wellness programs reduce medical costs, and I haven't seen credible evidence showing that they do or even a plausible explanation of how they would (within a timeframe relevant to most employers). This may seem jaded if someone's convinced you otherwise, or if you're a vendor dependent on marketing ROI (as, I know, many readers of this post are). But I've found this to be quite freeing, allowing me to focus on wellbeing rather than futilely chasing cost savings.
Though I've grown skeptical about employers' true motives, I know that most wellness professionals have great hearts and are committed to doing what's right for employees. It's inexcusable that our major industry conferences continue to be headlined by an old-boys-network who made their names at those same conferences in the 1980s and 1990s. An essential role for industry veterans is to support and promote newer voices.
If it's not voluntary, it's not wellness.
Most importantly, I still view employee wellbeing as a solemn obligation for employers and our society. If we are not moving forward on wellbeing, we will move backwards. And, as a society, we stand no chance of moving forward without employers -- along with industry groups, faith-based organizations, labor, community organizations, consumer groups, and, yes, even the government -- fully engaged. We, as an industry, need to conduct this work with authentic commitment and with rigor. Vendors should be respected partners, responding to our agenda... but not establishing it.

What aspect of your profession have you changed your mind about?

John Howard Is the Batman of Worker Health

Created on 2016-01-19 01:44

Published on 2016-01-19 19:12

A superhero of employee health is John Howard, director of the National Institute of Occupational Health and Safety, home of the Total Worker Health® (TWH) program.

I was fortunate enough to attend Dr. Howard's impassioned opening address at the 1st International Symposium to Advance Total Worker Health, which took place at the National Institutes of Health in 2014. Here are a couple of things he said:

Total Worker Health is promoting worker well-being in all its aspects, including appropriate indemnity and medical care for work injuries and illnesses, adequate paid sick and family leave, maternity and paternity leave, adequate vacation time, living wages, comprehensive health care, social pensions, along with safe and healthful workplace conditions as required by law.
We know that workplaces interested in wellness measures only in order to lower their health insurance costs are not likely to be workplaces that can achieve Total Worker Health.

Under the stewardship of Dr. Howard and his team, TWH is forging an agenda that recognizes the full range of forces at play in worker health.

The TWH website emphatically states what TWH is not:

TWH is not a collection of health promotion efforts implemented in a workplace where the work organization and structure contribute to worker injuries and illnesses. Workplace policies that discriminate against or penalize workers on the basis of health conditions or inadvertently create disincentives for improving health are not consistent with a TWH approach.

That last is a potshot at the section of the Affordable Care Act that legitimizes using wellness incentives and penalties to discriminate against workers. (Learn more about how ACA wellness provisions promote discrimination against disabled and other workers.)

In remarks at a more recent TWH conference, Dr. Howard declared the essential role of TWH:

Our hypothesis is that work itself plays a significant role in the health of workers, and we fund research based on that hypothesis. What good are all the population health efforts currently the fashion… if significant factors arising from work itself…are ignored, ultimately left unintegrated with the larger and more resourced world of population health?

John Howard is Batman! Imagine an employee well-being strategy that puts the needs of workers first.

L. Casey Chosewood, MD, MPH, Total Worker Health manager, hammered home Dr. Howard's point, outrightly distancing TWH from our commercialized, behavioral approach to wellness. In a Bloomberg BNA article, Robin...um, I mean Dr. Chosewood...was quoted as saying:

Total Worker Health is not now or never has been synonymous with workplace wellness programs. You cannot counter the negative health effects of 8 or 10 or 12 hours a day in difficult working conditions with a 30-minute health promotion program at the end of the day.

Bam! Take that, Joker!

If we know what TWH is not... Then what is it?

According to the program's website:

Total Worker Health advocates for integration of all organizational policies, programs and practices that contribute to worker safety, health and well-being, including those relevant to the control of hazards and exposures, the organization of work, compensation and benefits, built environment supports, leadership, changing workforce demographics, policy issues, and community supports.

Elsewhere on the site, TWH explains:

An integrated approach recognizes that risk factors in the workplace can contribute to many health problems previously considered unrelated to work, including cardiovascular disease, obesity, depression, and sleep disorders.

Total Worker Health is...well...total. It encompasses everything in a worker's life that interplays with work, as well as (and especially) the work itself. And it considers how these influences interact with all dimensions of well-being.

14 Wellness-Vendor Management Tips from an Industry Insider

Created on 2019-01-14 22:51

Published on 2019-01-15 14:23

Lofty talk about employee wellness is all well and good. But in companies everywhere, wellness managers are busy dealing with everyday corporate realities: limited resources; self-obsessed leaders; half-hearted cooperation from other departments that have higher priorities; and even program participants’ conflicting needs and expectations. Wellness managers rarely have time to hang out on social media reading Steve Jobs quotes, learning how employees’ "why" is more important than their blood pressure, debating flaws in the latest research, or putting up with judgment from the likes of you and me.

A Mash-Up of Vendor Management Tactics

In that spirit, I’m pleased to offer practical tips for wellness vendor management, one of the most demanding roles of employee wellness managers. Some of these — six tips for implementation and oversight, eight for selection and contracting — may be more relevant to larger corporations, but many are applicable to a spectrum of organizations and a variety of non-wellness vendors. They can help make a manager’s job easier, while eliciting higher levels of performance from vendors.

This list isn’t intended to be exhaustive. It’s a mash-up of tactics I learned — in 20+ years of contracting with vendors for wellness portals, tobacco cessation, team challenges, positive psychology, EAPs, condition management, biometric screenings, flu shots, self-care, employee recognition systems, and more — that I now find are elusive to many managers who can benefit from them.

Implementation and Oversight

Use a Vendor Scorecard — This may be the most important thing you’re not doing with your vendors. Put a performance management process in place, not unlike those many companies use for employees. Collaborate with your vendor to have them set goals for account management, customer service, new product development, communications, consultation, reporting, attention to detail, etc. These should relate to your program goals. Provide the vendor with a written report at least once a year, grading them on how they've done with each goal. They’ll appreciate the clarity about expectations, validation of what they’ve done well, and feedback regarding how they can improve. Check in with them regularly throughout the year, orally and in writing. They shouldn't be broadsided when you deliver their annual evaluation.
Conduct a Culture Orientation — As part of the implementation process, plan a “culture orientation” in which someone on your team presents (usually via webinar) an overview of your company’s culture for your vendor’s service reps. Include a quick history of your company, its values, and a description of your company’s product/service, in addition to the levels of service and quality your company’s employees expect.
Host a Vendor Orientation — Have your vendor’s account executive provide an orientation, live or via webinar, for your wellness champions and other key stakeholders. This should minimally include a demo of web- or app-based products.
Fact-Check Reports — Scrutinize your vendor’s numbers closely. One relatively easy quality assurance procedure: When the vendor team visits your office for the annual utilization review and strategy planning session, you should have the previous year’s reports with you. When they show how the current year’s data compares to the previous year’s data, compare what they now say is the previous year’s data to what they actually reported the previous year. In my experience, these are inconsistent more than 50% of the time, and you should find out why. (Or spare everyone the awkward moment: Ask your vendor to provide utilization reports in advance, so you have sufficient time to assess reporting quality — as well as results — that you can discuss at the meeting.)
Be a Data Detective — If your vendor says, for example, that your company’s 10,000 employees took enough steps in the past year to circle the earth 300 times (WOW!!), your boss and your boss’s boss may get giddy, but they need you to be smarter. To circle the earth 300 times in a year, 10,000 employees would average only about 4,100 steps per day. A mean average of 4,100 steps per day is a data point you can work with. “Circling the earth 300 times in a year” is a throwaway factoid designed to appeal to your emotions. (Another example: Your vendor tells you that participants lost a total of 20,000 pounds that year. One check on this unlikely outcome: Ask if they're calculating net weight change — total weight gained relative to total weight lost — or just adding up how much employees have lost. That is, if I lost 5 lbs in each of February, June, and September, it’s wrong to say I lost a total of 15 lbs that year if I gained 3 lbs in each of the other 9 months. But many vendors will do just that.) This isn’t sophisticated statistics, it’s just — as Al Lewis is fond of saying — basic math. Still, if numbers make your head explode, enlist one of your company’s data wonks to help.
Expect a Consultative Relationship —You want a vendor that 1) knows more than you do; 2) leverages their experience to help solve your problems; 3) provides resources (like communication specialists, project managers, etc.) to help fill gaps on your team; 4) stays ahead of industry trends; and 5) maintains a current, active roadmap to accommodate the changing needs of your employees. Vendors should be one step ahead of you, rather than you pulling them along.

Selection and Contracting

Meet the Right People — At finalist meetings, require vendors to bring the right people. This should include the account executive or account manager who’ll be your primary contact. Ask them questions directly to confirm they’re prepared to manage the account the way you expect, including advocating for your company’s needs at all levels of their organization. And it never hurts to get a sense of how you’ll mesh.
Terms of Service and Privacy — Read the Terms of Service and Privacy Policies that the vendor’s participants must agree to. Ideally, get your company’s legal counsel involved with this. This is especially important for very large or diversified vendors, who might plan to do gosh-knows-what with your employees’ data to slyly market other products to them. Always be a vigilant steward of your participants’ data and confidentiality.
Start-Up Fees — Negotiate hard to get start-up fees waived. (Remember: The salesperson is always hungry for your business. You’re in the driver’s seat.) The only good reason I can see to pay start-up fees is when implementation starts before a contract is signed (which it often does). True story: I once had a vendor try to slip a $50,000 start-up fee into a contract. I said, "We're not going to pay that. Take it out." They said, "Okay." I guess they felt it didn’t hurt to try.
Don’t Enable Deceptive Practices — The contract should not include a vendor stipulation that “this contract supersedes all previous communication.” Why agree to that? Require your vendors to keep their word on everything they’ve said in their sales proposals, presentations, and Statement of Work. (I also encourage them to honor what they've said on their website and other public communications). If necessary, working with your legal or purchasing teams, make all previous documents appendices to the contract.
Demand Real Performance Guarantees — You can accept a vendor’s performance guarantees, but propose some of your own — using metrics that don’t depend on the vendor to measure. And make them count. For example, a vendor’s ability to do their part to launch your program on time — without big mistakes, website overloads, long on-hold periods for your employees, etc. — should be worth a lot more than 1% or 2% of the first year’s total fees. 5%-10% isn’t unreasonable; after all, you only get one chance to launch a program. As much as possible, base performance guarantees on results. For example, speed-to-answer helpline calls — a common performance indicator — is an important metric, but helpline effectiveness and user satisfaction are what really counts.
Get Out of Vendor-Jail Free — Make sure your contract has an out-clause, so you can terminate the agreement without cause (after giving an agreed-upon amount of notice).
Do Site Visits — During your selection process, visit the offices of your finalist(s), if possible. You can learn a lot by the vibe, the attention to detail, the hospitality, the privacy practices, etc. Never let your vendor pay for your site visit. Doing so is a bad practice and probably violates your employer’s conflict-of-interest policy.
Wellness Reality Check — During your site visit, ask your prospective vendor’s employees about their company’s wellness program for their own employees. If they're not prepared to describe a genuine, knock-your-socks-off program, the vendor doesn’t believe in employee wellness and/or has no idea how to do it.

Do Your Part

A vendor can only do so much. Some wellness managers think that after signing a contract and checking off a few implementation tasks, their work is done and the rest is up to the vendor. No. Wellness managers need to manage. You need to rally enthusiasm at all levels of your company; execute an astonishing and ongoing communication strategy; listen to the changing needs of participants and non-participants; remain personally engaged in the program; oversee and coordinate resources; and nurture a collaborative relationship with your vendor as you manage their performance.

Drive your vendors without bullying them. If they’re good, they’ll recognize that your demands for the very highest quality only make them better. If they don’t want you involved, it’s time to use that “out clause” in your contract.

Health, Wellness, and Wellbeing Are the Same Thing

Created on 2016-05-02 23:01

Published on 2016-05-03 10:49

I recently read an article about business's revolutionary transition from employee wellness to wellbeing. "Historically speaking," the author wrote, "wellness has been thought of as strictly pertaining to physical health, usually measured by biometrics."

But, accurately speaking, this is not so.

Of course, there's no single arbiter who can proclaim what exactly health, wellness, or wellbeing mean, but it's worth understanding some of the ways these words have been interpreted in order to fully appreciate the implications, or lack thereof, of the "transition" from wellness to wellbeing

"Health" was defined by the World Health Organization (WHO) in 1946 as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."

WHO's definition, incorporated into its constitution, remains unchanged to this day. But in 1986 the organization held an International Conference on Health Promotion in Ottawa, which resulted in the famous Ottawa Charter for Health Promotion that elaborated on the definition, stating,

An individual or group must be able to identify and realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities.

The Charter went on to list the conditions for health: peace, shelter, education, food, income, a stable eco-system, sustainable resources, and social justice. A far cry from biometrics.

In the late 1950s, the chief of the US Office of Vital Statistics -- Halbert Dunn, MD -- described a dynamic state-of-being he called "high-level wellness." This is generally considered the founding of wellness, and Dr. Dunn's sermon-like lectures reveal his concept to be anything but a simple embodiment of physical health. Dr. Dunn said...

The state of being well is…a fascinating and ever-changing panorama of life itself, inviting exploration of its every dimension.

I believe Dr. Dunn was amplifying -- not refuting -- WHO's original definition, and the Ottawa Charter later adopted much of his take on wellness as a never-ending interaction with the environment.

But Dr. Dunn's framework may have proven too cosmic for the mainstream. And many thought leaders have since distilled wellness into the sum of its various dimensions.

The National Wellness Institute adopted a model that incorporates six dimensions of wellness -- occupational, physical, emotional, spiritual, intellectual, and social. Others have divvied wellness up into five, six, seven, or eight dimensions, sometimes tossing in a "relationship" dimension, sometimes "environmental," "financial," or "community." A quick image search reveals a galaxy of multidimensional wellness models in the shape of pies, hexagons, prisms, Venn diagrams, concentric circles, and geodesic domes.

I don't know exactly how "wellbeing," in the last few years, worked its way into the hearts of employers and the wellness industry. But one catalyst probably was the bestselling book, The Five Elements of Wellbeing, by Tom Rath and Jim Harter. Both authors are workplace consultants with Gallup (a partner of wellness vendor Healthways) and entrepreneurial marketers with a track record of successfully persuading employers to their way of thinking.

Rath and Harter argue, based on Gallup findings, that wellbeing is more profound than health and wellness, incorporating career, social, financial, physical, and community wellbeing. Sound familiar?

In practice, employers are rallying around mindfulness programs and financial planning, and repackaging stress management as resilience, and using these incremental expansions of the status quo as markers to distinguish wellbeing from wellness. Ultimately, the transition amounts to little more than a name change.

That's fine.

I'm more than happy to dispose of the word "wellness." I never cared for it -- not because of its definition, but because it has failed to resonate with employees or the public at large. And I see no harm in calling it wellbeing instead of wellness. Certainly, while the employee wellness industry has been celebrating this "transition," I doubt many employees have noticed a difference.

Besides, I'm open to the evolution of language, as long as it isn't contrived to cover up a deception (like calling participation "engagement," which I'm sure no self-respecting wellness professional would ever do).

Here's my bottom line based on this incomplete and superficial exploration of the terms health, wellness, and wellbeing: Some people are inclined to see connections, whereas others are more drawn to compartmentalize. Maybe surgeons and benefits directors are more likely to see what's tangible and quantifiable, while artists and farmers see the whole and the dynamics it contains. Both points of view probably deliver value.

Either way, I'm guessing that anyone who views health and wellness as only physical phenomena is likely to see wellbeing the same way. Others who view these concepts holistically are likely to do so regardless of the labels we attach to them.

Health, wellness, wellbeing: In the end, what we call it won't matter as much as how we think of it…and how we act on it.

NICE! Good Work Is the Key to Good Employee Health

Created on 2015-10-28 12:12

Published on 2015-10-28 12:15

On June 19, 2015, while the U.S. federal government was determining how much employers should be allowed to fine workers for high blood pressure and cholesterol, the United Kingdom's quasi-governmental National Institute for Health and Care Excellence (NICE) was doing something beneficial for employee wellness. NICE issued evidence-based guidelines for management practices and policies that support employee health.

In the U.S., where we lean on behavioral programs and medicalized approaches to try to manipulate worker health, NICE's focus on workforce management and policy may seem...um...foreign. But as often mentioned in this blog, much of the rest of the economically advanced world long ago realized that management practices -- especially those relating to job design and work environment -- are the foundation of employee health. Voluntary behavioral programs play a potentially important but supporting role.

In fact, a recent Stanford study, described in a previous post, determined that low job control, unemployment, long work hours, and work-family conflict had a greater affect on mortality than second hand smoke. And more than 120,000 deaths per year and approximately 5% to 8% of annual healthcare costs may be attributable to how U.S. companies manage their workforce.

The NICE guidance includes recommendations like...

• "Encourage employees to be involved in the design of their role to achieve a balance in the work demanded of them. Allow them to have a degree of control, appropriate to their role, over when and how work is completed."

• "Value and acknowledge employees' contribution across the organisation. If practical, act on their input and explain why this action was taken."

• "Create a supportive environment that enables employees to be proactive to protect and enhance their own health and wellbeing."

• "Ensure any unfair treatment of employees is addressed as a matter of priority."

• "Proactively challenge behaviour and actions that may adversely affect employee health and wellbeing."

• "If possible and within the needs of the organisation be flexible about work scheduling, giving employees control and flexibility over their own time."

These are just a few examples. Visit the NICE website to read the full Workplace Health: Management Practices guidance and the evidence upon which it's based.

In the U.S., we seek "disruption" in the form of new wellness programs, gizmos, and websites. But these aren't disruptive and in some cases they aren't even improvements. They're just new tricks for old dogs.

Even if behavior is the underpinning of health, as we insist on believing, employers have little influence over it, and may do some damage in the process of trying.

Employers do influence the workplace and the work, and that's where they can have the most impact on wellness.

Change the work. Not the worker.

❧❧❧❧

Financial Whatness? On Responsible Retirement Plan Stewardship and Financial Wellbeing

Created on 2019-09-05 16:57

Published on 2019-09-05 18:49

Which of these pictures is not like the other? Is it...

A. The announcement of an employer's retirement planning financial wellness activity?

B. The announcement of the same employer's financial wellbeing session on budgeting, spending, and saving strategies?

C. The court document from a class action lawsuit 16,000 university employees filed against the same employer, accusing it of costing tens of millions of dollars from their 401(k) as part of a sweetheart deal that yielded multi-million dollar donations and "lavish" personal gifts from the 401(k) services company?

If you guessed "C" you are correct! The court document comes from a case in which the university was accused of "abandoning employees" and violating ERISA by giving favorable status to a prominent financial services firm that cost the retirement plan millions of dollars in excessive fees and investment underperformance. The lawsuit details a variety of alleged quid-pro-quo deals, especially sketchy-looking because the CEO of the financial services firm has been a member of the university's Board of Trustees since 2007.

As a courtesy, I'm not mentioning the implicated organizations, largely because I'm leery of class action lawsuits, especially when they occur in bunches (more than 20 cases like this have been filed against universities in recent years, though the one discussed here is receiving extra media attention).

What's more, this particular university has a reputation as an excellent employer that, like many higher-ed institutions, offers relatively generous retirement benefits.

Nor would I suggest that the employer's HR department rein in its financial wellness programming. If we discontinued our employee wellbeing efforts every time an executive did something that contradicted them, even our best programs would vanish.

But I do think these cases should give us pause to consider the employer's responsibility for financial wellness, beyond getting employees to save more of their earnings.

Proposed: Financial Wellbeing Inventories

You know those organizational inventories we recommend for other dimensions of wellbeing? Before launching a physical wellness program, for example, we conduct audits of workplace factors that influence physical health, like pretty stairwells, healthy food in vending machines, and so forth. Before launching a culture-of-health strategy, we assess the current state of the organization's culture, using criteria like "Is wellness mentioned in the company's mission statement?" and "Does the CEO visibly model wellness behaviors?"

We should do the same with our ever-popular financial wellbeing strategies. Before launching strategies to promote savings, budgeting, debt management, and retirement planning, let's assess our organizational status with criteria like:

Do we offer livable wages?
How does our average frontline worker wage compare to our CEO pay, relative to benchmarks?
Do we offer affordable medical benefits?
Are employees' schedules predictable (so they can arrange for childcare, or even a second job, if necessary)?
How generous and inclusive is our family leave policy?
Do we provide college loan repayment assistance?
Do we provide adoption assistance?
How generous is our tuition remission benefit?
Do we offer paid vacation time and paid sick time, or generous PTO policies?
Do we offer disability insurance?
And...yes: Do we offer solid retirement plans, without sacrificing millions of our employees' retirement savings in order to garner large donations or tickets to the NBA Finals (like the execs allegedly did in the court case discussed here)?

Remember: Just as with our other workplace inventories, we don't have to check all the boxes (well, except numbers 1 and 11!). But we should understand our organization's wellbeing strengths, identify the gaps and aspire to fill them, and recognize that employers must share some accountability -- it can't all be about changing employee behavior -- for all dimensions of wellbeing, including (especially) for financial wellbeing.

Job Strain May Be Making You Ill

BY BOB MERBERG · DECEMBER 20, 2014

Job strain is a particularly insidious form of stress that goes far beyond overflowing inboxes or tight deadlines. It is characterized primarily by organizational environments and job structure in which employees have high levels of demands placed on them and limited control over those demands (that is, low “decisional latitude”). This is the demand-control model that was originally described and measured by Robert Karasek. Other organizational and job-related factors that contribute to unhealthy job-related stress are effort-rewards imbalances, long work hours (sometimes including long commutes), job insecurity, and lack of social support on the job. Some researchers have categorized all of these stressors as job strain, others differentiate them. But most agree that these stressors — all related to organizations and job design, and not to individual behavior — lead to negative health outcomes.

How unhealthy is job strain?

Job strain has been linked to hypertension and to heart disease. This is not a simple matter of people who have other risk factors, like pre-existing hypertension or what used to be called Type A personality, being drawn to stressful jobs. Research suggests a causal relationship between job strain and both hypertension and cardiovascular disease. (Some studies also have linked job strain to depression, musculoskeletal disorders, dyslipidemia, physical inactivity, obesity, and adverse birth outcomes.)

Blue collar workers are more prone to the effects of job strain compared to white collar workers, but no one is immune.

Not every study of job strain has confirmed this relationship, but most have. A 10-year prospective study of 22,086 female health professionals, published in 2012, revealed that women with active jobs (high demand, high control) and high levels of job strain (high demand, low control) were 38% more likely to experience a cardiovascular disease event (such as heart attack or diagnosis of atherosclerosis) compared to women reporting low job strain. During the study, there were 170 myocardial infarctions, 163 ischemic strokes, 440 coronary revascularizations, and 52 cardiovascular-disease-related deaths, reaffirming that cardiovascular disease is a major concern for employers and for public health.

A Finnish study of 812 employees, followed for more than 25 years, found that employees with high demands at work and low job control had a 2.2-fold increased cardiovascular mortality risk — independent of other risk factors — compared to their colleagues with low job strain.

Earlier this year, an Israeli study confirmed a link between job burnout and coronary heart disease. Job burnout was defined as physical, cognitive, and emotional exhaustion that results from stress at work. Factors contributing to burnout included most of those typically associated with job strain or job stress: heavy workload, lack of control over job situations, lack of emotional support, and long work hours. Over the course of the study, 8,838 male and female employees were followed for an average of 3.4 years. Each subject was measured for burnout, which, as it turned out, was associated with a 40% increased risk of developing heart disease. Of greatest concern, the 20% of participants with the highest burnout scores had a 79% increased risk of heart disease.

A British study of 6,014 workers, followed for an average of 11 years, found that three to four hours of overtime per day is associated with a 1.6-fold increase in coronary heart disease risk, independent of other risk factors. (More about overtime in a future post.)

Countless research studies have demonstrated the relationship between job strain and health. The Center for Social Epidemiology has published a compilation of classic studies and more recent studies.

Unlike many other countries (again…especially Scandinavian countries), American employers continue to insist on offering employees behaviorally based stress management programs, such as relaxation programs and time management seminars, rather than trying to address the program where the employer actually has the most control: the structure of the organization and the jobs within it.

Even the National Institute for Occupational Safety and Health declares, “Working conditions play a primary role in causing job stress” and it advises,

As a general rule, actions to reduce job stress should give top priority to organizational change to improve working conditions.

Check out the NIOSH page for some ideas about the type of organizational change that is needed.

Emphasis on the organization’s role, rather than the employee’s role, may have applications beyond stress. It may well be that it is the very nature of their work that is deleterious to employees’ health. Fitness challenges, biggest loser contests, tobacco-free campuses, incentives, health risk assessments, coaching, health screenings, yoga classes, and even culture-of-health have limited potential to evoke meaningful population health improvement…as long as the roots of the problem — toxic job design and sick organizations — persist.

Hostile Workplaces and Overtime Linked to Obesity

BY BOB MERBERG · JANUARY 24, 2015

The Wall Street Journal recently reported on employers’ increasingly aggressive efforts to get workers to lose weight, igniting the inevitable social media hullabaloo from pro- and anti-wellness pundits. The article featured a table, Obesity by Occupation, which reported the prevalence of obesity in 10 categories of occupations (ranging from 40.7% for police, firefighters, and security guards, to 14.2% for economists, scientists, and psychologists). But the newspaper and the pundits missed the scoop.

When the reporters discovered the obesity-per-occupation stats in a study published earlier in the year, they glossed over the most important findings. The study, Prevalence of Obesity Among U.S. Workers and Associations with Occupational Factors — published in the American Journal of Preventive Health (AJPH) — wasn’t just about job type. It was about the conditions of work and the work environment.

The study found a significant link between obesity and

1. Long work hours — more than 40 hours in a week
2. Hostile work environments (think bullying and harassment)

An association between job insecurity and obesity also was identified, but the statistical significance of this relationship withered when the data was adjusted for the confounding effect of health behaviors.

We’ll delve into long work hours, hostile work environments, job insecurity and more in future Health Shifting posts. For now, the focus of the WSJ article provides a prime example of our collective blindspot for the true levers of employee wellbeing.

The WSJ article focused on corporate weight management programs, including the trendy use of step-counting gizmos and apps, with some lip service to weight loss drugs and bariatric surgery. (Google “Memo to Staff: Time to Lose a Few Pounds” to find the full text, which otherwise is accessible only to WSJ subscribers)

But, based on their findings, the researchers who conducted the study cited in the article, all from the National Institute of Occupational Safety and Health (NIOSH), had called for something quite different:

Public health professionals and employers should consider workplace interventions aimed at reducing obesity that take organization-level factors, such as scheduling and prevention of workplace hostility, into account…

They went on to advocate for integration of organizational approaches with more conventional methods — specifically, diet and exercise.

Diet and exercise may very well be important personal levers of health, but their track record is dismal and employers don’t control them. The NIOSH study by no means made an ironclad case, but it was a step in the right direction: Employers stand a better chance of having a positive impact on employee health if they pull the levers they do control — like job schedules and work environment. They need to change the work — not the worker.

Trains, Pains, and Automobiles: Your Commute Influences Your Health

BY BOB MERBERG · MARCH 4, 2015

I’ve been commuting since I was in high school, when I had to take the F train to Coney Island to switch for the B train to Bay 50th. After college, it was a long schlep from Brooklyn to Manhattan, standing shoulder-to-shoulder with other passengers in a stiflingly hot subway car. Fast forward to my California days, forfeiting 90 minutes in each direction sitting in traffic on the 101, arriving at work drained and, later, missing dinner with the family. Then a new job I could ride my bike to, over a hill in Sonoma County, burning 500 calories each way! I can testify firsthand to the contrasting health effects of long commutes compared to short commutes — and active commuting compared to passive. But don’t take it from me…

§ A 2014 Canadian study showed that people with long car commutes committed less time to physical activity and reported lower levels of life satisfaction. The study found that well-being was not only related to the length of time spent commuting, but also to the quality of the commute — specifically, the level of traffic congestion.
§ An analysis in 2009 found significant evidence that commuters trade off commute time for exercise, sleep, and time spent preparing meals.
§ A study of commuters who take the train into Manhattan found that longer duration commutes are linked to more intense perceived stress, higher levels of stress hormones, and impaired task performance at the end of the commute.
§ A study of car commuters in three Texas cities found that longer commutes were associated with high blood pressure, excessive waist circumference, depression, anxiety, and social isolation.
§ A Gallup survey found that as time spent commuting increases, so do the odds of having elevated cholesterol, obesity, and head or neck discomfort. The findings were independent of full-time/part-time status, education, age, and income level.
§ A recent British study found that walking, bicycling and using public transportation all were better for mental health compared to commuting by car, and the researchers concluded that their study complemented previous findings specifically linking driving with a host of negative health effects.

Commute time isn’t dictated exclusively by distance between home and work. Many factors are at play, as noted in a recent national report on the topic. Time of departure (think rush hour vs. off-hours), as well as the availability, capacity, and performance of public transportation play a role. Some workers, certainly, have some control over their commute based on choice of residence and their commuting preferences (public transportation, driving, carpooling, walking or bicycling, and so forth).

But many employers are positioned to have a meaningful influence on employees’ commutes and, consequently, their health. While the ultimate goal may be to restructure the built environment so that residences and workplaces are closer and bicycling, walking, and rapid transit are more prevalent — employers should step up in their communities to help make this happen — in the interim employers can:

1.    Encourage work-from-home.
2.    Allow flexible schedules to help employees avoid rush hour.
3.    Subsidize employees’ public transportation expenses.
4.    Provide employees with opportunities for physical activity on-the-job to counteract the “lost opportunity” for exercise they experience during their commute.

As Gallup concluded in the summary of their survey on the ill-effects of commuting:

The results imply that many employers may need to reevaluate their options for helping workers manage those effects, particularly in light of the costs associated with low wellbeing.

According to Commuting in America 2013: The National Report on Commuting Patterns and Trends, average commute duration barely changed from 2000 to 2011, hovering around 25 minutes. 8.1 percent of commuters take 60 minutes or longer to reach their workplace. The Northeast is the outlier, with more than 12 percent traveling more than 60 minutes and almost 4 percent traveling more than 90 minutes. Commutes longer than 60 minutes make up 25.5 percent of all commuting time.

Workplace Health, Injustice, and Your Mother

by Bob Merberg · Published April 28, 2016

Your mother always told you life wasn’t fair. In few places did her words ring truer than workplaces where favoritism, bullying, discrimination, or broken promises rule the day.

But if life’s not fair, it may be no small consolation that, when facing an unjust and uncivil work environment day in and day out, life may not be very long either.

One study has shown that workers who felt they were treated unfairly at work — compared to well-treated workers — had a 55% greater risk of heart disease, even after controlling for other risk factors.

Organizational Injustice

Organizational unfairness, or injustice, refers to a pattern of exposure to inequitable conditions that undermine workers’ dignity and self-respect. It runs the gamut from being ignored… to being spoken to rudely… to being bullied… to being assaulted.

In addition to its link to heart disease, which includes documented cases of heart attack and angina — organizational injustice has been associated with a variety of physical and mental health problems.

In one study, 8% of workers reported being harassed within the previous 12 months. These workers were significantly more likely to be obese; sleep less; smoke more; and experience psychosocial distress, pain disorders, and lost work days.

Another study showed that men who felt their workplaces had a high level of justice had a 25% lower risk of developing metabolic syndrome than those working in unfair conditions. And a review of several studies revealed a consistent association between organizational justice and mental health.

The exact definitions may differ depending on which expert you talk to, but generally workers experience unfairness via four categories of organizational injustice:

Procedural injustice — Processes for the employer to interact with employees aren’t created or conducted in an equitable manner. For example, effective systems are absent to assure that workers in comparable circumstances are treated equally when decisions are being made about job performance issues, schedules, promotions, and transfers.
Interactional injustice — Workers aren’t treated respectfully and their value isn’t recognized. Bullying and hostile work environments are examples of interactional (also called relational) injustice.
Distributive injustice — Benefits, compensation, and other rewards aren’t extended equally to employees doing comparable work, or generally aren’t appropriate for the demands and expectations of the job. Workers who earn less due to discrimination based on race, gender, or religion experience distributive injustice.
Psychological breach — Promises are broken. This includes the expectations the organization sets — including those related to pay, responsibilities, job demands, opportunity, and job security — when workers are hired or assume a new role. This category isn’t always included in classical definitions of organizational injustice, but is a process that may amplify the other categories.

Failure to communicate accurate, timely information to workers and to offer conduits for meaningful input are common denominators of organizational injustice.

Manage Fairness for Better Health

A 2011 meta-analysis confirmed that organizational injustice is associated with physical health problems and mental health problems, especially depression, anxiety, and burnout. Interestingly, the study also found that the strength of the association with specific kinds of health problems depended largely on the type of organizational injustice:

Workers experiencing procedural injustice were most likely to have physical health issues
Those encountering distributive injustice mostly reported mental health problems.
Psychological contract breach was associated with burnout.

Reviewing the meta-analysis, the online publication I/O At Work proposed strategies employers can consider if they genuinely want to promote worker health:

Organizations have a great deal of control managing fairness (and unfairness) perceptions. To increase feelings of distributive justice, organizations should strive to make policies with outcomes that are the same for all employees regardless of gender, race, and tenure. Increasing perceptions of procedural justice can be accomplished by insuring that decision-making processes treat all employees equally. Finally, to increase perceptions of a sturdy psychological contract, openly and clearly communicate to employees, provide them with information, direction, and support in times of change, and treat employees with respect.

Your mother may have been right: Life’s not fair. But that doesn’t mean the workplace can’t be.

Our society of hard knocks may scoff at the notion of fairness at work — dismissing it as the product of a self-entitled workforce. And it may be hard for traditionalists to believe that justice and other organizational strategies are an avenue toward improved workforce health.

But sometimes it’s the employer that feels entitled or plays the victim. And the observational evidence that connects the dots from fairness to health is no less solid than that cited by the wellness industry to sell behavioral change.

Ultimately, organizational change and individual change are likely to complement each other in cultivating a healthier workforce. Of the various solutions to choose from, a combination of organizational and behavioral strategies may be the fairest of them all.

Getting Axed Is Hazardous To Your Health

by Bob Merberg · Published February 4, 2016

You look to your job not only for income and benefits, but also for purpose, social interaction, and daily routine. These influence your health, and the loss of them — or the threat of losing them — can suck the life right out of you.

Every day, millions of Americans either look for work or go to work. Their success at finding and/or maintaining a decent job with good benefits will, to a large degree, determine their current and future health.

— Robert Wood Johnson Foundation

Job loss, long periods of unemployment, and job insecurity have all been linked to deteriorating health. Yet, even companies that profess to support employee well-being have been known to contradict themselves by executing mass layoffs as a first line of financial defense rather than a last resort.

The Netflix exec who masterminded the vaunted slide deck about the company’s do-or-die culture boasted about the workers she’d laid off and fired. After being let go in 2015, she “doesn’t like to talk about it.”

As a business strategy, layoffs are a proven fail, a formulaic tactic executed by complacent executives in the absence of genuine leadership skills. Though frequently assumed to be a desperate measure, corporations often lay off workers when business is booming.

Of course, layoffs aren’t the only source of unemployment and job insecurity…

Workers get fired due to performance problems.
Businesses go belly-up.
Some employers foster job insecurity as an ill-fated method to drive productivity.

But mass layoffs — regardless of whether they are euphemistically called reductions-in-force, redundancies, right-sizing, down-sizing, or all-around-the-town-sizing — are responsible for the majority of job loss that is out of workers’ control.

Job Loss and Health

Compared to employed workers, people who have recently lost a job are…

80% more likely to feel unhealthy (self perception of health is an important measure of well-being).
Twice as likely to experience depression.
Up to twice as likely to die.

Unemployment and Health

According to Gallup, Americans who have been unemployed for a year or more are more likely to be obese than those unemployed for a shorter time. The obesity rate rises from 22.8%, among those who have been jobless for less than three weeks, to 32.7% among those unemployed for a year or more. Those who have been jobless for more than 26 weeks are twice as likely to have high blood pressure and high cholesterol compared to people who have been unemployed for shorter periods.

Gallup also found that 20% of people unemployed for a year or more suffer from depression — about twice the prevalence compared to people unemployed for less than six weeks.

The Robert Wood Johnson Foundation points to several pathways from unemployment to deteriorating health:

Reduced income, which leads to inadequate nutrition, shelter, and health care.
Increased stress and limited access to the physical, mental, and social activity that are underpinnings of well-being.
Increased likelihood of engaging in unhealthy behaviors, like alcohol consumption, smoking, and drug use.

Job Insecurity and Health

The jury is still out on whether job insecurity — the threat of involuntary job loss — causes measurable declines in health status, but plenty of studies suggest a connection.

Job insecurity harms health, even more than unemployment.

— The World Health Organization

One of the largest investigations of job insecurity and health analyzed data from more than 174,000 workers who were studied for nearly 10 years. It found that workers with job insecurity were 20% more likely to experience life-threatening heart disease compared to others who felt their jobs were a lock.

Research also has found that chronic job insecurity is a strong predictor of deteriorating health, even stronger than smoking or high blood pressure.

Job insecurity can lead to unhealthful behaviors like smoking, a Canadian analysis concluded, and avoidance of healthy behaviors like exercise and taking needed vacation and sick time off. It may even increase the risk of work-related injury and illness.

The relationship between job insecurity and health may depend on job type, economic conditions — how readily a laid off worker can land a new job — and workers’ attitudes about their employment and health. Case studies suggest that availability of social support and services for laid off workers may be differentiators for wellbeing.

#BREAKING: Yahoo to cut 1,700 workers as CEO tries to save her own job.

— NBC Bay Area (@nbcbayarea) February 2, 2016

Real Leaders Lead: Alternatives to Layoffs

Honeywell CEO Dave Cote doesn’t have a perfect record when it comes to worker well-being, but his decision to favor furloughs over layoffs during the Great Recession serves as a Harvard Business School case study on how to maintain competitive edge during economic downturns and recoveries. Cote’s process should be required reading for execs who succumb to arguments that layoffs are inevitable.

The benefits of using layoffs to manage costs during a recession didn’t make economic sense…

— Harvard Business School

The Wall Street Journal offers a tip sheet suggesting alternatives to layoffs.

Lessons about support for laid off workers also can be learned from the Unnatural Causes video comparing Electrolux layoffs in the US and Sweden and the Nokia Bridge program that granted seed money to laid off workers in Finland.

For workers in America, if you worked at a company like General Electric it’s more like you get a month’s salary and go. They lock the doors on the day you are fired. At Nokia there were people who knew they were going to be laid off in six months and were able to stay at Nokia with a Nokia email address with the Nokia laptop and spend time applying for new things, and Nokia helped them.

— Ari Tulla, laid off Nokia employee, now co-founder and CEO of BetterDoctor (quoted by BBC)

Karoshi: Death by Overwork in Japan

February 17, 2013

As American managers puzzle over how to help employees “thrive” at work, Japan struggles at the other end of the spectrum — how to keep employees from working themselves to death. Karoshi, literally translated as “death from overwork,” is an officially recognized cause-of-death in Japan. In the United States, one of the few countries where employees work more paid hours than Japanese employees, we commonly think of karoshi as someone else’s problem. But is it?

Karoshi is a well known phenomenon in Japan, where victims commonly work 14-hour days, seven-day weeks and die at an early age. Some karoshi victims have been known to work 80 straight days and more than 100 hours of overtime for months at a time. This brutal regimen is rooted in a culture that reveres hard work and self-sacrifice, as well as a 1980′s economic boom that drove demands for productivity, followed by a grueling economic recession that led to deep-seated job insecurity ever since. A 2004 International Labour Organization survey revealed that more than six million Japanese were working an average of more than 60 hours per week.

The first documented case of karoshi occurred in 1969, reportedly when a 29-year-old married man working in the shipping department of Japan’s largest newspaper died suddenly of stroke while at work. The Workers Compensation Bureau of Japan’s Ministry of Labor eventually deemed shift work and overwork as the causes of the death. Five years later, the man’s family received compensation.

In subsequent years, karoshi became an increasingly known phenomenon in Japan, predominantly among white collar workers known as “salary men.” The direct medical causes of karoshi were usually heart attack and stroke. A variation of the phenomenon is karo jisatsu, suicide due to overwork. (Suicide is believed to be underreported due to its stigma in Japanese culture, but in 2009 Japan’s national police agency estimated that 10,000 suicides, of the total 30,000 occurrences in Japan that year, were related to work.)

Tetsunojo Uehata, the medical authority who coined the term, defined karoshi as a “condition in which psychologically unsound work processes are allowed to continue in a way that disrupts the worker’s normal life rhythms, leading to a buildup of fatigue in the body and accompanied by a worsening of preexistent high blood pressure and a hardening of the arteries, finally resulting in a fatal breakdown.” More specifically, karoshi is linked to crushing workloads, relentless hours, absence of work/life balance, and silent suffering with no outlet to express dissatisfaction and no influence over work conditions.

In 1994, the government’s Institute of Economics estimated the number of karoshi deaths at around 1,000 or 5 percent of all deaths from cerebrovascular and cardiovascular disease in the 25 to 59 age group.

Some researchers have drawn a connection between the Japanese prevalence of karoshi and the nation’s commitment to lean production, the efficiency-above-all else approach to manufacturing that ultimately helped spawn the Lean Six Sigma approach that has taken American industry, especially healthcare, by storm.

One of the most notorious cases of karoshi occurred in 2002, when Kenichi Uchino, a 30-year-old manager of quality control at Toyota, collapsed dead at 4am — at work — having perservered more than 80 hours of overtime each month for the previous six months. Toyota and the Japanese government refused to compensate Uchino’s family, arguing that much of the overtime was voluntary and unpaid. Japanese courts didn’t buy it, and the family was compensated by both the government and Toyota. (Compensation for karoshi has been reported to frequently be the equivalent of $20,000 per year and up to $1 million dollars in punitive damages). The case led to systematic reform — new government regulations limiting overtime and promoting work-life balance, and corporate reforms, as well.

According to an insightful article by British journalist Emma Holmqvist

In response to mounting pressure, many Japanese companies are now making an effort to establish a better work-life balance… Toyota has upped its game, and has attempted to limit overtime to 360 hours a year, which amounts to about 30 hours monthly. Meanwhile, some companies run recorded announcements to urge their staff to go home or take a break at certain times, while firms such as Nissan have introduced telecommuting to ease the burden of employees with children. Taking the overtime issue more seriously still, a string of large corporations have begun operating with days strictly prohibiting overtime, requiring staff to leave the office promptly at 5:30pm.

But the extent to which these changes have influenced rates of karoshi is unclear. Widespread reports suggest that Japanese workers continue to work exorbitant overtime hours — off the books (“cloaked overtime” or furoshiki). And cases of overwork leading to non-disabling illness and to neglected health are not tracked. Indeed, the nature of the culture is that even true cases of karoshi, for which victims’ families can be compensated, are not likely to be reported. Some have speculated that the reigning issue has shifted — from prevalent work-related stroke and heart attack to a greater prevalence of work-related suicide.

Does karoshi exist in the United States, one of the few industrialized nations where employees work more reported hours than Japanese employees (though it’s believed that the Japanese tip the scales with cloaked overtime)? Some writers have drawn comparisons, such as Matthew Reiss writing on American Karoshi in the New Internationalist, and a Bostinno.com post called Karoshi: How Chronic Long Hours May Kill, And How Startup Life May Point to the Future.

American culture differs from Japan’s. In the United States, individualism reigns supreme. And the U.S. tradition of organized labor and workplace regulation reflects a different attitude toward the employee/employer relationship. Perhaps the difference in Japanese and American approaches to karoshi can best be illustrated with this observation: Whereas Japan has been criticized for sweeping karoshi under the rug, the U.S. has given karoshi little attention beyond one company’s development and the subsequent popularization of the video game “Karoshi: Suicide Salaryman.”

When it comes to employment and health, are Americans having strokes and heart attacks — or committing suicide — after suffering in silence under crushing workloads? Or is something else at work? We’ll get to that in an upcoming post.

Buddy System Trumps Incentives in New Study

A study that flew under the radar of most wellness professionals may have major implications for our understanding of how to influence health behavior and the role of outcomes-based incentives.

The study, published in the Annals of Internal Medicine, compared HbA1c improvements in three groups of diabetic patients:

A group provided with telephonic coaching (a “buddy system”) delivered by a peer who received training in motivational interviewing.
A second group offered a $100 incentive reward if their HbA1c dropped by one point after six months and $200 if their HbA1c dropped by two points or to 6.5%.
A control group.

All three groups received their usual medical care.

The study subjects were not typical workforce members. In fact, some may not have been workers at all. The study included 118 African Americans ages 50-70, with poor glucose control, being treated by the Veterans Administration. They were randomly assigned to one of three study groups and had their HbA1c drawn at enrollment and at the end of the six month study period.

For more specific information about the protocols and findings, see the reader-friendly Issue Brief or try this link for a pdf of the full Annals article.

This was not an employee wellness study, per se, but it is relevant because one of the interventions tested — an “outcomes-based” incentive in which participants earn an incentive for achieving a specific biometric value — is fast growing in popularity among employers, despite the scarcity of evidence to support it. And the main intervention offered, peer coaching, may prove to have benefit for employee populations.

It would be ideal to have more worksite-specific research, but we are better off paying attention to non-worksite evidence compared to the usual wellness approach: flying by the seat of our pants.

In this study, the peer-mentoring approach was more effective than the incentive-based approach. As stated in a patient summary developed by the Annals of Internal Medicine:

“Patients with diabetes who talked with a peer mentor on a regular basis achieved the greatest decreases in HbA1c level. Patients with diabetes who received a small monetary incentive for good control had smaller decreases in HbA1c level that were not considered clinically important.”

This can’t be considered a breakthrough study for benefits and wellness managers, but we should certainly sit up and take notice that, in one of the few studies of its kind, the intervention that honored the individual, fostered social connection, and elicited intrinsic motivation trumped the intervention that relied on cold hard cash.

June 5, 2013…

Arbejdsglaede: Happiness at Work

Things have gotten pretty dark around this blog recently, what with posts like “Karoshi: Death by Overwork in Japan” and “Bad Jobs Sicken Employees.” But now it’s time to look at the brighter side. I’ve previously mentioned that Scandinavia has pioneered research about job-related stress. Now, we learn that Scandinavian countries — specifically, Norway, Sweden, and Denmark — are the only ones that have a word for “happiness at work.” The word is arbejdsglaede. And, no, that’s not a typo.

There’s a YouTube video about arbejdsglaede (the video contrasts arbejdsglade and karoshi).

The video is oodles of fun, but I have one beef with it: It advances the conventional American notion that employers are not responsible for employee happiness, and that your happiness is entirely in your hands.

Certainly, you have some accountability for your own state-of-mind. But Scandinavian research has shown repeatedly that organizational structure and job design are the primary drivers of employee well-being. It’s futile to try to “fix” employees who struggle to survive in broken jobs.

Perhaps Scandinavians can’t even conceptualize what ails American workplaces. After all, Norway’s Work Environment Act, as an example, requires employers to tend to the psychosocial working environment “to preserve the employees’ integrity and dignity” and “to enable contact and communication with other employees of the undertaking.” And, in a strong endorsement of the demand-control model discussed in Bad Jobs Sicken Employees, the Work Environment Act requires employers to emphasize “giving employees the opportunity for self-determination, influence and professional responsibility.”

What’s more, Norway, like most industrialized nations, prohibits excessive overtime. The U.S. does not.

And Norway mandates that employees receive at least 21 days of vacation each year. Denmark and Sweden — where they also have the term arbetstidsförkortning, which means “work shortening” – require a minimum of 25 days of vacation. How much vacation are American employers required to grant employees? Oh, that’s right: Zilch.

So go ahead and grab yourself some arbejdsglaede – happiness at work — if you can find it. But don’t be too hard on yourself if you can’t.

August 3, 2010…

Biometric Health Screenings: More is Not Better

Annual biometric health screenings should not be considered an indispensable component of employee wellness programs. Despite being dubbed the “backbone” of wellness by some organizations, we should shake loose their status as sacred cow.

Most established wellness programs include annual biometric health screenings — either a lipid panel (including cholesterol and triglycerides, with glucose often thrown in) or a full panel of lab tests that’s likely to include several liver and kidney function measurements. Some screening vendors go so far as to push the aptly criticized prostate specific antigen (PSA) test; others hawk population-wide bone scans for osteoporosis — a test they really can’t begin to justify for, say, healthy male employees.

We must, unquestionably, strive to have everyone — companywide, nationwide, and worldwide — 100% up-to-date with necessary preventive health screenings. But in some of our employee wellness programs we overcompensate and naively act (and spend) like there’s no such thing as too much preventive care.

A different view is held by the United States Preventive Services Task Force (USPSTF), a panel of experts convened by the US Public Health Service to rigorously evaluate the merits of preventive procedures, including screening tests. The USPSTF came into the limelight in 2009 when they recommended against routine mammography for women in their 40s. But they were caught in the crossfire of the health care reform debate. In fact, since the 1980s the panel has released and updated prudent screening guidelines based on ever-changing evidence of their benefits and risks. Your physician may advise more frequent screenings based on your personal circumstances, but most likely he or she looks to the USPSTF guidelines as the gold standard.

By all means, conduct your annual employee screenings if you have good reason for doing so. But understand the benefits and the very real risks, take a look at the USPSTF guidelines to at least get a sense of their criteria, and consider the following:

There are no screenings that are recommended annually for the majority of healthy adults.
Employees with health conditions (like high cholesterol) that need to be monitored should be tested under the supervision of their physician, not via a worksite screening.
All screenings have risks. For most preventive screenings, risks include false negatives; false positives; and getting follow-up tests or even treatments that may not be necessary, with the potential for unsatisfactory outcomes, clinical complications, and financial burden. Fainting, hematoma, excessive bleeding, and infection are risks associated with blood draws.
The value of a screening is related to the safety, effectiveness, and availability of treatments for the health condition the screening is intended to identify.
As you prepare to commit thousands of dollars to your company’s annual cholesterol screening, consider the recommendation of the National Cholesterol Education Program regarding how frequently low-risk adults should be tested: Once every five years.
Excessive screening is a part of the health care problem, not part of the solution. It reinforces the construct that a relatively effortless invasive medical procedure — with all its appeal to data-obsessed execs and to the worried well — is the basis of health, as opposed to, say, exercise and healthy eating.

In self-care and health consumerism programs, we educate our employees to be judicious in their use of health care services. Why, then, would we model excessive use of preventive services? Just because it’s preventive does not mean more is better.

May 15, 2011…

Be Afraid: Behavioral Economics and Outcomes-Based Wellness

In their disjointed but best-selling book, Nudge, Richard Thaler and Cass Sunstein promulgate a trendy school of thought known as behavioral economics. The gist of their position is that bureaucrats are smarter than the rest of the “mindless Humans” (to use their term) and therefore obligated to manipulate our decisions to save us from our hopelessly irrational selves.

The manipulation is called a nudge — “shove” doesn’t sell books. The bureaucrats, those creating the nudge, are “choice architects.” Of course, truth be known, choice architecture has been around as long as Phillip Morris — longer even.

Thaler and Sunstein spin a web to persuade us that a hodgepodge of existing or proposed social initiatives have a common behavioral economics thread. Men’s-room hygiene, substance abuse, fast driving, organ donation, popcorn consumption, and 401(k) enrollment get lumped together as the playthings of choice architects who, for some reason that’s never made entirely clear, possess greater powers of reason than the rest of us.

The absence of any obvious connection between the various behaviors the authors choose to tackle makes the whole mess difficult to dispute. Inevitably, some of their tactics will serve us well. But does “nudging” men to aim for the center of a urinal qualify as behavioral economics? Is it really comparable to the complex problem of obesity? Is it anything at all?

Biometric Intrusions

Meanwhile, corporate-benefits-managers-gone-wild have taken the popularity of behavioral economics — and its zeal for financial incentives — as license to do whatever they want, brandishing their copies of Nudge like the torches of an angry mob. In employee wellness, this is most readily visible in schemes that offer financial rewards (often in the form of cheaper health insurance) to employees who reduce their body mass index — by whatever means possible (starvation, dehydration, and fad diets are known to work well) — lower their cholesterol and blood pressure, quit smoking, or excel in the employer’s or insurer’s notoriously flawed disease management programs. Employees’ failure or success is carefully monitored with blood draws, swab tests, and other biometric intrusions.

With a hubris that would make even Thaler and Sunstein blush, the human resources and benefits elite have dubbed their programs “outcomes-based wellness,” pressing home their point that true wellness does not manifest from behaviors like physical activity, healthy eating, and stress management, but by snatching some of your blood and shipping it off to the lab. (In fairness, it’s not all their fault. Employee benefits leaders have been worked into a frenzy by being assigned to control something — health care expenses — beyond their control. Desperation does not foster rational choice architecture.)

In fact, paying employees, or risk-rating their health insurance, for achieving pre-determined medical test results, is not an outcomes-based wellness program any more than paying a high schooler to increase his SAT score makes him a genius. No, these are not wellness programs at all. They are medical surveillance initiatives.

Scant Evidence

Employers are quick to point out that, in the insurance world, premiums have long been tied to levels of measurable risk. You pay more for homeowner’s insurance if you live in a flood plain, more for auto insurance if you’re a young male, and even more for life insurance if you smoke cigarettes or have out-of-range biometrics. But, then again, when your life insurer samples your blood, they don’t call it a wellness program. It’s risk-rated insurance — plain and simple. Wellness professionals should vehemently resist the euphemism “outcomes-based wellness,” as it undermines years of hard work genuinely promoting healthy lifestyles and achieving positive outcomes in an environment that respects employees.

Don’t be fooled. There is scant evidence that paying employees to achieve healthy outcomes, or penalizing them for unhealthy outcomes (Nudge’s preferred approach), is an effective strategy for improving health or controlling health care costs. Certainly there is not enough evidence to overshadow the research that suggests that incentives do not work either to motivate sustainable behavioral change or to improve health outcomes. Incentives may even reduce motivation.

In the words of The American Cancer Society, The American Diabetes Association, and the American Heart Association, published in their joint issue brief, Financial Incentives to Encourage Healthy Behaviors:

Based on evidence to date, … offering health promotion services such as smoking cessation programs, fitness centers, weight loss programs and exercise classes on-site, and offering healthy vending and food choices throughout the workplace environment will be more effective in improving employee health – and reducing employer health care costs – than applying financial incentives through their employer sponsored insurance plan.

Recycle your copy of Nudge — it will better serve society reincarnated as an eco-friendly fast-food container — and read the brighter and more evidence-based Drive (by Daniel Pink), or even Punished by Rewards, by Alfie Kohn, for the other side of the story.

Don’t Nudge. Drive.

Behavioral economics, formerly the darling of the Obama administration and, more recently, the Cameron administration in the UK, is gradually being nudged out of government. Only time will tell if this leads to the long overdue recognition of behavioral economics as the “Emperor’s New Clothes.” There’s nothing there at all.

Compare Nudge to Drive. Then you can make an informed decision about which approach (if you feel compelled to choose one) is truly most likely to evoke sustainable health behavior change. And, while you’re at it, consider which underpinnings — Nudges’s “libertarian paternalism” versus Drive’s “autonomy, mastery, and purpose” — are most likely to support other important business goals, such as employee engagement, trust, retention, and, ultimately, productivity.

March 27, 2012…

Behavioral Economists Challenge Outcomes-Based Wellness Incentives

I’ve had to eat so much crow since I started posting on this blog, you’d think I would’ve acquired a taste for it by now. My latest sampling was served up courtesy of behavioral economists and their connection, or lack thereof, to outcomes-based employee health incentives.

In one of my least popular posts ever, Be Afraid: Behavioral Economics and Outcomes-Based Wellness (May 2011), I criticized corporate benefits managers who, I argued, relied on the research of behavioral economists to…well, do just about anything they wanted. (I specifically targeted my criticism to the authors and readers of behavioral economics manifesto, Nudge.) I wrote:

“In employee wellness, this is most readily visible in schemes that offer financial rewards (often in the form of cheaper health insurance) to employees who reduce their body mass index, lower their cholesterol and blood pressure, quit smoking, or excel in the employer’s notoriously flawed disease management programs….There is scant evidence that paying employees to achieve healthy outcomes, or penalizing them for unhealthy outcomes, is an effective strategy for improving health or controlling health care costs.”

Imagine my surprise, while researching yesterday’s post about a study showing intrinsic motivational strategies to be more effective than outcomes-based incentives, to learn that the research was co-authored by prominent behavioral economists Kevin Volpp, MD and George Loewenstein. Volpp is Director of the Center for Health Incentives and Behavioral Economics at the University of Pennsylvania, and is one of of the most frequently cited researchers studying health incentives. Loewenstein is Professor of Economics and Psychology at Carnegie Mellon University and director of the Center for Behavioral Decision Research.

Further investigation led to an intriguing article Volpp and Loewenstein (and others) published in the New England Journal of Medicine in August 2011. In the article, Redesigning Employee Health Incentives — Lessons from Behavioral Economics (a must read if you have any interest in health incentives) — the authors advise caution in applying their pro-incentive research to the employer environment.

They wrote:

“Although it may seem obvious that charging higher premiums for smoking (or high body-mass index, cholesterol, or blood pressure) would encourage people to modify their habits to lower their premiums, evidence that differential premiums change health-related behavior is scant. Indeed, we’re unaware of any health insurance data that have convincingly demonstrated such effects.”

Volpp, Loewenstein and their co-authors describe tenets of behavioral economics — for example, that incentives need to follow desired behaviors as immediately as possible and that their effects are diminished when they are bundled (like premium discounts or cash rewards bundled in paychecks) — that lead them to hold little hope for the type of health incentive strategies many employers currently have in place.

The authors conclude:

“The effectiveness of outcome-based wellness incentives is uncertain, and their use raises concerns about distributional equity; nevertheless, these approaches are gaining momentum because of rising health care costs and payers’ belief that incentives should work in health care as they do in other spheres.”

I couldn’t agree more. Outcomes-based programs are based on belief. It is a house of cards purportedly built on a foundation of research. But the researchers are saying, “Not so fast.” Ultimately, Volpp and Loewenstein suggest that the momentum of the outcomes-based bandwagon may be unstoppable, and sensibly advocate testing a variety of designs to identify what works.

In my “Be Afraid” post, I criticized outcomes-based incentive proponents, and the behavioral economists they invoked, for imposing on employees an intrusive and unproven incentive system. Turns out, I prematurely judged the behavioral economists, whose work was being used to defend a practice about which, as it turns out, they are skeptical.

In the employee wellness arena, we need to cultivate healthy, constructive skepticism to counter the complacency that risks hindering our innovation, our evolution and — especially as it relates to our desperate strategies to contain health care costs — our wisdom.

Intent-to-Treat: It Counts

This entry was posted on March 6, 2012, 10:33 pm

If you’ve ever conducted an evaluation of your tobacco cessation program, you may be familiar with the distinction between intent-to-treat and responder quit rates. In case you’re not familiar with these terms, read on. Not only will knowledge of these methodologies inform your future evaluations of all your health promotion programs, but it will help you:

Identify the interventions that are best to offer your employees.
Present outcome data on your program’s interventions — not just tobacco cessation, but interventions for any health risk — in a more credible manner.
More readily identify “spin,” when it is applied to the success rate of treatments — for example, weight loss programs — in the lay press and in peer-reviewed journals.

Usually, in an employee wellness program, tobacco cessation programs are evaluated based on participant surveys conducted six months and/or one year after completion of the program. In the survey, the participants are asked whether they are still tobacco-free. (A few programs, especially pharmaceutical studies and some of the new so-called outcomes-based wellness programs, use cotinine tests.)

The two fundamental models for analyzing results are:

Intent-to-treat, in which the denominator includes all the participants who started the program. This leads to calculation of a lower quit rate.
Responder quit rate, in which only the participants who were reached for the survey and who responded are included in the denominator. This leads to a higher quit rate compared to the intent-to-treat rate.

Responder Analysis

Here’s an example: Let’s say 100 people participate in your smoking cessation class. One year after the class concludes, you attempt to survey the participants by phone, email, and snail mail. Fifty participants complete your questionnaire. Of those 50 people who complete the survey, 25 are still smoke free. Based on a responder methodology, your quit rate is 50%. That is, 50% of those who responded to the survey were smoke free.

Intent-to-Treat Analysis

Using those very same results, let’s calculate the intent-to-treat rate. You have 25 people who successfully quit, but now your denominator is 100 — the number of people who started the program (regardless of how many of them didn’t respond to your questionnaire or dropped out of the program). Your intent-to-treat quit rate is 25% — that is, you’ve established that 25% of the 100 people who started the program have quit.

Even if you used cotinine testing, you could still have an intent-to-treat methodology which counts everyone who started your program. The alternative would be to use as the denominator everyone you actually tested, disregarding those who dropped out of the program or were unreachable. In this case, your alternative is not called a responder quit rate — it may be called a per-protocol rate.

Neither the intent-to-treat rate nor the responder rate is incorrect. The intent-to-treat rate is more conservative. The responder rate more specifically measures the strict effectiveness of the intervention without regard, say, for adherence. It’s possible that the actual quit rate lies someplace in between the two calculations, as it’s entirely likely that some of the participants who did not complete your questionnaire did, in fact, quit smoking. On the other hand, when the percentage of participants not measured is large, the responder rate is almost certain to overstate the success of the program and sweeps under the carpet what is likely a large nonadherent population. Indeed, the response rate (percentage of participants who responded to the survey) must accompany any report of a responder quit rate.

When I present results of smoking cessation programs I oversee, I’m likely to present both rates, and to educate my audience about the difference. For quality improvement purposes, I prefer the intent-to-treat measures.

For a more detailed discussion of tobacco cessation (specifically, quit line) evaluation, including a detailed discussion of intent-to-treat vs. responder quit rates, see the North American Quit Line Consortium’s issue paper, Measuring Quit Rates.

Relying on responder or per-protocol analysis is a favorite strategy of weight loss marketers. Have you ever wondered how any weight loss intervention can boast high success rates, when all you have to do is look around (and read a few studies) to know that most don’t work? Weight loss programs use short measurement periods (a year or less) and per protocol rates to veil the fact that after 12 months, a large proportion of their participants have either dropped out or are in the process of relapse.

When you read studies or other reports of successful interventions, look for intent-to-treat methodology, or at least an acknowledgement of alternative methodology, as one sign of credibility.