Work as Opportunity and Problem When Trying to Impact Health and Risk
Summary and Keywords
Attention to population health issues is growing, and considering that people spend more time at work than in any other organization outside their home, worksites may offer a solution. For more than 30 years, many worksites have included programs to address employee health, safety, and risk. While some of these initiatives are mandated through legislation, other programs (e.g., workplace health programs (WHPs) or wellness initiatives) are often voluntary in the United States. Programs vary around the globe because some countries merge health, risk, and safety into one overarching regulated category, and there is a growing trend toward expanding these focus areas to include mental health and workplace stress. These programs can be quite innovative. Some interventions use technologies as prompts, such as mobile apps reminding employees to take medication. Other programs incorporate concepts from behavioral psychology and economics such as providing sleep pods at work and pricing healthy food in the cafeteria lower than high fat foods. Governmental incentives are offered in some countries that encourage employers to have WHPs. Yet despite the surface-level advantages of using the reach and access found in employing organizations to impact health, employees do not necessarily participate, and these programs are rarely or poorly evaluated. Furthermore, it is difficult to know how to make WHPs inclusive and how to communicate the availability of these programs. With the dual goals of directly impacting workers’ health and saving employers money, understanding how work can be a site for intervention is a worthwhile challenge to explore.
WHPs struggle to achieve documentable objectives for several reasons; theory-driven research is suggesting new ways to understand what might improve the outcomes of WHPs. Privacy and surveillance concerns have dominated the WHP conversation in countries like the United States due to fears that health data might be used to fire employees. Another concern is the need to tailor workplace health messages for diverse cultures, ethnicities, and gender identities. Two other concerns relate the power differentials inherent in workplace hierarchies to overt and covert pressure employees feel to participate and meet what is defined as an ideal level of health. While these major concerns could be difficult to overcome, several theories provide guidance for improving participation and producing positive behavioral outcomes. Employees who feel a part of their organization, or are identified with their group, are more likely to positively view health information originating from their organization. Growing evidence indicates that certain technologies might also tap into feelings of identification and help promote the uptake of workplace health information. In addition, workplaces recognized as having norms for safety and health cultures might be more influential in improving health, safety, and risk behaviors. Recognizing boundaries between employee and workplace can also be fruitful in elucidating the ethics and legality of WHPs. Finally, program evaluation must become an integrated part of these programs to effectively evaluate their impact.
Keywords: workplace health promotion, wellness programs, population health, program evaluation, mobile devices, organizational norms, stress, mental health, noncommunicable diseases, Affordable Health Care Act, OSHA, EU-OSHA, World Health Organization
Connected to Work
Most people spend approximately one-third of their waking lives working in organizations (U.S. Bureau of Labor Statistics, 2014). Regardless of where in the world people work, worksites—broadly defined as any physical or virtual place of work—have more contact with employees than most other organizations their workers encounter. In addition to the time spent formally at work, mobile devices allow—or compel—workers to check in and be accessible 24/7, thus extending worksite and work relationship contact substantially (Mazmanian, Orlikowski, & Yates, 2013; Wajcman, Bittman, & Brown, 2008). Furthermore, even people whose work is more entrepreneurial or home-based still have access to formal worksites through family and friends, and they often have professional ties to additional work-related organizations.
This consistent contact with people in the workforce places worksites in a position of potential substantial influence. This article explores both the opportunities and the problems involved in trying to impact health, risk, and safety at work. It begins with an overview of how health and safety is viewed in several countries, followed by two examples of innovative health and safety programs found in the top 20 best places to work. Next, the reasons why worksites are motivated to provide these types of services for their workforce are discussed. This information invites a discussion of the problems associated with these programs, specifically the organizational structures that facilitate and hinder WHP delivery. Thereafter, the article discusses the theoretical and empirical research that further explains why some of these programs are successful while others fail. The article concludes with a discussion of opportunities for future research as the focus on health prevention in our society is growing.
Health and Safety Programs Offered by Employers
Around the globe, worksites are being engaged to protect the health and safety of workers. One of the main reasons is that noncommunicable diseases (NCDs), often chronic, accounted for 63% of deaths around the globe in 2008, and many of these deaths were preventable (World Health Organization, 2013). These growing global trends are the reason that health associations like the American Health Association, the European Society of Cardiology, European Association for Cardiovascular Prevention and Rehabilitation, and the American College of Preventative Medicine are joining together to find ways combat NCDs through healthy lifestyle interventions (Arena et al., 2015). Workplaces are a key stakeholder identified by these international collaborations as important in helping address these alarming global health issues (Arena et al., 2015). However, workplaces have been relatively slow in creating high-quality health interventions (Kessler et al., 2003).
In the United States safety, and health programs are distinct. Governmental agencies like the Occupational Safety and Health Administration (OSHA), the National Institute for Occupational Safety and Health (NIOSH), and the Department of Labor provide oversight for workplace safety, but health and wellness programs are more voluntary. In countries other than the United States, employer responsibility for safety and health is often not separated, and these programs vary based on the social policies related to healthcare provision. For example, in Japan, the Industrial Safety and Health Law mandates that all employers provide workers yearly health checkups, including early detection of cardiovascular risk factors (Okamura, Sugiyama, Tanaka, & Dohi, 2014). In the European Union, at least 94 different hard and soft policies are now related to employer responsibility for employees mental and psycho-social health (Leka, Jain, Iavicoli, & Di Tecco, 2015). Furthermore, in 2016, the European Agency for Safety and Health at Work launched an extensive health workplace campaign that includes a focus on the aging workforce (EU-OSHA, 2016).
Researchers interested in workplace health and safety represent many social science and health fields. Parrott and Krueter (2011) in the Routledge Handbook of Health Communication suggest that much research in this area is multidisciplinary, interdisciplinary, and transdisciplinary. One dominant line of research on workplace health and safety originated in health psychology. The American Psychological Association has published a host of research in this area including the Handbook of Occupational Health Psychology (Quick & Tetrick, 2003) that pulls together research on topics ranging from occupational safety, organizational wellness programs, stress management at work, epidemiological perspectives, program evaluations, and economic evaluations. Medical, nursing, and health administration scholars have examined these worksite health programs primarily from the perspective of intervention effectiveness and economic impacts (e.g., Baicker, Cutler, & Song, 2010; Cancelliere, Cassidy, Ammendolia, & Cote, 2011; Hutchinson & Wilson, 2012; Jensen, 2011; Maes et al., 2012; Muto & Yamauchi, 2001).
Several different subfields of communication scholarship have examined WHPs. Some programs are explored through the lens of health campaign research where reach and access to employees are prominent considerations (e.g., Harrison et al., 2011). Organizational communication scholars have critiqued these programs as being sites for employee control (e.g., Ford & Scheinfeld, 2015; Kirby, 2006b; May, 2016; Zoller, 2003). Scholars also have explored organizational factors like identification (e.g., Dailey & Zhu, 2016; Stephens, Goins, & Dailey, 2014; Stephens et al., 2015; Stephens & Zhu, 2016), risk information seeking (Ford, 2016; Real, 2010), and models of healthy employees (e.g., Farrell & Geist-Martin, 2005), which could provide theoretical reasons why some people participate and others do not.
With the dramatic rise in noncommunicable diseases like obesity, as well as the fact that employees spend more time at work, U.S. government agencies like the Center for Disease Control and intergovernmental organizations like the United Nations and the World Health Organization have begun to push workplace wellness programs as imperative for disease prevention and healthy lifestyle maintenance (Kessler et al., 2003). Voluntary workplace health and wellness programs are commonplace in many U.S.-based organizations, with statistics claiming that anywhere between 50% of all U.S. employers with more than 50 employees (Mattke, Liu, Caloyeras, Huang, van Busum, & Khodyakov, 2013) and 61% of all U.S. employers (Society for Human Resource Management, 2016) offer some type of wellness program. Over the past decade, workplace wellness in the United States has become a $6 billion industry (RAND Corporation, 2014). Internationally, health organizations representing many different countries are joining together to better articulate an agenda and a set of policies aimed at conducting healthy lifestyle interventions (Arena et al., 2015). In addition to health and wellness programs, worksites have also been explored as locations to disseminate information about health-related programs like organ donation (Harrison et al., 2011).
Next, we provide examples of comprehensive wellness programs offered by two top-rated global companies according to Great Place to Work: Google and AT&T. These extended examples are provided to illustrate the breadth of some WHPs and to invite readers to consider the myriad ways these programs might positively impact health. Notably, while we present these as programs that have received considerable publicity for being creative, we also provide more balanced critiques of these types of programs later in this article.
Wellness at Google
The multinational technology company Google is listed on several U.S. rankings as a top company for employee well-being. In a 2015 survey, 96% of the 1,019 Google employees surveyed said that the company was a great place to work (Great Place to Work, 2016). Its nationwide locations are stocked with free healthy snacks for Googlers, like coconut water and fruit bars. Moreover, unhealthy items like chips and sodas are placed in less visible spots to encourage employees to select healthier options (Breene & Lebowitz, 2013). In many offices, cafeteria foods are color-coded based on their nutritional value (i.e., red is the worst option, green is the best option). To further promote healthy choices, Google cafeterias utilize small plates to encourage smaller portion sizes and, just like the snacks, place the healthiest options at eye level. The company even strategically manages the vending machines—the only food items Googlers must pay out of pocket—by pricing snacks according to their nutritional content: The more fat and sugar, the higher the price for the item. For example, a granola bar costs Googlers 15 cents, while a chocolate bar is priced at over $4 (Nestle, 2011).
Along with healthy food options, Google is steadfast in endorsing employee physical health and fitness. The corporation boasts nap pods and massage chairs for anytime use to promote a culture of well-rested and relaxed employees. Some Google locations have fitness centers and offer free fitness classes, while other sites offer subsidized gym memberships. The global headquarters, Mountain View, is home to on-site lap pools for mid-day swims and Google bicycles for employees to ride across campus. To make employees’ workspaces more customizable and comfortable, Google also offers stand-up desk options, which has been shown to improve muscle mass and burn more calories than sitting desks (Reiff, Marlatt, & Dengel, 2012). Furthermore, some Google locations offer on-site physicians, physical therapists, and chiropractors so employees have immediate access to medical care (Google Careers, n.d.). In 2015, the company upped its healthcare game by offering second opinions, virtual physician visits, and breast-cancer screenings onsite at Mountain View (Fortune, 2016).
In addition to supporting employees’ physical health, Google also promotes employee well-being through familial and social support. For example, on the company’s “How We Care for Googlers” page, Google claims that it helps employees prioritize family and personal needs through death benefits, savings plans, parental leave policies, and flexible work arrangements (Google Careers, n.d.). The company also recognizes employees through “gThanks,” a platform with which peers give kudos to one another for outstanding work. Moreover, the company holds free talks for employees such as “Search Inside Yourself,” a program that teaches employees how to engage in mindfulness and emotional intelligence (Essig, 2012).
Mobile Health and Safety at AT&T
In addition to the innovative wellness programs employers offer, some companies have been recognized for their commitment to safety, broadly defined here as workplace safety as well as disaster and emergency risk. Another highly ranked exemplar addressing both wellness and safety concerns is AT&T, Inc., a transnational telecommunications company, according to Great Place to Work. Specifically, AT&T is at the forefront of mHealth initiatives for its employees. The company’s primary initiative, AT&T ForHealth, is described by the company as “a practice area that is accelerating the delivery of new wireless, networked, and cloud-based solutions” to help both AT&T and the healthcare industry at large reduce healthcare costs and improve the patient experience (AT&T, 2012, p. 4).
The company offers the mobile platform GlowCaps, a program that sends emails, texts, and phone calls to employees about taking medication and medication refills, as well as sending medical care updates and caregiver visit reminders. AT&T is also the first company to integrate mobile disease management into its wellness program with the advent of DiabetesManager, the first type of program in the United States to be approved by the Federal Food & Drug Administration (FDA). Compatible with all U.S. cellular networks, this app provides employees diagnosed with type 2 diabetes with behavioral coaching, real-time blood-glucose data and feedback, and other self-management tools. Furthermore, this system integrates each employee’s entire healthcare experience by sending the patient’s data to their healthcare team. This procedure enables both monitoring and adjustment of the employees’ disease treatment plan (AT&T, 2012).
AT&T also encourages employees to tailor and take ownership of their health and fitness goals through Your Health Matters, an online portal launched in 2012. Your Health Matters helps employees gauge their health status and personalize their wellness goals through online health assessment questionnaires, tools for maintaining a healthy lifestyle, resources for taking care of trouble spots like tobacco use or obesity, and through online social resources. Specifically, AT&T offers online community building through tSpace, online health support groups that discuss challenges and successes, share health and wellness tips, and provide motivation and encouragement to other AT&T employees. This portal can also be used by employees’ family members to encourage household-wide health and wellness changes (AT&T, 2016a).
While many U.S. safety programs are mandated through government regulations, AT&T has taken an innovative approach to improving employee safety and the safety of the general public. For example, the company launched the DriveMode app, a component of the It Can Wait movement that helps keep drivers from texting on the road. The app is the first of its kind to be offered by a major U.S. wireless company. As of 2015, more than 75% of AT&T employees pledged themselves to the It Can Wait campaign (AT&T, 2016b). AT&T also produces emergency preparation documents for the general public that provide guidance concerning how to use mobile services during emergencies and disasters (AT&T, 2015). Notably, these programs serve multiple AT&T interests because mobile service is a fundamental part of their business model.
Defining Ideal Health and Safety Programs
What unites Google and AT&T as success stories, and as examples of the opportunities WHPs can provide for workers, is their ability to uphold what many reports and studies have identified as hallmarks of a strong wellness program. Their programs are expansive and respond to scholars’ calls for WHPs to include physical, psychological, spiritual, and social health (Farrell & Geist-Martin, 2005). The U.S. Department of Health and Human Services $10 million workplace health initiative, called Healthy People 2010, summarizes five defining characteristics of a workplace health program: (a) the environment supports employees physically and socially, (b) it links to similar employee assistance programs, (c) it promotes continuing health education, (d) it provides risk and prevention screenings, and (e) it is embedded in organizational culture. In a review of ten programs and 300 employee interviews, Berry and colleagues (2010) coined six similar pillars of a wellness program success: (a) support from multiple levels of leadership; (b) alignment with organizational culture; (c) consideration of quality, relevance, and scope of the program; (d) accessibility and convenience for both onsite and remote employees; (e) building internal and external partnerships for comprehensive wellness; and, perhaps most importantly, (f) tailored, consistent, and direct communication about wellness. Finally, in their review of wellness initiatives, Mattke and colleagues (2013) highlight five success facilitators: (a) strong communication with employees and management, (b) opportunities for employee engagement, (c) multilevel leadership support, (d) utilization of relationships and resources already available, and (e) continuous program assessment.
Regulated Versus Voluntary Workplace Safety/Risk and Health Programs
To understand why many work places offer the types of health, risk, and safety programs shared so far, it is important to understand some differences between regulated activities and voluntary programs. Because requirements for these programs vary considerably around the globe, the discussion includes only programs in the United States. The U.S. Department of Labor began regulating the health and safety of workers with the formation of the Occupational Safety and Health Administration (OSHA) in 1971. In the early formation of OSHA, the focus was primarily on workplace safety policies and regulations. During the past decade, OSHA has extended its reach into workplace health by providing guidelines for protecting employees against the avian flu in 2006 and against the influenza pandemic in 2007. OSHA is responsible for enforcement, but it also provides many training resources, and it requires organizations to document, report, and correct health and safety issues. Another key governmental organization that researches and provides recommended guidelines for health and safety is the National Institute for Occupational Safety and Health (NIOSH), a part of the Centers for Disease Control and Prevention. NIOSH provides considerable guidance for emergency preparedness, disease outbreaks, and industrial hygiene. Both agencies offer training resources designed to help workers recognize risks to health and safety and to take appropriate action before an accident occurs. These agencies try to be prevention-focused and to address safety and health violations.
Workplace health programs (WHPs), also called workplace health promotion or workplace wellness programs, are different. These programs have emerged voluntarily, and workplaces offer them for several reasons. In 2012, the RAND Corporation surveyed 3,000 employers concerning the utilization of their employers’ health programs (Mattke et al., 2013). They found that employers offer these types of programs for three primary reasons. They want to (a) improve employee health, (b) reduce healthcare costs, and (c) offer benefits that make them competitive with other employers. The RAND survey offers one of the most comprehensive and rigorous studies of employer health programs. This study was funded as part of the U.S. Affordable Care Act in an effort to gauge the role that workplaces play in providing prevention and healthcare enhancement programs in the United States. The authors of the study claim that a “clear picture is emerging regarding how employers have incorporated wellness into the workplace in 2012” (p. 35). Specifically, they argue that a holistic wellness approach includes “wellness programs that combine collection of data on health risks with interventions, wellness-related benefits such as gym discounts, and structural changes to promote healthy behaviors such as accessible staircases” (Mattke et al., 2013, p. 35).
Benefits of Workplace Health and Risk Programs
As the previous sections demonstrate wellness programs have been designed to improve outcomes for both the workplace and its workers. Previous systematic reviews have shown that WHPs can be effective—defined as both improving employee health and saving employers money—if they have committed employers, are well run and are focused on improving the health of participating employees (Mattke et al., 2013). The following section examines WHP benefits identified in research studies on programs around the globe.
Reviews conducted in U.S.-based programs have found that WHPs can improve overall health (Hutchinson & Wilson, 2012), increase employee self-esteem (Arneson & Ekberg, 2005), increase physical activity (Conn, Hafdahl, Cooper, Brown, & Lusk, 2009), and control employee obesity (Anderson et al., 2009). Systematic reviews of wellness programs in England have found that they can increase the physical activity of employees (Proper, Koning, van der Beek, Hildebrandt, Bosscher, & van Mechelen, 2003), and in Europe they have been found to positively influence the dietary behavior of employees as well (Ni Mhurchu, Aston, & Jebb, 2010; Maes et al., 2012). In his review of studies examining wellness programs in the United States, Canada, United Kingdom, and Denmark, Jensen (2011) concludes that diet-focused interventions can positively impact employee caloric intake, nutritional knowledge, and overall health. He also notes that work productivity, primarily assessed through reduced absenteeism and presenteeism, can increase by 1%–2% when organizations include dietary interventions, and that the costs of such programs are often offset by healthcare savings.
In addition to these reviews, several quality studies have found other positive outcomes related to heart hearth and skin-cancer prevention. Muto and Yamauchi (2001) found that a multicomponent workplace health promotion program in Japan was effective in improving obesity, high blood pressure, and hyperlipidemia when evaluated 18 months after the main intervention program. Through a group-randomized experimental study with a matched control group, employees who were exposed to the Go Sun Smart campaign reported less sunburn, engaged in more sun-safety behaviors, gained more knowledge of the program, and had more discussions about sun safety (Andersen et al., 2008).
In addition to employee benefits, wellness programs also have the potential to create advantages for employers. While the Affordable Care Act provides specific incentives to smaller organizations to help them create wellness programs, most organizations justify the existence of these programs through cost savings and other reasons that focus on benefits to the organization. Employers’ bottom lines are affected by poor employee health, and researchers around the globe have demonstrated that this may lead to increased absenteeism (Pricewaterhouse Coopers, 2010; Proper, van den Heuvel, de Vroome, Hildebrandt, & van der Beek, 2006; Robroek, van den Berg, Plat, & Burdorf, 2011), reduced productivity (Kuoppala, Lamminpaa, & Husman, 2008; Robroek et al., 2011; Williden, Schofield, & Duncan, 2012), and poorer work performance or presenteeism (Cancelliere et al., 2011).
The cost of healthcare will likely continue to rise from the $6.3 trillion spent on NCDs worldwide in 2010 to $13 trillion by 2030 (Atun et al., 2013). Employers, as well as governmental and nongovernmental organizations, are looking for preventative measures to keep healthcare costs low. For example, when employees have a chronic disease, indirect costs, like missing work, are four times higher than for employees without a chronic disease (Pricewaterhouse Coopers, 2010). Additionally, Bloom et al. (2011) note that presenteeism and absenteeism linked to cardiovascular diseases are estimated to cost organizations $389 billion worldwide, while mental health problems cost an estimated $1.6 trillion. Thus, WHPs have been positioned as the champion of these issues. They promote programs to help employees break bad habits like smoking; they serve as a prevention technique by fighting against chronic diseases like diabetes, and they allow organizations to play an active role in workers’ health while also achieving a return on their investment by retaining and attaining their work talent.
Challenges of Workplace Health and Risk Programs
At first glance, wellness programs seem to positively impact organizations and their employees. However, some downfalls arise when organizations communicate health and safety information to and with their workers. Scholars express two primary concerns with WHPs: uncertainty of impact and structural problems with sharing health and risk information.
Unsure About Impact
Mattke et al. (2013) report that in the United States less than 20% of employees actually participate in workplace health initiatives despite their widespread availability. Furthermore, conflicting information exists on the growth of health promotion programs over the years. Although some studies report health and wellness programs continue to rise, The Society for Human Resource Management, a U.S. human resources organization, recently published a survey polling 3,490 HR professionals. Their results showed a decline in workplace wellness programs and benefits to employees over the past 20 years—namely on-site flu shots, health coaching, nursing hotlines, and weight-loss and tobacco-free insurance premium discounts (Society for Human Resource Management, 2016). There are similar concerns around the globe. In an evaluation of 94 hard and soft psycho-social policies in the European Union, few programs have been fully assessed, and it is unclear whether they have impacted health (Leka et al., 2015). Similar unclear impacts, especially for smaller companies, exist in Japan’s effort to use annual checkups to improve cardiovascular health (Okamura et al., 2014). Scholars are working to determine exactly why employees are not participating in these programs that seemingly can only benefit them and why organizations are cutting back on certain components of these programs.
While most employers claim their health and wellness programs are successful, it is difficult to determine whether this is the case. The RAND study found that 60% of the employers surveyed said that their wellness program reduced their healthcare costs, and almost four-fifths claimed that their wellness program decreased absenteeism and increased productivity. But the veracity of these claims is questionable because only 44% of employers evaluated their wellness programs, and the quality of their evaluations varied (Mattke et al., 2013). This concern is similar to program evaluation concerns found in Japan (Okamura et al., 2014) and Europe (Leka et al., 2015).
Baicker et al. (2010) found that employers experienced a $3 payback for healthcare costs and a $3 gain for absenteeism for every $1 spent on wellness initiatives. On the other hand, a 2014 RAND report argued strikingly lower numbers: Of 600,000 employees surveyed at seven employers, wellness programs had little immediate influence on organizational outcomes. Disease management programs garnered a $3.80 ROI, while lifestyle management programs only produced a $0.50 return for every $1 spent on wellness, for an average ROI of $1.50 on all programs. In all, more research is needed to fully understand the impact of such programs.
Structural Problems with Worksites Providing Health & Safety Information
Although the structural and institutional reasons that worksites have problems influencing the health and risk awareness of their employees differ by country. In the United States, the primary issues with workplace wellness programs center around privacy, cultural differences, power differentials, and overt or covert forced participation. When these issues are raised, people often have strong opinions. For example, some scholars argue that applying subtle pressure to get people to stop smoking is a good thing because it improves overall health. In this way, worksites are clearly agents for change. But other scholars call this an abuse of organizational power (e.g., Zoller, 2003) because employees do not have a real choice in whether they participate or not (Kirby, 2006b).
In the United States, privacy rights are a central consideration for workplaces, and worksite health programs can be controversial. The U.S. Health Insurance Portability and Accountability Act of 1996 (HIPAA) was designed to protect an individual’s health information and to establish rules to govern how health information is disclosed. It is unclear whether and how commonly collected “wellness data” are covered by HIPAA. The Society for Human Resource Management recently summarized their interpretation of HIPAA and wellness programs. They claim that the regulations are confusing, and while HIPAA does cover wellness programs that are offered through an employer’s group health plan, not all wellness programs are covered by the privacy act (Brin, 2016). They raise issues of what is really voluntary participation and whether the data gathered are kept separate from employment data.
An example of questionable voluntary participation and the collection of health data is the use of technology to achieve organizational wellness goals. Technology complicates the privacy relationship between organizations and their employees. Wearable health technology, like step monitors and smart watches, can be used by employees—and their employers—to track blood pressure, heart rate, daily steps taken, vision quality, body temperature, and brain activity (Lupton, 2014a). Organizations can use this information to gauge worker health status and to make health recommendations to employees, or perhaps decide whether certain employees are too risky to retain (Ford & Scheinfeld, 2015; Lupton, 2014b). Thus, it is no longer an employee’s work product that is monitored, but his or her body as well. As Ford and Scheinfeld (2015) argue, “In addition to assessing workers’ completion of job-related tasks, organizations become a place where the entire body is audited, appraised, and encouraged to do more” (p. 288). This is an especially pertinent conversation surrounding the topic of surveillance because the employer has access to a worker’s health information (and sometimes a worker’s spousal and family-member information) not only while they are on the clock at work but also when employees leave the office and move into the personal-life domain. This fact adds an interesting dilemma to the negotiation of work- and home-life boundaries and begs the question: Is it ethical for organizations to infiltrate employees’, and perhaps their families’, lives 24/7?
Another consideration is how to disseminate wellness information to a diverse group of workers. Cultures—broadly defined as groups with shared beliefs, meanings, and behaviors—engage in health and wellness in vastly different ways (Ford & Scheinfeld, 2015). Because organizations are “the ‘containers’ of cultural diversity” (Ford & Scheinfeld, 2015, p. 282), organizational assumptions guiding the dissemination of health and risk information can come into direct tension with, and often discriminate against, employees in minority cultural groups (May, 2016). Specifically, Ford and Scheinfeld (2015) argue that sexual orientation and gender are two cultural dimensions in which organizational health biases become apparent. For example, even if workplaces promote inclusivity of LGBTQ employees, that does not always mean these employees receive the same health coverage. Although the Supreme Court of the United States ruled for same-sex marriages and calls for organizations to recognize all partners as spouses, companies that independently insure workers are not legally required to provide healthcare coverage to same-sex spouses (Silverman, 2015). Furthermore, it is widely known that men and women have different health needs. However, research shows that organizations often offer a “one-size-fits-all” healthcare policy that disadvantages women while benefiting men (Zoller, 2004).
Employers hold considerable power over employees who need a job to live. Recent research suggests that workers of different status, i.e., knowledge workers versus labor workers, interpret policies differently (Stephens & Ford, 2016). In workplace wellness programs, this could mean that some workers feel pressured to participate in programs. Another possibility is that lower-level and hourly workers may not be provided opportunities to participate in wellness programs. These hierarchical and job role differences may exclude some workers.
Distrust in Covert Approaches
In addition to the more hidden power differentials, some WHP programs use a covert approach to get employees to care for and improve their health. In a case study examining the results of a company’s mandated mountain climbing program, Kirby (2006b) found that many employees felt pressured to quit smoking and/or lose weight in the six months between the announcement of the company mountain climbing event and the actual climb itself. Zoller (2004) examined employee reactions to the development of a health and recreation center at a car manufacturer. She found that depending on how health initiatives are implemented, dominant approaches may actually create resentment among organizational members toward the organization. Multiple factors are associated with their negative reactions and lower participation, including the failure to sufficiently target programs to employee needs, the development of divisive gender issues, and reliance on disciplinary models of health (Zoller, 2004).
Theoretical Considerations for Workplace Health and Safety/Risk Programs
Much of the research that has explored using workplaces and other organizations for health interventions has focused on the fact that these centralized locations where people gather have access to members who are a captive audience (Krueter, Alcaraz, Pfeiffer, & Christopher, 2008). Logistical issues offer a key reason to examine worksites for the implementation of health and risk programs, but organizational scholars tend to consider theoretical reasons as well (Kirby, 2006a, 2006b; Stephens et al., 2014, 2014; Zoller, 2003, 2004). By integrating different disciplinary perspectives, there are many prospects for transdisciplinary research where theories can be integrated between “individual, professional, organizational, and societal systems” (Parrott & Krueter, 2011, p. 4). Worksites are a place where people can share, discuss, and engage in sensemaking—all vital processes to facilitate communicating about health (Apker, 2012).
A growing body of research suggests that the connection employees have with an organization—their identification with the organization—can influence how employees engage, interpret, and share health information (Crook, Stephens, Pastorek, Mackert, & Donovan, 2016; Dailey & Zhu, 2016; Stephens et al., 2014, 2015; Stephens & Zhu, 2016). Identification with organizations can be influenced by how organizations communicate their health and wellness programs (Farrell & Geist-Martin, 2005). Furthermore, when people participate in wellness programs, those programs play a key role in bridging between a personal and work identity (Dailey & Zhu, 2016). This area of research is grounded in an understanding of social identity theory (Tajfel & Turner, 1979; Tajfel & Turner, 1986) and the role that communication plays as people feel they belong with an organization (Mael & Ashforth, 1992; Scott, Corman, & Cheney, 1998). This can be a powerful force for influencing organizational members because people are more likely to behave like others in their group when they feel more identified (Ellemers, Kortekaas, & Ouwerkerk, 1999).
An area of research especially relevant for worksites concerns how organizations capitalize on the availability of new information and communication technologies (ICTs) like social media and mobile devices. Earlier in this article, examples were provided of companies using mobile apps and social media to actively engage workers in health programs (Great Place to Work, 2016). While it makes sense that ICTs should be considered when disseminating health information, research suggests that there are theoretical reasons that these technologies might also impact the health promotion process. For example, Stephens et al. (2014) ran an experiment testing what happens when organizations deliver health messages using a more socially relevant ICTs like Facebook. They found that peoples’ attitudes and overload perceptions were more positive when the people strongly identified with the organization. Linking their findings back to social identity theory, they also found that when people have a low level of identification with an organization, using social media to deliver a health message results in a significantly lower degree of health knowledge than using other tools like email or websites (Stephens et al., 2014).
Together, these findings suggest that strongly identified workers might pay more attention to health messages sent by their employer. Furthermore, these technologies can serve as socially relevant channels for organizations to harness member identification and effectively disseminate health information. This study did use a group of young adults in their experiment, so they caution that the use of Facebook, in particular, might not be successful with other groups. Yet the arguments they make concerning social-identity–building and social media could be used to test these types of interventions in various organizations.
In their summary of studies using social identity theory to understand workplace health communication, Stephens and Zhu (2016) developed a model explaining the key variables involved in how to increase participation in WHPs and achieve positive behavioral changes. They predict that people with high levels of organizational identification who receive a salient health message delivered through a relevant ICT will have a more positive attitude about the message and be more likely to change behavior. These scholars also recommend that future studies examine the impact of sending multiple health messages through different ICTs because in contexts other than health, this appears to have persuasive effects (Stephens & Rains, 2011). Finally, they highlight opportunities to examine the multiple identifications of workers (Scott et al., 1998) and to tailor health messages to reach different parts of people’s lives.
Organizational Norms and Culture
One of the top reasons that workplace wellness programs only achieve marginal, if any, success is a lack of employee engagement (Mattke et al., 2013). WHP programs need to meet multiple needs and social considerations (e.g., age, ethnicity, gender, and even physical location) rather than assume employees universally welcome such promotions (Zoller, 2004). To align organizational health ideologies with individual health identities, Farrell and Geist-Martin (2005) created a “Model of Working Well,” emphasizing that employees are expected to become actively involved in the creation and ongoing development of organizational health ideologies. Scarduzio and Geist-Martin (2016) expand this work by arguing that organizations must integrate whole-person wellness into their organizational cultures by moving beyond the biomedical approach to wellness and instead encouraging employees to regain and maintain physical, psychological, social, and spiritual health.
The impact of organizational norms on risk and safety information has also been examined. In her work, Ford (2016) extended the Kahlor (2010) Risk Information Seeking Model to include organizational considerations like organizational norms. She found that when employees seek risk information, the organizational norms for seeking safety information contribute significantly to that behavior. Her study essentially finds support for the importance of developing a safety culture (Ford, 2016), much like the arguments in the WHP literature that suggest developing a culture of health and well-being will influence employee health.
Safety culture and climate concerns are a reality across the globe. For example, in South Korea, there is a formal governmental program for occupational safety, but their budget for ongoing training is not consistent (Kwon & Kim, 2013). In their study of manufacturing industry employees, Kwon and Kim (2013) found that while safety knowledge and safety motivation positively influenced safety compliance, neither of these variables influenced perceived safeness of work environment—a measure of risk perception. They claim that their study reflects the limits of South Korea’s Occupational Safety and Health programs. In their comparative study between workers in Australia and Malaysia, Idris, Dollard, Coward, and Dormann (2012) found that perceptions of physical and psychosocial—i.e., work stress—safety climates in the Australian sample were stronger than in the Malaysian sample. While this study should not necessarily be interpreted as a multiple country comprehensive survey, they used a robust sample in both countries. Conservatively, we can conclude that safety climates, norms toward safety, and perceptions of risk are important, and that they vary by country.
Theorizing about the permeability of and tensions between organizational and individual boundaries represents another theoretical area relevant for research on workplace health promotion. As previously mentioned, WHPs can extend beyond the organization as companies ask their employees to log meal plans online, track their exercise routine after work, and share personal and family wellness progress through the use of online programs and wearable technology. This causes scholars to ask, how do employees manage and negotiate personal and work boundaries through WHPs? Two theories have been shown to be of particular value in this domain: boundary theory and communication privacy management (CPM) theory.
First, boundary theory explores how people compartmentalize or integrate the world around them (Nippert-Eng, 1996; Ashforth, Kreiner, & Fugate, 2000). Boundaries can be thin and weak, implying integration, or strong and more impermeable, implying segmentation. Boundary theory has been particularly useful in explaining how people navigate the work- and personal-life interface (Kreiner, Hollensbe, & Sheep, 2009). This boundary becomes particularly complicated when workplaces layer employee health—a domain that has typically been reserved for the private, home domain—into the organizational structure.
For example, Baxter and Kroll-Smith (2005) examined how the workplace nap has become an act of boundary blurring. While the nap was once an act of rebellion at work, napping—as we saw with Google nap pods—is becoming a normalized trend within many workplaces, as fatigued and drowsy employees are encouraged to stay well-rested and work with the appropriate amount of sleep. However, as Baxter and Kroll-Smith (2005) describe, although incorporating restorative naps within the work structure could improve efficiency and mental sharpness, it also “blurs the boundary between work and home, between work and sleep” (p. 51) by bringing something traditionally reserved for personal life into the public work front. By breaching this boundary, the nap could serve as a disciplining and control technique used by the workplace, as employees may be inclined to stay longer at the office.
Another interesting application of boundary theory could be how and to what effect health and risk information are integrated or segregated at the organizational level. For example, Hymel and colleagues (2011) show that workplaces traditionally take a segmenting approach to health and safety programs, and scholars like Real (2008, 2010) lament the dearth of research focused on communicating about organizational safety. By bounding and placing silos around health, safety, and risk initiatives, organizations are likely limiting the effectiveness of their programs. Hymel et al. make the case for health protection and promotion integration, theorizing the synergy and coordination of health and safety policies could lead to vast improvements in organizational outcomes, specifically improved employee health and well-being and decreased workplace illnesses and injuries. As Hymel and colleagues (2011) claim, “A healthier workforce can be a safer workforce; a safer workforce can be a healthier workforce” (p. 698). Thus, scholars interested in WHPs through a boundary-theory lens should examine the intricate, and often conflicting, implications of segmentation and integration through multilevel analyses.
Another useful theory for evaluating the implications of WHPs and wellness initiatives is communication privacy management (CPM) theory (Petronio, 2002). According to CPM, individuals make strategic decisions about how they regulate private information. People construct privacy boundaries that delineate which personal information is theirs and which information is co-owned or shared with others. These boundaries are managed through personal privacy rules, which serve as guidelines for what and how private information is to be shared, as well as with whom that information is to be disseminated. When privacy rules are broken and boundaries are crossed, boundary turbulence occurs.
The application of communication privacy management to WHPs is elaborated in Ford and Scheinfeld’s (2015) work. As these scholars argue, now that employers are playing the role of physician “the medicalization of work—as evidenced by WHPs—shifts privacy boundaries, [and] CPM helps scholars and practitioners to understand how employees manage health information at work” (p. 281). Specifically, Ford and Scheinfeld note that employees can experience boundary turbulence when employers highly encourage health and wellness programs that employees do not want to participate in. For example, a worker with an intense asthma condition might experience boundary turbulence when her workplace pushes employees to participate in a company 5K. The worker might feel pressured to participate despite her health condition, or she could feel violated and even stigmatized if she discloses she cannot participate because she is asthmatic. Hence, what was once the employee’s private health information about her asthma has now become information shared between employee and employer, and how her workplace uses her personal health information might be beyond her control. Scholars can use CPM to unearth how wellness programs can be used to disadvantage, penalize, and pressure employees in health information-sharing processes.
A Theoretical Analysis of Google and AT&T
Laying out the benefits, challenges, and theoretical applications of WHPs help researchers and practitioners better understand the impact of these programs on employees and their organizations, as well as foster a deeper, more critical analysis of WHPs. Although WHPs appear glossy and helpful on the surface, we have shown in previous sections of this article how WHPs present problematic privacy, boundary, power, and control dynamics between organizations and their workers. We will now return to our initial examples of Google and AT&T to theoretically explicate these opportunities and problems.
Google is a strong example of how wellness programs can foster employee and organizational health benefits. By color-coding cafeteria food options according to nutritional value, making unhealthy snacks more expensive in vending machines, offering gym memberships to employees, and promoting the use of on-site swimming pools and bikes, Googlers are well equipped to improve their diet and increase their physical activity. Google can also profit from these initiatives: Healthier employees can mean increased productivity, lower healthcare costs, and lower turnover. But the challenges of their initiatives must also be considered. Research shows cultural differences and power differentials affect employees’ experiences of wellness programs. Furthermore, how much Googlers identify with the company can affect how they perceive health and risk initiatives. For example, is a Google sales engineer going to experience the WHP in the same way as a Google janitor? Will these two workers have the same health opportunities and the same access to health services? Additionally, does the cafeteria offer nutritional information for pregnant Googlers, who have different dietary needs and identify with being a mother as much as, if not more than, they identify with being a Googler? These identification, culture, and power differences highlight how the WHP at Google may not be as seamless as what meets the eye.
AT&T’s wellness program illuminates the complexity of privacy and boundary concerns in WHPs as AT&T advances workplace wellness technological innovations. From the DiabetesManager to the DriveMode app, AT&T is pushing its employees to turn to their mobile devices when managing their health and well-being. AT&T’s technology services certainly make the employee healthcare experience more convenient, but this convenience can be compromised by privacy and boundary issues. Specifically, are the wellness data collected through Your Health Matters, DiabetesManager, and GlowCaps covered by HIPAA? Does AT&T have access to employee health information, or are these data reserved for employees and their healthcare team? Furthermore, is participation in AT&T’s online tools mandatory or optional for employees? And if these tools are voluntary, is there pressure from management or other employees that makes participation feel more obligatory than optional? These questions show how communication privacy management and boundary theory can be used to assess AT&T’s wellness technology services.
Trends to Watch and Future Directions for Research
The first trend to watch with worksite health and risk is the changing nature of population health. There is a strong shift toward a prevention focus, and worksite programs could be an ideal place to conduct high-quality comparison group and randomized control group studies. We have limited data in the United States on how worksites are using the provisions set forth in the Patient Protection and Affordable Care Act to incentivize workers for participating in healthy-lifestyles programs (Osilla et al., 2012). While these programs likely will be debated from a privacy-rights perspective, worksite access to people—both physically and relationally—has the potential to be a powerful force of behavior change. Understanding incentives and relating those tokens to privacy issues represents an area for research that is both theoretically interesting and helpful as companies make decisions that could influence the uptake of their healthy-lifestyle programs.
A second research trend is broadening the understanding of workplace health and wellness beyond the physical component. Scholars have found positive associations between reduced absenteeism and programs targeting physical issues like smoking, diet, exercise, and alcohol use; however, researchers need to establish a clearer link between mental health programs and their effects on organizational outcomes like absenteeism, presenteeism, and employee satisfaction (Mattke et al., 2013). In line with these calls, Scarduzio and Geist-Martin (2016) argue that scholars must consider all aspects of health: physical, psychological, social, and spiritual. This expanded view of wellness will make Europe and other countries that are writing mental and psycho-social well-being care into law the leaders in evaluating and sharing these programs.
A final important area for research is to focus on evaluating existing programs in real-world settings. This area is clearly lacking in the existing research (e.g., Leka et al., 2015; Mattke et al., 2013; Okamura et al., 2014). It is difficult for anyone to make a persuasive argument that worksites are true agents of change without a thorough evaluation. These evaluations need to be nuanced and must determine which specific wellness approaches produce which results and under which conditions (Mattke et al., 2013).
Contemplating Opportunities and Problems
Worksites may be an ideal place for health, risk, and safety interventions, but these programs vary widely around the globe. Where regulations mandating workplace safety exist, worksites seem to be agents for protecting the physical health of employees, but most of these programs are simply compliant, not innovative. In counties like Japan, where annual health exams are required, some people’s lives have been improved. But despite good intentions on the part of worksites to create voluntary wellness and health programs, it is difficult to determine whether they are effective, and participation is problematic. Furthermore, the ethical and legal ramifications of pushing employees to share private health information are also in question.
At a global population health level, we know that chronic, noncommunicable diseases are rising, and across the globe, health organizations have identified employing organizations as a key stakeholder in improving health. Based on the theories and research reviewed here, there are three major challenges that we must overcome. First, we must accept that the regulations around occupational health and safety vary by country, and we must find ways to collaborate that move beyond regulations and focus on the goal of population health. Second, we must find a way to balance our society-level need to improve population health with the individual’s need for privacy and control over his or her own health. Finally, we need more research into new communication technologies that can help us tailor interventions and deliver them in targeted, yet ethical, ways. These complex conversations about health will continue, and this is an important topic of dialogue between health and risk communication scholars. Our communication theories, past research, and program evaluation knowledge could help tackle these important societal issues.
Examining a topic like workplace health programs (WHPs) could be focused narrowly on the scholarly literature written about this topic, but that would omit considerable context. The scholarly literature provides theoretical and empirical research that both characterizes and critiques WHPs around the globe. These primary scholarly sources can be found by searching the keywords of workplace wellness, workplace health programs, and workplace health promotion. This body of literature is found primarily in the fields of health communication, organizational communication, and medicine. Additionally, exploring how nonprofit and community-based organizations influence health and risk outcomes will also broaden understanding.
In addition to the scholarly literature, topics on workplace health, risk, and safety invite further exploration into the impact of legislation. The documents cited in this article reference extensive policies found the European Union, Japan, and the United States, but there are policies worth exploring in almost every country. The U.S. Affordable Care Act is poised to undergo considerable changes in the next decade, and it could have direct impacts on WHPs. It is also worthwhile to see how some countries merge their health, safety, and risk policies, while other countries distinguish employer responsibilities quite clearly. Currently, there are serious discussions in countries like France, Germany, and Japan concerning reducing workplace stress by requiring or allowing workers to disengage electronically after work hours and on weekends. Finally, exploring the impacts between healthcare systems—e.g., private versus government—could shed additional light on the future of WHPs.
Some of the most exciting documents that can enhance an understanding of worksite health, safety, and risk programs describe what different companies are doing with their WHPs. Below are several resources that elaborate on the programs existing in 2016, but these are changing at a rapid pace. Our focus was on highly rated employers, but there are likely many novel programs associated with small employers and those who have partnerships with academic institutions who will evaluate the impact of their programs.
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