Are healthier workers really more likely to be program participants?
Study indicates work environment has a greater influence on employees
For years, conventional wellness wisdom has held that healthier employees are more likely to participate in wellness programs than those with less-healthy lifestyles. This challenging irony has frustrated wellness professionals for years. How can we get the employees who really need our programs to participate?
Now, a study published in the American Journal of Health Promotion challenges that long-held assumption.
"This study failed to find consistent support for the position that only healthier workers are likely to participate in health promotion activities,’’ wrote the authors of Worksite Health Promotion Programs in the United States: Factors Associated with Availability and Participation. "There were few, if any, systematic differences in participation for workers with healthy attributes (e.g., good to excellent general health), compared to workers with non-healthy attributes (e.g., fair to poor general health)."1
The study, called the National Health Interview Survey, is conducted yearly by the National Center for Health Statistics, Hyattsville, MD, which is part of the Centers for Disease Control and Prevention. This latest study, based on 1994 statistics, polled 100,000 people across the United States, including a random sample of 5,219 employees at companies of 50 or more workers.
"This is a very well-established study," asserts James W. Grosch, MBA, PhD, a research psychologist with the Cincinnati-based National Institute for Occupational Safety and Health and lead author of the study. "What you learn from this applies to the general population."
Each year, he explains, the core of the study remains constant, and a single module is added. "In 1994 we had a supplement added to look at work site health promotion programs."
The numbers don’t lie . . . do they?
Grosch stands firmly by his study’s findings. "What we did was look at participation as a function of these different health measures," he explains. "You might expect people who are healthier to do more. But we didn’t find consistently higher participation across health measures — it just doesn’t seem that a person who is healthier is more likely to participate."
Statistically speaking, there was no significant difference in participation in 22 of 24 measures used by the researchers.
In the two instances in which there was a statistically significant difference, workers not reporting high blood pressure were more likely to use exercise facilities than those who did, while workers with a body mass index (BMI) of less than 20% above their ideal were less likely to participate in at least one health promotion program or facility of any kind than workers whose BMI exceeded 20%.
Still, not all wellness experts are convinced by the study. "My experience at Conoco for 11 years and experience working as a consultant for five years with corporate, hospital, academic, and community groups have always found a similar dynamic: The people who are already exercising, interested in nutrition, and so forth, are the ones who are the most regular, consistent utilizers of health and fitness facilities and programs," asserts Karen Carrier, wellness consultant and president of Human Solutions Inc. in Houston.
"I have experienced a 20-60-20 bell curve-type effect," she continues. "The top 20% come no matter what you do, but they were very interested and active before your program. The middle 60% sign up, participate for a short while, drop out, and relapse into old behaviors. The bottom 20% want nothing to do with the program and put active energy into resisting any kind of participation."
Perhaps, Carrier suggests, the disparity has to do with the definition of "participation." As Grosch admits, his study was "broad-based," and defined "participation" as "participation in at least one exercise program, or use of at least one exercise facility." In other words, Carrier’s "drop-outs" might be counted in the study as "participants."
Still, the study has its supporters among health promotion professionals.
"I’ve always thought that [the link between health and participation rates] tends to be more associated with fitness programs," notes Robin Foust, PAHM, of Slabaugh, Morgan, White & Associates, a Richmond, VA-based firm specializing in employee benefits and health management services. "I haven’t found that to particularly be the case with more broad-based health management programs."
Joe Leutzinger, PhD, director of health promotion at Omaha, NE-based Union Pacific Railroad, can see merit on both sides of the argument.
"There are typically two groups who tend to participate — those who want to verify the fact that they are healthy, and those who are pretty certain they have a health problem," he says. He also notes that certain work groups or job types help dictate participation. "For example, it is easier to reach employees who are on regular shifts vs. those who are on irregular shifts," he says. "But I would certainly agree that participation is not simply related to health status."
It’s the environment!
Despite their divergent opinions and the relationship between health status and participation, there’s one finding in the study that drew unanimous agreement: "Attempts to increase participation should look beyond individual, health, and organizational variables to specific features of the work environment that encourage involvement in health promotion activities."1
"People often talk about a certain organizational culture that supports participation," explains Grosch. "It has to do with how the program is promoted; how seriously it is presented to the employees; and how seriously they are encouraged to participate. Some companies adopt a wellness program because it’s become the thing to do,’ while others take it real seriously and make it part of the culture. There’s a general understanding among employees of what’s important — of the values a company has. If health promotion is one of these values, it could lead to higher participation."
One simple way to communicate that value, suggests Carrier, is to offer health promotion activities and use of facilities on company time.
"It’s a very simple strategy for increasing participation, but very few organizations do it," she says. "It has been done routinely in many companies for years for safety programs. Because most organizations still do not value preventive health and wellness activities as much as they do safety activities, most organizations still require employees to participate in health promotion activities on their own time or to make up the time later."
Foust agrees. "If you have a supervisor who is not willing to let you off to participate in an activity that will benefit you, you’re not likely to ask."
The values held by employee leaders are also extremely important, adds Leutzinger.
"A lot of [participation] is driven by the whole informal leadership group," he says. "If the right people — who are respected by their peers and looked up to — say it’s OK, then it’s OK."
How your programs are positioned and promoted can also have a significant impact on participation, says Foust.
"For example, some of the more successful smoking cessation programs have even advertised by saying things like, Smokers Wanted!’ With this approach, rather than a flyer saying, Stop Smoking!’ you may have employees who are not ready to stop come to the program, and be able to possibly move them along in their readiness for action."
Availability of programs in general may need to be better communicated, adds Grosch, simply in terms of letting employees know what’s available, and when.
You must also be sensitive to what employees want and need — such as confidentiality. For example, many employees don’t want everybody else to know they have high blood pressure or that they’re trying to lose weight.
"If they attend classes, everyone there may see they’ve failed again,’" says Foust. "New delivery models through the Internet and CD-ROM might therefore bode well for increased participation."
Knowledge of the latest behavior change theories can give wellness professionals valuable insight into what makes employees tick, says Foust.
"The conviction/confidence model, developed by the Bayer Institute for Health Care Communi-cation, as well as the Stages of Change model, can be very helpful," she says. "If those are in place, you are more likely to get more participants."
"We clearly need a new focus," adds Carrier. "The lay population is clamoring for newer, more sophisticated programs that include the new mind/body medicine and alternative complementary therapies information. In some areas at Conoco, participation went up 200% to 300% when we made the transition and offered programs that honored the mind/body/spirit connection."
(Editor’s Note: For more information on the conviction/confidence model, see "Choices and Changes: A New Model for Influencing Patient Health Behavior," by Vaughn F. Keller, MFT, and Maysel Kemp White, PhD, in the November/December 1997 issue of Journal of Clinical Outcomes Management, pp. 33-35.)
Reference
1. Grosch JW, Alterman T, Petersen MR, et al. Work site health promotion programs in the U.S.: Factors associated with availability and participation. Am J Health Prom 1998; 13:36-45.
Sources
• Karen Carrier, Human Solutions Inc., P.O. Box 841436, Houston, TX 77284-1436. Telephone: (713) 849-9868.
• Robin Foust, Slabaugh, Morgan, White & Associates, 7204 Glen Forest Drive, Suite 304, Richmond, VA 23120. Telephone: (804) 673-4282.
• James W. Grosch, National Institute for Occupational Safety and Health, Applied Psychology and Ergonomics Branch, Division of Biomedical and Behavioral Science, 4676 Columbia Pkwy., MS C-24, Cincinnati, OH 45226. Telephone: (513) 533-8167. Fax: (513) 533-8596.
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