Defining A Culture Of Health In The Workplace.1 (002)

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Unauthorized reproduction of this article is prohibited Defining a Culture of Health in the Workplace Richard Safeer, MD and Judd Allen, PhD A number of groups and organizations are developing initiatives that purport to advance a culture of health including the Robert Wood Johnson Foundation and the US Centers for Disease Control and Prevention (CDC). 1 A culture of health has also been the focus of recent articles in journals such as the American Journal of Health Promotion and the Journal of Occupational and Environmental Medicine. 2–5 The increasing attention on culture is a great oppor- tunity to move employee health and well-being beyond interven- tions that have until now focused almost exclusively on the individual as the locus of change. In our experience, a supportive culture increases the effectiveness of worksite health promotion; particularly in achieving the primary objectives of lowering popu- lation health risk and of helping employees achieve lasting lifestyle improvement goals. However, much of this potential will be unre- alized if ‘‘culture of health’’ becomes a popular buzz phrase that lacks any reference to key culture frameworks and concepts. The workplace health promotion vendors, journals, and researchers appear to be rebranding the existing set of workplace programs without modifying their work so they actually align workplace cultures with health. This is a missed opportunity. Our goal is to better define a workplace culture of health and differentiate it from other approaches. Webster’s defines ‘‘culture’’ as ‘‘the behaviors and beliefs characteristic of a particular social, ethnic, or age group’’ (the workplace being the common denominator in our discussion). 6 These behaviors and beliefs are often the result of a complex web of social influences. Culture, as it pertains to health, is often embedded and demonstrated in food choices, relationships, sleep patterns, work life balance, safety precautions, and tobacco use. Health culture influences us through formal (ie, workplace policies) and informal (ie, how we spend our lunch break) mechanisms. 7 Cultural influences sometimes run contrary to a profession’s stated goal. Take for example, health care workers who regularly share foods high in sodium, fat, and sugar. Culture can be transmitted through formal training provided by leaders and the informal learning that is passed between peers. Cultures are often comprised of multiple subcultures that include unique subsets (ie, profession, work location, shift) of influences within a broader culture. 8 With this understanding of culture, it is fitting for our professional community to define a ‘‘Culture of Health’’ in the workplace to be ‘‘a web of social influences that manifests itself in shared healthy beliefs and behaviors.’’ Contrast Webster’s definition of culture with that of the CDC’s. The CDC defines culture of health as ‘‘a working environ- ment in which employee health and safety are valued, supported, and promoted through worksite health and well-being programs, policies, benefits, and environmental supports.’’ The CDC’s defini- tion says nothing about cultural beliefs, norms, traditions, peer support, and other social influences that determine the culture. While this definition speaks of assets that might influence behav- iors, it does not explicitly include the beliefs and behaviors of the employees that make up the culture. While intentional implemen- tation of health and well-being programs, policies, etc, by the employer could play a role in fostering a healthy workplace culture, these initiatives are not directed at transforming the social milieu which ultimately determines the culture. The CDC’s definition of health culture is similarly challenged by lack of specifically citing social influences such as cultural norms, shared values, peer sup- port, and the informal policies and practices that are critical determinants of a health culture. On a positive note, the Health Enhancement Research Organization recently updated their defini- tion of culture of health, which is more in line with Webster’s. 9 The goal of a culture of health initiative is to align social influences with healthy beliefs and behaviors. The individual and cultural approaches to workplace well-being are not mutually exclusive. They are complementary with the culture approach offering new tools for workplace programs. The efficacy of an exclusive focus on the culture has not been tested. Research on the best mix of individual and cultural approaches is needed. In our experience, a supportive culture provides the needed foundation for effective workplace programs. Some of the likely advantages provided by culture of health that are not inherent in workplace well-being programs include: 1. Reach the hard to reach. Unlike many health promotion pro- grams, the benefit occurs from being in the supportive environ- ment. Signing up for a program is not required to reap the benefits of a healthy workplace. 2. Maintain healthy behavior. It is easier to make progress in population health if people continue their healthy behaviors. An unsupportive culture pulls people in the wrong direction. 3. Increase lifestyle change success. While many people attempt to adopt healthy practices, most do not succeed for more than a brief period. Maintaining new positive practices is easier in a supportive culture. 4. Improve the social climate. It feels good to help others. Joining together to create a culture of health can be life affirming. We believe that the improved social atmosphere will have important health and productivity benefits. THE SPHERES OF CULTURAL INFLUENCE The culture shapes beliefs and behavior through a complex web of social influences. The complexity of cultures makes them resilient and resistant to change. In our experience, the best Learning Objectives Define the concept of workplace culture of health in the workplace and what distinguishes it from other approaches, as discussed in the editorial by Safeer and Allen. Identify and discuss the six primary overlapping spheres of influence involved in the workplace culture of health. Summarize the editorial authors’ views regarding the measurement of culture of health and evidence for the value added by this concept. From the Health Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland (Safeer); Human Resources Insti- tute, LLC, Burlington, Vermont (Allen). Safeer and Allen have no other relationships/conditions/circumstances that present potential conflict of interest. Address correspondence to: Richard Safeer, MD, 750 East Pratt Street, Baltimore, MD 21231 ([email protected]). Copyright ß2019 American College of Occupational and Environmental Medicine DOI: 10.1097/JOM.0000000000001684 JOEMVolume 61, Number 11, November 2019863 CME AVAILABLE FOR THISARTICLE ATACOEM.ORG Copyright © 2019 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited approach to achieving lasting culture change realigns multiple cultural influences. While it is difficult to capture all of the nuances and possible social influences in a single set of culture categories, it is helpful to start with an analysis of the most likely social factors. In order to focus attention on a more inclusive definition of culture, we have organized cultural influences into six primary and overlapping spheres of influence (Fig. 1). Together they provide a conceptual map for cultural analysis and change. Leadership Support Formal and informal leaders at all levels can make and break a population health initiative. 10 Among these leaders are senior executives, middle managers, and peer leaders. Similar to any other priority within an organization, if the leadership does not fully embrace employee health and well-being as a priority, it will be difficult to create a culture of health. Frequently, they are unfamiliar with how best to help. Leaders can: Serve as role models by making positive practices and health goals more visible. Align informal and formal policies. For example, insisting that people actually take agreed upon work breaks. Tie performance evaluations to the execution of the employee health and well-being strategic plan. Use healthy activities to strengthen the social climate. One method for building informal leadership support is through the creation of well-being champions. These champions are trained in how to explain current resources and upcoming programs. Champions also are trained on how to provide effective peer support. Shared Values Employee health and well-being need to be a top-tier prior- ity. 11 The benefits of the effort (aka value proposition) should have adequate appeal throughout the population. The shared value ver- biage needs to be reinforced through business objectives and tying goals to executive compensation, just like other organization imper- atives. This verbiage needs to be shared broadly and frequently with the general employee population. A workplace program should avoid focusing on a single benefit. For example, employee health and well-being programs may be promoted as a way to lower health care costs. While this benefit is true, a broader set of benefits may have greater appeal to segments of the workforce that are interested in work-life balance, lower stress, improved productivity and better morale. Norms Positive practices need to become ‘‘the way we do things around here.’’ Unhealthy behavior needs to become abnormal and unacceptable. Successful culture change is often directed at chang- ing specific norms. 12 An example is moving the norm from eating lunch at one’s desk to taking a short walk with a coworker after having lunch together. Leaders can increase the likelihood of healthy norms taking root or staying in place by engaging in these practices themselves. The institution can also influence norms through multiple levers, including policies. Many well-being initiatives lack the follow-through neces- sary to change norms. They adopt a well-being theme of the month or introduce important health topics without a follow-up strategy to make suggested behaviors into norms. Multiple cultural influences such as modeling, traditions, rewards, communication, and training (see ‘‘Touch Points’’ discussion below) must be realigned to estab- lish and reinforce the new norm. Peer Support The goal is to increase the quality and the quantity of assistance offered for adopting healthy practices. 12 Coworkers and friends are frequently the most likely sources of such support. Sometimes new support groups are formed for this purpose. For example, groups that meet to lose weight together are more likely to succeed than individuals who attempt to achieve weight loss goals. 13 The same is true of those trying to quit smoking. 14 The concept of peer support succeeding in helping members improve behaviors has also been shown to decrease health risks. 15,16 Employee health and well-being programs may not be addressing the support networks. Such programs often include group and team activities. Well-being coaches also offer a form of support that is very similar to peer support. 17,18 Temporary support systems can be useful early on in a personal change Leadership Support To u c h P o i n t s Peer Support Climate/Morale Shared Values Norms Culvang Employee Health & Well-being FIGURE 1.The spheres of cultural influ- ence. It is difficult to capture all of the nuances of social influence in a single set of culture categories. However, there are six primary and overlapping spheres of influence as demonstrated below. Together they provide a conceptual map for cultural analysis and change. Safeer and AllenJOEMVolume 61, Number 11, November 2019 864 ß2019 American College of Occupational and Environmental Medicine Copyright © 2019 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited process. 19 However, these support systems are not a substitute for the ongoing support that is available through family, friends, and coworkers. A lack of support from these peers can undermine health goals. 20 Culture change involves improving the quality and quantity of peer support found in employees’ social networks. 12,21 Touch Points Cultures have formal and informal systems for reinforcing behavior. 22 We choose the term ‘‘touch points’’ to note the various ways the work culture can ‘‘touch’’ the individual employee. Touch points can be arranged in 10 categories to make it easier to understand the various ways in which employee health is influenced by the employer. 2 Rewards and Recognition: Placing positive emphasis on healthy behaviors, actions, and messages is an excellent way of reinforc- ing these attributes. Are positive practices being undermined through rewards for unhealthy behavior? Can the current rewards systems be better aligned with health? Pushback: When the organization is endorsing unhealthy prac- tices, individuals can speak up and provide feedback to highlight the counterproductive activity. Does the culture allow employees to push back against unhealthy behavior and attitudes? Modeling: Role models in prominent positions throughout the organization are vital to making healthy behavior an acceptable part of the workplace culture. Do leaders model healthy behavior and refrain from modeling unhealthy behavior? Recruitment, First Impressions, and Orientation: The experience of how someone first views the workplace is critical in whether or not they even apply for a job, yet alone get started with how they will conduct themselves during their tenure as an employee in any given organization. Does the job advertisement include a health related message such as ‘‘We provide a smoke free campus?’’ During orientation, are new hires made aware of the many opportunities for pursuing and maintaining healthy lifestyles? Learning and Training: Resources provided to employees can be helpful. The absence of certain trainings or the inadvertent oversite during a training (offering donuts during a program) can be a detractor of a health culture. Language and Communication: Word choices, catch phrases, signs, body language, and frequency of topics are influential in how employees internalize messages. They can be supportive of, or a detriment to health. Traditions and Symbols: By incorporating healthy activities and symbols that are associated with health in to the workspace, employers can reinforce health as an organizational priority. Are there old traditions that might be adjusted so they do not undermine health attitudes and behavior? Resource Commitment: An organizational commitment to employee health and well-being without appropriate resource allocation is a shallow attempt to show concern for the population serving the mission. Resources go beyond budget and include time, marketing attention, and leadership support. Built Environment: Stairways, walking paths, shower facilities, water fountains, fitness facilities, and ergonomic design offer daily reminders of the culture. Is the physical environment conducive to healthy practices? Relationship Development: Workplace relationships can be sup- portive, friendly, and enjoyable. However, it’s also possible that workplace relationships can be contentious and stressful. Man- agement can play a role in shaping a positive experience amongst employees. Even the act of forming friendships at work, can be influenced around healthy behaviors (offering line dancing at lunch) and discouraged to be built around unhealthy behaviors (not allowing smoking on campus). Touch points are similar to formal policies, procedures, and programs that are incorporated into checklists offered by the Wellness Councils of America, the Health Enhancement Research Organization, and the CDC. Although these initiatives can influence the culture, they do not necessarily represent culture change. In addition, the existing touch points may run counter to a healthy culture. For example, raising money for a charity by promoting and selling unhealthy food is counterproductive to building a culture of health. An organization that strives for a healthy culture weaves this consideration in to all of their business decisions; just as financial impact is part of an evaluation. Social Climate The morale and social cohesiveness of groups are both health determinants and important to collaborative changes. 23 How people treat each other is immensely important in our emotional health (which in turn is critical to our physical health). Working in a supportive, non-judgmental environment is helpful. In addition, when there is a positive approach to challenges and when optimism is engrained, members of the culture are more likely to feel good about where they work. This sense of well-being is more likely to translate in to healthy behaviors. Managers, supervisors, and other leaders are critical in setting the tone within their team. Where there is a strong sense of community, a shared vision and a positive outlook, changes occur with relative ease. 21 Below are considerations when building a positive social climate: Choose uplifting language. Recognize current strengths when approaching change. People generally don’t like to be spoken of as if they are broken. Be sensitive to individuality such that employees aren’t seen as ‘‘high risk’’ or ‘‘diabetic,’’ but rather an employee with diabetes. Don’t pass judgement. Employees with health challenges aren’t necessarily disinterested in their health. Most people are actively engaged in trying to meet at least one health goal. For example, most smokers make a quit attempt each year. 24 Many however, choose to pursue their health goal outside of work. Give employees choices. Mandating employees to participate in employee health and well-being programs is a certain path to creating disgruntlement. Good effort building a positive social culture can quickly be doused by short sighted decisions. For example, promotions based on social connections (‘‘favoritism’’) rather than merit (ie, experience and skill) can be discouraging for the workforce. Note these spheres often overlap and are not distinct. For example, it is vital that leaders visibly support a health culture in the workplace. By leaders serving as role models (one touch point) of health, this shows it is an organizational priority (shared value). How that leadership support is communicated (another touch point) also plays a role in how well the message is adopted. MEASURING CULTURE OF HEALTH Recent studies do not measure the impact of culture change, but rather, the impact of following the well-being programming recommendations of the CDC, the Health Enhancement Research Organization, the Wellness Councils of America and other orga- nizations that have fostered the growth of the workplace well-being community. Most importantly, the current studies do not measure the employee perception of the health culture (eg, norms, peer support, and shared values). Cultural influences (particularly the informal influences) are not adequately measured directly in those conducting culture of health research and study. Instead, these studies examine the impact of well-being programming (ie, ‘‘check- lists’’) at the organizational and community levels. JOEMVolume 61, Number 11, November 2019Defining a Culture of Health in the Workplace ß2019 American College of Occupational and Environmental Medicine865 Copyright © 2019 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited The complexity of cultural influences lends itself to both quantitative and qualitative analysis. 25 In our experience, culture measurements must reflect both common beliefs and behaviors. Multi-method approaches, including interviews, surveys, and obser- vations are helpful in measuring the unique aspects of the culture. For example: A questionnaire assessing each of the six culture spheres of influence (ie, shared values, norms, etc.) 26–28 For example, a Likert scale that assesses the extent to which immediate super- visors are supportive of employee lifestyle improvement efforts. Interviews and focus groups used to determine the best approach to aligning cultural influences. This strategy can be used to reveal information difficult to discern through a survey. For example, a focus group may determine that employees do not feel manage- ment has a realistic understanding of their work day if health programs are only offered to certain shifts or in certain locations, thus limiting the realistic possibility of a portion of the popula- tion that can participate. Measuring the impact of policies and environmental changes. For example, measuring food and beverage sales after making changes in the cafeterias and vending machines. Building accurate, reliable and reproducible measurement processes, tools and metrics is critical for both internal success and external validation. Kwon et al, 25 takes a positive step in measuring culture by administering a survey to employees to understand their perspective of culture building elements. When we have a quality metric to measure culture of health in the workplace, this can be used as part of performance evaluations, particularly amongst executives, to hold them accountable for delivering on this impor- tant business objective. We might even get past the anecdotal stories of ‘‘healthiest workplaces’’ and provide a meaningful standard for cultures of health. Many awards programs are rather checklists of well-being programs. This checklist approach puts smaller and more economically challenged workplaces at a substantial disad- vantage. In our view, they fail to incorporate useful feedback from employees about cultural support. EVIDENCE SUPPORTING THE ADDED VALUE OF A CULTURE OF HEALTH Very few published health promotion and well-being studies examine the role of culture. 26 Other social sciences such as anthro- pology and history offer evidence that cultures vary in their impact on health behavior and attitudes. In these disciplines aggregate behavior and social context are primary. Perhaps the clearest cases of a culture of health at work can be seen in cultural support for safety. Norms for wearing safety gear, maintaining safe workspaces, and learning from accidents have changed over the past 100 years. 29 A concern for safety is also evident in the community with new norms for improved safety features in automobiles and the development of cycling and pedes- trian paths. 30 Much could be learned from this change to the culture of health. The study of the safety culture as a building block of a culture of health may be a fruitful direction for research. The culture change techniques deployed in achieving safety norms could be deployed to address other health behaviors. Studies of particularly healthy populations also provide impor- tant evidence of the value of a culture of health. Dan Buettner’sBlue Zonesexamined six such regions where people live much longer than in other populations. 31 They have unique cultures with norms that support positive health practices and attitudes. The sheep farming culture on Sardiniawas quitedifferentfrom the culturefound inLoma Linda, California with its high density of Seventh Day Adventists. Despitethemany differencesintheculturesof thesesix ‘‘blue zones,’’ there were also several commonalities. Each had a very supportive social network. It is also startling to learn the negative health con- sequences for people who move away from these Blue Zones and adopt the influences of less healthy cultures. This outcome of adopt- ing new behaviors is consistent with the community one joins has been demonstrated in Japanesemen as theymoved to Hawaii and then to California. As these men moved east, their diets changed, their cholesterol levels increased and their corresponding incidence of heart attack also rose. 32 It speaks to the power of the culture in which we live, not just the culture in which we were raised. There are employers actively engaged in culture building (in addition to implementing policies, environmental changes, etc). For example, Johns Hopkins Medicine and Ohio State University are building out well-being champion networks knowing that behavior is more often influenced by peers than by employers. 33 However, there is a dearth of research methodology available to effectively measure the impact of enhanced peer support and other cultural influences in the workplace. Nonetheless, research by Christakis and Fowler 34 make it abundantly clear the importance of our social networks in making health choices and thus employers and researchers in this space must create a path for intentional utilization of this strategy. Examples of how employers can support social networks for the purpose of promoting health include the formation of support groups for weight loss and tobacco cessation as well as creating a champion network as described elsewhere in this editorial. DIFFERENTIATING CULTURE OF HEALTH FROM WORKPLACE WELL-BEING There is a high level of interest in ‘‘culture of health’’ by employers. A global survey of workforce well-being found that 83% aspire to achieve a strong culture of well-being in the future. 35 Seeking to capitalize on this new awareness, many organizations are rebranding their initiatives under the culture of health banner, without substantive change to their approach. The culture approach is quite different from more traditional health promotion programs which focus on individual behavior change. Traditional ‘‘workplace well-being’’ programs are not specifically directed at changing the social environment. It would be a tragic mistake to adopt the culture of health brand without utilizing the many tools and helpful frameworks that the culture approach affords. It is difficult to see a direct link between culture change and well-being programs in their current form. In our experience, the vast majority of well-being initiatives are directed at individual transformation. The primary foci are personal motivation and skills. In addition, many programs remove barriers by subsidizing well- being activities and making changes to the physical environment. These are important efforts, but they are not culture change per say. It is likely that a useful measure of the impact of culture change would require those involved to address cultural influences directly. An effort to improve the quantity and quality of peer support for achieving healthier lifestyles (at work and at home) would be an example of culture change. A company’s systematic initiative to change an unhealthy norm for inadequate sleep among shift workers would be another example. CONCLUSION While we believe the pivot by those in the workplace health promotion field toward a discussion on culture could lead to positive changes for employees, we are concerned that the indiscriminate use of the phrase ‘‘Culture of Health’’ might result in little substantive change in the approach employers and vendors take in creating a healthy workplace. Edington and Pitts 36 agree that the CDC’s definition of culture of health falls short, stating ‘‘culture is also about relationships throughout the organization and how people respect, trust, and interact with each other, guided by a core set of shared values.’’ In an unsupportive culture, many of these formal Safeer and AllenJOEMVolume 61, Number 11, November 2019 866 ß2019 American College of Occupational and Environmental Medicine Copyright © 2019 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited well-being initiatives would be poorly received or ignored. Those researching culture of health should not confuse a checklist of well- being activities and programs with indicators of the underlying health culture. Although we know quite a bit about the influence of culture on health, the effectiveness of intentionally shaping the health culture in the workplace is a new frontier. By providing a framework for understanding the spheres that influence the culture within the workplace, we anticipate organizations will be able to more success- fully navigate options to support the health of their employees. We also believe that adopting a framework for building a culture of health is a necessary step toward accurately measuring a health culture. We are encouraged by the growing interest in culture of health and hope that our professional community can make mean- ingful progress on building a healthy workplace culture so that traditional workplace wellness programming can be more effective. By remembering that at the core of culture is ‘‘shared beliefs and behaviors,’’ we are optimistic that more influential employee health and well-being strategies will emerge. With cultures of health, our social connections and their influences are supportive and make it easier for a workforce to sustain positive behavior change and lower risks for disease. 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Creating a culture of health at Johns Hopkins Medicine. Am J Health Promot. 2018;32:1821–1823. 34. Christakis N, Fowler J.Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives – How Your Friends’ Friends’ Friends Affect Everything You Feel, Think, and Do.New York: Little, Brown and Company; 2009. 35. Working well: A global survey of workforce wellbeing strategies. Xerox Corporation; 2016. Available at: https://www.globalhealthyworkplace.org/ casestudies/2016_Global_Wellbeing_Survey_Executive-Summary.pdf. Accessed May 17, 2019. 36. Edington D, Pitts J. Shared Values - Shared Results: Positive Organizational Health as a Win-Win Philosophy; 2016. USA: Library of Congress Catalog- ing in Publication Data; pp. 144. JOEMVolume 61, Number 11, November 2019Defining a Culture of Health in the Workplace ß2019 American College of Occupational and Environmental Medicine867