Health Promotion and Workplace Productivity 

By Bob Karch

If a worker is adequately trained and given an appropriate tool set, does that person’s health status have any appreciable impact on his/her productivity? At first pass, the answer to this question would seem to be "yes." Similarly, when asked to respond to this same question, workplace managers, corporate executives, and business owners seem to be uniformly in agreement that healthy workers are a critical factor in any productive enterprise.

Hypotheticals

Research findings often support such intuitive responses. Over the past twenty years numerous worksite health promotion studies have quantified this relationship between good health and increased productivity. Most of these studies focused on and attempted to assess the impact of worksite health promotion programs on worker absenteeism. The basic assumption underpinning these research efforts was that one of the quantifiable outcomes of a well designed and properly administered worksite health promotion program would be healthier employees. Correspondingly, with healthier employees, less sick leave would be used. The net result is more productive hours in the workplace. For example, if a company is comprised of 1,000 workers and each of those workers is expected to work 2,000 hours per year (40 hours a week x 50 weeks), then the maximum work capacity, minus any overtime, that this workforce could apply toward productivity is 2 million hours. However, if the average worker is absent 10 sick days (8 hours per day) per year, then the actual worker hours able to be applied to productive output would need to be adjusted to 1,920,000 hours, (2 million hours – 80,000 hours) a 4 percent drop from full capacity. Let’s assume that the productivity capacity of each worker is expected to be four times his/her fully loaded salary. In this example, if a fully loaded salary is $50,000, then the expected productivity of each worker is $200,000 or $100 per hour. To calculate the amount of dollars lost to sick leave for the 1,000 workers, simply multiply the $100 per hour x 80,000 hours of total annual sick leave yielding a cost of $8 million of lost productivity. If a worksite health promotion program were to be successful in reducing the average number of sick days per worker from 10 to 7.5 days per year, the net gain in productivity would be $2 million. Further it would be reasonable to assume that a company would also experience some reduction in their healthcare expendures.

Productivity versus "presentism"

Clearly, worksite health promotion programs that help employees obtain and maintain a health status may make it possible for workers to be present in the workplace, thus generating potential savings. But additional productivity enhancements may accrue from such programs. The above example assumes that it is desirable to have workers in the workplace (well and productive) as opposed to out of the workplace (sick and unproductive). But being present does not always mean being productive. Indeed, numerous workplace productivity studies have suggested that the average worker present in the workplace operates at about 65 to 70 percent of his or her potential. Thus what is needed is maximization of the performance potential of each worker to who is present. It is in this area that the future of workplace health promotion programs will and should be founded. If a company invests in designing, developing and operating a comprehensive worksite health promotion program, addressing an array of worker needs, the potential for significant increases in the productivity of workers present in the workplace is greatly enhanced.

 Health and Productivity Management: What does this have to do with health promotion?

Adapted by Wolf Kirsten from Ron Goetzel, Ronald Ozminkowski, & Larry Yuhasz (Medstat Group)

A Role for Health Promotion

Health promotion can play a role beyond averting debilitating illness, enhancing health and well-being and thus positively impacting our personal and professional lives. Health promotion programs can address some of the most common health issues facing the overworked employee today, like for example stress. Balancing work and private life has become a challenge as employees not only work harder and longer, but have their private domains infringed upon, e.g., through cellular phones, e-mails, etc. This has led to greater stress, which in turn can lead to physical and mental disorders, e.g. musculoskeletal pain or depression. The organizational climate will eventually suffer due to low morale, burnout, increased absenteeism, turnover, etc. In addition, the costs of increased stress are measurable as illustrated by findings from a study conducted by the Health Research Enhancement Organization (see box introducing HERO). Comprehensive health promotion programs provide coping skills to deal with heightened stress as well as analyze the origins of stress, e.g., the work environment. The health promotion professional can play an integral role in creating both a healthier individual and environment, thereby improving organizational productivity. Health promotion can be a catalyst for Health and Productivity Management (HPM), an emerging business paradigm which focuses on improving the total value of human resource investments. Major challenges exist for the budding HPM movement. Productivity is hard to measure objectively outside of the blue-collar environment. Many companies measure productivity in terms of revenues or profits per employee. Related measures include absence, disability rates and safety incidents. However, absenteeism data is not always readily available, especially not for salaried workers. On top of that, the fact of being present does not account for gradations in worker output. The term "presenteeism" describes this phenomenon of being at work but not producing optimally. Therefore, it is important for employers to strive for developing tools to better quantify the value produced by employees. This will help make the connection between health and productivity. Studies in peer reviewed journals have shown that employee productivity is affected by such common health conditions as depression, migraine headache, allergies, stress, anxiety and back pain, (please see the literature citations in the sidebar for examples of such studies). It is essential that the individual units dealing with health issues, e.g., health promotion/wellness, occupational health, medical services, disease management, benefits, employee assistance programs, etc., work together and integrate functions in order to not duplicate functions. Not only must the total health of the employee be managed in an integrated manner, but total health must also be linked to the overall business goals.

Good Practices in Health & Productivity Management

The American Productivity and Quality Center (APQC) and the Medstat Group performed a benchmarking study in 1997 to identify good practices that contribute to employee health and well-being with regard to health & productivity management. Six major companies were investigated in ten different areas, which relate to employee health. The study identified ten themes that ran across all partner organizations and form a "foundation for success":

The HPM strategy is aligned with the overall business strategy.

1. There is an interdisciplinary team focus.
2. A champion or a team of champions exhibits vision and determination to make things happen.
3. Senior management and business operations are key members of the team.
4. Prevention, health promotion and wellness staff are heavily involved in the process.
5. The emphasis is on quality of life improvement, not just cost containment.
6. Data measurement, reporting, evaluation and return-on-investment studies become increasingly important over time, but integrated data systems were not built before action was taken.
7. Communication is constant and directed to all constituents throughout the organization.
8. The organizations strive to learn new ideas and approaches from others through benchmarking in order to improve.
9. The team is having "fun".

Increasing Significance for Human Resources

The increased market demands and pace of developments have forced companies to shift their outlook from a mere cost-cutting approach to a future-oriented, value-creating approach. The significance of human resources has increased in recognizing the importance of human capital with regard to corporate performance. In terms of health, this means evaluating the return of total investments in employee health. HPM is aimed at improving the total value of human resource investments. This emerging business strategy will not only grow in the United States, but, in the era of globalization, also find the attention of companies worldwide.

Examples of research articles that link health and worker productivity

Heaney, C.A., and Goetzel, R.Z., "A review of health-related outcomes of multi-component worksite health promotion programs." American Journal of Health Promotion, 11:3, January/February, 1997.

DeJoy, D.M. and Southern, D.J. 1993. An integrative perspective on worksite health promotion. Journal of Occupational Medicine, 35(12), 1221-1229.

Goetzel, R. Z., Guindon, A., Humphries, L., Newton, P., Turshen, J. and Webb, R. "Health and Productivity Management: Consortium Benchmarking Study Best Practice Report." American Productivity and Quality Center International Benchmarking Clearinghouse, Houston, TX, July, 1998.

Goetzel, R.Z., Juday, T. R., and Ozminkowski, R.J. "What’s the ROI? -- A Systematic Review of Return on Investment (ROI) Studies of Corporate Health and Productivity Management Initiatives." AWHP’s Worksite Health, Summer, 1999.

Claxton, A.J., Chawla, A.J., and Kennedy, S. Absenteeism among employees treated for depression. Journal of Occupational and Environmental Medicine, 41, 605-611, 1999.

Cockburn, I.M., Bailit, H.I., Berndt, E.R., and Finkelstein, S.N. Loss of work productivity due to illness and medical treatment. Journal of Occupational and Environmental Medicine, 41 (11), 948-953, 1999. Burton, W. N., Conti, D.J., Chin-Yu, C., Schultz, A.B., and Edington, D.W. The role of health risk factors and disease on worker productivity. Journal of Occupational and Environmental Medicine, 41 (10), 863-877, 1999.

The Health Enhancement Research Organization (HERO)

HERO is a national, research oriented, not-for-profit coalition of organizations with common interests in health promotion, disease management and health related productivity research. The HERO mission is to facilitate research that will impact health care by shifting the paradigm from a system dependent almost exclusively on diagnosis and treatment toward one with major emphasis on prevention and a more healthy and productive population. In support of this mission, HERO facilitates interaction among Sustaining Partners and others that have a common desire to collaborate on specific research projects. HERO then coordinates and manages a variety of research projects supported by HERO, private and public sector financial grants.

HERO’s objectives are:

• Facilitate interaction among organizations which have a common desire to conduct health promotion, disease management and health related productivity research.
• Create, sponsor and disseminate quality research which is the basis for programs and activities that:
• Maximize the quality of life by preventing and reversing clinical disease and correctable medical problems.
• Control health care utilization and reduce medical expenditures.
• Increase individual productivity at the worksite and throughout society by enhancing health and well-being.
• Provide an authoritative voice and serve as an advocate for health promotion, disease prevention and individual health related productivity research.

A series of groundbreaking studies performed by the Health Enhancement Research Organization (HERO) have investigated the link between health risks and medical costs. The studies were conducted by the Medstat Group and the StayWell Company, with oversight by the HERO Research Committee. The HERO database was developed by merging health risk and medical claims data from six large private and public employers. The database is by far the largest constructed for this type of research, totaling over 46,000 employees and over 100,000 life-years of data spanning a six-year period. Four separate studies have been conducted, which together provide strong support for investments in workplace health promotion.

For more information, please see the HERO website at http://www.the-hero.org/.

The Institute for Health and Productivity Management (IHPM)

The Institute for Health and Productivity Management has been established to promote the vital relationship between employee health and performance. The Institute's vision is to establish the value of employee health as a business investment in corporate success.

To realize this vision, the Institute has set four strategic goals:

1. To become a global resource on health and productivity by assembling the substantive evidence to support the value of investing in employee health.
2. To develop the tools, metrics and methods to drive and measure enhanced corporate performance through investments in health.
3. To be the champion of investing in health capital as a strategy for corporate success.
4. To educate and equip purchasers, providers and suppliers to generate greater value from investing in employee health.

The Institute's initiatives are designed to build the resource base, develop the products and deliver the message that will move all stakeholders—employers, providers, suppliers, health plans and workers—to a higher level of value from health care. As these stakeholders' incentives become aligned toward improving health and work performance, health care will have an integrating principle. This will break down the compartments within which employers have been managing health-related benefits and providers have been delivering health-related services. The result of breaking down and connecting these compartments will be:

• Better outcomes for individuals.
• Larger savings in total health-related costs for employers.
• Rational rewards for providers who deliver these outcomes and savings.
• A system that works for all the stakeholders.

Four Centers of Inquiry with teams of interdisciplinary experts have been established which examined and defined the emerging field of health and productivity management:

• Center for Health Promotion & Disease Prevention,
• Center for Workplace Environment,
• Center for Care Management (work-related injury and illness, and the impact of acute and chronic disease), and
• Center for Corporate Culture and Organizational Health. A multidisciplinary Integration and Methodology Team has been actively facilitating the work of the Centers of Inquiry. This team prepares executive reports to define and shape the emerging field of health and productivity management and continues to make a business case for investing in health to enhance corporate performance. From the IHPM website: http://www.ihpm.org/.

The Global Opportunities for Health and Work Performance Research

R. William Whitmer. MBA, President and CEO Health Enhancement Research Organization (HERO)

In many cases, the workplace is in the grip of constant change and transition. Whether it is mergers, acquisitions, downsizing, re-engineering, greater completion, reduced profits or falling stock markets that impact company valuation and individual retirement programs, we are in the most complex work environment in modern history. While these situations may affect employees in different ways, often they generate a loss of accurate perception, thought processes become faulty, creativity declines, self-esteem and confidence are reduced and acute and chronic diseases often increase. These and other factors combine to have a negative impact on work performance, which creates an escalating interest in the topic.

While there are several factors that can influence productivity, the association between health and productivity seems to be generating the most interest. Because of this, it is important to address the terms "health" and "productivity". Health is a very broad term and means different things. For example, if ten people are asked to provide a one sentence definition of health, there will probably be many different answers, some of which are drastically different. For this reason, in the HERO model, health is currently divided into four segments: 1) disease management, 2) behavioral risk modification, 3) substance abuse, and 4) organizational climate. It is possible that other specific health related variables will be added.

The term performance also presents problems. For many corporate executives and managers, productivity relates to a manufacturing like environment where "things" are made. This may not apply or be understood within the high-tech service industry. In some cases, productivity is often defined at the organizational level in terms of both output of goods or resources. There is no consideration of individual activity. Others feel that productivity relates just to profitability. Because of these varying interpretations, the HERO model uses the term "work performance", which is interchangeable with "job performance". Discussions with corporate executives and mangers suggest these terms are more widely understood. Regardless, as this new field of research moves forward, terminology will be important.

New Terminology – With increasing interest in the subject, new words are creeping into the health and work performance lexicon. One is "presenteeism". This describes something analogous to, but the opposite of absenteeism. Presenteeism refers to employees who are present for work almost always, but for a variety of reasons have work performance that is less than it could be or should be. Another is "knowledge worker". This refers to employees who produce cerebral products. Often, they use brainpower to create and activate ideas that advance the mission of the organization. Thus, it may not be long before we will be talking about and conducting research to measure the “presenteeism” of “knowledge workers”.

Current Work Performance Research – Goetzel (JOEM, January 2001) and other researchers have discussed the association between absenteeism or disability and work performance. Burton, et al (JOEM, January 2001 and 1994) have described the impact of depression and asthma on work performance. Kessler, et al (JOEM, March 2001) has presented research on the impact of a variety of diseases on work loss and work cutbacks. In the majority of these and other published health and work performance research, absenteeism, disability and/or work cutbacks have been the outcomes measured most often. While these are valuable studies and useful data, they usually do not measure the “presenteeism” of the “knowledge worker”.

What Needs to Be Done? – Because of the complexity of the work place, there is little question that the health and work performance research paradigm must move forward. In so doing, much work must be done on the work performance side of the research equation. What is needed is a fully validated work performance research data collection instrument. One with application to the internet is ideal. Recent surveys have identified several performance data collection instruments, but the levels of validity are questioned. Once the validated instruments are in place, any number of health related variables can be evaluated. The second major need is for a large scale, multi-employer health and work performance normative research database. This will permit the interpretation of the health and work performance research data that is conducted for individual employers.

A Global Situation - Regardless of the location of world headquarters, thousands of corporations are multi-national. Because of this, the association between health and work performance has major global interest. As the complexities of doing business around the world intensify, health and work performance protocols that can be used in a multi-national environment is essential. The World Health Organization (WHO) is currently conducting health and work performance research in 26 countries that could address this research need. Regardless, the next five years will be exciting as the global experience and expertise to define the “presenteeism” of “knowledge workers” moves forward.

The Rise of Productivity Measures in Health Promotion Research

Daniel Gold, PhD, StayWell

A new focus has emerged in health promotion research in the United Statess—a rapidly growing interest in productivity measures. Perhaps learning from our counterparts abroad, the health and productivity management (HPM) movement has broadened the perspective of worksite health promotion to recognize its potential impact on worker output, disability rates, absenteeism and employee satisfaction.

Over the last 20 years, the dominant outcome of interest in health promotion has been medical costs. Studies that measure the impact of programs in terms of medical dollars saved, including return-on-investment (ROI), are the gold standard for the worksite health promotion field. This narrow focus is reasonable, given the double-digit inflation rate of health care costs in the U.S. over the same period and the saliency of this issue for most business managers.

Recent research, however, suggests that examining medical costs alone may reveal just the tip of the iceberg. A recent analysis of a Midwest manufacturer with 72,000 employees by the Integrated Benefits Institute (IBI) found that medical costs accounted for only 20% of the total costs of poor employee health. The other 80% of costs came from disability absences and lost productivity, resulting in $1.24 billion in total health-related costs over 2.5 years ($6,889 per employee annually). Similarly, a health and productivity benchmarking study of 43 large public and private employers found that 53% of the median annual health and productivity costs ($9,992 per employee annually) were for workers’ compensation, turnover, absenteeism and non-occupational disability. Findings such as these have led health promotion researchers to begin quantifying the impact of worksite health beyond medical costs alone and to include measures of worker productivity.

Unfortunately, data on the impact of comprehensive programs on many productivity measures are limited. While evidence clearly shows an impact of these programs on risk reduction and medical cost savings, research on their impact on worker performance is not as good. A recent review by Riedel and associates summarized the evidence as qualitatively weak and quantitatively limited. Data is limited, often subjective in nature, and rarely integrated.

One measure of recent interest has been short-term disability (STD). In a 3-year study by our research team at a large telecommunications company, we found a significant impact of a comprehensive program on STD usage. A total of 1,628 employees on non-maternity STD leave was examined, with the analysis controlling for age, gender, job type, tenure and STD category. Self-selected program participants were compared to non-participants on net days lost at three assessment points: one year prior to program launch and the first two years post-launch. Results revealed no significant differences in STD usage between participants and non-participants at baseline. Post launch, however, non-participants’ average net STD days lost increased from 33.2 to 38.1, whereas participants’ average net days lost decreased from 29.2 to 27.8. The difference represented a 20% program impact and potential savings in excess of $1.3 million over a two-year period.

One recommendation based on these findings is to target employees on STD for health promotion programs. A recent study by IBI1 makes the same recommendation. They found that, while representing only 11% of employees, STD users account for 53% of the total dollars spent for medical and STD benefits. This suggests that by proactively managing STD episodes, employers may also be able to control medical expenses and increase productivity.

The movement to broaden our understanding of the impact of health promotion programs is encouraging. As research efforts continue, we will gain a better understanding of the link between health and productivity. Taken together, the current research suggests that environmental and organization-level factors have a tremendous impact on employee health and productivity. For example, stress and mental health, key drivers of medical claim costs, are closely related to the work environment. As the research better links health and productivity, it will help us go beyond individual-level interventions and include organizational and environment level intervention in our plans for health promotion in the workplace.

Country Profile: Workplace Health Protection in Nigeria: A Step Towards Health Promotion and Productivity 

By Godwin Nwadibia Aja, Babcock University, Ilishan-Remo, Nigeria

Introduction

Industrial development in Nigeria has shifted from the traditional manual methods of cultivation, construction, distribution and production to a more sophisticated factory-based technology-oriented manufacturing. Today, there are small scale, medium sized and large-scale companies across the country and the labor force has increased tremendously. It is estimated to peak at 62.1 million workers. Policies aimed at protecting workers’ wellness and thus their productivity have been in place since the middle of the twentieth-century.

Industrial Legislation

The general goal of industrial legislation in Nigeria before and after independence was to protect workers and others from industrial accidents in order to improve productivity and increase output. The initial attempt included the Workmen’s Ordinance of 1941, followed by the Labor Code Ordinance of 1945 and Factories Act of 1955, revised in 1958 and revoked and replaced with the Labor Decree of 1974. Further review of these existing laws culminated to the most recent Factories Decree of 1987.

Workplace Health Protection

By law, every employer of labor is required to make the workplace conducive for the employees and others having any business within the organization. The labor laws specify the rights and privileges of the employer and employee, including the need for the employer to present, in clear terms, the hazards or risks the employee is likely to be exposed to. Factory laws address directly issues related to safety in the workplace. Emphasis is often on protection against environmental hazards such as machines and equipment, excessive light and radiation, heavy noise, chemical agents, etc. Health-related provisions include: cleanliness, overcrowding, ventilation, lighting, drainage of floor, sanitary accommodation, etc.

Presently, the enforcement mechanism of the above laws seems very weak. Some of the pitfalls are:

• Some employers claim ignorance of certain aspects of the provisions of the ordinance, laws, code or decree.
• Desperate, job seekers are more interested in getting the job than worry about the effect on their health. The “man-must-die” syndrome is usually the posture. And when the realities of the new job begin to dawn on them, they refuse to discuss it with the employer for fear of losing the job.

Health Promotion

Workplace health promotion is more than protection against hazards arising from machinery, openings, stacks, tools, structures, atmosphere, fire, electricity, pressure vessels, ladder, attire, cranes, explosives, etc. It includes complementary social and political action for improved worker morale and productivity. Industrial legislative laws, decrees and enactment must take into consideration the continually changing trend in public health.

Conclusion

Factory laws in Nigeria provide a laudable framework for protecting the employer and especially the employee from ill health and industrial accidents. National advocacy for workplace health promotion that would include, not only safety rules, but also a coordinated action within the workplace appears necessary. Favorable educational, managerial, administrative and organizational support should be part of the overall process. A healthy workplace policy should start with social, epidemiological, environmental and behavioral diagnosis to determine ultimate needs and identify circumstances where work site hazards interact with worker behavior. This requires a combined effort of professionals, especially health promotion experts, employers and employeess—not just clinicians that are often accorded considerable discretion by government in health policy formulation.

Godwin Nwadibia Aja is a senior lecturer in community health, Dept. of Health Sciences, Babcock University, Ilishan-Remo, Nigeria. He is also Health Action International (HAI) Africa Volunteer Sub-regional Coordinator for Western Anglophone/Nigeria. He could be reached by email:aja@infoweb.abs.net

 Global Initiatives

'Beyond Blue' – A National Depression Initiative in Australia

"Beyond Blue" was announced in late October, 2000. It will be a flagship program to increase community understanding of depressive illness and make practical improvements to the lives of those with depression, their families and friends. The high community profile of this initiative is reflected by the Board members who have offered their skills and time to oversee the implementation of this Initiative and present positive messages on depression to the community. Each of the Board members is distinguished in a variety of fields from medicine, acting, elite sport, law, community advancement and of course, politics, with both sides of the political spectrum ably represented on the Board. With almost 800,000 Australian adults experiencing a depressive illness in any given year, "Beyond Blue" aims to raise community awareness of depression. The term 'blue' or the 'blues' has an entrenched place in Australian culture with countless songs based around the idea from the 'blues' tunes of the African Americans early this century right through to Billie Holiday and pop icons such as Phil Collins. So the name “Beyond Blue” will be widely recognizable and will portray a positive image of treatment of depression in the community. Also, “Beyond Blue” signifies that there is life beyond depression for the individuals and families, friends and workplaces that are affected by its debilitating impacts. This will assist in presenting and reinforcing the messages: that mental illness and depression are like any other illness; that mental illness and depression can be treated and the earlier they are recognized the better the outcomes; and that there is no shame about mental illness. These messages are the cornerstone on which Australia plans to build a community that accepts depression for what it is and assist individuals with depression to reduce its adverse impacts.

Religion, Health and Healing Initiative

"Korean shaman were both  healers and religious figures"

The Center for the Study of World Religions at Harvard University has embarked upon a new initiative in the field of Religion, Health and Healing. The RHH Initiative has been established in order to further cross-cultural studies of the intersections of healing and religion. The impetus for the initiative is the desire to turn rigorous intellectual attention to the many ways in which religious practices, beliefs and institutions construct, and are constructed by, experiences of illness, health and healing cross-culturally.

In many societies, religion and healing represent complementary means for dealing with problems of suffering, and in many cultures systems of healing and religious systems are conjoined, as are healers and ritual experts.

The centerpiece of the RHH Initiative will be a series of conferences addressing theoretical questions of importance to scholars of religion and to practitioners both of bio-medicine and of religion. Proposed topics include what is meant by healing efficacy in diverse situations, notions of the relationship between the body and the spirit, power and authority in the healer-patient relationship, the religious/medical management of death, illness and consciousness, and meanings of and responses to pain. In the first stage of a program that will eventually expand to include collaborative projects with scholars and practitioners in countries such as Thailand, India, Brazil and Israel, the RHH Initiative has begun to carry out a systematic reconnaissance of religious healing in Boston, concentrating upon Catholic, Jewish, Episcopalian, Hindu, Korean and Christian Science communities.

As an interdisciplinary program, the RHH Initiative is particularly eager to develop collaborative projects with a variety of partners, both inside and outside of the academy, both within medical institutions and within religious communities. For more information about the Religion, Health and Healing Initiative, or about the Mapping of Religious Healing in Boston Project, please contact Dr. Susan Sered at 617.496.6528, or via email at ssered@hds.harvard.edu.

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