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ACSM's Worksite Health Handbook
A Guide to Building Healthy and Productive Companies
by American College of Sports Medicine
400 Pages
Encouraging and maintaining a healthy workforce have become key components in the challege to reduce health care expenditures and health-related productivity losses. As companies more fully realize the impact of healthy workers on the financial health of their organization, health promotion professionals seek support to design and implement interventions that generate improvements in workers' health and business performance.
The second edition of ACSM's Worksite Health Handbook: A Guide to Building Healthy and Productive Companies connects worksite health research and practice to offer health promotion professionals the information, ideas, and approaches to provide affordable, scalable, and sustainable solutions for the organizations they serve.
Thoroughly updated with the latest research and expanded to better support the business case for worksite programs, the second edition of ACSM's Worksite Health Handbook includes the contributions of nearly 100 of the top researchers and practitioners in the field from Canada, Europe, and the United States. The book's mix of research, evidence, and practice makes it a definitive and comprehensive resource on worksite health promotion, productivity management, disease prevention, and chronic disease management.
ACSM's Worksite Health Handbook, Second Edition, has the following features:
-An overview of contextual issues, including a history of the field, the current state of the field, legal perspectives, and the role of health policy in worksite programs
-A review of the effectiveness of strategies in worksite settings, including economic impact, best practices, and the health–productivity relationship
-Information on assessment, measurement, and evaluation, including health and productivity assessment tools, the economic returns of health improvement programs, and appropriate use of claims-based analysis and planning
-A thorough discussion of program design and implementation, including the application of behavior change theory, new ways of using data to engage participants, use of technology and social networks to improve effectiveness, and key features of best-practice programs
-An examination of various strategies for encouraging employee involvement, such as incorporating online communities and e-health, providing incentives, using medical self-care programs, making changes to the built environment, and tying in wellness with health and safety
The book includes a chapter that covers the implementation process step by step so that you can see how all of the components fit together in the creation of a complete program. You'll also find four in-depth case studies that offer innovative perspectives on implementing programs in a variety of work settings. Each case study includes a profile of the company, a description of the program and the program goals, information on the population being served, the results of the program, and a summary or discussion of the program. Throughout the book you'll find practical ideas, approaches, and solutions for implementation as well as examples of best practices and successful programs that will support your efforts in creating interventions that improve both workers' health and business performance.
The book is endorsed by the International Association for Worksite Health Promotion, a new ACSM affiliate society.
Deepen your understanding of the key issues and challenges within worksite health promotion and find the most current research and practice-based information and approaches inside ACSM's Worksite Health Handbook: A Guide to Building Healthy and Productive Companies, Second Edition.
Part I: Setting the Context
Chapter 1: Population Health Management at the Worksite
Nicolaas P. Pronk, PhD, FACSM
Chapter 2: Employee Health Promotion: A Historical Perspective
R. William Whitmer, MBA
Chapter 3: Workplace-Based Health and Wellness Services
Raymond Fabius, MD, CPE, and Sharon Glave Frazee, PhD
Chapter 4: State of the Worksite Health Promotion Industry: The 2004 National Worksite Health Promotion Survey
Laura A. Linnan, ScD, CHES
Chapter 5: Health Promotion Programming in Small, Medium, and Large Businesses
Heather M. Bowen, MS, RD, LD; Todd D. Smith, MS, CSP, ARM; Mark G. Wilson, HSD; and David M. Dejoy, PhD
Chapter 6: Employee Health Promotion: A Legal Perspective
Alison Cline Earles, Esq, and Luann Heinen, MPP
Chapter 7: Health Care Policy and Health Promotion
John M. Clymer, AB; Garry Lindsay, MPH, CHES; Jennifer Childress, MS, CHES; and George J. Pfeiffer MSE
Chapter 8: The Case for Change: From Segregated to Integrated Employee Health Management
Ann Yaktine, PhD, and Mike Parkinson, MD, MPH
Part II: The Evidence for Employer-Sponsored Health Programs
Chapter 9: An Introduction to Evidence on Worksite Health Promotion
Jonathan E. Fielding, MD, MPH, MBA, and David P. Hopkins, MD, MPH
Chapter 10: The Assessment of Health Risks With Feedback: Results of a Systematic Review
Robin E. Soler, PhD; Matt Griffith, MPH; David P. Hopkins, MD, MPH; and Kimberly Leeks, PhD, MPH
Chapter 11: Practice and Research Connected: A Synergistic Process of Translation Through Knowledge Transfer
Nicolaas P. Pronk, PhD, FACSM
Chapter 12: Benchmarking and Best Practices in Worksite Health Promotion
Jessica Grossmeier, MPH; Lavaughn Palma-Davis, MA; K. Andrew Crighton, MD, CPE; Margaret Sabin, MHSA; and David R. Anderson, PhD
Chapter 13: Health and the Organization of Work
David Gimeno, PhD, and Benjamin C. Amick III, PhD
Chapter 14: Health and Productivity Management: An Overview
Joseph A. Leutzinger, PhD
Part III: Assessing Worker and Organizational Health
Chapter 15: Practical Program Evaluation: Ensuring Findings Are Used for Program Improvement
Thomas J. Chapel, MA, MBA, and Jason Lang, MPH, MS
Chapter 16: The Assessment of Health and Risk: Tools, Specific Uses, and Implementation Processes
Edward M. Framer, PhD, and Yosuke Chikamoto, PhD
Chapter 17: Organizational Assessment for Health
Thomas Golaszewski, EdD
Chapter 18: Assessment Tools for Employee Productivity
Nicolaas P. Pronk, PhD, FACSM
Chapter 19: Calculating the Economic Return of Health and Productivity Management Programs
Seth Serxner, PhD, MPH, and Daniel Gold, PhD
Chapter 20: Using Claims Analysis to Support Intervention Planning, Design, and Measurement
David H. Chenoweth, PhD, and Jeff A. Hochberg, MS
Part IV: Program Design and Implementation
Chapter 21: Organizing Intelligence to Achieve Increased Consumer Engagement, Behavior Change, and Health Improvement
Stephanie Pronk, MEd
Chapter 22: The Application of Behavior Change Theory in the Worksite Setting
Karen Glanz, PhD, MPH
Chapter 23: Keeping Healthy Workers Healthy: Creating a Culture of Health
Shirley Musich, PhD; Howard Schubiner, MD; and Timothy Mcdonald, MSHA
Chapter 24: Connecting the Program to Core Business Objectives
Steven P. Noeldner, PhD
Chapter 25: Addressing Diversity and Health Literacy at the Worksite
Antronette K. (Toni) Yancey, MD, MPH; A. Janet Tomiyama, MA; and Nicole Keith, PhD
Chapter 26: A Culture of Health: Creating and Sustaining Supportive Organizational Environments for Health
Nicolaas P. Pronk, PhD, FACSM, and Calvin U. Allen, MBA, CHIE
Chapter 27: Online Communities and Worksite Health Management
Neal Sofian, MSPH, and Daniel Newton, PhD
Chapter 28: Rewarding Change: Principles for Implementing Worksite Incentive Programs
Jeffrey J. VanWormer, MS, and Nicolaas P. Pronk, PhD, FACSM
Chapter 29: eHealth for Employee Health and Wellness: Optimizing Plan Design and Incentive Management
David K. Ahern, PhD; Lauren Buckel; Edward W. Aberger, PhD; and Michael J. Follick, PhD
Chapter 30: Effective Programs to Promote Worker Health Within Healthy and Safe Worksites
Glorian Sorensen, PhD, MPH, and Lisa Quintiliani, PhD
Chapter 31: Programs Designed to Improve Employee Health Through Changes in the Built Environment
Mireille N.M. van Poppel, PhD, and Luuk H. Engbers, PhD
Chapter 32: The Design, Implementation, and Evaluation of Medical Self-Care Programs
Don R. Powell, PhD, and Jeanette Karwan, RD
Chapter 33: Disease Management for Employed Populations
Dennis Richling, MD
Chapter 34: From the Basics to Comprehensive Programming
Mary Kruse, ATC
Part V: Case Studies
Chapter 35: The Occupational Athlete: Injury Reduction and Productivity Enhancement in Reforestation Workers
Delia Roberts, PhD, FACSM
Chapter 36: Employee Health at BAE Systems: An Employer–Health Plan Partnership Approach
N. Marcus Thygeson, MD; Jason Gallagher, MBA; Kathleen Cross, CANP; and Nicolaas P. Pronk, PhD, FACSM
Chapter 37: Health Promotion, Participation, and Productivity: A Case Study at Unilever PLC
Peter Mills, MD, and Jessica Colling, BSC, MSC
Chapter 38: Introducing Environmental Interventions at the Dow Chemical Company to Reduce Overweight and Obesity Among Workers
Ron Z. Goetzel, PhD; Jennie Bowen, MPH; Ronald J. Ozminkowski, PhD; Cheryl Kassed PhD, MSPH; Enid Chung Roemer, PhD; Maryam J. Tabrizi, MS, CHES; Meghan Short, BA; Shaohung Wang, PhD; Xiaofei Pei, PhD; Heather M. Bowen, MS, RD, LD; David M. Dejoy, PhD; Mark G. Wilson, HSD; Kristin M. Baker, MPH; Karen J. Tully, BS; John M. White, PhD; Gary M. Billotti, MS; and Catherine M. Baase, MD
Nicolaas P. Pronk, PhD, is the vice president of health management at HealthPartners in Bloomington, Minnesota, the largest consumer-governed, nonprofit health care organization in the nation. He is also senior research investigator at HealthPartners Research Foundation and health science officer of JourneyWell, a Minneapolis-based nationwide provider of health and wellness programs.
Pronk has 20 years of experience in the health promotion field as a researcher, developer, and administrator of health promotion programs and services. Since 1993 he has directed health improvement initiatives that involve a systems approach to generating health across multiple sectors, including business and industry. He is a member of the distinguished Task Force on Community Preventive Services, an independent panel supported by the Centers for Disease Control and Prevention, which presents evidence-based recommendations to the health field.
A member of the American College of Sports Medicine (ACSM) since 1984, Pronk served as section editor and contributor for the first edition of ACSM's Worksite Health Promotion Manual. He currently serves as associate editor for the ACSM's Health & Fitness Journal. He served as the chair for the ACSM Interest Group on Worksite Health Promotion until 2008, when it morphed into the International Association for Worksite Health Promotion (IAWHP), an ACSM affiliate society. Pronk is a founding member and inaugural president of the international board of directors for the IAWHP. Previously, he was a board member of the former Association for Worksite Health Promotion (AWHP).
Pronk and his wife, Stephanie, reside in Eagan, Minnesota. He enjoys spending time with his family and dogs, watching English Football Association soccer after a Saturday-morning run, and riding his Harley on country roads in the Minnesota northland.
ACSM advances and integrates scientific research to provide educational and practical applications of exercise science and sports medicine.
The American College of Sports Medicine, founded in 1954, is a professional membership society with more than 20,000 national, regional, and international members in more than 70 countries dedicated to improving health through science, education, and medicine. ACSM members work in a wide range of medical specialties, allied health professions, and scientific disciplines. Our members are committed to the diagnosis, treatment, and prevention of sport-related injuries and the advancement of the science of exercise.
Our members' diversity and expertise make ACSM the largest, most respected sports medicine and exercise science organization in the world. From astronauts and athletes to people with chronic diseases or physical challenges, ACSM continues to look for and find better methods to allow people to live longer and more productive lives. ACSM is leading the way in exercise science and sports medicine.
ACSM reaches professionals and the public through a variety of means:
-ACSM publishes periodicals such as Medicine & Science in Sports & Exercise, Sports Medicine Bulletin, Exercise and Sport Sciences Reviews, ACSM's Health & Fitness Journal, Current Sports Medicine Reports, and the online consumer newsletter ACSM Fit Society Page.
-The ACSM Web site, www.acsm.org, serves as a portal to research, information, and professional development resources.
-Meetings present the latest scientific research and practical and clinical applications as well as fitness techniques and public health issues.
-Through media outreach, ACSM experts provide accurate, evidence-based insight into sports medicine, exercise science, and health and fitness.
-Books, pamphlets, and other publications present consumer advice, standards and guidelines for practitioners, and other definitive iinformation.
“The second edition of this comprehensive handbook is a welcome addition to the field of worksite health promotion… [It] provides an excellent foundation to help guide health promotion professionals and students with an interest in worksite health promotion to craft interventions to improve workforce health and wellness; and to improve their understanding of the key issues involved in supporting and expanding worksite health and wellness programs. Highly recommended.”
CHOICE (Current Reviews for Academic Libraries)
Social network can increase worksite health program participation
How can we take advantage of new communication technologies in creating more prolific change while reaching far more people than we ever could have imagined? There is little reason to believe that people with a broken wrist or inflamed tonsils want to become part of a social network of people who share the same transient health issue. So what are the types of issues that are appropriate for online communities and social networks to address?
How can we take advantage of new communication technologies in creating more prolific change while reaching far more people than we ever could have imagined? There is little reason to believe that people with a broken wrist or inflamed tonsils want to become part of a social network of people who share the same transient health issue. To build purposeful and effective social networks, it is important to consider the following factors.
- Trust: Participants feel the network is a trusted source of useful knowledge.
- Relevance: The knowledge that is shared applies directly to participants on an ongoing basis.
- Urgency: The resources shared help members solve a problem quickly and meaningfully. There is often an emotional tie to the issue.
- Chronicity: The issue is ongoing and merits getting involved and staying involved.
- Incentive: Participation provides a personal benefit. Collaborating helps advance career or job status, personal health, and son on-from the participant's point of view, it's worth it.
- Serial reciprocity: Participants believe, "If I help others with my knowledge or experience, they may help someone else, and someone else may help me."
However, in order to build such social networks, we need to know the participant. Criteria that allow us to know the participant are difficult to identify-let alone act upon-given most current uses of new communication technologies. In fact, most of today's computer-mediated or IVR and wireless health interventions tend to offer one-way communication-the producer of the site provides static information about a health topic that goes from the site to the user. It is assumed that accurate information is sufficient to activate a behavior change or at best provide questions with branching logic to deepen the level of detail of the information provided. Even sites that offer bulletin boards are limited. Postings are categorized by topic, and off-topic communication is discouraged. This makes it difficult for people to get to know one another the way they might during the general chitchatting, visiting, and relationship forming that happens in the real world when groups get together regularly around a common topic or cause.
So what are the types of issues that are appropriate for online communities and social networks to address? Here are just a few. On the illness end of the health spectrum, communities can affect diabetes, cancer, obesity, Crohn's disease, Lyme disease, and substance addiction. For caregivers, online communities can help with caring for children with disabilities or for patients with Alzheimer's disease or with end-of-life care. On the health management and health promotion end of the spectrum, areas such as weight loss, smoking cessation, new parent support, and worksite-based team physical activity (cycling, walking, calorie expenditure, and so on) are all suitable targets for online communities.
What are the behaviors we wish to encourage within an online community that will help motivate health behavior change? They are the same behaviors found in other forms of social interactions: receiving support, searching for relevant information and resources when needed, learning how to apply information to personal circumstances, sharing our own stories and resources, and connecting with others regarding our circumstances.
People may share details about their life circumstances or backgrounds that allow them to connect in an infinite variety of unpredictable ways. They may talk about pets, kids, politics, or a local sport team. While such connections may seem inconsequential, over time they allow people to feel a sense of belonging that can build confidence, which is often as significant as the behavior change itself. Without these connections, the participants' bond to the group is only as strong as their interest in the very specific issue that they came for. In the world of social support, such limited interest is rarely enough to sustain the relationship over the long term. The goal is to build as many strands of social capital as possible. You may come to a Web community for one specific reason. You often stay for many additional ones.
So What Does All This Mean for Worksite Health Management?
We are not suggesting that social networks replace existing health management interventions. Quite the opposite! One way for a social network or online community to be used in worksite health promotion is to leverage such tools to increase the participation of employees and their dependents in the many different interventions that are offered by a corporation. The contextually relevant recommendations of others can drive participation through personal stories, ratings, and even incentives tied to using the social network. For example, it is possible to match people with similar fitness interests and goals. The network becomes a place not only to find a cycling buddy but also to create virtual competitions with other employees-regardless of location or department-that can be displayed and shared on the Web. Participants can score points for tracking their times and progress, virtual teams can be formed, stories and pictures can be shared, and people with common interests or capabilities can be matched to encourage ongoing participation.
Not all of this will have to depend on the employee's initiative. Imagine that when you complete a health risk appraisal, it is possible to identify risks you prefer or feel most confident to address. From these data, along with personal profile information, you can be matched to the best programs available from the company. Moreover, you can be provided with an up-to-date search of selected information sources on the Web and then introduced to a support community of people like you. You can read their stories about how they successfully improved their health condition or risk status and then connect with them.
But we can go further yet. By integrating community with coaching, it becomes possible for a telephonic coach to not only intervene with an employee but also facilitate groups of employees receiving similar coaching who can support each other. Instead of a coach making five separate calls to 15 different employees (75 coaching sessions), the coach may only need to complete two calls to each participant, introduce members to each other, and facilitate ongoing sessions. This not only reduces the cost of the coaching intervention but also creates far more opportunities for ongoing support and intervention, taking advantage of employees by making them both recipients and providers of the intervention. In an age of consumer-directed health care, the inclusion of social networks around the existing suite of health promotion interventions creates a more effective and efficient system that actually models the concept of consumer directedness.
Beyond this integration, a community can also provide a means to tie health management to actual health care delivery. There is a growing movement for the use of electronic medical records (EMR) and personal health records (PHR). There is a similar growth in the use of on-site health care clinics. Imagine if we can not only connect phone coaches with employees within the community but also link medical providers to this process, ensuring that there is a closed loop between the employee (consumer) and the whole spectrum of health care and management providers.
To accomplish this sort of integration will require a different set of tools and skills than most programs currently maintain. The expansion of social networking, online communities, and collaborative technologies has several implications for the future of worksite health management. Inherent in these technologies are capabilities that will change the way we communicate and intervene with worksite populations. We will need to collect data not only about risks, diseases, and demographics but also about the preferences of users. We will need to understand that relationships drive behavior as much as information. We will need to understand that knowledge is the domain of the user as well as the provider. Ultimately, our role as professionals will include being facilitators as much as being purveyors of truth.
In return for building these new capabilities, practitioners will be in a position to create a truly integrated approach to delivery of health and medical care within the context of a community of care and caring. The opportunities are exciting and limited only by our imagination. The technology exists to do all this today. The dogs are hungry and ready for us to give them something to eat.
Consideration of socieconomic factors leads to more effective worksite health programs
Ethnic minority or lower-income populations experience monumental economic and cultural challenges to healthy eating, physical activity participation, and many other health protective behaviors. Such barriers are inherent in the physical, social, organizational, and political environments of underserved communities.
Addressing Underserved Populations in Workplace Health Promotion: Obesity Prevention and Control
Obesity represents a major public health threat. Addressing obesity as a health concern for underserved populations in the worksite setting is a challenging objective. A discussion on this issue is presented here.
Challenges
American society, as is true of most developed nations, is obesogenic, or obesity producing, and substantial effort and resources are necessary to achieve and maintain a healthy lifestyle when living in the United States. However, obstacles to healthy eating and active living are concentrated in underserved communities. Ethnic minority or lower-income populations experience monumental economic and cultural challenges to healthy eating, physical activity participation, and many other health protective behaviors. Such barriers are inherent in the physical, social, organizational, and political environments of underserved communities. These barriers are detailed in the following discussion.
Economic factors pose enormous challenges to engaging in healthy behaviors (table 25.1). Geographic proximity to healthy foods and physical activity opportunities is strikingly limited for poorer communities. For example, park space in Los Angeles African American, Asian, and Latino communities is less than 1/100 of that in White communities in the same city (39). Similarly, fewer stores stock fresh or frozen produce, and the selection and quality of produce are much poorer. Conversely, fast-food restaurants are more plentiful in low-income and ethnic minority communities. From the higher proportions of inexpensive refined carbohydrate and fat in the food supply to the ubiquitous availability of brand-name sodas and coffee drinks available from vendors and vending machines, dietary quality reflects the nutrition environment of low-income and ethnic minority communities.
Hazardous neighborhood conditions are common. For example, people in low-income neighborhoods are more likely to be located near pollutants (environmental justice issues), face higher levels of exposure to environmental tobacco smoke, and experience higher rates of both intentional injury (due to gunplay or gang infestation) and unintentional injury (due to fewer pedestrian accommodations such as bridges over streets with high traffic volume, speed bumps, sidewalks, and street lamps in good repair). In addition, commercial marketing (including advertising and promotion) undoubtedly influences consumption preferences and purchasing behaviors. Marketing of health-compromising goods and services is pervasive in the United States, but increased exposure to commercial advertising for tobacco, unhealthy foods and beverages, and sedentary entertainment and transportation-as well as decreased exposure to health-promoting goods and services-has been documented in ethnic minority and neighborhoods, ethnically targeted publications, and Black audience prime-time television. However, attacks on this predatory marketing are not always politically feasible. Minority media, long ignored by most industries, have literally survived financially on culturally targeted fast-food, soda, alcohol, tobacco, film, and automobile ads that present sociodemographically marginalized groups in a very positive light.
Employment characteristics of lower-income workers present obstacles as well. Those who are lower in the work hierarchy have little flexibility to integrate physical activity into their lifestyles. They have little decisional latitude, rigid schedules (time clocks), and highly structured and supervised (assembly line) work processes. Sites employing a majority of low-income workers, such as low-income residential areas, have fewer healthy food options in close proximity and short lunchtimes. Long commuting times and multiple jobs further constrain leisure, despite higher rates of mass transit use and active transportation.
Leisure-time physical activity and foods with high nutrient value and low energy density are costly for individuals from low-income and ethnic minority backgrounds, both in time and money. Home meal preparation may assume a lower priority than meeting basic needs such as earning sufficient income for household expenses, caring for children and elders, religious observance, and relaxing at home. Federal farm subsidies for corn, used in cattle feed and high-fructose corn syrup, depress the cost of burgers and sodas relative to healthier offerings; the latter are already more expensive because of their more perishable nature, shorter shelf lives, and lower sales volumes (also due, in part, to less aggressive marketing). Low levels of enjoyment of physical activity and suboptimal motor skills may result from exposure to poor-quality physical education as youths.
Sociocultural obstacles to healthy lifestyle adherence are no less-and perhaps even more-influential than economic barriers. Culturally grounded norms, perceptions, and values surrounding physical activity and eating, including gender roles and role modeling, govern the ease or difficulty of participating in healthy behaviors. Many negative perceptions of physical activity have cultural origins with historical underpinnings. Commercially or socially marketed exercise fads and trends have traditionally emphasized sports, structured aerobics, or calisthenics that are consistent with the values of affluent Whites, especially males. Consequently, these exercise traditions have often been dismissed as incongruous by nonmainstream cultures. Sometimes these exercise traditions are even ridiculed-for example, jogging is perceived as a bourgeois waste of time and energy in less affluent or ethnic minority communities. In part, this may be attributed to the traditionally arduous lives of people from socioeconomically marginalized groups. The manual labor of the past has perhaps historically programmed an overestimation of daily work-related exertion and ingrained the need for rest after work to manage stress. A corollary misperception is that sweating reflects moderate to vigorous physical activity (when in fact sweating can accompany minimal exertion depending upon fitness level and ambient temperature).
Similarly, perceptions of healthful foods and healthy eating are culturally rooted. Certain foods, recipes, and food preparation techniques have been associated with particular ethnic identities. One example is the popularity of soul food, typified by fried catfish, fatback-seasoned collard greens, and corn bread, among African Americans. These tastes and smells produce positive affective responses summoning connection to family and nationality or culture of origin. The stressful lives of many individuals from socioeconomically marginalized groups also precipitate the use of nutrient-poor foods (comfort foods) as stress management. Job and residential segregation by income and ethnicity, magnified by the concentration of fast-food restaurants and paucity of dining options with a broader range of cuisines, preclude the usual sampling of a variety of foods as youths become more independent. Since most learning optimally incorporates an experiential component, there is little opportunity for multiple exposures associated with developing preferences for certain foods such as fruits and vegetables, whole grains, and low-fat dairy products (8). This may be compounded by the lack of vigorous exercise, which increases consumption of water and water-bearing foods and decreases preferences for highly sweetened beverages. Even the definition of what constitutes healthy foods varies among groups.
Social roles are key elements of identity influenced by culture of origin. Gender roles reflect culturally grounded notions of femininity and appropriate role behaviors. For example, concerns about maintaining a professional appearance (hair and makeup, skirts, high-heeled shoes) may deter women from exercising during the workday. In very traditional societies, vigorous exercise may even be seen as compromising a girl's virginity and negatively affecting her marriageability. Women are less frequently in positions of authority, and even when they are, expectations of acquiescence may decrease their influence on corporate policy. For women and people from ethnic minority groups, few culturally relevant role models may be available. At the same time, substantial social distance between line staff (who are more likely to be overweight or unfit) and management (who are more likely to be active) may persuade the former to reject healthier behaviors as pretentious or irrelevant.
Potential Solutions
Worksites are captive audiences of adults representing the entire demographic spectrum of a society. They present unparalleled opportunities to leverage organizational policy and practice change to improve the overall health of the workforce and, perhaps, to spur widespread social norm change. However, the promise of worksite health promotion beyond tobacco control has largely been squandered by the differential engagement of younger employees of higher socioeconomic status. The voluntary nature of these interventions, targeted at the individual level, engages primarily the motivated and fit-often fewer than 1 in 20 workers.
Workplace environmental change approaches may be designed to preferentially target ethnic minority and lower-income employees. Particularly, these approaches include push strategies that make physical activity and healthy food choices hard to avoid (23). These approaches tend to reduce health disparities, increasing the likelihood of delivering substantial ROI to employers (and to local governments that bear many of the costs of sedentariness) by engaging the more sedentary and overweight population segments less successfully reached by traditional worksite programs. Push strategies include exercise breaks on nondiscretionary time, healthy food services and procurement, walking meetings, vending and vendor restrictions, nearby parking restrictions, and substantive fiscal incentives for mass transit use. They are potentially more sustainable, as they rely less on individual motivation and initiation-the daunting myriad daily decisions and actions that must be undertaken to acquire and prepare healthy foods, to resist the temptations of highly palatable, widely marketed, and nutrient-poor foods and of sedentary entertainment, and to seek out and take advantage of ways to expend energy.
Changing the workplace-driven sociocultural and organizational environment is much more feasible than changing the built environment in these communities. The former changes obviate barriers such as unsafe or unappealing outdoor surroundings, lack of residential access to high-quality produce and recreational facilities, and copious perspiration and lack of enjoyment associated with longer bouts of strenuous exercise. Innovative indoor architectural design (e.g., skip-stop elevators, nested well-lit stairwells, standing workstations), private development of mixed-use neighborhoods, public construction of walking trails, and commercial location of fitness facilities are unlikely to garner a high priority in areas that cannot even regularly secure such basic services as streetlight maintenance, foliage trimming, and sidewalk repair.
Successful health promotion innovations in diverse work settings may share certain fundamental principles, or ingredients. Many, for example, build on cultural assets such as the normative nature of structural integration of group physical activity, in the form of dance or movement to music in social gatherings throughout the life span; the cultural salience of many plant-based foods; and the collectivist versus individualist values. Key ingredients of culturally proficient approaches are outlined in table 25.2.
Social network can increase worksite health program participation
How can we take advantage of new communication technologies in creating more prolific change while reaching far more people than we ever could have imagined? There is little reason to believe that people with a broken wrist or inflamed tonsils want to become part of a social network of people who share the same transient health issue. So what are the types of issues that are appropriate for online communities and social networks to address?
How can we take advantage of new communication technologies in creating more prolific change while reaching far more people than we ever could have imagined? There is little reason to believe that people with a broken wrist or inflamed tonsils want to become part of a social network of people who share the same transient health issue. To build purposeful and effective social networks, it is important to consider the following factors.
- Trust: Participants feel the network is a trusted source of useful knowledge.
- Relevance: The knowledge that is shared applies directly to participants on an ongoing basis.
- Urgency: The resources shared help members solve a problem quickly and meaningfully. There is often an emotional tie to the issue.
- Chronicity: The issue is ongoing and merits getting involved and staying involved.
- Incentive: Participation provides a personal benefit. Collaborating helps advance career or job status, personal health, and son on-from the participant's point of view, it's worth it.
- Serial reciprocity: Participants believe, "If I help others with my knowledge or experience, they may help someone else, and someone else may help me."
However, in order to build such social networks, we need to know the participant. Criteria that allow us to know the participant are difficult to identify-let alone act upon-given most current uses of new communication technologies. In fact, most of today's computer-mediated or IVR and wireless health interventions tend to offer one-way communication-the producer of the site provides static information about a health topic that goes from the site to the user. It is assumed that accurate information is sufficient to activate a behavior change or at best provide questions with branching logic to deepen the level of detail of the information provided. Even sites that offer bulletin boards are limited. Postings are categorized by topic, and off-topic communication is discouraged. This makes it difficult for people to get to know one another the way they might during the general chitchatting, visiting, and relationship forming that happens in the real world when groups get together regularly around a common topic or cause.
So what are the types of issues that are appropriate for online communities and social networks to address? Here are just a few. On the illness end of the health spectrum, communities can affect diabetes, cancer, obesity, Crohn's disease, Lyme disease, and substance addiction. For caregivers, online communities can help with caring for children with disabilities or for patients with Alzheimer's disease or with end-of-life care. On the health management and health promotion end of the spectrum, areas such as weight loss, smoking cessation, new parent support, and worksite-based team physical activity (cycling, walking, calorie expenditure, and so on) are all suitable targets for online communities.
What are the behaviors we wish to encourage within an online community that will help motivate health behavior change? They are the same behaviors found in other forms of social interactions: receiving support, searching for relevant information and resources when needed, learning how to apply information to personal circumstances, sharing our own stories and resources, and connecting with others regarding our circumstances.
People may share details about their life circumstances or backgrounds that allow them to connect in an infinite variety of unpredictable ways. They may talk about pets, kids, politics, or a local sport team. While such connections may seem inconsequential, over time they allow people to feel a sense of belonging that can build confidence, which is often as significant as the behavior change itself. Without these connections, the participants' bond to the group is only as strong as their interest in the very specific issue that they came for. In the world of social support, such limited interest is rarely enough to sustain the relationship over the long term. The goal is to build as many strands of social capital as possible. You may come to a Web community for one specific reason. You often stay for many additional ones.
So What Does All This Mean for Worksite Health Management?
We are not suggesting that social networks replace existing health management interventions. Quite the opposite! One way for a social network or online community to be used in worksite health promotion is to leverage such tools to increase the participation of employees and their dependents in the many different interventions that are offered by a corporation. The contextually relevant recommendations of others can drive participation through personal stories, ratings, and even incentives tied to using the social network. For example, it is possible to match people with similar fitness interests and goals. The network becomes a place not only to find a cycling buddy but also to create virtual competitions with other employees-regardless of location or department-that can be displayed and shared on the Web. Participants can score points for tracking their times and progress, virtual teams can be formed, stories and pictures can be shared, and people with common interests or capabilities can be matched to encourage ongoing participation.
Not all of this will have to depend on the employee's initiative. Imagine that when you complete a health risk appraisal, it is possible to identify risks you prefer or feel most confident to address. From these data, along with personal profile information, you can be matched to the best programs available from the company. Moreover, you can be provided with an up-to-date search of selected information sources on the Web and then introduced to a support community of people like you. You can read their stories about how they successfully improved their health condition or risk status and then connect with them.
But we can go further yet. By integrating community with coaching, it becomes possible for a telephonic coach to not only intervene with an employee but also facilitate groups of employees receiving similar coaching who can support each other. Instead of a coach making five separate calls to 15 different employees (75 coaching sessions), the coach may only need to complete two calls to each participant, introduce members to each other, and facilitate ongoing sessions. This not only reduces the cost of the coaching intervention but also creates far more opportunities for ongoing support and intervention, taking advantage of employees by making them both recipients and providers of the intervention. In an age of consumer-directed health care, the inclusion of social networks around the existing suite of health promotion interventions creates a more effective and efficient system that actually models the concept of consumer directedness.
Beyond this integration, a community can also provide a means to tie health management to actual health care delivery. There is a growing movement for the use of electronic medical records (EMR) and personal health records (PHR). There is a similar growth in the use of on-site health care clinics. Imagine if we can not only connect phone coaches with employees within the community but also link medical providers to this process, ensuring that there is a closed loop between the employee (consumer) and the whole spectrum of health care and management providers.
To accomplish this sort of integration will require a different set of tools and skills than most programs currently maintain. The expansion of social networking, online communities, and collaborative technologies has several implications for the future of worksite health management. Inherent in these technologies are capabilities that will change the way we communicate and intervene with worksite populations. We will need to collect data not only about risks, diseases, and demographics but also about the preferences of users. We will need to understand that relationships drive behavior as much as information. We will need to understand that knowledge is the domain of the user as well as the provider. Ultimately, our role as professionals will include being facilitators as much as being purveyors of truth.
In return for building these new capabilities, practitioners will be in a position to create a truly integrated approach to delivery of health and medical care within the context of a community of care and caring. The opportunities are exciting and limited only by our imagination. The technology exists to do all this today. The dogs are hungry and ready for us to give them something to eat.
Consideration of socieconomic factors leads to more effective worksite health programs
Ethnic minority or lower-income populations experience monumental economic and cultural challenges to healthy eating, physical activity participation, and many other health protective behaviors. Such barriers are inherent in the physical, social, organizational, and political environments of underserved communities.
Addressing Underserved Populations in Workplace Health Promotion: Obesity Prevention and Control
Obesity represents a major public health threat. Addressing obesity as a health concern for underserved populations in the worksite setting is a challenging objective. A discussion on this issue is presented here.
Challenges
American society, as is true of most developed nations, is obesogenic, or obesity producing, and substantial effort and resources are necessary to achieve and maintain a healthy lifestyle when living in the United States. However, obstacles to healthy eating and active living are concentrated in underserved communities. Ethnic minority or lower-income populations experience monumental economic and cultural challenges to healthy eating, physical activity participation, and many other health protective behaviors. Such barriers are inherent in the physical, social, organizational, and political environments of underserved communities. These barriers are detailed in the following discussion.
Economic factors pose enormous challenges to engaging in healthy behaviors (table 25.1). Geographic proximity to healthy foods and physical activity opportunities is strikingly limited for poorer communities. For example, park space in Los Angeles African American, Asian, and Latino communities is less than 1/100 of that in White communities in the same city (39). Similarly, fewer stores stock fresh or frozen produce, and the selection and quality of produce are much poorer. Conversely, fast-food restaurants are more plentiful in low-income and ethnic minority communities. From the higher proportions of inexpensive refined carbohydrate and fat in the food supply to the ubiquitous availability of brand-name sodas and coffee drinks available from vendors and vending machines, dietary quality reflects the nutrition environment of low-income and ethnic minority communities.
Hazardous neighborhood conditions are common. For example, people in low-income neighborhoods are more likely to be located near pollutants (environmental justice issues), face higher levels of exposure to environmental tobacco smoke, and experience higher rates of both intentional injury (due to gunplay or gang infestation) and unintentional injury (due to fewer pedestrian accommodations such as bridges over streets with high traffic volume, speed bumps, sidewalks, and street lamps in good repair). In addition, commercial marketing (including advertising and promotion) undoubtedly influences consumption preferences and purchasing behaviors. Marketing of health-compromising goods and services is pervasive in the United States, but increased exposure to commercial advertising for tobacco, unhealthy foods and beverages, and sedentary entertainment and transportation-as well as decreased exposure to health-promoting goods and services-has been documented in ethnic minority and neighborhoods, ethnically targeted publications, and Black audience prime-time television. However, attacks on this predatory marketing are not always politically feasible. Minority media, long ignored by most industries, have literally survived financially on culturally targeted fast-food, soda, alcohol, tobacco, film, and automobile ads that present sociodemographically marginalized groups in a very positive light.
Employment characteristics of lower-income workers present obstacles as well. Those who are lower in the work hierarchy have little flexibility to integrate physical activity into their lifestyles. They have little decisional latitude, rigid schedules (time clocks), and highly structured and supervised (assembly line) work processes. Sites employing a majority of low-income workers, such as low-income residential areas, have fewer healthy food options in close proximity and short lunchtimes. Long commuting times and multiple jobs further constrain leisure, despite higher rates of mass transit use and active transportation.
Leisure-time physical activity and foods with high nutrient value and low energy density are costly for individuals from low-income and ethnic minority backgrounds, both in time and money. Home meal preparation may assume a lower priority than meeting basic needs such as earning sufficient income for household expenses, caring for children and elders, religious observance, and relaxing at home. Federal farm subsidies for corn, used in cattle feed and high-fructose corn syrup, depress the cost of burgers and sodas relative to healthier offerings; the latter are already more expensive because of their more perishable nature, shorter shelf lives, and lower sales volumes (also due, in part, to less aggressive marketing). Low levels of enjoyment of physical activity and suboptimal motor skills may result from exposure to poor-quality physical education as youths.
Sociocultural obstacles to healthy lifestyle adherence are no less-and perhaps even more-influential than economic barriers. Culturally grounded norms, perceptions, and values surrounding physical activity and eating, including gender roles and role modeling, govern the ease or difficulty of participating in healthy behaviors. Many negative perceptions of physical activity have cultural origins with historical underpinnings. Commercially or socially marketed exercise fads and trends have traditionally emphasized sports, structured aerobics, or calisthenics that are consistent with the values of affluent Whites, especially males. Consequently, these exercise traditions have often been dismissed as incongruous by nonmainstream cultures. Sometimes these exercise traditions are even ridiculed-for example, jogging is perceived as a bourgeois waste of time and energy in less affluent or ethnic minority communities. In part, this may be attributed to the traditionally arduous lives of people from socioeconomically marginalized groups. The manual labor of the past has perhaps historically programmed an overestimation of daily work-related exertion and ingrained the need for rest after work to manage stress. A corollary misperception is that sweating reflects moderate to vigorous physical activity (when in fact sweating can accompany minimal exertion depending upon fitness level and ambient temperature).
Similarly, perceptions of healthful foods and healthy eating are culturally rooted. Certain foods, recipes, and food preparation techniques have been associated with particular ethnic identities. One example is the popularity of soul food, typified by fried catfish, fatback-seasoned collard greens, and corn bread, among African Americans. These tastes and smells produce positive affective responses summoning connection to family and nationality or culture of origin. The stressful lives of many individuals from socioeconomically marginalized groups also precipitate the use of nutrient-poor foods (comfort foods) as stress management. Job and residential segregation by income and ethnicity, magnified by the concentration of fast-food restaurants and paucity of dining options with a broader range of cuisines, preclude the usual sampling of a variety of foods as youths become more independent. Since most learning optimally incorporates an experiential component, there is little opportunity for multiple exposures associated with developing preferences for certain foods such as fruits and vegetables, whole grains, and low-fat dairy products (8). This may be compounded by the lack of vigorous exercise, which increases consumption of water and water-bearing foods and decreases preferences for highly sweetened beverages. Even the definition of what constitutes healthy foods varies among groups.
Social roles are key elements of identity influenced by culture of origin. Gender roles reflect culturally grounded notions of femininity and appropriate role behaviors. For example, concerns about maintaining a professional appearance (hair and makeup, skirts, high-heeled shoes) may deter women from exercising during the workday. In very traditional societies, vigorous exercise may even be seen as compromising a girl's virginity and negatively affecting her marriageability. Women are less frequently in positions of authority, and even when they are, expectations of acquiescence may decrease their influence on corporate policy. For women and people from ethnic minority groups, few culturally relevant role models may be available. At the same time, substantial social distance between line staff (who are more likely to be overweight or unfit) and management (who are more likely to be active) may persuade the former to reject healthier behaviors as pretentious or irrelevant.
Potential Solutions
Worksites are captive audiences of adults representing the entire demographic spectrum of a society. They present unparalleled opportunities to leverage organizational policy and practice change to improve the overall health of the workforce and, perhaps, to spur widespread social norm change. However, the promise of worksite health promotion beyond tobacco control has largely been squandered by the differential engagement of younger employees of higher socioeconomic status. The voluntary nature of these interventions, targeted at the individual level, engages primarily the motivated and fit-often fewer than 1 in 20 workers.
Workplace environmental change approaches may be designed to preferentially target ethnic minority and lower-income employees. Particularly, these approaches include push strategies that make physical activity and healthy food choices hard to avoid (23). These approaches tend to reduce health disparities, increasing the likelihood of delivering substantial ROI to employers (and to local governments that bear many of the costs of sedentariness) by engaging the more sedentary and overweight population segments less successfully reached by traditional worksite programs. Push strategies include exercise breaks on nondiscretionary time, healthy food services and procurement, walking meetings, vending and vendor restrictions, nearby parking restrictions, and substantive fiscal incentives for mass transit use. They are potentially more sustainable, as they rely less on individual motivation and initiation-the daunting myriad daily decisions and actions that must be undertaken to acquire and prepare healthy foods, to resist the temptations of highly palatable, widely marketed, and nutrient-poor foods and of sedentary entertainment, and to seek out and take advantage of ways to expend energy.
Changing the workplace-driven sociocultural and organizational environment is much more feasible than changing the built environment in these communities. The former changes obviate barriers such as unsafe or unappealing outdoor surroundings, lack of residential access to high-quality produce and recreational facilities, and copious perspiration and lack of enjoyment associated with longer bouts of strenuous exercise. Innovative indoor architectural design (e.g., skip-stop elevators, nested well-lit stairwells, standing workstations), private development of mixed-use neighborhoods, public construction of walking trails, and commercial location of fitness facilities are unlikely to garner a high priority in areas that cannot even regularly secure such basic services as streetlight maintenance, foliage trimming, and sidewalk repair.
Successful health promotion innovations in diverse work settings may share certain fundamental principles, or ingredients. Many, for example, build on cultural assets such as the normative nature of structural integration of group physical activity, in the form of dance or movement to music in social gatherings throughout the life span; the cultural salience of many plant-based foods; and the collectivist versus individualist values. Key ingredients of culturally proficient approaches are outlined in table 25.2.
Social network can increase worksite health program participation
How can we take advantage of new communication technologies in creating more prolific change while reaching far more people than we ever could have imagined? There is little reason to believe that people with a broken wrist or inflamed tonsils want to become part of a social network of people who share the same transient health issue. So what are the types of issues that are appropriate for online communities and social networks to address?
How can we take advantage of new communication technologies in creating more prolific change while reaching far more people than we ever could have imagined? There is little reason to believe that people with a broken wrist or inflamed tonsils want to become part of a social network of people who share the same transient health issue. To build purposeful and effective social networks, it is important to consider the following factors.
- Trust: Participants feel the network is a trusted source of useful knowledge.
- Relevance: The knowledge that is shared applies directly to participants on an ongoing basis.
- Urgency: The resources shared help members solve a problem quickly and meaningfully. There is often an emotional tie to the issue.
- Chronicity: The issue is ongoing and merits getting involved and staying involved.
- Incentive: Participation provides a personal benefit. Collaborating helps advance career or job status, personal health, and son on-from the participant's point of view, it's worth it.
- Serial reciprocity: Participants believe, "If I help others with my knowledge or experience, they may help someone else, and someone else may help me."
However, in order to build such social networks, we need to know the participant. Criteria that allow us to know the participant are difficult to identify-let alone act upon-given most current uses of new communication technologies. In fact, most of today's computer-mediated or IVR and wireless health interventions tend to offer one-way communication-the producer of the site provides static information about a health topic that goes from the site to the user. It is assumed that accurate information is sufficient to activate a behavior change or at best provide questions with branching logic to deepen the level of detail of the information provided. Even sites that offer bulletin boards are limited. Postings are categorized by topic, and off-topic communication is discouraged. This makes it difficult for people to get to know one another the way they might during the general chitchatting, visiting, and relationship forming that happens in the real world when groups get together regularly around a common topic or cause.
So what are the types of issues that are appropriate for online communities and social networks to address? Here are just a few. On the illness end of the health spectrum, communities can affect diabetes, cancer, obesity, Crohn's disease, Lyme disease, and substance addiction. For caregivers, online communities can help with caring for children with disabilities or for patients with Alzheimer's disease or with end-of-life care. On the health management and health promotion end of the spectrum, areas such as weight loss, smoking cessation, new parent support, and worksite-based team physical activity (cycling, walking, calorie expenditure, and so on) are all suitable targets for online communities.
What are the behaviors we wish to encourage within an online community that will help motivate health behavior change? They are the same behaviors found in other forms of social interactions: receiving support, searching for relevant information and resources when needed, learning how to apply information to personal circumstances, sharing our own stories and resources, and connecting with others regarding our circumstances.
People may share details about their life circumstances or backgrounds that allow them to connect in an infinite variety of unpredictable ways. They may talk about pets, kids, politics, or a local sport team. While such connections may seem inconsequential, over time they allow people to feel a sense of belonging that can build confidence, which is often as significant as the behavior change itself. Without these connections, the participants' bond to the group is only as strong as their interest in the very specific issue that they came for. In the world of social support, such limited interest is rarely enough to sustain the relationship over the long term. The goal is to build as many strands of social capital as possible. You may come to a Web community for one specific reason. You often stay for many additional ones.
So What Does All This Mean for Worksite Health Management?
We are not suggesting that social networks replace existing health management interventions. Quite the opposite! One way for a social network or online community to be used in worksite health promotion is to leverage such tools to increase the participation of employees and their dependents in the many different interventions that are offered by a corporation. The contextually relevant recommendations of others can drive participation through personal stories, ratings, and even incentives tied to using the social network. For example, it is possible to match people with similar fitness interests and goals. The network becomes a place not only to find a cycling buddy but also to create virtual competitions with other employees-regardless of location or department-that can be displayed and shared on the Web. Participants can score points for tracking their times and progress, virtual teams can be formed, stories and pictures can be shared, and people with common interests or capabilities can be matched to encourage ongoing participation.
Not all of this will have to depend on the employee's initiative. Imagine that when you complete a health risk appraisal, it is possible to identify risks you prefer or feel most confident to address. From these data, along with personal profile information, you can be matched to the best programs available from the company. Moreover, you can be provided with an up-to-date search of selected information sources on the Web and then introduced to a support community of people like you. You can read their stories about how they successfully improved their health condition or risk status and then connect with them.
But we can go further yet. By integrating community with coaching, it becomes possible for a telephonic coach to not only intervene with an employee but also facilitate groups of employees receiving similar coaching who can support each other. Instead of a coach making five separate calls to 15 different employees (75 coaching sessions), the coach may only need to complete two calls to each participant, introduce members to each other, and facilitate ongoing sessions. This not only reduces the cost of the coaching intervention but also creates far more opportunities for ongoing support and intervention, taking advantage of employees by making them both recipients and providers of the intervention. In an age of consumer-directed health care, the inclusion of social networks around the existing suite of health promotion interventions creates a more effective and efficient system that actually models the concept of consumer directedness.
Beyond this integration, a community can also provide a means to tie health management to actual health care delivery. There is a growing movement for the use of electronic medical records (EMR) and personal health records (PHR). There is a similar growth in the use of on-site health care clinics. Imagine if we can not only connect phone coaches with employees within the community but also link medical providers to this process, ensuring that there is a closed loop between the employee (consumer) and the whole spectrum of health care and management providers.
To accomplish this sort of integration will require a different set of tools and skills than most programs currently maintain. The expansion of social networking, online communities, and collaborative technologies has several implications for the future of worksite health management. Inherent in these technologies are capabilities that will change the way we communicate and intervene with worksite populations. We will need to collect data not only about risks, diseases, and demographics but also about the preferences of users. We will need to understand that relationships drive behavior as much as information. We will need to understand that knowledge is the domain of the user as well as the provider. Ultimately, our role as professionals will include being facilitators as much as being purveyors of truth.
In return for building these new capabilities, practitioners will be in a position to create a truly integrated approach to delivery of health and medical care within the context of a community of care and caring. The opportunities are exciting and limited only by our imagination. The technology exists to do all this today. The dogs are hungry and ready for us to give them something to eat.
Consideration of socieconomic factors leads to more effective worksite health programs
Ethnic minority or lower-income populations experience monumental economic and cultural challenges to healthy eating, physical activity participation, and many other health protective behaviors. Such barriers are inherent in the physical, social, organizational, and political environments of underserved communities.
Addressing Underserved Populations in Workplace Health Promotion: Obesity Prevention and Control
Obesity represents a major public health threat. Addressing obesity as a health concern for underserved populations in the worksite setting is a challenging objective. A discussion on this issue is presented here.
Challenges
American society, as is true of most developed nations, is obesogenic, or obesity producing, and substantial effort and resources are necessary to achieve and maintain a healthy lifestyle when living in the United States. However, obstacles to healthy eating and active living are concentrated in underserved communities. Ethnic minority or lower-income populations experience monumental economic and cultural challenges to healthy eating, physical activity participation, and many other health protective behaviors. Such barriers are inherent in the physical, social, organizational, and political environments of underserved communities. These barriers are detailed in the following discussion.
Economic factors pose enormous challenges to engaging in healthy behaviors (table 25.1). Geographic proximity to healthy foods and physical activity opportunities is strikingly limited for poorer communities. For example, park space in Los Angeles African American, Asian, and Latino communities is less than 1/100 of that in White communities in the same city (39). Similarly, fewer stores stock fresh or frozen produce, and the selection and quality of produce are much poorer. Conversely, fast-food restaurants are more plentiful in low-income and ethnic minority communities. From the higher proportions of inexpensive refined carbohydrate and fat in the food supply to the ubiquitous availability of brand-name sodas and coffee drinks available from vendors and vending machines, dietary quality reflects the nutrition environment of low-income and ethnic minority communities.
Hazardous neighborhood conditions are common. For example, people in low-income neighborhoods are more likely to be located near pollutants (environmental justice issues), face higher levels of exposure to environmental tobacco smoke, and experience higher rates of both intentional injury (due to gunplay or gang infestation) and unintentional injury (due to fewer pedestrian accommodations such as bridges over streets with high traffic volume, speed bumps, sidewalks, and street lamps in good repair). In addition, commercial marketing (including advertising and promotion) undoubtedly influences consumption preferences and purchasing behaviors. Marketing of health-compromising goods and services is pervasive in the United States, but increased exposure to commercial advertising for tobacco, unhealthy foods and beverages, and sedentary entertainment and transportation-as well as decreased exposure to health-promoting goods and services-has been documented in ethnic minority and neighborhoods, ethnically targeted publications, and Black audience prime-time television. However, attacks on this predatory marketing are not always politically feasible. Minority media, long ignored by most industries, have literally survived financially on culturally targeted fast-food, soda, alcohol, tobacco, film, and automobile ads that present sociodemographically marginalized groups in a very positive light.
Employment characteristics of lower-income workers present obstacles as well. Those who are lower in the work hierarchy have little flexibility to integrate physical activity into their lifestyles. They have little decisional latitude, rigid schedules (time clocks), and highly structured and supervised (assembly line) work processes. Sites employing a majority of low-income workers, such as low-income residential areas, have fewer healthy food options in close proximity and short lunchtimes. Long commuting times and multiple jobs further constrain leisure, despite higher rates of mass transit use and active transportation.
Leisure-time physical activity and foods with high nutrient value and low energy density are costly for individuals from low-income and ethnic minority backgrounds, both in time and money. Home meal preparation may assume a lower priority than meeting basic needs such as earning sufficient income for household expenses, caring for children and elders, religious observance, and relaxing at home. Federal farm subsidies for corn, used in cattle feed and high-fructose corn syrup, depress the cost of burgers and sodas relative to healthier offerings; the latter are already more expensive because of their more perishable nature, shorter shelf lives, and lower sales volumes (also due, in part, to less aggressive marketing). Low levels of enjoyment of physical activity and suboptimal motor skills may result from exposure to poor-quality physical education as youths.
Sociocultural obstacles to healthy lifestyle adherence are no less-and perhaps even more-influential than economic barriers. Culturally grounded norms, perceptions, and values surrounding physical activity and eating, including gender roles and role modeling, govern the ease or difficulty of participating in healthy behaviors. Many negative perceptions of physical activity have cultural origins with historical underpinnings. Commercially or socially marketed exercise fads and trends have traditionally emphasized sports, structured aerobics, or calisthenics that are consistent with the values of affluent Whites, especially males. Consequently, these exercise traditions have often been dismissed as incongruous by nonmainstream cultures. Sometimes these exercise traditions are even ridiculed-for example, jogging is perceived as a bourgeois waste of time and energy in less affluent or ethnic minority communities. In part, this may be attributed to the traditionally arduous lives of people from socioeconomically marginalized groups. The manual labor of the past has perhaps historically programmed an overestimation of daily work-related exertion and ingrained the need for rest after work to manage stress. A corollary misperception is that sweating reflects moderate to vigorous physical activity (when in fact sweating can accompany minimal exertion depending upon fitness level and ambient temperature).
Similarly, perceptions of healthful foods and healthy eating are culturally rooted. Certain foods, recipes, and food preparation techniques have been associated with particular ethnic identities. One example is the popularity of soul food, typified by fried catfish, fatback-seasoned collard greens, and corn bread, among African Americans. These tastes and smells produce positive affective responses summoning connection to family and nationality or culture of origin. The stressful lives of many individuals from socioeconomically marginalized groups also precipitate the use of nutrient-poor foods (comfort foods) as stress management. Job and residential segregation by income and ethnicity, magnified by the concentration of fast-food restaurants and paucity of dining options with a broader range of cuisines, preclude the usual sampling of a variety of foods as youths become more independent. Since most learning optimally incorporates an experiential component, there is little opportunity for multiple exposures associated with developing preferences for certain foods such as fruits and vegetables, whole grains, and low-fat dairy products (8). This may be compounded by the lack of vigorous exercise, which increases consumption of water and water-bearing foods and decreases preferences for highly sweetened beverages. Even the definition of what constitutes healthy foods varies among groups.
Social roles are key elements of identity influenced by culture of origin. Gender roles reflect culturally grounded notions of femininity and appropriate role behaviors. For example, concerns about maintaining a professional appearance (hair and makeup, skirts, high-heeled shoes) may deter women from exercising during the workday. In very traditional societies, vigorous exercise may even be seen as compromising a girl's virginity and negatively affecting her marriageability. Women are less frequently in positions of authority, and even when they are, expectations of acquiescence may decrease their influence on corporate policy. For women and people from ethnic minority groups, few culturally relevant role models may be available. At the same time, substantial social distance between line staff (who are more likely to be overweight or unfit) and management (who are more likely to be active) may persuade the former to reject healthier behaviors as pretentious or irrelevant.
Potential Solutions
Worksites are captive audiences of adults representing the entire demographic spectrum of a society. They present unparalleled opportunities to leverage organizational policy and practice change to improve the overall health of the workforce and, perhaps, to spur widespread social norm change. However, the promise of worksite health promotion beyond tobacco control has largely been squandered by the differential engagement of younger employees of higher socioeconomic status. The voluntary nature of these interventions, targeted at the individual level, engages primarily the motivated and fit-often fewer than 1 in 20 workers.
Workplace environmental change approaches may be designed to preferentially target ethnic minority and lower-income employees. Particularly, these approaches include push strategies that make physical activity and healthy food choices hard to avoid (23). These approaches tend to reduce health disparities, increasing the likelihood of delivering substantial ROI to employers (and to local governments that bear many of the costs of sedentariness) by engaging the more sedentary and overweight population segments less successfully reached by traditional worksite programs. Push strategies include exercise breaks on nondiscretionary time, healthy food services and procurement, walking meetings, vending and vendor restrictions, nearby parking restrictions, and substantive fiscal incentives for mass transit use. They are potentially more sustainable, as they rely less on individual motivation and initiation-the daunting myriad daily decisions and actions that must be undertaken to acquire and prepare healthy foods, to resist the temptations of highly palatable, widely marketed, and nutrient-poor foods and of sedentary entertainment, and to seek out and take advantage of ways to expend energy.
Changing the workplace-driven sociocultural and organizational environment is much more feasible than changing the built environment in these communities. The former changes obviate barriers such as unsafe or unappealing outdoor surroundings, lack of residential access to high-quality produce and recreational facilities, and copious perspiration and lack of enjoyment associated with longer bouts of strenuous exercise. Innovative indoor architectural design (e.g., skip-stop elevators, nested well-lit stairwells, standing workstations), private development of mixed-use neighborhoods, public construction of walking trails, and commercial location of fitness facilities are unlikely to garner a high priority in areas that cannot even regularly secure such basic services as streetlight maintenance, foliage trimming, and sidewalk repair.
Successful health promotion innovations in diverse work settings may share certain fundamental principles, or ingredients. Many, for example, build on cultural assets such as the normative nature of structural integration of group physical activity, in the form of dance or movement to music in social gatherings throughout the life span; the cultural salience of many plant-based foods; and the collectivist versus individualist values. Key ingredients of culturally proficient approaches are outlined in table 25.2.
Social network can increase worksite health program participation
How can we take advantage of new communication technologies in creating more prolific change while reaching far more people than we ever could have imagined? There is little reason to believe that people with a broken wrist or inflamed tonsils want to become part of a social network of people who share the same transient health issue. So what are the types of issues that are appropriate for online communities and social networks to address?
How can we take advantage of new communication technologies in creating more prolific change while reaching far more people than we ever could have imagined? There is little reason to believe that people with a broken wrist or inflamed tonsils want to become part of a social network of people who share the same transient health issue. To build purposeful and effective social networks, it is important to consider the following factors.
- Trust: Participants feel the network is a trusted source of useful knowledge.
- Relevance: The knowledge that is shared applies directly to participants on an ongoing basis.
- Urgency: The resources shared help members solve a problem quickly and meaningfully. There is often an emotional tie to the issue.
- Chronicity: The issue is ongoing and merits getting involved and staying involved.
- Incentive: Participation provides a personal benefit. Collaborating helps advance career or job status, personal health, and son on-from the participant's point of view, it's worth it.
- Serial reciprocity: Participants believe, "If I help others with my knowledge or experience, they may help someone else, and someone else may help me."
However, in order to build such social networks, we need to know the participant. Criteria that allow us to know the participant are difficult to identify-let alone act upon-given most current uses of new communication technologies. In fact, most of today's computer-mediated or IVR and wireless health interventions tend to offer one-way communication-the producer of the site provides static information about a health topic that goes from the site to the user. It is assumed that accurate information is sufficient to activate a behavior change or at best provide questions with branching logic to deepen the level of detail of the information provided. Even sites that offer bulletin boards are limited. Postings are categorized by topic, and off-topic communication is discouraged. This makes it difficult for people to get to know one another the way they might during the general chitchatting, visiting, and relationship forming that happens in the real world when groups get together regularly around a common topic or cause.
So what are the types of issues that are appropriate for online communities and social networks to address? Here are just a few. On the illness end of the health spectrum, communities can affect diabetes, cancer, obesity, Crohn's disease, Lyme disease, and substance addiction. For caregivers, online communities can help with caring for children with disabilities or for patients with Alzheimer's disease or with end-of-life care. On the health management and health promotion end of the spectrum, areas such as weight loss, smoking cessation, new parent support, and worksite-based team physical activity (cycling, walking, calorie expenditure, and so on) are all suitable targets for online communities.
What are the behaviors we wish to encourage within an online community that will help motivate health behavior change? They are the same behaviors found in other forms of social interactions: receiving support, searching for relevant information and resources when needed, learning how to apply information to personal circumstances, sharing our own stories and resources, and connecting with others regarding our circumstances.
People may share details about their life circumstances or backgrounds that allow them to connect in an infinite variety of unpredictable ways. They may talk about pets, kids, politics, or a local sport team. While such connections may seem inconsequential, over time they allow people to feel a sense of belonging that can build confidence, which is often as significant as the behavior change itself. Without these connections, the participants' bond to the group is only as strong as their interest in the very specific issue that they came for. In the world of social support, such limited interest is rarely enough to sustain the relationship over the long term. The goal is to build as many strands of social capital as possible. You may come to a Web community for one specific reason. You often stay for many additional ones.
So What Does All This Mean for Worksite Health Management?
We are not suggesting that social networks replace existing health management interventions. Quite the opposite! One way for a social network or online community to be used in worksite health promotion is to leverage such tools to increase the participation of employees and their dependents in the many different interventions that are offered by a corporation. The contextually relevant recommendations of others can drive participation through personal stories, ratings, and even incentives tied to using the social network. For example, it is possible to match people with similar fitness interests and goals. The network becomes a place not only to find a cycling buddy but also to create virtual competitions with other employees-regardless of location or department-that can be displayed and shared on the Web. Participants can score points for tracking their times and progress, virtual teams can be formed, stories and pictures can be shared, and people with common interests or capabilities can be matched to encourage ongoing participation.
Not all of this will have to depend on the employee's initiative. Imagine that when you complete a health risk appraisal, it is possible to identify risks you prefer or feel most confident to address. From these data, along with personal profile information, you can be matched to the best programs available from the company. Moreover, you can be provided with an up-to-date search of selected information sources on the Web and then introduced to a support community of people like you. You can read their stories about how they successfully improved their health condition or risk status and then connect with them.
But we can go further yet. By integrating community with coaching, it becomes possible for a telephonic coach to not only intervene with an employee but also facilitate groups of employees receiving similar coaching who can support each other. Instead of a coach making five separate calls to 15 different employees (75 coaching sessions), the coach may only need to complete two calls to each participant, introduce members to each other, and facilitate ongoing sessions. This not only reduces the cost of the coaching intervention but also creates far more opportunities for ongoing support and intervention, taking advantage of employees by making them both recipients and providers of the intervention. In an age of consumer-directed health care, the inclusion of social networks around the existing suite of health promotion interventions creates a more effective and efficient system that actually models the concept of consumer directedness.
Beyond this integration, a community can also provide a means to tie health management to actual health care delivery. There is a growing movement for the use of electronic medical records (EMR) and personal health records (PHR). There is a similar growth in the use of on-site health care clinics. Imagine if we can not only connect phone coaches with employees within the community but also link medical providers to this process, ensuring that there is a closed loop between the employee (consumer) and the whole spectrum of health care and management providers.
To accomplish this sort of integration will require a different set of tools and skills than most programs currently maintain. The expansion of social networking, online communities, and collaborative technologies has several implications for the future of worksite health management. Inherent in these technologies are capabilities that will change the way we communicate and intervene with worksite populations. We will need to collect data not only about risks, diseases, and demographics but also about the preferences of users. We will need to understand that relationships drive behavior as much as information. We will need to understand that knowledge is the domain of the user as well as the provider. Ultimately, our role as professionals will include being facilitators as much as being purveyors of truth.
In return for building these new capabilities, practitioners will be in a position to create a truly integrated approach to delivery of health and medical care within the context of a community of care and caring. The opportunities are exciting and limited only by our imagination. The technology exists to do all this today. The dogs are hungry and ready for us to give them something to eat.
Consideration of socieconomic factors leads to more effective worksite health programs
Ethnic minority or lower-income populations experience monumental economic and cultural challenges to healthy eating, physical activity participation, and many other health protective behaviors. Such barriers are inherent in the physical, social, organizational, and political environments of underserved communities.
Addressing Underserved Populations in Workplace Health Promotion: Obesity Prevention and Control
Obesity represents a major public health threat. Addressing obesity as a health concern for underserved populations in the worksite setting is a challenging objective. A discussion on this issue is presented here.
Challenges
American society, as is true of most developed nations, is obesogenic, or obesity producing, and substantial effort and resources are necessary to achieve and maintain a healthy lifestyle when living in the United States. However, obstacles to healthy eating and active living are concentrated in underserved communities. Ethnic minority or lower-income populations experience monumental economic and cultural challenges to healthy eating, physical activity participation, and many other health protective behaviors. Such barriers are inherent in the physical, social, organizational, and political environments of underserved communities. These barriers are detailed in the following discussion.
Economic factors pose enormous challenges to engaging in healthy behaviors (table 25.1). Geographic proximity to healthy foods and physical activity opportunities is strikingly limited for poorer communities. For example, park space in Los Angeles African American, Asian, and Latino communities is less than 1/100 of that in White communities in the same city (39). Similarly, fewer stores stock fresh or frozen produce, and the selection and quality of produce are much poorer. Conversely, fast-food restaurants are more plentiful in low-income and ethnic minority communities. From the higher proportions of inexpensive refined carbohydrate and fat in the food supply to the ubiquitous availability of brand-name sodas and coffee drinks available from vendors and vending machines, dietary quality reflects the nutrition environment of low-income and ethnic minority communities.
Hazardous neighborhood conditions are common. For example, people in low-income neighborhoods are more likely to be located near pollutants (environmental justice issues), face higher levels of exposure to environmental tobacco smoke, and experience higher rates of both intentional injury (due to gunplay or gang infestation) and unintentional injury (due to fewer pedestrian accommodations such as bridges over streets with high traffic volume, speed bumps, sidewalks, and street lamps in good repair). In addition, commercial marketing (including advertising and promotion) undoubtedly influences consumption preferences and purchasing behaviors. Marketing of health-compromising goods and services is pervasive in the United States, but increased exposure to commercial advertising for tobacco, unhealthy foods and beverages, and sedentary entertainment and transportation-as well as decreased exposure to health-promoting goods and services-has been documented in ethnic minority and neighborhoods, ethnically targeted publications, and Black audience prime-time television. However, attacks on this predatory marketing are not always politically feasible. Minority media, long ignored by most industries, have literally survived financially on culturally targeted fast-food, soda, alcohol, tobacco, film, and automobile ads that present sociodemographically marginalized groups in a very positive light.
Employment characteristics of lower-income workers present obstacles as well. Those who are lower in the work hierarchy have little flexibility to integrate physical activity into their lifestyles. They have little decisional latitude, rigid schedules (time clocks), and highly structured and supervised (assembly line) work processes. Sites employing a majority of low-income workers, such as low-income residential areas, have fewer healthy food options in close proximity and short lunchtimes. Long commuting times and multiple jobs further constrain leisure, despite higher rates of mass transit use and active transportation.
Leisure-time physical activity and foods with high nutrient value and low energy density are costly for individuals from low-income and ethnic minority backgrounds, both in time and money. Home meal preparation may assume a lower priority than meeting basic needs such as earning sufficient income for household expenses, caring for children and elders, religious observance, and relaxing at home. Federal farm subsidies for corn, used in cattle feed and high-fructose corn syrup, depress the cost of burgers and sodas relative to healthier offerings; the latter are already more expensive because of their more perishable nature, shorter shelf lives, and lower sales volumes (also due, in part, to less aggressive marketing). Low levels of enjoyment of physical activity and suboptimal motor skills may result from exposure to poor-quality physical education as youths.
Sociocultural obstacles to healthy lifestyle adherence are no less-and perhaps even more-influential than economic barriers. Culturally grounded norms, perceptions, and values surrounding physical activity and eating, including gender roles and role modeling, govern the ease or difficulty of participating in healthy behaviors. Many negative perceptions of physical activity have cultural origins with historical underpinnings. Commercially or socially marketed exercise fads and trends have traditionally emphasized sports, structured aerobics, or calisthenics that are consistent with the values of affluent Whites, especially males. Consequently, these exercise traditions have often been dismissed as incongruous by nonmainstream cultures. Sometimes these exercise traditions are even ridiculed-for example, jogging is perceived as a bourgeois waste of time and energy in less affluent or ethnic minority communities. In part, this may be attributed to the traditionally arduous lives of people from socioeconomically marginalized groups. The manual labor of the past has perhaps historically programmed an overestimation of daily work-related exertion and ingrained the need for rest after work to manage stress. A corollary misperception is that sweating reflects moderate to vigorous physical activity (when in fact sweating can accompany minimal exertion depending upon fitness level and ambient temperature).
Similarly, perceptions of healthful foods and healthy eating are culturally rooted. Certain foods, recipes, and food preparation techniques have been associated with particular ethnic identities. One example is the popularity of soul food, typified by fried catfish, fatback-seasoned collard greens, and corn bread, among African Americans. These tastes and smells produce positive affective responses summoning connection to family and nationality or culture of origin. The stressful lives of many individuals from socioeconomically marginalized groups also precipitate the use of nutrient-poor foods (comfort foods) as stress management. Job and residential segregation by income and ethnicity, magnified by the concentration of fast-food restaurants and paucity of dining options with a broader range of cuisines, preclude the usual sampling of a variety of foods as youths become more independent. Since most learning optimally incorporates an experiential component, there is little opportunity for multiple exposures associated with developing preferences for certain foods such as fruits and vegetables, whole grains, and low-fat dairy products (8). This may be compounded by the lack of vigorous exercise, which increases consumption of water and water-bearing foods and decreases preferences for highly sweetened beverages. Even the definition of what constitutes healthy foods varies among groups.
Social roles are key elements of identity influenced by culture of origin. Gender roles reflect culturally grounded notions of femininity and appropriate role behaviors. For example, concerns about maintaining a professional appearance (hair and makeup, skirts, high-heeled shoes) may deter women from exercising during the workday. In very traditional societies, vigorous exercise may even be seen as compromising a girl's virginity and negatively affecting her marriageability. Women are less frequently in positions of authority, and even when they are, expectations of acquiescence may decrease their influence on corporate policy. For women and people from ethnic minority groups, few culturally relevant role models may be available. At the same time, substantial social distance between line staff (who are more likely to be overweight or unfit) and management (who are more likely to be active) may persuade the former to reject healthier behaviors as pretentious or irrelevant.
Potential Solutions
Worksites are captive audiences of adults representing the entire demographic spectrum of a society. They present unparalleled opportunities to leverage organizational policy and practice change to improve the overall health of the workforce and, perhaps, to spur widespread social norm change. However, the promise of worksite health promotion beyond tobacco control has largely been squandered by the differential engagement of younger employees of higher socioeconomic status. The voluntary nature of these interventions, targeted at the individual level, engages primarily the motivated and fit-often fewer than 1 in 20 workers.
Workplace environmental change approaches may be designed to preferentially target ethnic minority and lower-income employees. Particularly, these approaches include push strategies that make physical activity and healthy food choices hard to avoid (23). These approaches tend to reduce health disparities, increasing the likelihood of delivering substantial ROI to employers (and to local governments that bear many of the costs of sedentariness) by engaging the more sedentary and overweight population segments less successfully reached by traditional worksite programs. Push strategies include exercise breaks on nondiscretionary time, healthy food services and procurement, walking meetings, vending and vendor restrictions, nearby parking restrictions, and substantive fiscal incentives for mass transit use. They are potentially more sustainable, as they rely less on individual motivation and initiation-the daunting myriad daily decisions and actions that must be undertaken to acquire and prepare healthy foods, to resist the temptations of highly palatable, widely marketed, and nutrient-poor foods and of sedentary entertainment, and to seek out and take advantage of ways to expend energy.
Changing the workplace-driven sociocultural and organizational environment is much more feasible than changing the built environment in these communities. The former changes obviate barriers such as unsafe or unappealing outdoor surroundings, lack of residential access to high-quality produce and recreational facilities, and copious perspiration and lack of enjoyment associated with longer bouts of strenuous exercise. Innovative indoor architectural design (e.g., skip-stop elevators, nested well-lit stairwells, standing workstations), private development of mixed-use neighborhoods, public construction of walking trails, and commercial location of fitness facilities are unlikely to garner a high priority in areas that cannot even regularly secure such basic services as streetlight maintenance, foliage trimming, and sidewalk repair.
Successful health promotion innovations in diverse work settings may share certain fundamental principles, or ingredients. Many, for example, build on cultural assets such as the normative nature of structural integration of group physical activity, in the form of dance or movement to music in social gatherings throughout the life span; the cultural salience of many plant-based foods; and the collectivist versus individualist values. Key ingredients of culturally proficient approaches are outlined in table 25.2.
Social network can increase worksite health program participation
How can we take advantage of new communication technologies in creating more prolific change while reaching far more people than we ever could have imagined? There is little reason to believe that people with a broken wrist or inflamed tonsils want to become part of a social network of people who share the same transient health issue. So what are the types of issues that are appropriate for online communities and social networks to address?
How can we take advantage of new communication technologies in creating more prolific change while reaching far more people than we ever could have imagined? There is little reason to believe that people with a broken wrist or inflamed tonsils want to become part of a social network of people who share the same transient health issue. To build purposeful and effective social networks, it is important to consider the following factors.
- Trust: Participants feel the network is a trusted source of useful knowledge.
- Relevance: The knowledge that is shared applies directly to participants on an ongoing basis.
- Urgency: The resources shared help members solve a problem quickly and meaningfully. There is often an emotional tie to the issue.
- Chronicity: The issue is ongoing and merits getting involved and staying involved.
- Incentive: Participation provides a personal benefit. Collaborating helps advance career or job status, personal health, and son on-from the participant's point of view, it's worth it.
- Serial reciprocity: Participants believe, "If I help others with my knowledge or experience, they may help someone else, and someone else may help me."
However, in order to build such social networks, we need to know the participant. Criteria that allow us to know the participant are difficult to identify-let alone act upon-given most current uses of new communication technologies. In fact, most of today's computer-mediated or IVR and wireless health interventions tend to offer one-way communication-the producer of the site provides static information about a health topic that goes from the site to the user. It is assumed that accurate information is sufficient to activate a behavior change or at best provide questions with branching logic to deepen the level of detail of the information provided. Even sites that offer bulletin boards are limited. Postings are categorized by topic, and off-topic communication is discouraged. This makes it difficult for people to get to know one another the way they might during the general chitchatting, visiting, and relationship forming that happens in the real world when groups get together regularly around a common topic or cause.
So what are the types of issues that are appropriate for online communities and social networks to address? Here are just a few. On the illness end of the health spectrum, communities can affect diabetes, cancer, obesity, Crohn's disease, Lyme disease, and substance addiction. For caregivers, online communities can help with caring for children with disabilities or for patients with Alzheimer's disease or with end-of-life care. On the health management and health promotion end of the spectrum, areas such as weight loss, smoking cessation, new parent support, and worksite-based team physical activity (cycling, walking, calorie expenditure, and so on) are all suitable targets for online communities.
What are the behaviors we wish to encourage within an online community that will help motivate health behavior change? They are the same behaviors found in other forms of social interactions: receiving support, searching for relevant information and resources when needed, learning how to apply information to personal circumstances, sharing our own stories and resources, and connecting with others regarding our circumstances.
People may share details about their life circumstances or backgrounds that allow them to connect in an infinite variety of unpredictable ways. They may talk about pets, kids, politics, or a local sport team. While such connections may seem inconsequential, over time they allow people to feel a sense of belonging that can build confidence, which is often as significant as the behavior change itself. Without these connections, the participants' bond to the group is only as strong as their interest in the very specific issue that they came for. In the world of social support, such limited interest is rarely enough to sustain the relationship over the long term. The goal is to build as many strands of social capital as possible. You may come to a Web community for one specific reason. You often stay for many additional ones.
So What Does All This Mean for Worksite Health Management?
We are not suggesting that social networks replace existing health management interventions. Quite the opposite! One way for a social network or online community to be used in worksite health promotion is to leverage such tools to increase the participation of employees and their dependents in the many different interventions that are offered by a corporation. The contextually relevant recommendations of others can drive participation through personal stories, ratings, and even incentives tied to using the social network. For example, it is possible to match people with similar fitness interests and goals. The network becomes a place not only to find a cycling buddy but also to create virtual competitions with other employees-regardless of location or department-that can be displayed and shared on the Web. Participants can score points for tracking their times and progress, virtual teams can be formed, stories and pictures can be shared, and people with common interests or capabilities can be matched to encourage ongoing participation.
Not all of this will have to depend on the employee's initiative. Imagine that when you complete a health risk appraisal, it is possible to identify risks you prefer or feel most confident to address. From these data, along with personal profile information, you can be matched to the best programs available from the company. Moreover, you can be provided with an up-to-date search of selected information sources on the Web and then introduced to a support community of people like you. You can read their stories about how they successfully improved their health condition or risk status and then connect with them.
But we can go further yet. By integrating community with coaching, it becomes possible for a telephonic coach to not only intervene with an employee but also facilitate groups of employees receiving similar coaching who can support each other. Instead of a coach making five separate calls to 15 different employees (75 coaching sessions), the coach may only need to complete two calls to each participant, introduce members to each other, and facilitate ongoing sessions. This not only reduces the cost of the coaching intervention but also creates far more opportunities for ongoing support and intervention, taking advantage of employees by making them both recipients and providers of the intervention. In an age of consumer-directed health care, the inclusion of social networks around the existing suite of health promotion interventions creates a more effective and efficient system that actually models the concept of consumer directedness.
Beyond this integration, a community can also provide a means to tie health management to actual health care delivery. There is a growing movement for the use of electronic medical records (EMR) and personal health records (PHR). There is a similar growth in the use of on-site health care clinics. Imagine if we can not only connect phone coaches with employees within the community but also link medical providers to this process, ensuring that there is a closed loop between the employee (consumer) and the whole spectrum of health care and management providers.
To accomplish this sort of integration will require a different set of tools and skills than most programs currently maintain. The expansion of social networking, online communities, and collaborative technologies has several implications for the future of worksite health management. Inherent in these technologies are capabilities that will change the way we communicate and intervene with worksite populations. We will need to collect data not only about risks, diseases, and demographics but also about the preferences of users. We will need to understand that relationships drive behavior as much as information. We will need to understand that knowledge is the domain of the user as well as the provider. Ultimately, our role as professionals will include being facilitators as much as being purveyors of truth.
In return for building these new capabilities, practitioners will be in a position to create a truly integrated approach to delivery of health and medical care within the context of a community of care and caring. The opportunities are exciting and limited only by our imagination. The technology exists to do all this today. The dogs are hungry and ready for us to give them something to eat.
Consideration of socieconomic factors leads to more effective worksite health programs
Ethnic minority or lower-income populations experience monumental economic and cultural challenges to healthy eating, physical activity participation, and many other health protective behaviors. Such barriers are inherent in the physical, social, organizational, and political environments of underserved communities.
Addressing Underserved Populations in Workplace Health Promotion: Obesity Prevention and Control
Obesity represents a major public health threat. Addressing obesity as a health concern for underserved populations in the worksite setting is a challenging objective. A discussion on this issue is presented here.
Challenges
American society, as is true of most developed nations, is obesogenic, or obesity producing, and substantial effort and resources are necessary to achieve and maintain a healthy lifestyle when living in the United States. However, obstacles to healthy eating and active living are concentrated in underserved communities. Ethnic minority or lower-income populations experience monumental economic and cultural challenges to healthy eating, physical activity participation, and many other health protective behaviors. Such barriers are inherent in the physical, social, organizational, and political environments of underserved communities. These barriers are detailed in the following discussion.
Economic factors pose enormous challenges to engaging in healthy behaviors (table 25.1). Geographic proximity to healthy foods and physical activity opportunities is strikingly limited for poorer communities. For example, park space in Los Angeles African American, Asian, and Latino communities is less than 1/100 of that in White communities in the same city (39). Similarly, fewer stores stock fresh or frozen produce, and the selection and quality of produce are much poorer. Conversely, fast-food restaurants are more plentiful in low-income and ethnic minority communities. From the higher proportions of inexpensive refined carbohydrate and fat in the food supply to the ubiquitous availability of brand-name sodas and coffee drinks available from vendors and vending machines, dietary quality reflects the nutrition environment of low-income and ethnic minority communities.
Hazardous neighborhood conditions are common. For example, people in low-income neighborhoods are more likely to be located near pollutants (environmental justice issues), face higher levels of exposure to environmental tobacco smoke, and experience higher rates of both intentional injury (due to gunplay or gang infestation) and unintentional injury (due to fewer pedestrian accommodations such as bridges over streets with high traffic volume, speed bumps, sidewalks, and street lamps in good repair). In addition, commercial marketing (including advertising and promotion) undoubtedly influences consumption preferences and purchasing behaviors. Marketing of health-compromising goods and services is pervasive in the United States, but increased exposure to commercial advertising for tobacco, unhealthy foods and beverages, and sedentary entertainment and transportation-as well as decreased exposure to health-promoting goods and services-has been documented in ethnic minority and neighborhoods, ethnically targeted publications, and Black audience prime-time television. However, attacks on this predatory marketing are not always politically feasible. Minority media, long ignored by most industries, have literally survived financially on culturally targeted fast-food, soda, alcohol, tobacco, film, and automobile ads that present sociodemographically marginalized groups in a very positive light.
Employment characteristics of lower-income workers present obstacles as well. Those who are lower in the work hierarchy have little flexibility to integrate physical activity into their lifestyles. They have little decisional latitude, rigid schedules (time clocks), and highly structured and supervised (assembly line) work processes. Sites employing a majority of low-income workers, such as low-income residential areas, have fewer healthy food options in close proximity and short lunchtimes. Long commuting times and multiple jobs further constrain leisure, despite higher rates of mass transit use and active transportation.
Leisure-time physical activity and foods with high nutrient value and low energy density are costly for individuals from low-income and ethnic minority backgrounds, both in time and money. Home meal preparation may assume a lower priority than meeting basic needs such as earning sufficient income for household expenses, caring for children and elders, religious observance, and relaxing at home. Federal farm subsidies for corn, used in cattle feed and high-fructose corn syrup, depress the cost of burgers and sodas relative to healthier offerings; the latter are already more expensive because of their more perishable nature, shorter shelf lives, and lower sales volumes (also due, in part, to less aggressive marketing). Low levels of enjoyment of physical activity and suboptimal motor skills may result from exposure to poor-quality physical education as youths.
Sociocultural obstacles to healthy lifestyle adherence are no less-and perhaps even more-influential than economic barriers. Culturally grounded norms, perceptions, and values surrounding physical activity and eating, including gender roles and role modeling, govern the ease or difficulty of participating in healthy behaviors. Many negative perceptions of physical activity have cultural origins with historical underpinnings. Commercially or socially marketed exercise fads and trends have traditionally emphasized sports, structured aerobics, or calisthenics that are consistent with the values of affluent Whites, especially males. Consequently, these exercise traditions have often been dismissed as incongruous by nonmainstream cultures. Sometimes these exercise traditions are even ridiculed-for example, jogging is perceived as a bourgeois waste of time and energy in less affluent or ethnic minority communities. In part, this may be attributed to the traditionally arduous lives of people from socioeconomically marginalized groups. The manual labor of the past has perhaps historically programmed an overestimation of daily work-related exertion and ingrained the need for rest after work to manage stress. A corollary misperception is that sweating reflects moderate to vigorous physical activity (when in fact sweating can accompany minimal exertion depending upon fitness level and ambient temperature).
Similarly, perceptions of healthful foods and healthy eating are culturally rooted. Certain foods, recipes, and food preparation techniques have been associated with particular ethnic identities. One example is the popularity of soul food, typified by fried catfish, fatback-seasoned collard greens, and corn bread, among African Americans. These tastes and smells produce positive affective responses summoning connection to family and nationality or culture of origin. The stressful lives of many individuals from socioeconomically marginalized groups also precipitate the use of nutrient-poor foods (comfort foods) as stress management. Job and residential segregation by income and ethnicity, magnified by the concentration of fast-food restaurants and paucity of dining options with a broader range of cuisines, preclude the usual sampling of a variety of foods as youths become more independent. Since most learning optimally incorporates an experiential component, there is little opportunity for multiple exposures associated with developing preferences for certain foods such as fruits and vegetables, whole grains, and low-fat dairy products (8). This may be compounded by the lack of vigorous exercise, which increases consumption of water and water-bearing foods and decreases preferences for highly sweetened beverages. Even the definition of what constitutes healthy foods varies among groups.
Social roles are key elements of identity influenced by culture of origin. Gender roles reflect culturally grounded notions of femininity and appropriate role behaviors. For example, concerns about maintaining a professional appearance (hair and makeup, skirts, high-heeled shoes) may deter women from exercising during the workday. In very traditional societies, vigorous exercise may even be seen as compromising a girl's virginity and negatively affecting her marriageability. Women are less frequently in positions of authority, and even when they are, expectations of acquiescence may decrease their influence on corporate policy. For women and people from ethnic minority groups, few culturally relevant role models may be available. At the same time, substantial social distance between line staff (who are more likely to be overweight or unfit) and management (who are more likely to be active) may persuade the former to reject healthier behaviors as pretentious or irrelevant.
Potential Solutions
Worksites are captive audiences of adults representing the entire demographic spectrum of a society. They present unparalleled opportunities to leverage organizational policy and practice change to improve the overall health of the workforce and, perhaps, to spur widespread social norm change. However, the promise of worksite health promotion beyond tobacco control has largely been squandered by the differential engagement of younger employees of higher socioeconomic status. The voluntary nature of these interventions, targeted at the individual level, engages primarily the motivated and fit-often fewer than 1 in 20 workers.
Workplace environmental change approaches may be designed to preferentially target ethnic minority and lower-income employees. Particularly, these approaches include push strategies that make physical activity and healthy food choices hard to avoid (23). These approaches tend to reduce health disparities, increasing the likelihood of delivering substantial ROI to employers (and to local governments that bear many of the costs of sedentariness) by engaging the more sedentary and overweight population segments less successfully reached by traditional worksite programs. Push strategies include exercise breaks on nondiscretionary time, healthy food services and procurement, walking meetings, vending and vendor restrictions, nearby parking restrictions, and substantive fiscal incentives for mass transit use. They are potentially more sustainable, as they rely less on individual motivation and initiation-the daunting myriad daily decisions and actions that must be undertaken to acquire and prepare healthy foods, to resist the temptations of highly palatable, widely marketed, and nutrient-poor foods and of sedentary entertainment, and to seek out and take advantage of ways to expend energy.
Changing the workplace-driven sociocultural and organizational environment is much more feasible than changing the built environment in these communities. The former changes obviate barriers such as unsafe or unappealing outdoor surroundings, lack of residential access to high-quality produce and recreational facilities, and copious perspiration and lack of enjoyment associated with longer bouts of strenuous exercise. Innovative indoor architectural design (e.g., skip-stop elevators, nested well-lit stairwells, standing workstations), private development of mixed-use neighborhoods, public construction of walking trails, and commercial location of fitness facilities are unlikely to garner a high priority in areas that cannot even regularly secure such basic services as streetlight maintenance, foliage trimming, and sidewalk repair.
Successful health promotion innovations in diverse work settings may share certain fundamental principles, or ingredients. Many, for example, build on cultural assets such as the normative nature of structural integration of group physical activity, in the form of dance or movement to music in social gatherings throughout the life span; the cultural salience of many plant-based foods; and the collectivist versus individualist values. Key ingredients of culturally proficient approaches are outlined in table 25.2.
Social network can increase worksite health program participation
How can we take advantage of new communication technologies in creating more prolific change while reaching far more people than we ever could have imagined? There is little reason to believe that people with a broken wrist or inflamed tonsils want to become part of a social network of people who share the same transient health issue. So what are the types of issues that are appropriate for online communities and social networks to address?
How can we take advantage of new communication technologies in creating more prolific change while reaching far more people than we ever could have imagined? There is little reason to believe that people with a broken wrist or inflamed tonsils want to become part of a social network of people who share the same transient health issue. To build purposeful and effective social networks, it is important to consider the following factors.
- Trust: Participants feel the network is a trusted source of useful knowledge.
- Relevance: The knowledge that is shared applies directly to participants on an ongoing basis.
- Urgency: The resources shared help members solve a problem quickly and meaningfully. There is often an emotional tie to the issue.
- Chronicity: The issue is ongoing and merits getting involved and staying involved.
- Incentive: Participation provides a personal benefit. Collaborating helps advance career or job status, personal health, and son on-from the participant's point of view, it's worth it.
- Serial reciprocity: Participants believe, "If I help others with my knowledge or experience, they may help someone else, and someone else may help me."
However, in order to build such social networks, we need to know the participant. Criteria that allow us to know the participant are difficult to identify-let alone act upon-given most current uses of new communication technologies. In fact, most of today's computer-mediated or IVR and wireless health interventions tend to offer one-way communication-the producer of the site provides static information about a health topic that goes from the site to the user. It is assumed that accurate information is sufficient to activate a behavior change or at best provide questions with branching logic to deepen the level of detail of the information provided. Even sites that offer bulletin boards are limited. Postings are categorized by topic, and off-topic communication is discouraged. This makes it difficult for people to get to know one another the way they might during the general chitchatting, visiting, and relationship forming that happens in the real world when groups get together regularly around a common topic or cause.
So what are the types of issues that are appropriate for online communities and social networks to address? Here are just a few. On the illness end of the health spectrum, communities can affect diabetes, cancer, obesity, Crohn's disease, Lyme disease, and substance addiction. For caregivers, online communities can help with caring for children with disabilities or for patients with Alzheimer's disease or with end-of-life care. On the health management and health promotion end of the spectrum, areas such as weight loss, smoking cessation, new parent support, and worksite-based team physical activity (cycling, walking, calorie expenditure, and so on) are all suitable targets for online communities.
What are the behaviors we wish to encourage within an online community that will help motivate health behavior change? They are the same behaviors found in other forms of social interactions: receiving support, searching for relevant information and resources when needed, learning how to apply information to personal circumstances, sharing our own stories and resources, and connecting with others regarding our circumstances.
People may share details about their life circumstances or backgrounds that allow them to connect in an infinite variety of unpredictable ways. They may talk about pets, kids, politics, or a local sport team. While such connections may seem inconsequential, over time they allow people to feel a sense of belonging that can build confidence, which is often as significant as the behavior change itself. Without these connections, the participants' bond to the group is only as strong as their interest in the very specific issue that they came for. In the world of social support, such limited interest is rarely enough to sustain the relationship over the long term. The goal is to build as many strands of social capital as possible. You may come to a Web community for one specific reason. You often stay for many additional ones.
So What Does All This Mean for Worksite Health Management?
We are not suggesting that social networks replace existing health management interventions. Quite the opposite! One way for a social network or online community to be used in worksite health promotion is to leverage such tools to increase the participation of employees and their dependents in the many different interventions that are offered by a corporation. The contextually relevant recommendations of others can drive participation through personal stories, ratings, and even incentives tied to using the social network. For example, it is possible to match people with similar fitness interests and goals. The network becomes a place not only to find a cycling buddy but also to create virtual competitions with other employees-regardless of location or department-that can be displayed and shared on the Web. Participants can score points for tracking their times and progress, virtual teams can be formed, stories and pictures can be shared, and people with common interests or capabilities can be matched to encourage ongoing participation.
Not all of this will have to depend on the employee's initiative. Imagine that when you complete a health risk appraisal, it is possible to identify risks you prefer or feel most confident to address. From these data, along with personal profile information, you can be matched to the best programs available from the company. Moreover, you can be provided with an up-to-date search of selected information sources on the Web and then introduced to a support community of people like you. You can read their stories about how they successfully improved their health condition or risk status and then connect with them.
But we can go further yet. By integrating community with coaching, it becomes possible for a telephonic coach to not only intervene with an employee but also facilitate groups of employees receiving similar coaching who can support each other. Instead of a coach making five separate calls to 15 different employees (75 coaching sessions), the coach may only need to complete two calls to each participant, introduce members to each other, and facilitate ongoing sessions. This not only reduces the cost of the coaching intervention but also creates far more opportunities for ongoing support and intervention, taking advantage of employees by making them both recipients and providers of the intervention. In an age of consumer-directed health care, the inclusion of social networks around the existing suite of health promotion interventions creates a more effective and efficient system that actually models the concept of consumer directedness.
Beyond this integration, a community can also provide a means to tie health management to actual health care delivery. There is a growing movement for the use of electronic medical records (EMR) and personal health records (PHR). There is a similar growth in the use of on-site health care clinics. Imagine if we can not only connect phone coaches with employees within the community but also link medical providers to this process, ensuring that there is a closed loop between the employee (consumer) and the whole spectrum of health care and management providers.
To accomplish this sort of integration will require a different set of tools and skills than most programs currently maintain. The expansion of social networking, online communities, and collaborative technologies has several implications for the future of worksite health management. Inherent in these technologies are capabilities that will change the way we communicate and intervene with worksite populations. We will need to collect data not only about risks, diseases, and demographics but also about the preferences of users. We will need to understand that relationships drive behavior as much as information. We will need to understand that knowledge is the domain of the user as well as the provider. Ultimately, our role as professionals will include being facilitators as much as being purveyors of truth.
In return for building these new capabilities, practitioners will be in a position to create a truly integrated approach to delivery of health and medical care within the context of a community of care and caring. The opportunities are exciting and limited only by our imagination. The technology exists to do all this today. The dogs are hungry and ready for us to give them something to eat.
Consideration of socieconomic factors leads to more effective worksite health programs
Ethnic minority or lower-income populations experience monumental economic and cultural challenges to healthy eating, physical activity participation, and many other health protective behaviors. Such barriers are inherent in the physical, social, organizational, and political environments of underserved communities.
Addressing Underserved Populations in Workplace Health Promotion: Obesity Prevention and Control
Obesity represents a major public health threat. Addressing obesity as a health concern for underserved populations in the worksite setting is a challenging objective. A discussion on this issue is presented here.
Challenges
American society, as is true of most developed nations, is obesogenic, or obesity producing, and substantial effort and resources are necessary to achieve and maintain a healthy lifestyle when living in the United States. However, obstacles to healthy eating and active living are concentrated in underserved communities. Ethnic minority or lower-income populations experience monumental economic and cultural challenges to healthy eating, physical activity participation, and many other health protective behaviors. Such barriers are inherent in the physical, social, organizational, and political environments of underserved communities. These barriers are detailed in the following discussion.
Economic factors pose enormous challenges to engaging in healthy behaviors (table 25.1). Geographic proximity to healthy foods and physical activity opportunities is strikingly limited for poorer communities. For example, park space in Los Angeles African American, Asian, and Latino communities is less than 1/100 of that in White communities in the same city (39). Similarly, fewer stores stock fresh or frozen produce, and the selection and quality of produce are much poorer. Conversely, fast-food restaurants are more plentiful in low-income and ethnic minority communities. From the higher proportions of inexpensive refined carbohydrate and fat in the food supply to the ubiquitous availability of brand-name sodas and coffee drinks available from vendors and vending machines, dietary quality reflects the nutrition environment of low-income and ethnic minority communities.
Hazardous neighborhood conditions are common. For example, people in low-income neighborhoods are more likely to be located near pollutants (environmental justice issues), face higher levels of exposure to environmental tobacco smoke, and experience higher rates of both intentional injury (due to gunplay or gang infestation) and unintentional injury (due to fewer pedestrian accommodations such as bridges over streets with high traffic volume, speed bumps, sidewalks, and street lamps in good repair). In addition, commercial marketing (including advertising and promotion) undoubtedly influences consumption preferences and purchasing behaviors. Marketing of health-compromising goods and services is pervasive in the United States, but increased exposure to commercial advertising for tobacco, unhealthy foods and beverages, and sedentary entertainment and transportation-as well as decreased exposure to health-promoting goods and services-has been documented in ethnic minority and neighborhoods, ethnically targeted publications, and Black audience prime-time television. However, attacks on this predatory marketing are not always politically feasible. Minority media, long ignored by most industries, have literally survived financially on culturally targeted fast-food, soda, alcohol, tobacco, film, and automobile ads that present sociodemographically marginalized groups in a very positive light.
Employment characteristics of lower-income workers present obstacles as well. Those who are lower in the work hierarchy have little flexibility to integrate physical activity into their lifestyles. They have little decisional latitude, rigid schedules (time clocks), and highly structured and supervised (assembly line) work processes. Sites employing a majority of low-income workers, such as low-income residential areas, have fewer healthy food options in close proximity and short lunchtimes. Long commuting times and multiple jobs further constrain leisure, despite higher rates of mass transit use and active transportation.
Leisure-time physical activity and foods with high nutrient value and low energy density are costly for individuals from low-income and ethnic minority backgrounds, both in time and money. Home meal preparation may assume a lower priority than meeting basic needs such as earning sufficient income for household expenses, caring for children and elders, religious observance, and relaxing at home. Federal farm subsidies for corn, used in cattle feed and high-fructose corn syrup, depress the cost of burgers and sodas relative to healthier offerings; the latter are already more expensive because of their more perishable nature, shorter shelf lives, and lower sales volumes (also due, in part, to less aggressive marketing). Low levels of enjoyment of physical activity and suboptimal motor skills may result from exposure to poor-quality physical education as youths.
Sociocultural obstacles to healthy lifestyle adherence are no less-and perhaps even more-influential than economic barriers. Culturally grounded norms, perceptions, and values surrounding physical activity and eating, including gender roles and role modeling, govern the ease or difficulty of participating in healthy behaviors. Many negative perceptions of physical activity have cultural origins with historical underpinnings. Commercially or socially marketed exercise fads and trends have traditionally emphasized sports, structured aerobics, or calisthenics that are consistent with the values of affluent Whites, especially males. Consequently, these exercise traditions have often been dismissed as incongruous by nonmainstream cultures. Sometimes these exercise traditions are even ridiculed-for example, jogging is perceived as a bourgeois waste of time and energy in less affluent or ethnic minority communities. In part, this may be attributed to the traditionally arduous lives of people from socioeconomically marginalized groups. The manual labor of the past has perhaps historically programmed an overestimation of daily work-related exertion and ingrained the need for rest after work to manage stress. A corollary misperception is that sweating reflects moderate to vigorous physical activity (when in fact sweating can accompany minimal exertion depending upon fitness level and ambient temperature).
Similarly, perceptions of healthful foods and healthy eating are culturally rooted. Certain foods, recipes, and food preparation techniques have been associated with particular ethnic identities. One example is the popularity of soul food, typified by fried catfish, fatback-seasoned collard greens, and corn bread, among African Americans. These tastes and smells produce positive affective responses summoning connection to family and nationality or culture of origin. The stressful lives of many individuals from socioeconomically marginalized groups also precipitate the use of nutrient-poor foods (comfort foods) as stress management. Job and residential segregation by income and ethnicity, magnified by the concentration of fast-food restaurants and paucity of dining options with a broader range of cuisines, preclude the usual sampling of a variety of foods as youths become more independent. Since most learning optimally incorporates an experiential component, there is little opportunity for multiple exposures associated with developing preferences for certain foods such as fruits and vegetables, whole grains, and low-fat dairy products (8). This may be compounded by the lack of vigorous exercise, which increases consumption of water and water-bearing foods and decreases preferences for highly sweetened beverages. Even the definition of what constitutes healthy foods varies among groups.
Social roles are key elements of identity influenced by culture of origin. Gender roles reflect culturally grounded notions of femininity and appropriate role behaviors. For example, concerns about maintaining a professional appearance (hair and makeup, skirts, high-heeled shoes) may deter women from exercising during the workday. In very traditional societies, vigorous exercise may even be seen as compromising a girl's virginity and negatively affecting her marriageability. Women are less frequently in positions of authority, and even when they are, expectations of acquiescence may decrease their influence on corporate policy. For women and people from ethnic minority groups, few culturally relevant role models may be available. At the same time, substantial social distance between line staff (who are more likely to be overweight or unfit) and management (who are more likely to be active) may persuade the former to reject healthier behaviors as pretentious or irrelevant.
Potential Solutions
Worksites are captive audiences of adults representing the entire demographic spectrum of a society. They present unparalleled opportunities to leverage organizational policy and practice change to improve the overall health of the workforce and, perhaps, to spur widespread social norm change. However, the promise of worksite health promotion beyond tobacco control has largely been squandered by the differential engagement of younger employees of higher socioeconomic status. The voluntary nature of these interventions, targeted at the individual level, engages primarily the motivated and fit-often fewer than 1 in 20 workers.
Workplace environmental change approaches may be designed to preferentially target ethnic minority and lower-income employees. Particularly, these approaches include push strategies that make physical activity and healthy food choices hard to avoid (23). These approaches tend to reduce health disparities, increasing the likelihood of delivering substantial ROI to employers (and to local governments that bear many of the costs of sedentariness) by engaging the more sedentary and overweight population segments less successfully reached by traditional worksite programs. Push strategies include exercise breaks on nondiscretionary time, healthy food services and procurement, walking meetings, vending and vendor restrictions, nearby parking restrictions, and substantive fiscal incentives for mass transit use. They are potentially more sustainable, as they rely less on individual motivation and initiation-the daunting myriad daily decisions and actions that must be undertaken to acquire and prepare healthy foods, to resist the temptations of highly palatable, widely marketed, and nutrient-poor foods and of sedentary entertainment, and to seek out and take advantage of ways to expend energy.
Changing the workplace-driven sociocultural and organizational environment is much more feasible than changing the built environment in these communities. The former changes obviate barriers such as unsafe or unappealing outdoor surroundings, lack of residential access to high-quality produce and recreational facilities, and copious perspiration and lack of enjoyment associated with longer bouts of strenuous exercise. Innovative indoor architectural design (e.g., skip-stop elevators, nested well-lit stairwells, standing workstations), private development of mixed-use neighborhoods, public construction of walking trails, and commercial location of fitness facilities are unlikely to garner a high priority in areas that cannot even regularly secure such basic services as streetlight maintenance, foliage trimming, and sidewalk repair.
Successful health promotion innovations in diverse work settings may share certain fundamental principles, or ingredients. Many, for example, build on cultural assets such as the normative nature of structural integration of group physical activity, in the form of dance or movement to music in social gatherings throughout the life span; the cultural salience of many plant-based foods; and the collectivist versus individualist values. Key ingredients of culturally proficient approaches are outlined in table 25.2.
Social network can increase worksite health program participation
How can we take advantage of new communication technologies in creating more prolific change while reaching far more people than we ever could have imagined? There is little reason to believe that people with a broken wrist or inflamed tonsils want to become part of a social network of people who share the same transient health issue. So what are the types of issues that are appropriate for online communities and social networks to address?
How can we take advantage of new communication technologies in creating more prolific change while reaching far more people than we ever could have imagined? There is little reason to believe that people with a broken wrist or inflamed tonsils want to become part of a social network of people who share the same transient health issue. To build purposeful and effective social networks, it is important to consider the following factors.
- Trust: Participants feel the network is a trusted source of useful knowledge.
- Relevance: The knowledge that is shared applies directly to participants on an ongoing basis.
- Urgency: The resources shared help members solve a problem quickly and meaningfully. There is often an emotional tie to the issue.
- Chronicity: The issue is ongoing and merits getting involved and staying involved.
- Incentive: Participation provides a personal benefit. Collaborating helps advance career or job status, personal health, and son on-from the participant's point of view, it's worth it.
- Serial reciprocity: Participants believe, "If I help others with my knowledge or experience, they may help someone else, and someone else may help me."
However, in order to build such social networks, we need to know the participant. Criteria that allow us to know the participant are difficult to identify-let alone act upon-given most current uses of new communication technologies. In fact, most of today's computer-mediated or IVR and wireless health interventions tend to offer one-way communication-the producer of the site provides static information about a health topic that goes from the site to the user. It is assumed that accurate information is sufficient to activate a behavior change or at best provide questions with branching logic to deepen the level of detail of the information provided. Even sites that offer bulletin boards are limited. Postings are categorized by topic, and off-topic communication is discouraged. This makes it difficult for people to get to know one another the way they might during the general chitchatting, visiting, and relationship forming that happens in the real world when groups get together regularly around a common topic or cause.
So what are the types of issues that are appropriate for online communities and social networks to address? Here are just a few. On the illness end of the health spectrum, communities can affect diabetes, cancer, obesity, Crohn's disease, Lyme disease, and substance addiction. For caregivers, online communities can help with caring for children with disabilities or for patients with Alzheimer's disease or with end-of-life care. On the health management and health promotion end of the spectrum, areas such as weight loss, smoking cessation, new parent support, and worksite-based team physical activity (cycling, walking, calorie expenditure, and so on) are all suitable targets for online communities.
What are the behaviors we wish to encourage within an online community that will help motivate health behavior change? They are the same behaviors found in other forms of social interactions: receiving support, searching for relevant information and resources when needed, learning how to apply information to personal circumstances, sharing our own stories and resources, and connecting with others regarding our circumstances.
People may share details about their life circumstances or backgrounds that allow them to connect in an infinite variety of unpredictable ways. They may talk about pets, kids, politics, or a local sport team. While such connections may seem inconsequential, over time they allow people to feel a sense of belonging that can build confidence, which is often as significant as the behavior change itself. Without these connections, the participants' bond to the group is only as strong as their interest in the very specific issue that they came for. In the world of social support, such limited interest is rarely enough to sustain the relationship over the long term. The goal is to build as many strands of social capital as possible. You may come to a Web community for one specific reason. You often stay for many additional ones.
So What Does All This Mean for Worksite Health Management?
We are not suggesting that social networks replace existing health management interventions. Quite the opposite! One way for a social network or online community to be used in worksite health promotion is to leverage such tools to increase the participation of employees and their dependents in the many different interventions that are offered by a corporation. The contextually relevant recommendations of others can drive participation through personal stories, ratings, and even incentives tied to using the social network. For example, it is possible to match people with similar fitness interests and goals. The network becomes a place not only to find a cycling buddy but also to create virtual competitions with other employees-regardless of location or department-that can be displayed and shared on the Web. Participants can score points for tracking their times and progress, virtual teams can be formed, stories and pictures can be shared, and people with common interests or capabilities can be matched to encourage ongoing participation.
Not all of this will have to depend on the employee's initiative. Imagine that when you complete a health risk appraisal, it is possible to identify risks you prefer or feel most confident to address. From these data, along with personal profile information, you can be matched to the best programs available from the company. Moreover, you can be provided with an up-to-date search of selected information sources on the Web and then introduced to a support community of people like you. You can read their stories about how they successfully improved their health condition or risk status and then connect with them.
But we can go further yet. By integrating community with coaching, it becomes possible for a telephonic coach to not only intervene with an employee but also facilitate groups of employees receiving similar coaching who can support each other. Instead of a coach making five separate calls to 15 different employees (75 coaching sessions), the coach may only need to complete two calls to each participant, introduce members to each other, and facilitate ongoing sessions. This not only reduces the cost of the coaching intervention but also creates far more opportunities for ongoing support and intervention, taking advantage of employees by making them both recipients and providers of the intervention. In an age of consumer-directed health care, the inclusion of social networks around the existing suite of health promotion interventions creates a more effective and efficient system that actually models the concept of consumer directedness.
Beyond this integration, a community can also provide a means to tie health management to actual health care delivery. There is a growing movement for the use of electronic medical records (EMR) and personal health records (PHR). There is a similar growth in the use of on-site health care clinics. Imagine if we can not only connect phone coaches with employees within the community but also link medical providers to this process, ensuring that there is a closed loop between the employee (consumer) and the whole spectrum of health care and management providers.
To accomplish this sort of integration will require a different set of tools and skills than most programs currently maintain. The expansion of social networking, online communities, and collaborative technologies has several implications for the future of worksite health management. Inherent in these technologies are capabilities that will change the way we communicate and intervene with worksite populations. We will need to collect data not only about risks, diseases, and demographics but also about the preferences of users. We will need to understand that relationships drive behavior as much as information. We will need to understand that knowledge is the domain of the user as well as the provider. Ultimately, our role as professionals will include being facilitators as much as being purveyors of truth.
In return for building these new capabilities, practitioners will be in a position to create a truly integrated approach to delivery of health and medical care within the context of a community of care and caring. The opportunities are exciting and limited only by our imagination. The technology exists to do all this today. The dogs are hungry and ready for us to give them something to eat.
Consideration of socieconomic factors leads to more effective worksite health programs
Ethnic minority or lower-income populations experience monumental economic and cultural challenges to healthy eating, physical activity participation, and many other health protective behaviors. Such barriers are inherent in the physical, social, organizational, and political environments of underserved communities.
Addressing Underserved Populations in Workplace Health Promotion: Obesity Prevention and Control
Obesity represents a major public health threat. Addressing obesity as a health concern for underserved populations in the worksite setting is a challenging objective. A discussion on this issue is presented here.
Challenges
American society, as is true of most developed nations, is obesogenic, or obesity producing, and substantial effort and resources are necessary to achieve and maintain a healthy lifestyle when living in the United States. However, obstacles to healthy eating and active living are concentrated in underserved communities. Ethnic minority or lower-income populations experience monumental economic and cultural challenges to healthy eating, physical activity participation, and many other health protective behaviors. Such barriers are inherent in the physical, social, organizational, and political environments of underserved communities. These barriers are detailed in the following discussion.
Economic factors pose enormous challenges to engaging in healthy behaviors (table 25.1). Geographic proximity to healthy foods and physical activity opportunities is strikingly limited for poorer communities. For example, park space in Los Angeles African American, Asian, and Latino communities is less than 1/100 of that in White communities in the same city (39). Similarly, fewer stores stock fresh or frozen produce, and the selection and quality of produce are much poorer. Conversely, fast-food restaurants are more plentiful in low-income and ethnic minority communities. From the higher proportions of inexpensive refined carbohydrate and fat in the food supply to the ubiquitous availability of brand-name sodas and coffee drinks available from vendors and vending machines, dietary quality reflects the nutrition environment of low-income and ethnic minority communities.
Hazardous neighborhood conditions are common. For example, people in low-income neighborhoods are more likely to be located near pollutants (environmental justice issues), face higher levels of exposure to environmental tobacco smoke, and experience higher rates of both intentional injury (due to gunplay or gang infestation) and unintentional injury (due to fewer pedestrian accommodations such as bridges over streets with high traffic volume, speed bumps, sidewalks, and street lamps in good repair). In addition, commercial marketing (including advertising and promotion) undoubtedly influences consumption preferences and purchasing behaviors. Marketing of health-compromising goods and services is pervasive in the United States, but increased exposure to commercial advertising for tobacco, unhealthy foods and beverages, and sedentary entertainment and transportation-as well as decreased exposure to health-promoting goods and services-has been documented in ethnic minority and neighborhoods, ethnically targeted publications, and Black audience prime-time television. However, attacks on this predatory marketing are not always politically feasible. Minority media, long ignored by most industries, have literally survived financially on culturally targeted fast-food, soda, alcohol, tobacco, film, and automobile ads that present sociodemographically marginalized groups in a very positive light.
Employment characteristics of lower-income workers present obstacles as well. Those who are lower in the work hierarchy have little flexibility to integrate physical activity into their lifestyles. They have little decisional latitude, rigid schedules (time clocks), and highly structured and supervised (assembly line) work processes. Sites employing a majority of low-income workers, such as low-income residential areas, have fewer healthy food options in close proximity and short lunchtimes. Long commuting times and multiple jobs further constrain leisure, despite higher rates of mass transit use and active transportation.
Leisure-time physical activity and foods with high nutrient value and low energy density are costly for individuals from low-income and ethnic minority backgrounds, both in time and money. Home meal preparation may assume a lower priority than meeting basic needs such as earning sufficient income for household expenses, caring for children and elders, religious observance, and relaxing at home. Federal farm subsidies for corn, used in cattle feed and high-fructose corn syrup, depress the cost of burgers and sodas relative to healthier offerings; the latter are already more expensive because of their more perishable nature, shorter shelf lives, and lower sales volumes (also due, in part, to less aggressive marketing). Low levels of enjoyment of physical activity and suboptimal motor skills may result from exposure to poor-quality physical education as youths.
Sociocultural obstacles to healthy lifestyle adherence are no less-and perhaps even more-influential than economic barriers. Culturally grounded norms, perceptions, and values surrounding physical activity and eating, including gender roles and role modeling, govern the ease or difficulty of participating in healthy behaviors. Many negative perceptions of physical activity have cultural origins with historical underpinnings. Commercially or socially marketed exercise fads and trends have traditionally emphasized sports, structured aerobics, or calisthenics that are consistent with the values of affluent Whites, especially males. Consequently, these exercise traditions have often been dismissed as incongruous by nonmainstream cultures. Sometimes these exercise traditions are even ridiculed-for example, jogging is perceived as a bourgeois waste of time and energy in less affluent or ethnic minority communities. In part, this may be attributed to the traditionally arduous lives of people from socioeconomically marginalized groups. The manual labor of the past has perhaps historically programmed an overestimation of daily work-related exertion and ingrained the need for rest after work to manage stress. A corollary misperception is that sweating reflects moderate to vigorous physical activity (when in fact sweating can accompany minimal exertion depending upon fitness level and ambient temperature).
Similarly, perceptions of healthful foods and healthy eating are culturally rooted. Certain foods, recipes, and food preparation techniques have been associated with particular ethnic identities. One example is the popularity of soul food, typified by fried catfish, fatback-seasoned collard greens, and corn bread, among African Americans. These tastes and smells produce positive affective responses summoning connection to family and nationality or culture of origin. The stressful lives of many individuals from socioeconomically marginalized groups also precipitate the use of nutrient-poor foods (comfort foods) as stress management. Job and residential segregation by income and ethnicity, magnified by the concentration of fast-food restaurants and paucity of dining options with a broader range of cuisines, preclude the usual sampling of a variety of foods as youths become more independent. Since most learning optimally incorporates an experiential component, there is little opportunity for multiple exposures associated with developing preferences for certain foods such as fruits and vegetables, whole grains, and low-fat dairy products (8). This may be compounded by the lack of vigorous exercise, which increases consumption of water and water-bearing foods and decreases preferences for highly sweetened beverages. Even the definition of what constitutes healthy foods varies among groups.
Social roles are key elements of identity influenced by culture of origin. Gender roles reflect culturally grounded notions of femininity and appropriate role behaviors. For example, concerns about maintaining a professional appearance (hair and makeup, skirts, high-heeled shoes) may deter women from exercising during the workday. In very traditional societies, vigorous exercise may even be seen as compromising a girl's virginity and negatively affecting her marriageability. Women are less frequently in positions of authority, and even when they are, expectations of acquiescence may decrease their influence on corporate policy. For women and people from ethnic minority groups, few culturally relevant role models may be available. At the same time, substantial social distance between line staff (who are more likely to be overweight or unfit) and management (who are more likely to be active) may persuade the former to reject healthier behaviors as pretentious or irrelevant.
Potential Solutions
Worksites are captive audiences of adults representing the entire demographic spectrum of a society. They present unparalleled opportunities to leverage organizational policy and practice change to improve the overall health of the workforce and, perhaps, to spur widespread social norm change. However, the promise of worksite health promotion beyond tobacco control has largely been squandered by the differential engagement of younger employees of higher socioeconomic status. The voluntary nature of these interventions, targeted at the individual level, engages primarily the motivated and fit-often fewer than 1 in 20 workers.
Workplace environmental change approaches may be designed to preferentially target ethnic minority and lower-income employees. Particularly, these approaches include push strategies that make physical activity and healthy food choices hard to avoid (23). These approaches tend to reduce health disparities, increasing the likelihood of delivering substantial ROI to employers (and to local governments that bear many of the costs of sedentariness) by engaging the more sedentary and overweight population segments less successfully reached by traditional worksite programs. Push strategies include exercise breaks on nondiscretionary time, healthy food services and procurement, walking meetings, vending and vendor restrictions, nearby parking restrictions, and substantive fiscal incentives for mass transit use. They are potentially more sustainable, as they rely less on individual motivation and initiation-the daunting myriad daily decisions and actions that must be undertaken to acquire and prepare healthy foods, to resist the temptations of highly palatable, widely marketed, and nutrient-poor foods and of sedentary entertainment, and to seek out and take advantage of ways to expend energy.
Changing the workplace-driven sociocultural and organizational environment is much more feasible than changing the built environment in these communities. The former changes obviate barriers such as unsafe or unappealing outdoor surroundings, lack of residential access to high-quality produce and recreational facilities, and copious perspiration and lack of enjoyment associated with longer bouts of strenuous exercise. Innovative indoor architectural design (e.g., skip-stop elevators, nested well-lit stairwells, standing workstations), private development of mixed-use neighborhoods, public construction of walking trails, and commercial location of fitness facilities are unlikely to garner a high priority in areas that cannot even regularly secure such basic services as streetlight maintenance, foliage trimming, and sidewalk repair.
Successful health promotion innovations in diverse work settings may share certain fundamental principles, or ingredients. Many, for example, build on cultural assets such as the normative nature of structural integration of group physical activity, in the form of dance or movement to music in social gatherings throughout the life span; the cultural salience of many plant-based foods; and the collectivist versus individualist values. Key ingredients of culturally proficient approaches are outlined in table 25.2.
Social network can increase worksite health program participation
How can we take advantage of new communication technologies in creating more prolific change while reaching far more people than we ever could have imagined? There is little reason to believe that people with a broken wrist or inflamed tonsils want to become part of a social network of people who share the same transient health issue. So what are the types of issues that are appropriate for online communities and social networks to address?
How can we take advantage of new communication technologies in creating more prolific change while reaching far more people than we ever could have imagined? There is little reason to believe that people with a broken wrist or inflamed tonsils want to become part of a social network of people who share the same transient health issue. To build purposeful and effective social networks, it is important to consider the following factors.
- Trust: Participants feel the network is a trusted source of useful knowledge.
- Relevance: The knowledge that is shared applies directly to participants on an ongoing basis.
- Urgency: The resources shared help members solve a problem quickly and meaningfully. There is often an emotional tie to the issue.
- Chronicity: The issue is ongoing and merits getting involved and staying involved.
- Incentive: Participation provides a personal benefit. Collaborating helps advance career or job status, personal health, and son on-from the participant's point of view, it's worth it.
- Serial reciprocity: Participants believe, "If I help others with my knowledge or experience, they may help someone else, and someone else may help me."
However, in order to build such social networks, we need to know the participant. Criteria that allow us to know the participant are difficult to identify-let alone act upon-given most current uses of new communication technologies. In fact, most of today's computer-mediated or IVR and wireless health interventions tend to offer one-way communication-the producer of the site provides static information about a health topic that goes from the site to the user. It is assumed that accurate information is sufficient to activate a behavior change or at best provide questions with branching logic to deepen the level of detail of the information provided. Even sites that offer bulletin boards are limited. Postings are categorized by topic, and off-topic communication is discouraged. This makes it difficult for people to get to know one another the way they might during the general chitchatting, visiting, and relationship forming that happens in the real world when groups get together regularly around a common topic or cause.
So what are the types of issues that are appropriate for online communities and social networks to address? Here are just a few. On the illness end of the health spectrum, communities can affect diabetes, cancer, obesity, Crohn's disease, Lyme disease, and substance addiction. For caregivers, online communities can help with caring for children with disabilities or for patients with Alzheimer's disease or with end-of-life care. On the health management and health promotion end of the spectrum, areas such as weight loss, smoking cessation, new parent support, and worksite-based team physical activity (cycling, walking, calorie expenditure, and so on) are all suitable targets for online communities.
What are the behaviors we wish to encourage within an online community that will help motivate health behavior change? They are the same behaviors found in other forms of social interactions: receiving support, searching for relevant information and resources when needed, learning how to apply information to personal circumstances, sharing our own stories and resources, and connecting with others regarding our circumstances.
People may share details about their life circumstances or backgrounds that allow them to connect in an infinite variety of unpredictable ways. They may talk about pets, kids, politics, or a local sport team. While such connections may seem inconsequential, over time they allow people to feel a sense of belonging that can build confidence, which is often as significant as the behavior change itself. Without these connections, the participants' bond to the group is only as strong as their interest in the very specific issue that they came for. In the world of social support, such limited interest is rarely enough to sustain the relationship over the long term. The goal is to build as many strands of social capital as possible. You may come to a Web community for one specific reason. You often stay for many additional ones.
So What Does All This Mean for Worksite Health Management?
We are not suggesting that social networks replace existing health management interventions. Quite the opposite! One way for a social network or online community to be used in worksite health promotion is to leverage such tools to increase the participation of employees and their dependents in the many different interventions that are offered by a corporation. The contextually relevant recommendations of others can drive participation through personal stories, ratings, and even incentives tied to using the social network. For example, it is possible to match people with similar fitness interests and goals. The network becomes a place not only to find a cycling buddy but also to create virtual competitions with other employees-regardless of location or department-that can be displayed and shared on the Web. Participants can score points for tracking their times and progress, virtual teams can be formed, stories and pictures can be shared, and people with common interests or capabilities can be matched to encourage ongoing participation.
Not all of this will have to depend on the employee's initiative. Imagine that when you complete a health risk appraisal, it is possible to identify risks you prefer or feel most confident to address. From these data, along with personal profile information, you can be matched to the best programs available from the company. Moreover, you can be provided with an up-to-date search of selected information sources on the Web and then introduced to a support community of people like you. You can read their stories about how they successfully improved their health condition or risk status and then connect with them.
But we can go further yet. By integrating community with coaching, it becomes possible for a telephonic coach to not only intervene with an employee but also facilitate groups of employees receiving similar coaching who can support each other. Instead of a coach making five separate calls to 15 different employees (75 coaching sessions), the coach may only need to complete two calls to each participant, introduce members to each other, and facilitate ongoing sessions. This not only reduces the cost of the coaching intervention but also creates far more opportunities for ongoing support and intervention, taking advantage of employees by making them both recipients and providers of the intervention. In an age of consumer-directed health care, the inclusion of social networks around the existing suite of health promotion interventions creates a more effective and efficient system that actually models the concept of consumer directedness.
Beyond this integration, a community can also provide a means to tie health management to actual health care delivery. There is a growing movement for the use of electronic medical records (EMR) and personal health records (PHR). There is a similar growth in the use of on-site health care clinics. Imagine if we can not only connect phone coaches with employees within the community but also link medical providers to this process, ensuring that there is a closed loop between the employee (consumer) and the whole spectrum of health care and management providers.
To accomplish this sort of integration will require a different set of tools and skills than most programs currently maintain. The expansion of social networking, online communities, and collaborative technologies has several implications for the future of worksite health management. Inherent in these technologies are capabilities that will change the way we communicate and intervene with worksite populations. We will need to collect data not only about risks, diseases, and demographics but also about the preferences of users. We will need to understand that relationships drive behavior as much as information. We will need to understand that knowledge is the domain of the user as well as the provider. Ultimately, our role as professionals will include being facilitators as much as being purveyors of truth.
In return for building these new capabilities, practitioners will be in a position to create a truly integrated approach to delivery of health and medical care within the context of a community of care and caring. The opportunities are exciting and limited only by our imagination. The technology exists to do all this today. The dogs are hungry and ready for us to give them something to eat.
Consideration of socieconomic factors leads to more effective worksite health programs
Ethnic minority or lower-income populations experience monumental economic and cultural challenges to healthy eating, physical activity participation, and many other health protective behaviors. Such barriers are inherent in the physical, social, organizational, and political environments of underserved communities.
Addressing Underserved Populations in Workplace Health Promotion: Obesity Prevention and Control
Obesity represents a major public health threat. Addressing obesity as a health concern for underserved populations in the worksite setting is a challenging objective. A discussion on this issue is presented here.
Challenges
American society, as is true of most developed nations, is obesogenic, or obesity producing, and substantial effort and resources are necessary to achieve and maintain a healthy lifestyle when living in the United States. However, obstacles to healthy eating and active living are concentrated in underserved communities. Ethnic minority or lower-income populations experience monumental economic and cultural challenges to healthy eating, physical activity participation, and many other health protective behaviors. Such barriers are inherent in the physical, social, organizational, and political environments of underserved communities. These barriers are detailed in the following discussion.
Economic factors pose enormous challenges to engaging in healthy behaviors (table 25.1). Geographic proximity to healthy foods and physical activity opportunities is strikingly limited for poorer communities. For example, park space in Los Angeles African American, Asian, and Latino communities is less than 1/100 of that in White communities in the same city (39). Similarly, fewer stores stock fresh or frozen produce, and the selection and quality of produce are much poorer. Conversely, fast-food restaurants are more plentiful in low-income and ethnic minority communities. From the higher proportions of inexpensive refined carbohydrate and fat in the food supply to the ubiquitous availability of brand-name sodas and coffee drinks available from vendors and vending machines, dietary quality reflects the nutrition environment of low-income and ethnic minority communities.
Hazardous neighborhood conditions are common. For example, people in low-income neighborhoods are more likely to be located near pollutants (environmental justice issues), face higher levels of exposure to environmental tobacco smoke, and experience higher rates of both intentional injury (due to gunplay or gang infestation) and unintentional injury (due to fewer pedestrian accommodations such as bridges over streets with high traffic volume, speed bumps, sidewalks, and street lamps in good repair). In addition, commercial marketing (including advertising and promotion) undoubtedly influences consumption preferences and purchasing behaviors. Marketing of health-compromising goods and services is pervasive in the United States, but increased exposure to commercial advertising for tobacco, unhealthy foods and beverages, and sedentary entertainment and transportation-as well as decreased exposure to health-promoting goods and services-has been documented in ethnic minority and neighborhoods, ethnically targeted publications, and Black audience prime-time television. However, attacks on this predatory marketing are not always politically feasible. Minority media, long ignored by most industries, have literally survived financially on culturally targeted fast-food, soda, alcohol, tobacco, film, and automobile ads that present sociodemographically marginalized groups in a very positive light.
Employment characteristics of lower-income workers present obstacles as well. Those who are lower in the work hierarchy have little flexibility to integrate physical activity into their lifestyles. They have little decisional latitude, rigid schedules (time clocks), and highly structured and supervised (assembly line) work processes. Sites employing a majority of low-income workers, such as low-income residential areas, have fewer healthy food options in close proximity and short lunchtimes. Long commuting times and multiple jobs further constrain leisure, despite higher rates of mass transit use and active transportation.
Leisure-time physical activity and foods with high nutrient value and low energy density are costly for individuals from low-income and ethnic minority backgrounds, both in time and money. Home meal preparation may assume a lower priority than meeting basic needs such as earning sufficient income for household expenses, caring for children and elders, religious observance, and relaxing at home. Federal farm subsidies for corn, used in cattle feed and high-fructose corn syrup, depress the cost of burgers and sodas relative to healthier offerings; the latter are already more expensive because of their more perishable nature, shorter shelf lives, and lower sales volumes (also due, in part, to less aggressive marketing). Low levels of enjoyment of physical activity and suboptimal motor skills may result from exposure to poor-quality physical education as youths.
Sociocultural obstacles to healthy lifestyle adherence are no less-and perhaps even more-influential than economic barriers. Culturally grounded norms, perceptions, and values surrounding physical activity and eating, including gender roles and role modeling, govern the ease or difficulty of participating in healthy behaviors. Many negative perceptions of physical activity have cultural origins with historical underpinnings. Commercially or socially marketed exercise fads and trends have traditionally emphasized sports, structured aerobics, or calisthenics that are consistent with the values of affluent Whites, especially males. Consequently, these exercise traditions have often been dismissed as incongruous by nonmainstream cultures. Sometimes these exercise traditions are even ridiculed-for example, jogging is perceived as a bourgeois waste of time and energy in less affluent or ethnic minority communities. In part, this may be attributed to the traditionally arduous lives of people from socioeconomically marginalized groups. The manual labor of the past has perhaps historically programmed an overestimation of daily work-related exertion and ingrained the need for rest after work to manage stress. A corollary misperception is that sweating reflects moderate to vigorous physical activity (when in fact sweating can accompany minimal exertion depending upon fitness level and ambient temperature).
Similarly, perceptions of healthful foods and healthy eating are culturally rooted. Certain foods, recipes, and food preparation techniques have been associated with particular ethnic identities. One example is the popularity of soul food, typified by fried catfish, fatback-seasoned collard greens, and corn bread, among African Americans. These tastes and smells produce positive affective responses summoning connection to family and nationality or culture of origin. The stressful lives of many individuals from socioeconomically marginalized groups also precipitate the use of nutrient-poor foods (comfort foods) as stress management. Job and residential segregation by income and ethnicity, magnified by the concentration of fast-food restaurants and paucity of dining options with a broader range of cuisines, preclude the usual sampling of a variety of foods as youths become more independent. Since most learning optimally incorporates an experiential component, there is little opportunity for multiple exposures associated with developing preferences for certain foods such as fruits and vegetables, whole grains, and low-fat dairy products (8). This may be compounded by the lack of vigorous exercise, which increases consumption of water and water-bearing foods and decreases preferences for highly sweetened beverages. Even the definition of what constitutes healthy foods varies among groups.
Social roles are key elements of identity influenced by culture of origin. Gender roles reflect culturally grounded notions of femininity and appropriate role behaviors. For example, concerns about maintaining a professional appearance (hair and makeup, skirts, high-heeled shoes) may deter women from exercising during the workday. In very traditional societies, vigorous exercise may even be seen as compromising a girl's virginity and negatively affecting her marriageability. Women are less frequently in positions of authority, and even when they are, expectations of acquiescence may decrease their influence on corporate policy. For women and people from ethnic minority groups, few culturally relevant role models may be available. At the same time, substantial social distance between line staff (who are more likely to be overweight or unfit) and management (who are more likely to be active) may persuade the former to reject healthier behaviors as pretentious or irrelevant.
Potential Solutions
Worksites are captive audiences of adults representing the entire demographic spectrum of a society. They present unparalleled opportunities to leverage organizational policy and practice change to improve the overall health of the workforce and, perhaps, to spur widespread social norm change. However, the promise of worksite health promotion beyond tobacco control has largely been squandered by the differential engagement of younger employees of higher socioeconomic status. The voluntary nature of these interventions, targeted at the individual level, engages primarily the motivated and fit-often fewer than 1 in 20 workers.
Workplace environmental change approaches may be designed to preferentially target ethnic minority and lower-income employees. Particularly, these approaches include push strategies that make physical activity and healthy food choices hard to avoid (23). These approaches tend to reduce health disparities, increasing the likelihood of delivering substantial ROI to employers (and to local governments that bear many of the costs of sedentariness) by engaging the more sedentary and overweight population segments less successfully reached by traditional worksite programs. Push strategies include exercise breaks on nondiscretionary time, healthy food services and procurement, walking meetings, vending and vendor restrictions, nearby parking restrictions, and substantive fiscal incentives for mass transit use. They are potentially more sustainable, as they rely less on individual motivation and initiation-the daunting myriad daily decisions and actions that must be undertaken to acquire and prepare healthy foods, to resist the temptations of highly palatable, widely marketed, and nutrient-poor foods and of sedentary entertainment, and to seek out and take advantage of ways to expend energy.
Changing the workplace-driven sociocultural and organizational environment is much more feasible than changing the built environment in these communities. The former changes obviate barriers such as unsafe or unappealing outdoor surroundings, lack of residential access to high-quality produce and recreational facilities, and copious perspiration and lack of enjoyment associated with longer bouts of strenuous exercise. Innovative indoor architectural design (e.g., skip-stop elevators, nested well-lit stairwells, standing workstations), private development of mixed-use neighborhoods, public construction of walking trails, and commercial location of fitness facilities are unlikely to garner a high priority in areas that cannot even regularly secure such basic services as streetlight maintenance, foliage trimming, and sidewalk repair.
Successful health promotion innovations in diverse work settings may share certain fundamental principles, or ingredients. Many, for example, build on cultural assets such as the normative nature of structural integration of group physical activity, in the form of dance or movement to music in social gatherings throughout the life span; the cultural salience of many plant-based foods; and the collectivist versus individualist values. Key ingredients of culturally proficient approaches are outlined in table 25.2.
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