Thoughts on Wellness Programs and the Need for More Research

Sadly, yet another high quality research study has shown that an employer’s workplace wellness program has been ineffective. That’s the bottom line of a randomized clinical trial recently published in the Journal of the American Medical Association.  See for yourself in this summary abstract of the article from JAMA.  

Now a reader might reasonably ask:  Was the design of this particular workplace program unusual or inferior in some way?  Or does this study continue the trend that is casting doubt on the effectiveness of ALL workplace wellness programs? 

Please note:  this is not my “first wellness rodeo.”  In fact, since I entered the occupational medicine field in the mid-1980’s I have watched at least THREE waves of enthusiasm pass through employers – eager (desperate?) for various forms of health improvement program cures for the costs and consequences of ill health among the workforce -- followed by disillusion and abandonment of the idea (for a while).

If not now, WHEN will employers stop buying weak wellness programs?  I continue to worry about low quality programs discrediting the whole idea.  Years ago an employer asked me to create a wellness program, but when he told me how much he wanted to invest, it became clear he fundamentally wanted a “decorative” program – so he could LOOK like a good employer  – NOT BECAUSE he was really ready to invest the real money and effort required make profound changes in his company that would create a return on that investment.  I declined.

I suspect we have paid too much attention / done too many studies focused on the COMPONENTS of wellness programs.  We have paid too little attention / done too few studies of the UNDERLYING human issues (organizational and individual) that make programs like this fail or succeed.  The current study is an example of one that neither assessed nor meaningfully addressed some powerful factors. 

• Organizational risk factors:  Ever since the  the UK’s ground-breaking Whitehall Studies, which first documented the major impact on sickness and mortality of factors that are now called ‘social determinants of health,’ showed that low-ranking workers had mortality rates three times as high as high-ranking ones, research has been accumulating about the difference between “healthy” and “unhealthy” workplaces from an organizational design/job design/human interaction perspective. Clearly, all BJ’s stores are not the same, even though they try to be. Management varies; employees vary.  The program did not seem to address or control for organizational factors such as workplace climate and culture, the quality of local management as measured by comparative store performance, employee turnover, daily absence rate, and so on. For more information on the impact of organizational risk factors on health and how to minimize them, see this remarkable book Preventive Stress Management in Organizationswhich puts it all together: https://www.amazon.com/Preventive-Stress-Management-Organizations-Campbell/dp/1433811855   (This is the brand new second edition;  I hope it’s as good as the first – and just ordered a copy.)
• Individual risk factors: As we all know, roughly 80% or more of costs are generated by 20% or less of the workforce. The BJ’s wellness program seems to have relied mostly on educational and “motivational” sessions conducted by dieticians -- the kind that attract the worried well.  But most people with poor diet and exercise/risky health habits persist in doing so DESPITE having already received PLENTY of information and encouragement to change. Many of the unhealthiest employees probably have hidden vulnerabilities, often, for example, a history of Adverse Childhood Experiences (ACEs). According to a CDC survey, between 8 and 14 percent of adult Americans had a heavy dose of ACEs in childhood.  A severely traumatic childhood changes one’s nervous system permanently, often producing adults with low resilience, weak coping and life skills, low stress tolerance, for whom risky behaviors look like a solution -- an attempt at self-soothing. This group can be cynical about, or frightened by the “happy happy” tone of wellness programs because it doesn’t match up with their everyday reality. Recently I was stunned and delighted when I heard the FIRST EVER clinician who is involved with wellness/health promotion programs express an awareness of the need to MEANINGFULLY connect with that vulnerable sub-group by using the phrase “trauma-informed care.” For more information on ACEs, see https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/aboutace.html 
    

An accompanying editorial in the JAMA made me wonder about something else. Here’s an excerpt: “[G]rowing evidence that demonstrates limited or no program effects should encourage wellness companies and employers to critically assess the programs they are offering and increase their willingness to innovate, test, and evaluate novel designs…. Continued investments in research, development, and the generation of high-quality evaluations are needed to determine whether specific program designs and implementation strategies can generate sustained health behavior changes that in turn can lead to measurable health and economic benefits. Given their broad diffusion, employer wellness programs that are able to demonstrate positive outcomes can provide a valuable complement to health system – and community-based approaches for reducing chronic disease prevalence and its economic effects on society.” 

To which I reply:  WHOSE money should be invested in further research in these programs? Businesses are not in the business to create/generate/enrich (and share) the body of knowledge needed to improve the nation’s health system/the health of the working age population as a whole. Businesses are supposed to be investing their time and money in things that produce a good return on investment.  Since the workplace is increasingly being viewed as an ideal delivery site for many public health programs, maybe it would be appropriate for charitable foundations or government research money to pitch in and subsidize this on-going basic research.

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