the HAES® files: Workplace Wellness Revisited

by Health At Every Size® Blog

by Fall Ferguson, JD, MA

“Nowadays people know the price of everything and the value of nothing.”
~ Oscar Wilde

I planned this blog post as a follow-up to a piece that I wrote about a year ago suggesting possible actions that the HAES community might want to consider taking with regard to workplace wellness in light of a meta-study that came out this summer looking at program effectiveness. But as I read and contemplated the current state of workplace wellness, I became increasingly uncomfortable with the discourse itself. I found myself questioning what we really mean when we talk about health and wellness in the workplace context. I find myself revisiting and questioning the pragmatic point of view I espoused a year ago, that in order to persuade employers to move away from healthist and weight-based wellness programs, we have to engage in their discourse on effectiveness.

Should we promote the replacement of traditional wellness programs with HAES-oriented wellness programs, and encourage research showing the value of such replacement programs? A year ago, this was a “no-brainer” for me. Now I find myself contemplating a more radical stance: is it possible that the entire framework of “workplace wellness” is incompatible with a multi-dimensional, non-judgmental, and socially just definition of health as contemplated by the HAES principles?

Please don’t misunderstand – I am grateful that there are HAES advocates who provide workplace wellness programs that do not use weight to define health. As long as there are workplace wellness systems, it seems important to support non-weight-focused programming. Rather, I am looking at this issue from a systems lens: I fear that the overall system of workplace wellness in its current form may be intractably healthist, racist, classist, and sizeist, and may thus harm our collective well-being far more than it helps.

ROI and Wellness Programs

Much has been made of a recently published meta-study in the American Journal of Health Promotion based on studies from 9 different countries that tends to show, among other things, that the more rigorous the methodology of a study, the less likely it is to show that a given worksite health program is effective in terms of “return on investment” or “ROI.” The highest quality studies actually yield a negative ROI. This suggests that employers may be spending more on workplace wellness programs than they “save” on costs such as health care expenditures, absenteeism, presenteeism, etc.

The importance of this study depends, of course, on who is talking. Not surprisingly, workplace wellness vendor Staywell Health Management asserted its disagreement with “those who dismiss all positive ROI findings based on the shortcomings of lower quality, less rigorous studies.” In contrast, wellness expert and HAES advocate Jon Robison asserts that the study “settles the matter once and for all”: traditional wellness programs are not cost-effective. Workplace wellness author Al Lewis is quoted by Jon Robison to the effect that the key finding of the study is, “valid studies show traditional workplace wellness is a loser.”

Editor-in-chief of the American Journal of Health Promotion Michael O’Donnell may provide the most useful way of understanding the study. While he calls it “the most extensive and well-conceived review conducted to date” he notes significant areas that are still not being addressed by researchers. Most of these deficits relate to the finer points of research methodology, but he also makes the very interesting observation that the research studies to date have not addressed the quality of the wellness programs being studied. Researchers are not looking into whether the programs address actual health needs of the people participating in them.

Is Health a Matter of Economics?

When it comes to decisions about who gets what health care services or decisions about public spending on health promotion programs, then I would answer this question in the affirmative: of course, an economic analysis must be part of the conversation. In every society in the world, resources are limited to some degree or another. It’s important for us to have intentional, collective discussions about how those resources should be allocated. For example, the Coalition for Health Funding is a U.S. non-profit dedicated to marshalling the evidence for increasing public health spending to save money on health care spending. I am all for having conversations about the best way to allocate our public spending on health in order to save lives and improve our collective well-being.

Many employers are currently obsessed with the ROI of employee health programs. This discourse has a very different quality than debates over allocating public health spending. The workplace wellness discourse focuses on whether employers can justify spending money to promote employee well-being based on their bottom line. At some point in the process, an employee’s well-being is reduced to a commodity that can be valued in dollars and cents. And all too often, that commodity is measured by BMI or waist circumference.

I used to think that the “solution” was to build better (HAES-oriented) programs and then watch as the ROI went up. My fantasy was that HAES-oriented programs would be proven so effective by the research that employers would clamor to hire HAES advocates to design their programs for them.

If Health Is a Human Right, Then We Have to Stop Treating It Like a Commodity

Now, I grow increasingly uncomfortable with conversations about “return on investment” in the context of health. In most countries, health is regarded as a human right, though not in the U.S. The World Health Organization (WHO) offers us a way to understand what we mean by health as a human right:

“The right to health means that governments must generate conditions in which everyone can be as healthy as possible. Such conditions range from ensuring availability of health services, healthy and safe working conditions, adequate housing and nutritious food. The right to health does not mean the right to be healthy.”

Contrast the WHO’s broad statement about our collective responsibility for generating health-promoting conditions with the idea that U.S. law is currently financially incenting employers to provide health promotion programs that have no known relation to the health needs of the employees but instead are evaluated in terms of ROI, i.e., the company’s bottom line. These ideas seem incompatible to me.

Healthism of Workplace Wellness Leads to Racism, Classism, and Sizeism

There is also something inherently healthist about most employer programs. While it’s possible to have a wellness program at work that doesn’t fall into this category, most employer programs create hierarchies in which employees seen as healthy and compliant are rewarded and employees seen as unhealthy and noncompliant are punished. (See this post and this post for more on this phenomenon in the U.S.) In this context, employers have the power and thus get to define what “healthy” is.

The essence of healthism is the belief that individuals are responsible for their own health outcomes; we all just need to pull our personal wellness up by the bootstraps. This illusion of control is peculiarly Western in its nature, and especially evocative of American rugged individualism. For some (for example rich, white people in the aggregate), the bootstraps approach to health may prove more accurate. For those who are poor and/or who identify with stigmatized groups within our society, social determinants of health are likely to outweigh the impact of individual behaviors.

There is good reason to fear that the implicit hierarchy embedded within employee health will disproportionately affect those with the fewest resources. Prevention Institute author Carla Saporta notes that the punitive measures built into the emerging workplace wellness system affect people of color and low income workers especially: “These workers are most likely to suffer from chronic conditions and to lack resources to improve their health, virtually guaranteeing that they will be disproportionately penalized.”

So, maybe the problem isn’t that we are talking about health and economics in the same breath. Maybe the problem is that we are having the wrong conversations about health and economics. Discourses about employers’ ROIs on workplace wellness distract us from the implicitly unfair nature of our health systems. And I fear that until we recognize health as a fundamental right, and align our social systems with that recognition, we will continue having the wrong conversations.

I leave you with questions for further consideration: As HAES advocates, do we seek to influence workplace wellness toward more humane and health-positive approaches, or do we seek to disband systems in which private employers set the terms for access to health care and health promotion, resulting in deepening health inequities? I suspect the answer may be “both/and,” but what do these solutions look like? How do we get there?

11 Comments to “the HAES® files: Workplace Wellness Revisited”

  1. Fantastic column, Fall. What would it look like if the employers were carrying out a mandate that was set not by the corporate DNA to increase shareholder profits but rather the larger community’s agenda to create as many opportunities and as much access to the environments that support well-being as possible?

    • Thanks bodypositive! I love your question. My initial, somewhat flippant answer to it is: “It would probably look like certain European countries” but I’d have to do some research on that.

      Here’s a survey question for readers in countries other than the US – do employers tend to have wellness programs in your country, and if they do, what are those programs like? Can you answer bodypostive’s question in a more serious way than I can? Or do employers take the same paternalistic, bottom-line driven approach in your country as employers do here in the US?

  2. There is a lot that employers could actually do to address actual wellness if they wanted to. But they don’t, and they won’t. For example, the irony never escapes me when employers create unbearably stressful conditions, for example, by not empowering employees to actually solve problems but by blaming them when those problems persist, by under-resourcing employees, laying off employees and leaving those still working with 2 or 3 people’s jobs to do, requiring 110% effort 110% of the time (something which NO human is capable of over an extended period of time), by paying some employees so little that they are still living in poverty despite working full time, etc., etc. — and then nannying those same employees with messages from the wellness program dwelling on the health horrors of stress and chewing them out if they do not report participating in stress reduction programs after work on their own time.

    Current workplace wellness programs have nothing to do with employee wellness. They are RISK MANAGEMENT programs and their purpose is to reduce the EMPLOYER’s INSURANCE CARRIER’s risk, not to address actual employee well-being.

    Those can and should cheerfully be chucked.

    Maybe some future effort that actually addressed the actual health and welfare of employees might be HAES-friendly. I could almost imagine that. But I don’t believe the current model can be convoluted into that more laudable goal, so I think they all just need to be ditched.

    • You make some salient points, rg. It is ironic that our employment situations are often the source of much of the stress that harms our well-being. Then to be “nannyed” (great expression!) by those same employers about our health — well, it’s insulting and cold-hearted at the very least. Systems that encourage employers to treat employees’ health like a commodity actually harm, rather than promote, employee well-being.

  3. Here’s one way to visualize the ridiculousness of all this. Imagine that the response to Upton Sinclair’s novel, “The Jungle,” had been to institute workplace wellness programs. Design any workplace wellness program you like, with whatever incentives you wish, to address the wellness of the characters in “The Jungle.”

    ‘Nuff said.

  4. IMO a major paradigm shift is necessary and I am hoping imminent (our book will be out in about 8 weeks) – some thoughts:

    1) there is simply no valid research that shows that the current rage of what we refer to as 4P (pry,poke, prod, punish) “wellness or else” programs save money or improve health. And there is growing evidence that they increase costs and harm employees by contributing to the massive overdiagnosis and overtreatment that already exists in this country for privileged groups and the discrimination and undercare that exists for more disadvantaged groups.

    2) the issues of “poor health” at the workplace are much more related to the employee experience at work than they are with with how much broccoli people are eating or how much their gym memberships are being reimbursed. Fully 70% of workers are not engaged at work -costing business 100’s of billions of dollars every year. Engagement is a measure of how people feel about their work and their workplace – it has nothing to do with how involved they are in “wellness” programs – that is participation – and when rewards and punishments are involved it is really – compliance.

    3) For the most part “wellness” initiatives do not address this lack of engagement and the financial as well as emotional costs associated with it – The literature is clear that these can only helped by addressing employees autonomy (ability to think and do for themselves), mastery (opportunities to become more skilled at what they do) and purpose (having work be associated with something greater than just themselves or profits) –

    4) In fact, in general “wellness” programs tend to do the opposite of #3 – by treating people as if they were controllable, predictable machines, lab rats, cattle or small children – rewarding and punishing them for not participating in programs or not getting their biometric markers right. This is the current rage for programs spurred on by the claims of the so-called Safeway amendment in the ACA – that turned out to be 100% fabricated. –

    5) Instead of using extrinsic motivation to “get” people to change – an approach that 30 plus years of research clearly and consistently demonstrates does not work for helping people make sustainable change and carries with it all kinds of iatrogenic consequences – the answer is to help organizations “create the conditions” under which people will motivate themselves – this is not simple or easy, but it can be done – by attending to the quality of leadership and management, and by promoting autonomy, mastery and purpose for employees. There is no gimmick or quick fix or technical solution to this problem – THE ONLY WAY to have employees who act like responsible, thinking, creative, autonomous adults – is to treat them as if that is exactly what they are.

    6) – I think a closer reading of the AJHP article really reveals the confusion ( and doublespeak) of the wellness industry. That study clearly showed (as every other recent study has) that when the research is valid these programs do not pay for themselves. When the research is faulty (comparing motivated participants to unmotivated ones, ignoring regression to the mean with respect to risk factors, ignoring dropouts etc, etc, etc. vendors can tease out savings.) The conclusion reached by the exec. editor – that if you average high quality studies with lower quality studies you can come up with an average that shows a positive ROI for “wellness” programs is like saying that you can average Ptolemy and Copernicus and come up with the conclusion that the earth revolves half way around the sun. That study was a good one for the reason that it DID separate reasonably well done from poorly done studies. We should pay attention to the conclusion – which was – when studies are done well these programs do not pay for themselves.

    • “And there is growing evidence that they increase costs and harm employees by contributing to the massive overdiagnosis and overtreatment that already exists in this country for privileged groups and the discrimination and undercare that exists for more disadvantaged groups.”

      I’d like to add to the “overdiagnosis” and “undercare” issues, a third problem that doesn’t have a catchy name but maybe you can think of one. An example of it is when a fat person continuously and repeatedly keeps being diagnosed as fat (“obese”) regardless of the presenting problem. While it is not untrue or inaccurate that a fat person is fat, there’s a problem when that fact is seen as explanatory for every other illness, symptom, injury or health concern that might ever happen to that fat person.

      (I have even seen it reported that fat people are more likely to be injured in car accidents, so my imagination is that if I ever get rear-ended by a drunk driver and rushed to the hospital unconscious, the diagnosis is going to be MVA secondary to obesity along with treatment recommendations for obesity in order to avoid recurrences of similar motor vehicle accidents.)

      • Thanks for the insightful comment rg – Totally agree and there is a name for it – though I would not call it “catchy” – it is called a moral panic and if you have not previously read it I would recommend The Obesity Myth by Paul Campos – here is a link to an interview with him that explains the concept – thanks again and I hope you find this helpful – take care – Jon

        Jon Robison, PhD, MS, MA SalveoPartners, LLC My new book, with Dr. Rosie Ward – “How to Build A Thriving Culture at Work, Featuring the 7 Points of Transformation,” is coming out this October! Find out more & reserve your advance copy today! Blog – my latest article: The Debate About Workplace Wellness ROI is Over! Twitter – @DrJonRobison ________________________________

  5. Thanks for the detailed comment. drjonrobison – this is such an important critique of our “wellness” system including workplace wellness. For readers newer to this blog, you really to check out Dr. Robison’s blog posts here, including the eye-opening critiq

    • sorry – accidentally hit “post” too early… what I was saying, is that newer readers should check out Dr. Robison’s posts on this blog ( including the eye opening post on the Safeway debacle….

      Jon – you are more optimistic, I think, than I am. I am not convinced a paradigm shift is “imminent” – the current paradigm seems very entrenched to me. However, you are actively working in this field and I am observing from academia, so let’s hope that you are correct! I also am awfully glad that you are out there doing the workplace wellness work that you do, and hope that your version of wellness continues to gain a wider acceptance.

    • Thanks Fall – well – guess I wouldn’t say I am “convinced” change is imminent – but I am seeing movement thanks to people like Al Lewis, Vik Khanna, Tom Emerick and my co-author/co-conspirator Dr. Rosie Ward – I am hoping that we all can turn around this insanity before more people are negatively impacted – keep up the great work – It is one of the things I would love to come and talk to the Asdah group about if there was a way to make that happen – take care for now – Jon

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