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Managerial style and health promotion programs
Sot. Sci. Med. Vol. 36, No. 3, pp. 227-235,
1993
0277-9536/93 $6.00 + 0.00 Copyright 0 1993 Pergamon Press Ltd
Printed in Great Britain. All rights reserved
MANAGERIAL STYLE AND HEALTH PROMOTION PROGRAMS* KIM WITTE Department
of Speech Communication,
Texas A&M University,
College Station,
TX 77843-4234,
U.S.A.
Abstract-Organizational correlates of worksite health promotion programs were isolated and interpreted within a diffusion of innovation framework. A sample of managers from California (U.S.A.) 500 organizations were interviewed via telephone on their corporate management styles and health care strategies. Organizational management style was found to be related to prevalence of health promotion programs and future plans for health promotion programs. Specifically, this study found that organizations with democratic management styles are more likely to plan, adopt, and/or implement worksite health promotion programs when compared to organizations with authoritarian management styles. An additional contribution of this study was the development and validation of the Organizational Management Style (OMS) scale. These results have important theoretical and practical implications. For example, these findings explain why some organizations are more or less likely to adopt health promotion programs. Both diffusion of innovation and social control explanations are used to interpret the results. Key words-health promotion innovation, social control
programs,
organizational
A major goal of American employers as well as the United States government is to contain sky-rocketing health care costs and medical expenditures [l, 21. Health care costs currently account for 12% of the United States’ entire gross national product [3]. Of the total United States annual medical budget of $551 billion, private corporations pay 40-43% [4]. Promoting health among employees is considered advantageous because “healthy employees are absent less, are more productive, and use fewer medical benefits” 15, p. 11. The worksite is thought to be an efficient place to promote health and prevent disease, given that employees spend a substantial amount of time on the job [2,6]. Some evidence suggests that worksite health promotion programs can be successful tools in (a) containing corporate health care costs and (b) promoting employee health [7, 81. For example in a study of blue collar workers, Bertera [9] found that a comprehensive health promotion program led to a 14% drop in disability days, compared to a 5.8% drop at equivalent control group sites. He reported that the “total return on investment over two years averaged $1.42 in lower disability wage costs for every $1 invested in health promotion” [9, p. 11031. Bly, Jones and Richardson [lo] found that sites with worksite health promotion programs had nearly half the overall inpatient cost increases compared to sites without programs, even though initial employee health habits were similar at all sites. Additionally, they found lower rates of increase for hospital admis*An earlier version of this paper was presented at the 1990 Annual Convention of the Western States Communication Association, Sacramento, California.
behavior,
management
style,
diffusion
of
sions and time spent in the hospital for sites with health promotion programs. One longitudinal study revealed that health promotion program participants had “24% lower health care costs than nonparticipants” [l 1, p. 8261. Finally, employee participants in a worksite health promotion program had significantly less absenteeism over 1 year than nonparticipants, when controlling for age, gender, ethnicity, and the previous year’s absenteeism rate [12]. While many of these studies are well-designed, it is important to note that some suffer from methodological limitations that prevent a clear assessment of the efficacy of worksite health promotion programs. For example, organizations attributing decreased absenteeism and health care costs to worksite health promotion programs, may simply have attracted healthier employees in the first place. This problem is apparent in Bertera’s [9] study, where control sites were compared to intervention sites that “selfselected themselves by initiating comprehensive health promotion activities” [9, p. 11041. In addition, new worksite health promotion programs may yield significant effects over the short-term when enthusiasm is high, but not the long-term. For example, in an evaluation of smoking cessation programs, shortterm successes were relatively high (35-47% quit rates initially), long-term successes less so (18-22% quit rates at 12 months) [13]. Although logistically difficult, controlled randomized longitudinal studies are desperately needed to truly assess the effectiveness of worksite health promotion programs [8]. In summary, although more research is warranted [14], the evidence to date suggests that (a) worksite health promotjon programs at least partially facilitate containment of health care costs, and (b) those
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KIM WITTE
individuals who participate in programs may cost employers less in terms of absenteeism and health care expenses. Given these potential benefits, why haven’t more organizations adopted worksite health promotion programs? The goal of the present work is to examine explanations for the adoption and implementation of worksite health promotion programs. Descriptive research on worksite health promotion programs is abundant and has documented the type, nature, and frequency of health promotion programs in larger businesses [5,7, 15-171. For instance, the U.S. National Survey on Health Promotion [5] reported that of businesses with more than 50 employees, 65.5% had at least one health promotion activity. To do the same type of study for smaller businesses may be prohibitively expensive as well as a logistical nightmare. Thus, a logical direction for health promotion research to go is toward analysis of the antecedents of health promotion program adoption and implementation. By doing this, researchers may gain a better understanding as to why some organizations adopt and implement health promotion programs while others do not. In addition, thorough understanding of ‘non-adopting’ worksites will enable policy makers and educators to achieve their health promotion goals [5, 181. Some researchers have examined antecedents to adoption of health promotion programs within ‘diffusion of innovation’ theory. Diffusion of innovation theory is concerned with patterns and rates of adoption of an innovation in a specific population [19, 201. Five categories of ‘adopters,’ ranging from those likely to adopt as soon as the innovation appears (i.e. innovators), to those who adopt an innovation only after everyone else has (i.e. laggards), have been delineated by Rogers [19]. More specifically, the innovativeness continuum of adoption is best represented by a normal distribution and consists of the following categories: (a) innovators (‘venturesome’), 2.5% of the population; (b) early adopters (‘respectable’), 13.5% of the population; (c) early majority (‘deliberate’), 34% of the population; (d) late majority (‘skeptical’), 34% of the population; and, (e) laggards (‘traditional’), 16% of the population [19, pp. 183-1851. Worksite health promotion programs can be considered ‘innovations’ given their relatively recent appearance into the United States workplace. Conrad [2] notes that worksite health promotion programs began to surface during the mid-1970s and that they are, in many ways, unique to the United States. The diffusion of innovation framework offers a starting point for researchers to theoretically understand the reasons for corporate *Other important factors influencing the adoption and implementation of worksite health promotion programs-but beyond the scope of the present discussion-include governmental policies (occupational health and safety laws) and social norms (especially important for long-term adherence to programs).
adoption or non-adoption of worksite health promotion programs. Using the diffusion of innovation perspective, Davis [20] isolated several organizational characteristics related to health promotion program adoption in a study of 24 companies (i.e. sound financial status; humanistic management philosophy; emphasis on employee benefits, morale, and productivity; limited emphasis on finances in the decision process; expanded responsibility for employees; the presence of a health promotion/disease prevention ‘angel’ in top management; availability of facilities; and, exposure to a model health promotion/disease prevention program). These characteristics are remarkably similar to popular definitions of ‘democratic’ management styles [21], as well as to Rogers’ definition of innovators, early adopters, and the early majority [19]. Orlandi [22] also takes a diffusion of innovation viewpomt but unlike Davis, he argues that adoption of a health promotion program is only one of several steps in the diffusion of innovation process. He said researchers should focus on the implementation process because effective or ineffective implementation can result in the success or failure of a program. For example, a health promotion program can be adopted by managers but not implemented successfully, thereby leading to ultimate failure. Missing from both of these perspectives is the non-adopting or non-implementing worksite organization. What characterizes organizations which do not have health promotion programs as compared to those which do? Davis [20] alludes to the idea that a particular management style (humanistic) may be a factor in adoption. Orlandi [22] addresses overall barriers to implementation of programs but does not discuss the characteristics of implementing vs nonimplementing organizations. Management style has long been thought to be a predicting factor in whether an organization adopts and/or implements health promotion programs.* However, the evidence for this hypothesis has been anecdotal. For example, Fielding [23] argues that for health promotion programs to be successful, top management should support the concept and employees should be involved in the decision-making process. Other writers hypothesize that healthy employees and health promotion program successes develop in organizations with more open and participative management styles [24, 251. Overall, it appears that health promotion programs are more likely to be planned, adopted, and implemented in organizations with open, participative, and facilitative managements. The management style of an organization is likely to play a crucial role in adoption and/or implementation of health promotion programs because an organization’s management determines whether a program is adopted or implemented. In terms of diffusion of innovation theory, if democratic organizations can be thought of as innovators, early
Managerial style and health promotion programs adopters, or the early majority (and the characteristics of a democratic organization, define shortly, suggest this), then it is plausible that the more democratic an organization, the more likely they will have implemented health promotion programs. Given these analyses, an empirical investigation of the relationship between management style and health promotion programs is warranted. The specific purpose of this field study is to examine whether organizations which plan, adopt, and/or implement health promotion programs have distinctly different management styles than those organizations which do not have any health promotion programs.
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from (and not part of) health promotion programs (e.g. non-smoking policies were not considered to be health promotion activities). The reason for this was that several of the organizations inteviewed were located in a municipality which had a law prohibiting smoking in the workplace. Therefore, non-smoking policies emanated from an outside source, not from organizational decision-makers. In sum, worksite health promotion programs consist “of health education, screening and/or intervention designed to change employees’ behavior in a healthward direction” [2, p. 4851. HYPOTHESES
DEFINITIONS
Studies of leadership behavior have suggested two predominant styles of management: authoritarian and democratic [21,26]. The authoritarian management style has been called the traditional, scientific, classical, and autocratic style. Authoritarian managements emphasize performance and production as methods to satisfy the needs of the organization. The focus is on task and efficient completion of the task. The democratic management style has been called the human relations, participatory, and innovative style. Democratic managements share planning, execution, and leadership responsibilities with the employees. Framed in the terminology of diffusion of innovation theory, organizations with more authoritarian management styles are skeptical (i.e. the late majority) and traditional (i.e. laggards). More democratic organizations appear to fit the innovator, early adopter, and early majority categories of the innovativeness continuum. As with leaders, organizations usually cannot be identified as having simply one management style over another. Rather, like Tannenbaum and Schmidt’s [26] leadership style continuum, management style can be likened to a continuum at which one end is an authoritarian style and at the other end is the democratic style. An organization’s management style falls somewhere between the two on a continuum. Although this is admittedly simplistic, it gives us some basis with which to determine an overall organizational management style. For the purposes of this study, health promotion programs were defined as “consisting of a range of programs that have the common goal of impacting the long-term health status of participants by changing their long-term lifestyle practices” [27, p. 391. Corporate policies were considered to be distinct *Economic and geographical limits led us to constrain our sample to the 66 California 500 organizations located in Orange County, California, U.S.A. tThis figure referred to number of employees in the total organization, including all branches (i.e. worksites), but not including separate, subsidiary companies (which might have had different presidents, and thus, different management styles).
With these definitions were examined:
in mind, two hypotheses
Hl: Organizations with health promotion programs will have more democratic management styles; organizations without health promotion programs will have more authoritarian management styles (reflecting adoption and implementation decisions). H2: Organizations with future plans for health promotion programs will have more democratic management styles; organizations without future plans for health promotion programs will have more authoritarian management styles (reflecting planning and adoption decisions). Two additional hypotheses to explain why organizations adopt or implement health promotion programs are (a) that incidence of health promotion programs increases as the size (in terms of employee numbers) of the organization increases, and (b) that as amount of organizational revenues increases, so will health promotion programs [15, 17,231. These also will be examined. METHODS
Subjects The sample was comprised of all California 500 companies located in a large, Southern California county, in the U.S.A. [28].* California 500 companies are similar to Fortune 500 companies but limited to California. This sample was representative of the total population in terms of the numbers of employees, the amount of revenues, and the type of organization. Sixty-six businesses comprised the original sample. However, due to relocation, bankruptcy, or mergers, the sample was reduced to 52 organizations. Managers in charge of employee health care from 48 organizations agreed to be interviewed, yielding a 92.3% response rate. Half (50.1%) of the organizations were in hightechnology fields with the remainder in heavy industry, banking, service, and retail. Yearly revenues ranged from 22 million to 4660 million and number of employees ranged from 40 to 17,000.t A middle-
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KIM WITTE
manager (as opposed to executive management or non-management) was the contact in 85.4% of the cases. The contact was from one of the following departments: human resources, 48.9%; personnel, 23.4%; benefits, 12.8%; finance, 6.4%; administration, 4.3%; and other, 4.3%. Apparatus
A telephone interview assessed information in four areas. The first section queried managers on general organizational information (e.g. number of employees, department in charge of employee health). The second section was comprised of a semantic differential management style scale developed and validated specifically for this survey. The third section consisted of environmental health assessment questions (e.g. do you ever assess the possible health effects of noise levels). The four section focused on organizational health care policies (e.g. non-smoking or drug-use policies) and practices (e.g. extent and nature of health promotion programs). In this last section, managers were asked whether they had any of 10 specific health promotion programs (e.g. health appraisals, physical fitness, weight control, stress management, etc.) [see 171 in addition to an openended question asking whether there were ‘any other health promotion programs in your organization?’ Specific questions were asked about each health promotion program offered (e.g. ‘How is this program funded?’ ‘Please describe the program,’ ‘How often is this program offered?‘). Finally, each manager was asked whether their organization had future plans for (additional) health promotion programs. Management
style scaling procedures
A management style scale designed specifically for telephone interview use was developed for this study. Because the validity of the study depends on the validity of this scale, the scale will be explained in depth. The Organizational Management Style (OMS) scale was designed to measure a somewhat abstract concept, ot~erali organizational tnanagement style. Thus, it deals with perception’s employees have of the organizational management style as a whole. An organization’s overall management style is a specific and more concrete construct than organizational culture. For example, an organization’s management style includes such factors as information flow patterns, decision-making style, communication style, methods of management (task or instrumental focus), and management structure [21]. A two-step scaling procedure was employed to develop the scale. First, the items were selected and scaled. Then, the multi-trait, multi-method technique was used to establish validity and reliability [29-311. The first task in the OMS construction was to establish the ‘true’ meaning of an ‘authoritarian’ management style and ‘democratic’ management style, by using the semantic differential concept developed by Osgood and others [32-341. When construct-
Table
I. The Organizational
Management
Style (OMS) scale
Is the management style of this organization:
flexible* or structured?
Is the management of this organization:
stable or dynamic?*
style
Is the management style of ttm organization:
constraed
Is the management style of this organization:
progressive*
Is the management of this organization:
participatory*
or spacious?*
or traditional?
style
Is the management style of this organization.
constrained
Is the management of this organization:
intimate*
or directive?
or open’!*
style or remote?
Is the management style of this organization:
voluntary*
Is the management of this organization:
contemporary*
style
Is the management style of this organization: *Democratic
or compulsory?
unsociable
or
old-fashioned?
or sociable?*
items. Each * item receives a score of I.
ing a semantic differential scale, one takes a word or concept and chooses between bi-polar terms with the idea that by eliminating and choosing certain terms, one gets closer to the true meaning of the construct. Osgood, Suci and Tannenbaum [33] likened this process to the game ‘20 questions’. Forty-five bi-polar terms deemed face valid for the construct management style were given to two groups of organizational behavior experts, made up of even numbers of professors and doctoral students at a graduate school of management at a major university. One of the expert groups was asked to choose which term out of each pair best described a democratic management style. The other expert group was asked to choose which term best described an authoritarian management style. Percentage agreement within each group was calculated for each pair of terms. Then, percentage agreement between the two groups (with the authoritarian group’s answers being negatively scored) was calculated for each pair of terms. Eleven pairs of terms had 100% agreement between the two groups. However, one of the pairs of terms appeared to be ‘value-laden’ according to the groups of experts and was dropped from the scale. The final scale (Table 1) consisted of 10 bi-polar pairs of terms with one term indicating an authoritarian management style and the other a democratic management style. The scale was scored by setting all authoritarian terms equal to 0 and all democratic terms equal to 1. Therefore, the final scale ranged on an 11-point continuum from 0 (authoritarian management style) to 10 (democratic management style). For example, if an interviewee chose three terms that the experts have determined to be indicative of a democratic management style and seven terms at the
Managerial style and health promotion programs experts have determined to be authoritarian, then the management style of that organization would fall on the number 3 on the 11-point scale and would indicate that the management style of that organization was more authoritarian. When administering the scale, subjects were reminded that their answers were confidential and that their perceptions of the organization’s management style as a whole were sought. Specifically, subjects were asked which of the two terms in each question best characterized the management style of their organization. The respondents did not know which terms were judged to be authoritarian or democratic by the experts. In addition to the first validation process, a multitrait, multi-method analysis was conducted using information from the telephone interview field study reported here, and an additional pilot study, to further establish the validity of the scale. The pilot study surveyed multiple contacts in two organizations (N = 5 and N = 6) with paper-and-pencil questionnaires. Scale vakdity
Construct validity was examined by comparing constructs which were hypothesized to converge (i.e. correlate) with the construct of management style, and comparing constructs which were hypothesized to discriminate (i.e. not correlate) from management style [29]. The pattern of correlations is key in the multi-trait multi-method technique with convergent validity correlations being substantially greater than discriminant validity correlations [29]. Overall organizational decision-making style was the trait used to test for convergent validity. Because managers’ decision-making styles are one aspect of the construct managerial style, this trait should be at least moderately correlated to the overall management style of the organization. These two constructs should not have too high a correlation, however, because overall decision-making style is but one component of the whole construct of management style. Thus, a moderate-to-high correlation should be expected (0.40-0.75). The scale measuring overall decision-making style presented contacts from the field study with a decision-making scenario. Contacts were asked how ‘typical’ managers in the overall organization were likely to make a decision regarding ‘increasing quality in your department.’ The responses ranged 5 points from ‘lets you and your peers make the decision’ to ‘makes the decision and announces it to you and your peers’. The correlation between the management style scale and the decision-making scale was 0.54. This correlation indicates convergent validity between overall decision-making style and overall organizational management style. Discriminant validity was assessed through the paper-and-pencil tests administered to multiple contacts in two organizations. The construct ‘social
231
desirability’ was chosen to test for discriminant validity because it was feared that subjects may answer in a socially desirable manner in order to protect their organization. The Marlowe-Crowne Social Desirability Scale [35] was used to assess discriminant validity. In both organizations, the correlation between management style and social desirability indicated suitable discriminant validity with low correlations of 0.12 and -0.23. An additional discriminant validity check was included in the paper-and-pencil tests. The researcher wanted to make sure that the overall organization management style was being assessed in the OMS, not the decision-making style of the employee’s immediate superior and primary referent. Therefore, pilot subjects (i.e. multiple contacts in the same organization) were given the same decision-making scale as administered in the telephone interviews with one difference-instead of asking about the organization us a whole, the scenario asked how ‘your immediate superior would make this decision’. The correlations between the ‘immediate supervisor’ questions and the OMS were low at 0.22 and -0.17, suggesting further support for discriminant validity between the OMS and other concepts. Thus, the scale appears to measure what it is intended to measure-overall organizational management style. In addition, it appears to be free from social desirability biases. Finally, to determine whether multiple contacts in the same organization had the same perceptions of overall organization management style, inter-rater reliability within each organization was determined. Inter-rater reliability was assessed by using the Kuder-Richardson 21 method [30,36], which is appropriate for dichotomous measures and multiple ‘coders’ (or in this case, subjects). Organization 1 had a mean OMS score of 5.6 with a K-R 21 inter-rater reliability score of 0.92. Organization 2 had a mean OMS score of 3.5 with a 0.79 inter-rater reliability score. These scores indicate good to excellent inter-rater reliability among members of an organization in terms of their perceptions of overall organizational management style. Therefore, the pilot results indicated that multiple contacts in an organization agreed about an organizations overall management style. This finding gives confidence that the telephone interview contact from the field study served as an adequate representative of that organization, especially given that he or she was a middle manager and had been at the institution at least 6 months. The patterns provided by the convergent and discriminant validity correlations with the management style scale support the validity of the OMS. It converges with similar constructs (i.e. overall decisionmaking style) and diverges from constructs which should occupy domains separate from overall organizational management style (i.e. social desirability, immediate superior’s decision-making style).
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KIM WITTE
-
n lLn_L J
Fig. 1. Type and extent of health
promotion
Reliabilitv The management style scale was reliable and internally consistent as indicated by a Cronbach’s alpha of 0.84 for the field study sample, and an average of 0.80 for the pilot sample. Procedures Initially, each organization was contacted by telephone, to locate the appropriate person ‘in charge of employee health care’. Then, an advance letter explaining the purpose and sequence of the study was sent. Next, the person in charge of the organization’s health care was interviewed over the telephone. Interview lengths ranged from 10 min (organizations with no health promotion programs) to lf hr (organizations with health promotion programs). Analysis
RESULTS
Of managers interviewed, 39.6% said they had at least one health promotion program. The type and extent of health promotion programs offered is illustrated in Fig. 1. Figure 2(a) shows that organizations offer health promotion programs with the primary goal of containing health care costs. Managers at organizations
offered
in sample.
without health promotion programs said the main barrier to program adoption was lack of time (Fig. 2b). _ _ Hypothesis 1 was supported in both the t-tests and correlational analyses. Organizations with health promotion programs had more democratic management styles, while organizations without health promotion programs had more authoritarian management styles (Table 2). In addition, the greater (a) 40 35 30 25 15 10 %
Descriptive statistics were calculated for health promotion programs and management styles. A median split for OMS scores was employed to separate authoritarian organizations from democratic organizations (median = 6). Organizations that scored greater than 6 were classified as more democratic, and those that scored 6 or less were categorized as more authoritarian. The hypotheses were tested with ttests, Pearson product-moment correlations, and logistic regression analysis.
programs
5 200 I
(b) 70 60 50 %
40 30 20 10 0
1
1
I
_I L
B Fig. 2. (a) Reasons managers gave promotion
programs. (b) Reasons of health promotion
for offering health managers gave for lack programs.
Managerial style and health promotion programs Table 2. Hypothesis 1 r-tests for management style differences between organizations with and without existinghealth promotion programs, and Hypothesis 2 f-tests for management style differences between organizations with and without future plans for health twomotion OMS
A. Health promotion programs Yes No
mean
SD
N
t-test
;:$
;I;;
;;
r(46)= -2.05*
;I;;
;I;;
;;
1(43)= -2.57..
B. Future plans for health oromotion oromams Yes No
.-
lP < 0.03; **P < 0.01.
number of health promotion programs, the more democratic the organization (r = 0.33, P < 0.012). Twenty-eight percent of organizations with an authoritarian management style had one or more health promotion program as compared to 52.2% of organizations with a democratic management style. Twenty-four percent of organizations with an authoritarian management style reported two or more health promotion programs as compared to 38.9% of organizations with a democratic management style. Hypothesis 2 also was supported. Businesses with future plans for health promotion programs had more democratic management styles, while businesses without future plans for health promotion programs had more authoritarian management styles (Table 2). Twenty-five percent of organizations with authoritarian management styles had future plans for health promotion programs compared to 61.9% of organizations with democratic management styles having future health promotion plans. Only management style predicted whether an organization had a health promotion program (Table 3). According to the goodness-of-fit tests (i.e. whether the observed data fit the predicted or expected model), the model with management style predicting health promotion program prevalence offered the best fit to the observed data (x2 = 49.04, df= 46, P = 0.35). Adding revenues or employee numbers to the logistic model offered no improvement in fit (i.e. model 2). Table 3. Logistic regression predicting health promotion program arevalence Ives/no)
Variable Model 1’ Management style Model 2b Yearly revenues Number of employees
Estimated odds ratio
Wald test
,$ Improvement (d/)
0.22 (12) 0.0005 (0.0004)
1.25
3.75.
1.00
1.73
4.26’ (1) 2.67 (2)
o.oOOQ7 (0.0001)
1.00
0.42
Beta (SE)
‘P < 0.05. *Model 1 is comprised of management style only. bModel 2 is comprised of managements style, yearly revenues. and number of employees.
233
DISCUSSION
The results of this study demonstrate that organizational managerial style is related to prevalence of health promotion programs. The first hypothesis, that organizations with health promotion programs will be more democratic and organizations without health promotion programs will be more authoritarian, was supported with the descriptive, t-test, and logistic regression analyses. Thus, in this sample, the more democratic the organization, the more likely it was to have health promotion programs. The second hypothesis, that organizations with future plans for health promotion programs are more likely to be democratic and organizations without future plans are more likely to be authoritarian, also was supported. That is, democratic organizations are more likely to plan health promotion programs than authoritarian organizations. Neither amount of revenues nor number of employees had any relation to health promotion program prevalence. There are at least two explanations for these results. The first relates to diffusion of innovation theory. Democratic and authoritarian organizations appear to fall on different sides of the innovativeness adoption distribution. If democratic organizations may be classified as innovators, early adopters, or the early majority, we would expect them to adopt and implement programs early in the worksite health promotion program innovation curve. The present study’s findings suggest that this is what happened. Authoritarian organizations appear to fit the categories of the late majority and laggards, given their lack of adoption and implementation. It would be interesting to follow democratic and authoritarian organizations in a longitudinal study to ascertain the adoption and implementation patterns of worksite health promotion programs. The present study implies that as worksite health promotion programs become less of an innovation, and more of an expected employee benefit, authoritarian organizations will be likely to adopt and implement health promotion programs, just as democratic organizations have. A second explanation for the study’s findings centers on the ‘social control hypothesis’ advanced by Conrad and Walsh [37]. It appears that authoritarian organizations engage in ‘old’ forms of social control, while democratic organizations engage in ‘new’ forms of social control. Conrad and Walsh argue that “the new corporate health ethic is about much more than reducing health costs, it is about controlling productivity by shaping values and attitudes of employees toward lifestyle and indirectly toward work through a culture that rewards fitness, striving and strength, and invariably breeds intolerance for signs of weakness” [37, p. 1051. It is plausible that authoritarian management style organizations, which are by definition more traditional in their outlook, engage in the ‘old’ form of social control, where procedures and
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KIM WI~TE
jobs are routinized and institutionalized in an attempt to control the labor force. Authoritarian organizations claim no jurisdiction over lifestyle-related health behaviors, because these fall outside the scope of corporate control. Thus, authoritarian organizations do not view health promotion programs as necessary or beneficial. Therefore, authoritarian organizations engaging in ‘old’ forms of social control would not be expected to have any health promotion programs. In contrast, it appears that democratic organizations may be engaging in an emergent ‘new’ form of social control where employers, in the name of health and wellness, attempt to control lifestyle behaviors inside as well as outside the organization through the creation of a corporate “culture that rewards fitness, striving and strength, and invariably breeds intolerance for signs of weakness” [37, p. 1051. Conrad and Walsh note: virtually all earlier forms of control focused directly on the labor process and the organization of work itself as the locus within which to control workers and productivity. The new corporate health ethic, by contrast, focuses beyond the workplace on the lifestyle of the worker. Attending to the worker’s lifestyle allows corporations to select or shape workers in the name of health, bypassing modern discrimination laws that have limited the employer’s degrees of freedom to select and fire employees [37, p. 1041.
Thus, democratic organizations engaging in the ‘new’ form of social control may be more likely to offer health promotion programs, which may be seen as a better means to control employee productivity and commitment than ‘old’ forms of social control. The new form of control may be inadvertent at first, “but managers may well come to understand the latent benefits attached to these new policies, and continue their support of the health programs for their increment of new control” [37, p. 1051. In some ways this form of social control is more insidious than the ‘old’ form of social control in that it blurs work/private life distinctions and threatens employee privacy [7]. Kasl and Serxner [7] have noted that existing worksite health promotion studies “represent a missed opportunity to add to our scientific and theoretical knowledge about health promotion” [7, p. 391. Many would grant that worksite health promotion programs benefit the employee (although individual programs may be more or less effective) [7]. However, development of theory in the worksite health promotion context has been neglected. This work provides a first step toward theoretical health promotion research. Thus, this study served three purposes. First, theoretical research into the diffusion of innovations was furthered. Second, practical knowledge was gained by isolating corporate characteristics associated with health promotion programs. Third, a reliable and valid scale to measure organizational management style was developed. This scale has much practical
utility given its ease of administration and explanatory value. This study is not without limitations. First, caution should be used in generalizing these results given that the sample was drawn from organizations in California, U.S.A. Future studies should test these hypotheses in other regions. Second, it must be recognized that this sample represents larger companies only. Health promotion programs may be more difficult to adopt and implement for smaller companies with limited resources. However, if the innovation curve is followed, smaller companies may attempt to provide at least some worksite health promotion programs (e.g. health risk appraisals) or smaller companies may combine resources to offer a limited array of worksite health promotion programs (e.g. fitness facilities). In any case, a significant and important relation between managerial style and health promotion program prevalence was found in this study. These results provide a basis to launch further research into worksite health promotion. Overall, this study has contributed to both theoretical and practical understanding of why some organizations ddopt and implement health promotion programs, while others do not. Acknowledgement-This from the Irvine Health
research was supported Foundation.
by a grant
REFERENCES D. Containing corporate health care costs 1. Chenoweth requires input from all participants. Occupaf. Hlth Safety 56, 46-48, 1987. The social con2. Conrad P. Worksite health promotion: text. Sot. Sci. Med. 26, 485-489, 1988. Houston Post, Bl, 24 August 1991. 3. Medical Rationing. Health Promotion Research 4. Pelletier K. R. Corporate Program. Paper presented at the Work Environments and Cardiovascular Disease Conference, Irvine, California, 1989. of Health and Human Services, Office 5. U.S. Department of Disease Prevention and Health Promotion. National Survey of Worksite Health Promotion Activities: A Sum mary, Monograph Series, p. 1. U.S. Government Printing Office, Washington, DC, 1987. 6. Fielding J. E. and Piserchia P. V. Freauencv of worksite health promotion activities. Am. J. p&l. Hith 79, 16-20, 1989. in the 7. Kasl S. V. and Serxner S. Health promotion workplace. Int. Rev. Hlth Psycho/. In press. for state govern8. Stieg P. R. Worksite health promotion ment employees. Am. J. pubi. Hlfh 81, 801-802, 1991. 9. Bertera R. L. The effects of workplace health promotion on absenteeism and employment costs in a large industrial population. Am. J.-pub/. Hlth 80, 1101-l 105, 1990. J. E. Impact of 10. Blv J. L., Jones R. C. and Richardson worksite health promotion on health care costs and utilization: Evaluation of Johnson & Johnson’s Live for Life program. JAMA 256, 3235-3240, 1986. 11. Gibbs J. O., Mulvaney D., Henes C. and Reed R. W. Worksite health promotion: Five-year trend in employee health care costs. J. Occupat. Med 27, 826-830, 1985.
Managerial
style and health
12. Blair S. N., Smith M., Collingwood T. R., Reynolds R., Prentice M. C. and Sterling C. L. Health promotion for educators: Impact on absenteeism. Prevent. Med. 15, 166-175, 1986. 13. Hymowitz N., Campbell K. and Feuerman M. Longterm smoking intervention at the worksite: Effects of quit-smoking groups and an “enriched milieu” on smoking cessation in adult white-co1 lar employees. Hlth Psychol. 10, 366-369, 1991. 14. Warner K. E., Wickizer T. M., Wolfe R. A., Schildroth J. E. and Samuelson M. H. Economic implications of workplace health promotion programs: Review of the literature. J. Occupuf. Med. 30, 106-112, 1988. 15. Fielding J. E. and Breslow L. Health promotion programs sponsored by California employers. Am. J. publ. . . zirth 13; 538-542, i983. 16. Davis M. F., Rosenberg K., Iverson D. C., Vernon T. M. and Bauer J. Worksite health promotion in Colorado. Publ. Hlth Rep. 99, 5388543, 1984. 17. Hollander R. B. and Lengermann J. J. Cornorate characteristics and worksite health promotion programs: Survey findings from Fortune 500 companies. Sot. Sci. Med. 26, 491-501, 1988. 18. U.S. Department of Health and Human Services. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. U.S. Government Printing Office Washington, DC, 1990. 19. Rogers E. M. and Shoemaker F. F. Communicalion of Innooations: A Cross-Cultural Approach, 2nd edn. The Free Press, New York, 1971. 20. Davis M. F. Worksite Health Promotion/Disease Prevention: A Study in the D&%sion of Innovation. University Microfilms. International, Ann Arbor, MI, 1985. 21. Hersev P. and Blanchard K. H. Munuaement of Organizational Behavior: Utilizing Human -Resources, 6. 3. Prentice-Hall, Englewood Cliffs, NJ, 1982. 22. Orlandi M. A. The diffusion and adoption of worksite health promotion innovations: An analysis of barriers. Prevent. Med. 15, 522-536, 1986. 23. Fielding J. E. Health promotion and disease prevention
promotion
24.
25.
26.
27. 28. 29.
30.
31. 32. 33.
34. 35.
36.
37.
programs
235
at the worksite. Ann. Rev. publ. Hlth 5, 237-265, 1984. Rosen R. H. Healthy Companies: A Human Resources Approach. AMA Management Briefing, New York, 1986. Terborg J. R. Health promotion at the worksite: a research challege for personnel and human resources management. Res. Personnel hum. Res. Manag. 4, 225-267, 1986. Tannenbaum R. and Schmidt W. H. How to choose a leadership pattern. Harvard Business Rev. pp. 95-102, March-April, 1958. O’Donnell M. P. and Ainsworth T. H. Health Promotion in the Workplace. Wiley, New York, 1984. The California 500. California Business Mugazine, pp. 53-62, January, 1988. _ Camnbell D. T. and Fiske D. W. Convergent and discriminant validation by the multitrait-m&method matrix. Psychol. Bull. 56, 81-105, 1959. Ghiselli E. E., Campbell J. P. and Zedeck S. Measurement Theory for the Behavioral Sciences. W. H. Freeman, New York, 1981. Kerlinger F. N. Foundations of Behavioral Research, 3rd edn. Holt, Rinehart and Winston, New York, 1986. Osgood C. E. The nature and measurement of meaning. Psychol. Bull. 49, 197-237, 1952. Osgood C. E., Suci G. J. and Tannenbaum P. H. The Measurement of Meaning. University of Illinois Press, Urbana, 1957. Snider J. G. and Osgood C. E. Semantic D@rential Techniques: A Sourcebook. Aldine, Chicago, 1969. Crowne D. P. and Marlowe D. A new scale of social desirability independent of psychopathology. J. Consult. Psvchol. 24. 349-354. 1960. Kuder G. F. and Richardson M.. W. The theory of the estimation of test reliability. Psychomefrika 2, 151-160, 1937. Conrad P. and Walsh D. C. The new corporate health ethic: lifestyle and the social control of work. Inr. J. Hlrh Services 22, 89-l 11, 1992.
1993
0277-9536/93 $6.00 + 0.00 Copyright 0 1993 Pergamon Press Ltd
Printed in Great Britain. All rights reserved
MANAGERIAL STYLE AND HEALTH PROMOTION PROGRAMS* KIM WITTE Department
of Speech Communication,
Texas A&M University,
College Station,
TX 77843-4234,
U.S.A.
Abstract-Organizational correlates of worksite health promotion programs were isolated and interpreted within a diffusion of innovation framework. A sample of managers from California (U.S.A.) 500 organizations were interviewed via telephone on their corporate management styles and health care strategies. Organizational management style was found to be related to prevalence of health promotion programs and future plans for health promotion programs. Specifically, this study found that organizations with democratic management styles are more likely to plan, adopt, and/or implement worksite health promotion programs when compared to organizations with authoritarian management styles. An additional contribution of this study was the development and validation of the Organizational Management Style (OMS) scale. These results have important theoretical and practical implications. For example, these findings explain why some organizations are more or less likely to adopt health promotion programs. Both diffusion of innovation and social control explanations are used to interpret the results. Key words-health promotion innovation, social control
programs,
organizational
A major goal of American employers as well as the United States government is to contain sky-rocketing health care costs and medical expenditures [l, 21. Health care costs currently account for 12% of the United States’ entire gross national product [3]. Of the total United States annual medical budget of $551 billion, private corporations pay 40-43% [4]. Promoting health among employees is considered advantageous because “healthy employees are absent less, are more productive, and use fewer medical benefits” 15, p. 11. The worksite is thought to be an efficient place to promote health and prevent disease, given that employees spend a substantial amount of time on the job [2,6]. Some evidence suggests that worksite health promotion programs can be successful tools in (a) containing corporate health care costs and (b) promoting employee health [7, 81. For example in a study of blue collar workers, Bertera [9] found that a comprehensive health promotion program led to a 14% drop in disability days, compared to a 5.8% drop at equivalent control group sites. He reported that the “total return on investment over two years averaged $1.42 in lower disability wage costs for every $1 invested in health promotion” [9, p. 11031. Bly, Jones and Richardson [lo] found that sites with worksite health promotion programs had nearly half the overall inpatient cost increases compared to sites without programs, even though initial employee health habits were similar at all sites. Additionally, they found lower rates of increase for hospital admis*An earlier version of this paper was presented at the 1990 Annual Convention of the Western States Communication Association, Sacramento, California.
behavior,
management
style,
diffusion
of
sions and time spent in the hospital for sites with health promotion programs. One longitudinal study revealed that health promotion program participants had “24% lower health care costs than nonparticipants” [l 1, p. 8261. Finally, employee participants in a worksite health promotion program had significantly less absenteeism over 1 year than nonparticipants, when controlling for age, gender, ethnicity, and the previous year’s absenteeism rate [12]. While many of these studies are well-designed, it is important to note that some suffer from methodological limitations that prevent a clear assessment of the efficacy of worksite health promotion programs. For example, organizations attributing decreased absenteeism and health care costs to worksite health promotion programs, may simply have attracted healthier employees in the first place. This problem is apparent in Bertera’s [9] study, where control sites were compared to intervention sites that “selfselected themselves by initiating comprehensive health promotion activities” [9, p. 11041. In addition, new worksite health promotion programs may yield significant effects over the short-term when enthusiasm is high, but not the long-term. For example, in an evaluation of smoking cessation programs, shortterm successes were relatively high (35-47% quit rates initially), long-term successes less so (18-22% quit rates at 12 months) [13]. Although logistically difficult, controlled randomized longitudinal studies are desperately needed to truly assess the effectiveness of worksite health promotion programs [8]. In summary, although more research is warranted [14], the evidence to date suggests that (a) worksite health promotjon programs at least partially facilitate containment of health care costs, and (b) those
228
KIM WITTE
individuals who participate in programs may cost employers less in terms of absenteeism and health care expenses. Given these potential benefits, why haven’t more organizations adopted worksite health promotion programs? The goal of the present work is to examine explanations for the adoption and implementation of worksite health promotion programs. Descriptive research on worksite health promotion programs is abundant and has documented the type, nature, and frequency of health promotion programs in larger businesses [5,7, 15-171. For instance, the U.S. National Survey on Health Promotion [5] reported that of businesses with more than 50 employees, 65.5% had at least one health promotion activity. To do the same type of study for smaller businesses may be prohibitively expensive as well as a logistical nightmare. Thus, a logical direction for health promotion research to go is toward analysis of the antecedents of health promotion program adoption and implementation. By doing this, researchers may gain a better understanding as to why some organizations adopt and implement health promotion programs while others do not. In addition, thorough understanding of ‘non-adopting’ worksites will enable policy makers and educators to achieve their health promotion goals [5, 181. Some researchers have examined antecedents to adoption of health promotion programs within ‘diffusion of innovation’ theory. Diffusion of innovation theory is concerned with patterns and rates of adoption of an innovation in a specific population [19, 201. Five categories of ‘adopters,’ ranging from those likely to adopt as soon as the innovation appears (i.e. innovators), to those who adopt an innovation only after everyone else has (i.e. laggards), have been delineated by Rogers [19]. More specifically, the innovativeness continuum of adoption is best represented by a normal distribution and consists of the following categories: (a) innovators (‘venturesome’), 2.5% of the population; (b) early adopters (‘respectable’), 13.5% of the population; (c) early majority (‘deliberate’), 34% of the population; (d) late majority (‘skeptical’), 34% of the population; and, (e) laggards (‘traditional’), 16% of the population [19, pp. 183-1851. Worksite health promotion programs can be considered ‘innovations’ given their relatively recent appearance into the United States workplace. Conrad [2] notes that worksite health promotion programs began to surface during the mid-1970s and that they are, in many ways, unique to the United States. The diffusion of innovation framework offers a starting point for researchers to theoretically understand the reasons for corporate *Other important factors influencing the adoption and implementation of worksite health promotion programs-but beyond the scope of the present discussion-include governmental policies (occupational health and safety laws) and social norms (especially important for long-term adherence to programs).
adoption or non-adoption of worksite health promotion programs. Using the diffusion of innovation perspective, Davis [20] isolated several organizational characteristics related to health promotion program adoption in a study of 24 companies (i.e. sound financial status; humanistic management philosophy; emphasis on employee benefits, morale, and productivity; limited emphasis on finances in the decision process; expanded responsibility for employees; the presence of a health promotion/disease prevention ‘angel’ in top management; availability of facilities; and, exposure to a model health promotion/disease prevention program). These characteristics are remarkably similar to popular definitions of ‘democratic’ management styles [21], as well as to Rogers’ definition of innovators, early adopters, and the early majority [19]. Orlandi [22] also takes a diffusion of innovation viewpomt but unlike Davis, he argues that adoption of a health promotion program is only one of several steps in the diffusion of innovation process. He said researchers should focus on the implementation process because effective or ineffective implementation can result in the success or failure of a program. For example, a health promotion program can be adopted by managers but not implemented successfully, thereby leading to ultimate failure. Missing from both of these perspectives is the non-adopting or non-implementing worksite organization. What characterizes organizations which do not have health promotion programs as compared to those which do? Davis [20] alludes to the idea that a particular management style (humanistic) may be a factor in adoption. Orlandi [22] addresses overall barriers to implementation of programs but does not discuss the characteristics of implementing vs nonimplementing organizations. Management style has long been thought to be a predicting factor in whether an organization adopts and/or implements health promotion programs.* However, the evidence for this hypothesis has been anecdotal. For example, Fielding [23] argues that for health promotion programs to be successful, top management should support the concept and employees should be involved in the decision-making process. Other writers hypothesize that healthy employees and health promotion program successes develop in organizations with more open and participative management styles [24, 251. Overall, it appears that health promotion programs are more likely to be planned, adopted, and implemented in organizations with open, participative, and facilitative managements. The management style of an organization is likely to play a crucial role in adoption and/or implementation of health promotion programs because an organization’s management determines whether a program is adopted or implemented. In terms of diffusion of innovation theory, if democratic organizations can be thought of as innovators, early
Managerial style and health promotion programs adopters, or the early majority (and the characteristics of a democratic organization, define shortly, suggest this), then it is plausible that the more democratic an organization, the more likely they will have implemented health promotion programs. Given these analyses, an empirical investigation of the relationship between management style and health promotion programs is warranted. The specific purpose of this field study is to examine whether organizations which plan, adopt, and/or implement health promotion programs have distinctly different management styles than those organizations which do not have any health promotion programs.
229
from (and not part of) health promotion programs (e.g. non-smoking policies were not considered to be health promotion activities). The reason for this was that several of the organizations inteviewed were located in a municipality which had a law prohibiting smoking in the workplace. Therefore, non-smoking policies emanated from an outside source, not from organizational decision-makers. In sum, worksite health promotion programs consist “of health education, screening and/or intervention designed to change employees’ behavior in a healthward direction” [2, p. 4851. HYPOTHESES
DEFINITIONS
Studies of leadership behavior have suggested two predominant styles of management: authoritarian and democratic [21,26]. The authoritarian management style has been called the traditional, scientific, classical, and autocratic style. Authoritarian managements emphasize performance and production as methods to satisfy the needs of the organization. The focus is on task and efficient completion of the task. The democratic management style has been called the human relations, participatory, and innovative style. Democratic managements share planning, execution, and leadership responsibilities with the employees. Framed in the terminology of diffusion of innovation theory, organizations with more authoritarian management styles are skeptical (i.e. the late majority) and traditional (i.e. laggards). More democratic organizations appear to fit the innovator, early adopter, and early majority categories of the innovativeness continuum. As with leaders, organizations usually cannot be identified as having simply one management style over another. Rather, like Tannenbaum and Schmidt’s [26] leadership style continuum, management style can be likened to a continuum at which one end is an authoritarian style and at the other end is the democratic style. An organization’s management style falls somewhere between the two on a continuum. Although this is admittedly simplistic, it gives us some basis with which to determine an overall organizational management style. For the purposes of this study, health promotion programs were defined as “consisting of a range of programs that have the common goal of impacting the long-term health status of participants by changing their long-term lifestyle practices” [27, p. 391. Corporate policies were considered to be distinct *Economic and geographical limits led us to constrain our sample to the 66 California 500 organizations located in Orange County, California, U.S.A. tThis figure referred to number of employees in the total organization, including all branches (i.e. worksites), but not including separate, subsidiary companies (which might have had different presidents, and thus, different management styles).
With these definitions were examined:
in mind, two hypotheses
Hl: Organizations with health promotion programs will have more democratic management styles; organizations without health promotion programs will have more authoritarian management styles (reflecting adoption and implementation decisions). H2: Organizations with future plans for health promotion programs will have more democratic management styles; organizations without future plans for health promotion programs will have more authoritarian management styles (reflecting planning and adoption decisions). Two additional hypotheses to explain why organizations adopt or implement health promotion programs are (a) that incidence of health promotion programs increases as the size (in terms of employee numbers) of the organization increases, and (b) that as amount of organizational revenues increases, so will health promotion programs [15, 17,231. These also will be examined. METHODS
Subjects The sample was comprised of all California 500 companies located in a large, Southern California county, in the U.S.A. [28].* California 500 companies are similar to Fortune 500 companies but limited to California. This sample was representative of the total population in terms of the numbers of employees, the amount of revenues, and the type of organization. Sixty-six businesses comprised the original sample. However, due to relocation, bankruptcy, or mergers, the sample was reduced to 52 organizations. Managers in charge of employee health care from 48 organizations agreed to be interviewed, yielding a 92.3% response rate. Half (50.1%) of the organizations were in hightechnology fields with the remainder in heavy industry, banking, service, and retail. Yearly revenues ranged from 22 million to 4660 million and number of employees ranged from 40 to 17,000.t A middle-
230
KIM WITTE
manager (as opposed to executive management or non-management) was the contact in 85.4% of the cases. The contact was from one of the following departments: human resources, 48.9%; personnel, 23.4%; benefits, 12.8%; finance, 6.4%; administration, 4.3%; and other, 4.3%. Apparatus
A telephone interview assessed information in four areas. The first section queried managers on general organizational information (e.g. number of employees, department in charge of employee health). The second section was comprised of a semantic differential management style scale developed and validated specifically for this survey. The third section consisted of environmental health assessment questions (e.g. do you ever assess the possible health effects of noise levels). The four section focused on organizational health care policies (e.g. non-smoking or drug-use policies) and practices (e.g. extent and nature of health promotion programs). In this last section, managers were asked whether they had any of 10 specific health promotion programs (e.g. health appraisals, physical fitness, weight control, stress management, etc.) [see 171 in addition to an openended question asking whether there were ‘any other health promotion programs in your organization?’ Specific questions were asked about each health promotion program offered (e.g. ‘How is this program funded?’ ‘Please describe the program,’ ‘How often is this program offered?‘). Finally, each manager was asked whether their organization had future plans for (additional) health promotion programs. Management
style scaling procedures
A management style scale designed specifically for telephone interview use was developed for this study. Because the validity of the study depends on the validity of this scale, the scale will be explained in depth. The Organizational Management Style (OMS) scale was designed to measure a somewhat abstract concept, ot~erali organizational tnanagement style. Thus, it deals with perception’s employees have of the organizational management style as a whole. An organization’s overall management style is a specific and more concrete construct than organizational culture. For example, an organization’s management style includes such factors as information flow patterns, decision-making style, communication style, methods of management (task or instrumental focus), and management structure [21]. A two-step scaling procedure was employed to develop the scale. First, the items were selected and scaled. Then, the multi-trait, multi-method technique was used to establish validity and reliability [29-311. The first task in the OMS construction was to establish the ‘true’ meaning of an ‘authoritarian’ management style and ‘democratic’ management style, by using the semantic differential concept developed by Osgood and others [32-341. When construct-
Table
I. The Organizational
Management
Style (OMS) scale
Is the management style of this organization:
flexible* or structured?
Is the management of this organization:
stable or dynamic?*
style
Is the management style of ttm organization:
constraed
Is the management style of this organization:
progressive*
Is the management of this organization:
participatory*
or spacious?*
or traditional?
style
Is the management style of this organization.
constrained
Is the management of this organization:
intimate*
or directive?
or open’!*
style or remote?
Is the management style of this organization:
voluntary*
Is the management of this organization:
contemporary*
style
Is the management style of this organization: *Democratic
or compulsory?
unsociable
or
old-fashioned?
or sociable?*
items. Each * item receives a score of I.
ing a semantic differential scale, one takes a word or concept and chooses between bi-polar terms with the idea that by eliminating and choosing certain terms, one gets closer to the true meaning of the construct. Osgood, Suci and Tannenbaum [33] likened this process to the game ‘20 questions’. Forty-five bi-polar terms deemed face valid for the construct management style were given to two groups of organizational behavior experts, made up of even numbers of professors and doctoral students at a graduate school of management at a major university. One of the expert groups was asked to choose which term out of each pair best described a democratic management style. The other expert group was asked to choose which term best described an authoritarian management style. Percentage agreement within each group was calculated for each pair of terms. Then, percentage agreement between the two groups (with the authoritarian group’s answers being negatively scored) was calculated for each pair of terms. Eleven pairs of terms had 100% agreement between the two groups. However, one of the pairs of terms appeared to be ‘value-laden’ according to the groups of experts and was dropped from the scale. The final scale (Table 1) consisted of 10 bi-polar pairs of terms with one term indicating an authoritarian management style and the other a democratic management style. The scale was scored by setting all authoritarian terms equal to 0 and all democratic terms equal to 1. Therefore, the final scale ranged on an 11-point continuum from 0 (authoritarian management style) to 10 (democratic management style). For example, if an interviewee chose three terms that the experts have determined to be indicative of a democratic management style and seven terms at the
Managerial style and health promotion programs experts have determined to be authoritarian, then the management style of that organization would fall on the number 3 on the 11-point scale and would indicate that the management style of that organization was more authoritarian. When administering the scale, subjects were reminded that their answers were confidential and that their perceptions of the organization’s management style as a whole were sought. Specifically, subjects were asked which of the two terms in each question best characterized the management style of their organization. The respondents did not know which terms were judged to be authoritarian or democratic by the experts. In addition to the first validation process, a multitrait, multi-method analysis was conducted using information from the telephone interview field study reported here, and an additional pilot study, to further establish the validity of the scale. The pilot study surveyed multiple contacts in two organizations (N = 5 and N = 6) with paper-and-pencil questionnaires. Scale vakdity
Construct validity was examined by comparing constructs which were hypothesized to converge (i.e. correlate) with the construct of management style, and comparing constructs which were hypothesized to discriminate (i.e. not correlate) from management style [29]. The pattern of correlations is key in the multi-trait multi-method technique with convergent validity correlations being substantially greater than discriminant validity correlations [29]. Overall organizational decision-making style was the trait used to test for convergent validity. Because managers’ decision-making styles are one aspect of the construct managerial style, this trait should be at least moderately correlated to the overall management style of the organization. These two constructs should not have too high a correlation, however, because overall decision-making style is but one component of the whole construct of management style. Thus, a moderate-to-high correlation should be expected (0.40-0.75). The scale measuring overall decision-making style presented contacts from the field study with a decision-making scenario. Contacts were asked how ‘typical’ managers in the overall organization were likely to make a decision regarding ‘increasing quality in your department.’ The responses ranged 5 points from ‘lets you and your peers make the decision’ to ‘makes the decision and announces it to you and your peers’. The correlation between the management style scale and the decision-making scale was 0.54. This correlation indicates convergent validity between overall decision-making style and overall organizational management style. Discriminant validity was assessed through the paper-and-pencil tests administered to multiple contacts in two organizations. The construct ‘social
231
desirability’ was chosen to test for discriminant validity because it was feared that subjects may answer in a socially desirable manner in order to protect their organization. The Marlowe-Crowne Social Desirability Scale [35] was used to assess discriminant validity. In both organizations, the correlation between management style and social desirability indicated suitable discriminant validity with low correlations of 0.12 and -0.23. An additional discriminant validity check was included in the paper-and-pencil tests. The researcher wanted to make sure that the overall organization management style was being assessed in the OMS, not the decision-making style of the employee’s immediate superior and primary referent. Therefore, pilot subjects (i.e. multiple contacts in the same organization) were given the same decision-making scale as administered in the telephone interviews with one difference-instead of asking about the organization us a whole, the scenario asked how ‘your immediate superior would make this decision’. The correlations between the ‘immediate supervisor’ questions and the OMS were low at 0.22 and -0.17, suggesting further support for discriminant validity between the OMS and other concepts. Thus, the scale appears to measure what it is intended to measure-overall organizational management style. In addition, it appears to be free from social desirability biases. Finally, to determine whether multiple contacts in the same organization had the same perceptions of overall organization management style, inter-rater reliability within each organization was determined. Inter-rater reliability was assessed by using the Kuder-Richardson 21 method [30,36], which is appropriate for dichotomous measures and multiple ‘coders’ (or in this case, subjects). Organization 1 had a mean OMS score of 5.6 with a K-R 21 inter-rater reliability score of 0.92. Organization 2 had a mean OMS score of 3.5 with a 0.79 inter-rater reliability score. These scores indicate good to excellent inter-rater reliability among members of an organization in terms of their perceptions of overall organizational management style. Therefore, the pilot results indicated that multiple contacts in an organization agreed about an organizations overall management style. This finding gives confidence that the telephone interview contact from the field study served as an adequate representative of that organization, especially given that he or she was a middle manager and had been at the institution at least 6 months. The patterns provided by the convergent and discriminant validity correlations with the management style scale support the validity of the OMS. It converges with similar constructs (i.e. overall decisionmaking style) and diverges from constructs which should occupy domains separate from overall organizational management style (i.e. social desirability, immediate superior’s decision-making style).
232
KIM WITTE
-
n lLn_L J
Fig. 1. Type and extent of health
promotion
Reliabilitv The management style scale was reliable and internally consistent as indicated by a Cronbach’s alpha of 0.84 for the field study sample, and an average of 0.80 for the pilot sample. Procedures Initially, each organization was contacted by telephone, to locate the appropriate person ‘in charge of employee health care’. Then, an advance letter explaining the purpose and sequence of the study was sent. Next, the person in charge of the organization’s health care was interviewed over the telephone. Interview lengths ranged from 10 min (organizations with no health promotion programs) to lf hr (organizations with health promotion programs). Analysis
RESULTS
Of managers interviewed, 39.6% said they had at least one health promotion program. The type and extent of health promotion programs offered is illustrated in Fig. 1. Figure 2(a) shows that organizations offer health promotion programs with the primary goal of containing health care costs. Managers at organizations
offered
in sample.
without health promotion programs said the main barrier to program adoption was lack of time (Fig. 2b). _ _ Hypothesis 1 was supported in both the t-tests and correlational analyses. Organizations with health promotion programs had more democratic management styles, while organizations without health promotion programs had more authoritarian management styles (Table 2). In addition, the greater (a) 40 35 30 25 15 10 %
Descriptive statistics were calculated for health promotion programs and management styles. A median split for OMS scores was employed to separate authoritarian organizations from democratic organizations (median = 6). Organizations that scored greater than 6 were classified as more democratic, and those that scored 6 or less were categorized as more authoritarian. The hypotheses were tested with ttests, Pearson product-moment correlations, and logistic regression analysis.
programs
5 200 I
(b) 70 60 50 %
40 30 20 10 0
1
1
I
_I L
B Fig. 2. (a) Reasons managers gave promotion
programs. (b) Reasons of health promotion
for offering health managers gave for lack programs.
Managerial style and health promotion programs Table 2. Hypothesis 1 r-tests for management style differences between organizations with and without existinghealth promotion programs, and Hypothesis 2 f-tests for management style differences between organizations with and without future plans for health twomotion OMS
A. Health promotion programs Yes No
mean
SD
N
t-test
;:$
;I;;
;;
r(46)= -2.05*
;I;;
;I;;
;;
1(43)= -2.57..
B. Future plans for health oromotion oromams Yes No
.-
lP < 0.03; **P < 0.01.
number of health promotion programs, the more democratic the organization (r = 0.33, P < 0.012). Twenty-eight percent of organizations with an authoritarian management style had one or more health promotion program as compared to 52.2% of organizations with a democratic management style. Twenty-four percent of organizations with an authoritarian management style reported two or more health promotion programs as compared to 38.9% of organizations with a democratic management style. Hypothesis 2 also was supported. Businesses with future plans for health promotion programs had more democratic management styles, while businesses without future plans for health promotion programs had more authoritarian management styles (Table 2). Twenty-five percent of organizations with authoritarian management styles had future plans for health promotion programs compared to 61.9% of organizations with democratic management styles having future health promotion plans. Only management style predicted whether an organization had a health promotion program (Table 3). According to the goodness-of-fit tests (i.e. whether the observed data fit the predicted or expected model), the model with management style predicting health promotion program prevalence offered the best fit to the observed data (x2 = 49.04, df= 46, P = 0.35). Adding revenues or employee numbers to the logistic model offered no improvement in fit (i.e. model 2). Table 3. Logistic regression predicting health promotion program arevalence Ives/no)
Variable Model 1’ Management style Model 2b Yearly revenues Number of employees
Estimated odds ratio
Wald test
,$ Improvement (d/)
0.22 (12) 0.0005 (0.0004)
1.25
3.75.
1.00
1.73
4.26’ (1) 2.67 (2)
o.oOOQ7 (0.0001)
1.00
0.42
Beta (SE)
‘P < 0.05. *Model 1 is comprised of management style only. bModel 2 is comprised of managements style, yearly revenues. and number of employees.
233
DISCUSSION
The results of this study demonstrate that organizational managerial style is related to prevalence of health promotion programs. The first hypothesis, that organizations with health promotion programs will be more democratic and organizations without health promotion programs will be more authoritarian, was supported with the descriptive, t-test, and logistic regression analyses. Thus, in this sample, the more democratic the organization, the more likely it was to have health promotion programs. The second hypothesis, that organizations with future plans for health promotion programs are more likely to be democratic and organizations without future plans are more likely to be authoritarian, also was supported. That is, democratic organizations are more likely to plan health promotion programs than authoritarian organizations. Neither amount of revenues nor number of employees had any relation to health promotion program prevalence. There are at least two explanations for these results. The first relates to diffusion of innovation theory. Democratic and authoritarian organizations appear to fall on different sides of the innovativeness adoption distribution. If democratic organizations may be classified as innovators, early adopters, or the early majority, we would expect them to adopt and implement programs early in the worksite health promotion program innovation curve. The present study’s findings suggest that this is what happened. Authoritarian organizations appear to fit the categories of the late majority and laggards, given their lack of adoption and implementation. It would be interesting to follow democratic and authoritarian organizations in a longitudinal study to ascertain the adoption and implementation patterns of worksite health promotion programs. The present study implies that as worksite health promotion programs become less of an innovation, and more of an expected employee benefit, authoritarian organizations will be likely to adopt and implement health promotion programs, just as democratic organizations have. A second explanation for the study’s findings centers on the ‘social control hypothesis’ advanced by Conrad and Walsh [37]. It appears that authoritarian organizations engage in ‘old’ forms of social control, while democratic organizations engage in ‘new’ forms of social control. Conrad and Walsh argue that “the new corporate health ethic is about much more than reducing health costs, it is about controlling productivity by shaping values and attitudes of employees toward lifestyle and indirectly toward work through a culture that rewards fitness, striving and strength, and invariably breeds intolerance for signs of weakness” [37, p. 1051. It is plausible that authoritarian management style organizations, which are by definition more traditional in their outlook, engage in the ‘old’ form of social control, where procedures and
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jobs are routinized and institutionalized in an attempt to control the labor force. Authoritarian organizations claim no jurisdiction over lifestyle-related health behaviors, because these fall outside the scope of corporate control. Thus, authoritarian organizations do not view health promotion programs as necessary or beneficial. Therefore, authoritarian organizations engaging in ‘old’ forms of social control would not be expected to have any health promotion programs. In contrast, it appears that democratic organizations may be engaging in an emergent ‘new’ form of social control where employers, in the name of health and wellness, attempt to control lifestyle behaviors inside as well as outside the organization through the creation of a corporate “culture that rewards fitness, striving and strength, and invariably breeds intolerance for signs of weakness” [37, p. 1051. Conrad and Walsh note: virtually all earlier forms of control focused directly on the labor process and the organization of work itself as the locus within which to control workers and productivity. The new corporate health ethic, by contrast, focuses beyond the workplace on the lifestyle of the worker. Attending to the worker’s lifestyle allows corporations to select or shape workers in the name of health, bypassing modern discrimination laws that have limited the employer’s degrees of freedom to select and fire employees [37, p. 1041.
Thus, democratic organizations engaging in the ‘new’ form of social control may be more likely to offer health promotion programs, which may be seen as a better means to control employee productivity and commitment than ‘old’ forms of social control. The new form of control may be inadvertent at first, “but managers may well come to understand the latent benefits attached to these new policies, and continue their support of the health programs for their increment of new control” [37, p. 1051. In some ways this form of social control is more insidious than the ‘old’ form of social control in that it blurs work/private life distinctions and threatens employee privacy [7]. Kasl and Serxner [7] have noted that existing worksite health promotion studies “represent a missed opportunity to add to our scientific and theoretical knowledge about health promotion” [7, p. 391. Many would grant that worksite health promotion programs benefit the employee (although individual programs may be more or less effective) [7]. However, development of theory in the worksite health promotion context has been neglected. This work provides a first step toward theoretical health promotion research. Thus, this study served three purposes. First, theoretical research into the diffusion of innovations was furthered. Second, practical knowledge was gained by isolating corporate characteristics associated with health promotion programs. Third, a reliable and valid scale to measure organizational management style was developed. This scale has much practical
utility given its ease of administration and explanatory value. This study is not without limitations. First, caution should be used in generalizing these results given that the sample was drawn from organizations in California, U.S.A. Future studies should test these hypotheses in other regions. Second, it must be recognized that this sample represents larger companies only. Health promotion programs may be more difficult to adopt and implement for smaller companies with limited resources. However, if the innovation curve is followed, smaller companies may attempt to provide at least some worksite health promotion programs (e.g. health risk appraisals) or smaller companies may combine resources to offer a limited array of worksite health promotion programs (e.g. fitness facilities). In any case, a significant and important relation between managerial style and health promotion program prevalence was found in this study. These results provide a basis to launch further research into worksite health promotion. Overall, this study has contributed to both theoretical and practical understanding of why some organizations ddopt and implement health promotion programs, while others do not. Acknowledgement-This from the Irvine Health
research was supported Foundation.
by a grant
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