- Email: [email protected]
Toward a sociology of worksite health promotion: A few reactions and reflections
Sm. Sci. Med. Vol. 26, No. 5, pp. 569-575,
1988
0277-9536188
Printed in Great Britain. All rights reserved
Copyright c
$3.00 + 0.00
1988 Pergamon Journals Ltd
TOWARD A SOCIOLOGY OF WORKSITE HEALTH PROMOTION: A FEW REACTIONS AND REFLECTIONS DIANA CHAPMAN WALSH Health Policy
Institute,
Boston
University,
53 Bay State Road,
collection of papers fairly represents the range and depth of current sociological thinking on health promotion at the worksite. In so doing, it invites scholarly attention to a field that is embryonic and in many ways still struggling to formulate workable answers to a cascade of pressing questions about what works best, and why, and at what price, borne by whom (whether wittingly or not). Sociological analysis of health promotion has been relatively rare. As Conrad observes in his introduction to this special issue, the literature on worksite health promotion programs has been concentrated mostly in health education, occupational health, and public health journals. Also, it has been bifurcated. By far the larger branch has been decidedly utilitarian, looking for practical insights into how best to organize programs the value of which is taken mostly for granted. The smaller, more critical branch has sounded alarms about social control, hidden agendas, and harmful and/or unintended consequences. The first group of writings has tended to adopt a positivist tone and to be basically atheoretical; the second has been more frankly polemical, but often short on valid or compelling data. The present collection begins to bridge the gap between the two branches and to adumbrate what sociology can bring to the study of health promotion on the job. More than answers, the worksite health promotion field urgently needs a more self-conscious approach to the posing of answerable-and fundamental--questions. This question posing is what the authors of these eight new papers are struggling to do, with varying degrees of success because the field is so new. Nevertheless there is much we can learn from these papers: from what they say or neglect to say and from difficulties they encounter. Rather than try to canvass all the terrain they collectively cover, I will dwell on the two issues they raise that seem to me most salient. They are intertwined and can be thought of as issues of meanings and questions of motives.
The search for meanings is a central enterprise in most if not all of the papers here, a reflection, it would seem, of the protean nature of the field and the felt need for some standardization of vocabulary. Several of the studies wrestle with an operational definition of worksite health promotion as a construct that plays a role here as both independent and dependent variable. Others seek to look beyond
MA 02215,
U.S.A.
surface definitions for deeper meanings-manifest or latent motives-that may explain the behavior of program sponsors and/or participants.
This
MEANINGS
Boston.
What is worksite health promotion?
What is most striking about the initial definitional task is how complicated it quickly becomes. Conrad begins with a broad definition, elastic enough to stretch around an elaborate menu of program possibilities. Hollander and Lengermann then report having altogether finessed the definitional issue; they left their survey respondents “free to answer on the basis of their own perceptions whether such a program exists in their organizations”. Roman and Blum, by contrast, see the resolution of definitional ambiguity as the first-order task in laying the groundwork for future research in the field. And their idea of refining the definition of health promotion by comparing and contrasting it with employee assistance is a helpful one. More remains to be done, though, in drawing out the essential distinctions between two types of company-sponsored health program with very different origins, but now following trajectories that seem in many ways to be blending them into one. The primary versus secondary prevention distinction needs closer analysis. For example, some EAPs try to do primary prevention by looking for stressors in the workplace or by training employees to manage their own stress [ 11;and when health promotion programs screen for hypertension, they are engaged in secondary, not primary prevention. Historically, what has been different about EAPs is the centrality of job performance as the linchpin in both their administrative and therapeutic rationales [2]. The specific role supervisors and of the importance of confidentiality-two other distinctions Roman and Blum make-relate to this job performance issue because EAPs, unlike health promotion programs, are often working at a precipice where an employee’s job is in jeopardy. Should health promotion come to look more and more like employee assistance, the implications for social control merit closer sociological analysis. The opportunities for coercion become especially worrisome, as Roman and Blum suggest and as some of the Kotarba and Bentley data poignantly attest, if Conrad’s ‘cultural wellness’ has a mean streak, where ‘zealots’ can exclude and stigmatize nonconformists. If simply defining a health promotion program seems inordinately complex, among the chief challenges to taxonomic consensus are the idiosyncracies 569
570
DIANA CHAPMANWALSH
of different programs rallying under the same banner. Several of the papers remark on this variation, which bespeaks an underlying lack of clarity concerning what such a program minimally entails. Conrad draws a distinction between health promotion programs and activities traditionally carried out under the orthodox rubric of occupational health and safety. Yet, on closer examination, it appears that many of the ostensibly new ‘wellness programs’ in American industry scarcely expand things that occupational health physicians and nurses have been doing for years. An element of old wine in new bottles has entered the promotion of health promotion. In line with that, it is interesting to wonder, in response to Conrad’s observation about the apparent absence of formal health promotion programs in European and Pacific companies, whether American industry is ‘ahead’ in its sponsorship of stand-alone health promotion, or ‘behind’ in the fragmented and distorted view of health (as acute-care medicine) that requires a special effort to give simple preventive activities the attention they clearly warrant. In the Scandanavian countries, particularly, this would be an interesting question to pursue. Also related to the peculiarities of the American health care system, a second definitional imprecision arises out of the problem of standard preventative medical services-periodic medical examinations, prenatal and well-baby care, Pap smears and other routine screening conducted by personal physicians. Such services are often covered in third-party payment programs financed in America through the employment relationship. Certainly these services are part of classic preventive medicine and they are covered to one degree or another in some, but by no means all, employee benefit plans. Whether this coverage should confer ‘credit’ in a tally of worksite health promotion programs is a question survey researchers have yet adequately to address. Finally, and more complicated still, survey researchers have done little so far to take account of the intensity or scope of a given effort. Most sizeable employers do something to promote healthy lifestyles: they hand out materials provided for free by voluntary health agencies, or support the Great American Smoke-Out every year, they run occasional health tips in the house organ or sponsor a health fair once in a while. In a 1985 national survey of a probability sample of all private sector worksites with 50 or more employees, the federal Office of Disease Prevention and Health Promotion found at least one health promotion activity at nearly 66% overall, with substantially higher rates at larger installations [3]. At what threshold any one or any combination of these activities begins to weigh in as a genuine health promotion ‘program’ is a judgment call that research to date has generally left the respondent to make on his or her own. Hollander and Lengermann do raise the issue of “the nature and extent” of programs, but lack the finely-grained data on the inputs to specific initiatives that would be required to array respondents’ programs along any kind of intensity scale. The next generation of survey research on the extent of health promotion programming in industry will be able to build on the work reported here and sharpen the precision of operational definitions.
What is ‘risk’? When they do, one of the constructs badly needing greater clarification is the notion of ‘risk’ taken up by Alexander and glancingly mentioned by others here. Alexander seems to be writing mostly of the company’s risk, although her major point is that the model of disease etiology that puts individual risk factors at its center is a narrow and, for corporations, in many ways a self-serving one that blames victims, shifts costs to employees, and ignores the social production of disease. While raising some important questions, she leaves ample room for others to follow up, defining much more clearly the ideological construct of ‘risk’ and the role it has played historically and will continue to play in the evolution of worksite health promotion programs. One distinction that may shed some light on notions of risk has been made by Perry and Jessor [4] among others [5]. They argue that, ideally, health promotion should be more than disease prevention, just as health should be more than the mere absence of disease. Disease prevention, or health conservation, involves a search for those at elevated risk, usually through some kind of screening process. Once identified, these high-risk individuals are discouraged from continuing their specific health-compromising behavior (smoking, drinking dangerously, ignoring their hypertension). The program seeks to increase their knowledge, teach them new skills, instill and reinforce motivation. Health promotion, or health enhancement, by contrast, focuses on a population as a whole, not just those whose risk is elevated in some measurable way. It seeks to encourage health-enhancing behaviors (regular aerobic exercise, a health-conscious diet, defensive driving and seatbelt use). Ideally, it should be amplifying feelings of mastery and control. Health-enhancing interventions, theoretically, are directed not just at the individual level, but also at the environment, both physical and psychosocial, where an effort is made to remove any noxious agents that may be harmful to health and to influence values and norms in the workplace as they relate to health, to mobilize role models and social supports, to provide opportunities for pursuing health and to make sure support structures are in place. As Alexander properly points out, the risk factor approach has limitations. a case Syme has argued elsewhere in cogent detail. Years of good epidemiological research has established three principal risk factors for coronary heart disease: hypertension, smoking and cholesterol. Yet only a small proportion of the people who have all three risk factors actually develop heart disease, and of all who do develop the disease fully a quarter have had no risk factors or only one [6]. What this says, as Syme points out, is what Alexander is bringing to our attention: important though known risk factors may be, other factors come into play in the etiology of disease. Risk factors do increase the probability of becoming ill, but a risk factor approach overlooks the environment: physical, social and cultural. Diseases are socially produced, and risk factors are too; they are not a function simply of individual choice. One of the ways we know this is that gender, marital status, and social class are
Toward a sociology of worksite health promotion among the most robust variables social epidemiologists associate with patterns of disease. These variables need to be explained (and influenced) in terms of group (not individual) experiences and processes. Because of these social factors and how important they are, placing responsibility for personal lifestyle just on individuals tends to burden them with something that may be less a choice than a response to social constraints. Alexander correctly observes that it is unusual to find a corporate manager who thinks in these broader terms, but some do; and few that I know see the world in the narrow cost-benefit terms that she seems to impute to them. This brings us to the question of motives. MOTIVES
That motives are mixed and splintered among interest groups in the worksite health promotion world seems self evident to all the authors here (and to anyone who bothers to look). Two kinds of motives or interests emerge as preeminent concerns: those of corporations in the decision to sponsor programs and those of individual employees in the decision to partake of them or not. Both merit close attention, as survival issues for the worksite health promotion ‘movement’, and as sociological questions harboring real complexity. What motivates
corporate sponsors?
From the corporate perspective, these authors repeatedly assert, there are strong incentives on employers to act, because promoting health promotion is in the long-term economic self-interest of American companies, beset as they are by a persistent upward trend in the costs associated with health benefit plans. The extent to which health promotion can realistically be expected to affect health care costs is the subject of increasing debate, as several of the authors here grant. Both Conrad and Alexander emphasize how thin the available evidence truly is, although neither cites the recent work of economists like Russell [7], Warner [S], and Schelling [9], each of whom has, in different ways, mounted a forceful attack on the evidence that investing in health promotion will serve the narrow economic self-interest of a business firm. Parenthetically, it is worth noting a small but telling mistake that several of the authors in this collection and many others in the field inadvertently make. To actually ‘reduce’ health benefit costs through a health promotion strategy is a possibility few sophisticated corporate managers seriously entertain: what they aspire to do to costs is at best to ‘contain’, or ‘stabilize’, or ‘manage’ them. Behind this semantic nicety lies a more worrisome doubt about how completely the authors in this collection have actually captured the nuances of corporate thinking about investing in health promotion. For example, Hollander and Lengermann make a somewhat offhand assertion that has become a shibboleth in the field, namely that there is something not quite rational about the way companies go about deciding to invest in health promotion and that this irrationality stands in stark contrast to decision making “techniques. . typically [applied] to production
571
and other service activities”. This claim has become part of the folklore of worksite health promotion. To its credit, the Hollander paper does begin to question one of the underlying assumptions, and begins to ask what goes into corporate planning of health promotion initiatives. Someone now needs to take the same critical approach to the other element in the putative equation. It does not go without saying, in my view, that companies are any more purposeful in their planning for other kinds of investments that they make on a comparable scale. We have no data in any of these papers on how much companies are actually investing in health promotion, but for many, I submit, the cost is little more than a rounding error in the context of their total human resource investment. There is doubtlessly much we can learn by examining corporate decision making in health compared to other decisions, but we need to pay more attention to the selection of a valid comparison set. No one, to my knowledge, has thought very deeply about what kinds of other corporate pursuits would be truly comparable to health promotion programs, and why. Is the decision to implement a health promotion program like the one to continue an employee’s health insurance coverage after s/he retires? The latter is a far more expensive benefit than health promotion is, and has grown like topsy in recent years, with no evidence of systematic planning. Does the health promotion innovation resemble a dental plan? Many companies instituted those in the seventies and were soon publicly lamenting large unanticipated costs. Is health promotion decision-making so much less ‘rational’ than this? The high-tech versus low-tech dichotomy in the Hollander and Lengennann paper seeks to bring some empirical data to bear on their question of corporate ‘rationality’. And that dichotomy implies (although this is my interpretation, not theirs) that worksite health promotion is analogous to a product investment. They stratify companies according to an index of investment in research and development, as a proxy measure for a company’s innovativeness. There are serious validity concerns about the index itself and what it may represent. As one of many possible examples, consider some implications of the fact that workforces in high R&D companies are markedly more likely than those in smokestack industries to comprise disproportionate shares of employees who have already adopted a ‘wellness’-oriented lifestyle. Moreover the relevance to health promotion of this index is questionable: it relates to what Thompson [lo] would call an organization’s ‘core technology’. If health promotion initiatives are to be compared to product investments designed to yield future profits, the connection needs to be made more closely, and the comparability of the two types of decision should be argued, not simply asserted or assumed. To my knowledge, no one has explored this question, perhaps because it is highly complex. To argue that corporate health decisions resemble those shaping product development, one needs a sophisticated understanding of corporate resource allocation decisions [ll]. One also needs to know how much money is really at issue, in light of Simon’s [I21
572
DIANA CHAPMAN WALSH
insight that corporate decisions are not ‘maximizing’ but ‘satisficing’, that the search for another increment of information is generally called off when the search costs outweigh the potential benefits that the additional information could bring in uncertainty averted. For a low-cost program like health promotion that everyone seems to like, how much uncertainty (in downside risks or hidden costs) is really at stake? If the potential costs of an incorrect decision are negligible, what rational justification is there to engage in expensive purposeful planning? There are a number of empirical questions here that someone with some data could begin to resolve. Roman and Blum find their analogies closer at hand, in comparisons that, for me, have more face validity than extrapolations to product investments. They seek to place worksite health promotion in the larger context of corporate culture in the management of human resources. But, again, our understanding would be enhanced if, alongside of the somewhat subjective ‘culture’ variables, we had some harder measures of the nature and scope of the range of different activities different companies support in human resources. Still, in contrasting health promotion to employee assistance, Roman and Blum do broach the interesting question of boundaries around separate programs. More can be done with the concepts from organizational theory of boundaries and boundary spanning, but the notion of distinct organizational entities vying for influence within a business firm suggests a deeper way of thinking about our ‘rationality’ concern. The rationality which many observers seem to find lacking in corporate decisions about health is evocative of the ‘rational actor’ model in Graham Allison’s book, Essence of Decision [13]. A rational actor model holds that nations (in Allison’s case, or in ours, organizations like corporations) maximize utilities. They are driven by incentives, carefully calculated self-interest, and make rational decisions. The point of Allison’s book is to show that at least two competing explanatory models can fit the data just as well. The second is an ‘organizational process’ model, in which decisions grow out of bureaucratic imperatives, standard operating procedures, and the outputs of organizational subunits, characterized by inertia, or inevitability, that limits options and information and shapes the course of events. In the third model, decisions are produced by individuals as political actors, positioning themselves, using power, jockeying for advantage, and influencing the direction of change. When we shift from the rational actor lens through which many observers seem to look, we move from a world where economic self-interest is the decisive factor (the hope of money to be saved), to one in which worksite health promotion programs emerged willy nilly, as outputs of organizations going about their business. Our focus accordingly shifts to organizations and organizational subunits and their vested interests in the health promotion game. The Alexander paper has alerted us to the centrality of vested interests, and when we take them as a point of departure, we turn our attention to: (1) government, retreating from and seeking to dismantle the welfare state, as too expensive; (2) insurance carriers, trying
hard to survive in a newly turbulent environment, a more hostile and competitive environment than in the past; (3) hospitals, competing for a share of a shrinking market, positioning themselves to attract patients, now in short supply; (4) other vendors of health promotion services, proliferating rapidly in a dynamic and competitive market; (5) employers. both as buyers and as sellers of health promotion services. Looking through an organizational lens, just at the employer sector, compels attention to organizational subunits of business firms, each, again. with a distinct purview on the functions of health promotion programs: (1) Human resource professionals. charged with attracting and holding the best possible employees, see health promotion as a kind of magnet to compete in labor markets and perhaps even to draw especially high performers. (2) Benefit specialists. struggling to contain health care costs. want to accomplish this goal without appearing to renege on old promises from the 1960s when companies felt more expansive about what they could do for employees. Health promotion programs, as Conrad points out, are a low-cost way (a ‘symbolic exchange’) to sugar-coat the pill of ‘take-aways’ from the benefit package. (3) Corporate physicians have long been a medical subspeciality in search of a pursuasive mission, and the urgency of that search is intensifying as American industry strips away a layer of middle management and demands tighter justifications for nonproductive expenditures. This puts new pressure on medical departments to quantify an impact, and health promotion is one of the areas to which their attention has turned [14]. (4) Legal and risk management staffs within corporations are contemplating malpractice and other torts, for example, from nonsmokers who are exposed to secondhand smoke. Offering a health promotion program may become a defense against that future liability. (5) Finally, corporate image specialists have noted Conrad’s phenomenon of ‘cultural wellness’ and see in it a chance to capitalize on a broad secular shift, reinforcing the message that theirs is a caring and modern company. It seems more than coincidental that many of the leading firms in the corporate health promotion field are companies that try very hard, in their corporate advertising, to project a youthful, vital image. When we shift, finally, to Allison’s third explanatory model, we find events occurring because individuals who have power, resources, influence and persistence decide, for their own reasons, that they want to invest the energy into making them occur. The worksite health promotion field is replete with anecdotes in which committed individuals (a chief executive or other senior officer, a medical director or benefits manager or a health educator at the grass roots) are believed to have made singular contributions, influencing decisions to support companies’ innovative programs. Doing so has repaid some well, advancing their own careers or self-esteem, enhancing their organization’s prestige, or serving some other latent function. Is this behavior so ‘irrational’; I believe not. The notion of irrational decisions comes from a narrow view of health promotion as being ‘about’ cost containment, first and foremost. The Allison
Toward a sociology of worksite health promotion approach alerts us to the idea that these innovations are about widely differing utilities, depending not only on the circumstances but also on the conceptual model we apply. Health promotion at the workplace is about employee satisfaction, about morale and productivity, about humanitarianism, about fitness, about health, about personal career ambition, competition in many forms, corporate public relations, about all these desiderata, and no doubt others too. A thorough empirical study of these different motivations would yield fascinating results. We must be careful not to simplify the complex. When the question of the program’s meaning is being framed in limited utilitarian or cost-benefit terms we need to ask ourselves, as Alexander begins to do, who is casting it thus and why: whose interests are being served, what are some alternative formulations, how does one achieve hegemony over the others? My own experience of the evolution of worksite health promotion (as one who has been on the sidelines for the past decade) differs markedly from the historical account that Alexander has pieced together. First of all, ‘overutilitization’ as an ideological construct originated not with industry but with the state. It was when certification of need programs and professional standards review organizations were being introduced in the late 1960s and early 1970s that the logic of overutilization reached the published literature [ 151. Because HMOs used many fewer hospital bed days per capita than did unstructured fee for service (with no evidence of different outcomes), it was asserted that there must be substantial overutilization throughout the health care system. Only later did private industry take up the cudgels against ‘excessive utilitzers’. Moreover, the argument that industry’s interests would be served by promoting health promotion emanated, again, from the state and some public health activists, who sought to secure industrial support for wellness programs at the worksite. They conceived a worksite strategy as an integral part of a ‘second public health revolution’ they wanted to rally, and viewed the workplace as a complex sociotechnical system, where, in theory, employers have the full range of change mechanisms at their command: education, incentives, social values and norms, even coercive power in the form of corporate policies and rules, backed up by implicit or overt sanctions. The deeper questions Alexander raises about the ideological functionality of worksite health promotion are fascinating and important ones. To advance them we now need a combination of Alexander’s critical and historical perspective with a much closer and more richly textured account of what it is that corporate managers and representatives of the other vested interests (especially the state) are really thinking, saying and doing. What motkates
employee participants?
Rich texture and close touch with the perspectives of participants make the two ethnographic studies my personal favorites in this collection. John Naisbitt, in his bestseller Megatrends [ 161 conducted content analyses of media outlets and identified the ‘wellness movement’ as one of only ten broad-gauge ‘mega-
573
trends’ that he predicted are here to stay. The evidence is all around us, but the interesting question is why and why now: what new need in the psyches of some contemporary men and women is the wellness megatrend tapping into and how; and who are those who manage to resist its appeal? Some speculative thoughts on these questions of meaning have been published in the past [17], but Conrad’s study of Medical Technology Company and Kotarba and Bentley’s of Wellness Inc. go beyond speculation and take the position of those whose behavior we are trying to understand. They do not claim to have full answers yet, but do provide some intriguing leads. Fitting in is a crucial factor in the decision to join a program, indeed the quest for ‘fitness’ that Conrad sees as the driving force in these programs seems in the Kotarba and Bentley study to be broader than physical fitness; it is people looking for a place to fit, a place to belong, a new, more comfortable or more ‘fitting’ sense of self. Conrad’s distinction between fitness and health needs more elaboration, I believe. Whitbeck [IS] has observed that fitness is “a significant component of health, so that, other things equal, a more physically fit person is more healthy”, that is, has a greater “psychophysiological capacity to respond appropriately to a wide variety of situations”, which is her definition of ‘health’. By this definition, smoking is an indication of being less healthy (because it diminishes physical lung capacity), whereas not wearing seatbelts, or having a dangerous job do elevate risk but do not compromise health. Achieving physical fitness does improve health (by enhancing muscle tone, circulation, and cardiac reserve, and the density of bones) but a more fit person can be less healthy than a less fit one, for example, if the latter is “so ridden by phobias and neuroses that, in many situations, the most appropriate responses would be blocked by an anxiety reaction” [18, p. 6191. I will not attempt further elaboration here, but simply want to suggest that we need more refined descriptions of participants’ own definitions of both ‘fitness’ and ‘health’, before we can accept the assertion that they are pursuing one to the exclusion of the other. I suspect that most would say, as one of Conrad’s subjects did, that they are pursuing fitness as one avenue to greater health. It may be significant, moreover, that of all the risk factor interventions on the standard menu of health promotion programs, aerobic exercise produces the most immediate feedback: exercisers perspire, feel their pulses race, and sometimes get an ‘endorphin rush’, in short they directly, physically experience Kotarba’s “health-asaccomplishment”. No such immediate physical rewards attach to the accomplishments of dieting, cutting down on cigarettes or alcohol, or buckling a seatbelt. But, again, it would be instructive to hear in greater detail how participants and nonparticipants in programs answer these subtler questions. If worksite health promotion programs are really about fitting in or belonging, about alienation from a sense of community and a perceived need for social support, then it is interesting to wonder about the social costs of the wellness movement. Bellah et al. argued that Americans are retreating into homogeneous “lifestyle enclaves”, and that this trend is
DIANA CHAPMANWALSH
514
undermining communities, where public and private life come together in heterogeneous mutual support groups (191. Could it be that health promotion is a lifestyle enclave in the worksite and if so is it deflecting energy from collective efforts to improve the quality of workhfe for all? Is it possible that the positive health outcomes, now being reported by some worksite health promotion programs, could be achieved by very different approaches to building a sense of mutual support and community on the job-for example ‘workplace democracy’ or ‘quality circle’ programs without any ‘health’ trappings at all? These are some of the many questions that these provocative papers raise. Finally, on the question of motives, we come to the issue of gender differences. Kotarba and Bentley discuss it in passing and Spilman attacks it frontally. Health promotion on the job seems to signify something different for women than for men. The difference is no doubt a complex interaction of different social locations, intermingled with different experiences, both of work and of health. There is wide terrain here for more intensive explorations of gender and other demographic variables (especially job status) and of the interplay that Zimmerman and associates highlight between life at work and life at home. SUMMING
UP
The eight papers collected here provide much food for thought on social factors in the success or failure of wo’rksite health promotion programs, from the separate perspectives of program sponsors and participants. They position worksite health promotion as a problem area opening to questions germane to the sociology of organizations and professions, of health and of work, of communities and families, even the sociology of knowledge and theories of social change and deviance. Conrad, in his introduction, lays out an agenda for future research, so I will simply conclude with a brief comment on design and methodology. A number of these studies are admittedly exploratory and are recognized by their authors to suffer severe methodological limitations related to small samples, low response rates, inadequate or missing baseline measures and/or comparison groups, uncertain reliability or validity of measures, and the construct validity issues implicit in the definitional ambiguities belabored above. For the immediate
future, as the field matures, two investigative approaches will bear the most fruit. The first will be tightly designed intervention studies (ideally using randomization or else rigorous quasiexperimental designs) that compare two or more fundamentally different strategies seeking to achieve the same result. These studies should be theoretically informed, but will address narrowly circumscribed questions about what works best for whom. The second kind of investigation that will advance the field will tackle some of the broader and more sociological questions the writers here have begun to pose. But these studies will need to attend more closely to middle-range detail. to use a combination of qualitative and quantitative techniques in designs that conform better to accepted methodological stan-
dards, and to build much more securely on established sociological literature. In particular, there are two bodies of research that the studies here inadequately plumb. The extensive body of organizational theory and research needs to be brought more squarely into future investigations of corporate motives, goals, decisions and behavior in the health promotion arena. Even more striking, however, is the relative absence here of grounding in the substantial literature on disease prevention and health promotion. Systematic theories have been developed and tested to explain preventive health behaviors, the influence of social supports, of selfefficicacy and locus of control, of values, and of structural variables, among many contingencies [20]. Future research on worksite health promotion will have to concern itself with a wider range of explanatory variables than are introduced here, and with complex interactions among a web of predisposing, enabling, and reinforcing factors that contribute to health behavior. In this way, the field can progress toward the development of encompassing theoretical frameworks that will permit the specification of causal relationships between a broad range of mutually-interacting explanatory variables moving through time. A thorough review of the relevant sociological literature, leading to specific recommendations for future research on worksite health promotion, would be a useful contribution at this time. Meanwhile, we have a good start here, despite limitations that the authors themselves grant, and with it what amounts to an open invitation to a field which will certainly benefit from the application of sociological theory and methods, and which as surely will repay the debt in new insights into a slice of the social world that is variegated, perplexing, tightly bound up with larger social forces, and imperfectly understood. AcknowledgPmenu-The research on which this commentary draws was funded in part by the Pew Memorial Trust, the General Electric Foundation, the Commonwealth Fund, the National Institute on Alcohol Abuse and Alcoholism, and the W. K. Kellogg Foundation.
REFERENCES
I. Walsh D. C. and Kelleher S. Preventing alcohol and drug abuse through programs at the worksite. Work&e Wellness Media Report, Washington Business Group on Health and Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, 1987. 2. Walsh D. C. Employee assistance programs. Milbank Meml Fund Q.lHlth Sot. 60(3), 492-511, 1982. and Health Promotion. 3. Office of Disease Prevention National Survey of Worksite Heath Promotion Activities Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services. P.O. Box 1133. Washinaton, DC 20013-I 133. Unpublished manuscript. 4. Perry C. L. and Jessor R. The concept of health promotion and the prevention of adolescent drug abuse. Hlrh Educn Q. 12(2), 169-184, Summer 1985. 5. See Collings G. H. Jr. Managing the health of the employee. J. occup. Med. 24, 15-17, 1982. 6. Syme S. L. Strategies for health promotion. Preuenf. Med. 15, 497, 1986.
Toward
a sociology
of worksite
7. Russell L. Is Prevention Berter than Cure? Brookings Institute, Washington, D.C., 1986. to corporate 8. Warner K. E. Selling health promotion America. Hlth Educn Q. 14, 39-55, Spring 1987. and cigarettes. Prevenr. Med. 9. Schelling T. Economics 15, 549-560, 1986. J. Organizations in Acfion. McGraw-Hill, 10. Thompson New York, 1967. II. Bower J. Managing the Resource Allocation Process. (R.D.) Irwin, Homewood, 111. 1970. goal. Ad12. Simon H. On the concept of organizational min. Sri. Q. In press. 13. Allison G. Essence of Decision. Little Brown, Boston, Mass., 1971. 14. Walsh D. C. Corporafe Physicians: Berween Medicine and Managemenf. Yale University Press, New Haven, Conn., 1987. of need: 15. Bicknell W J. and Walsh D. C. Certification the Massachusetts experience. New Engl. J. Med. 292, 1054-1067, 15 May, 1975. J. Megatrends: Ten New Directions Trans16. Naisbitt forming Our Lives. Warner Books, New York, 1982. 17. Gillick M. R. Health promotion, jogging and the pur-
health
promotion
575
suit of the moral life. J. Hlth PO&.. Policy & Law 9, 369-387, 1984. 18. Whitbeck C. A theory of health. In Concepts of Health and Disease : Interdisciplinary Perspectives (Edited by Caplan A.. Engelhardt H. T. Jr and McCartnev J. J.). pp.. 661626. Addison-Wesley, Reading, Mass.: 198 1: 19. Bellah R. N.. Madsen R.. Sullivan W. M.. Swidler A. and Tipton S. M. Habits of the Heart. Harper & Row, New York, 1985. 20. See Mechanic D. Medical Socioloav. Free Press. New York, 1978; Green L. W., Kreuter M. W., Deeds S. and Partridge K. B. Health Education Planning: A Diagnosric Approach. Mayfield, Palo Alto, Calif: 1980: Hambrug D. A., Elliott G. R. and Parron D. L. Health and Behavior. National Academy Press, Washington, D.C., 1982; Behavioral Health: A Handbook for Health Enhancement and Disease Prevenrion (Edited by Matarazxo J., Miller N. E. and Weiss S. M.). Wiley, New York. 1984; Promoting Adolescent Health: A Dialog on Research and Practice (Edited by Coates T. J., Peterson A. C. and Perry C.). Academic Press, New York, 1982; Handbook of Medical Sociology (Edited by Freeman H. E., Levine S. and Reeder L. G.). Prentice Hall. Englewood Cliffs, N.J., 1979.
1988
0277-9536188
Printed in Great Britain. All rights reserved
Copyright c
$3.00 + 0.00
1988 Pergamon Journals Ltd
TOWARD A SOCIOLOGY OF WORKSITE HEALTH PROMOTION: A FEW REACTIONS AND REFLECTIONS DIANA CHAPMAN WALSH Health Policy
Institute,
Boston
University,
53 Bay State Road,
collection of papers fairly represents the range and depth of current sociological thinking on health promotion at the worksite. In so doing, it invites scholarly attention to a field that is embryonic and in many ways still struggling to formulate workable answers to a cascade of pressing questions about what works best, and why, and at what price, borne by whom (whether wittingly or not). Sociological analysis of health promotion has been relatively rare. As Conrad observes in his introduction to this special issue, the literature on worksite health promotion programs has been concentrated mostly in health education, occupational health, and public health journals. Also, it has been bifurcated. By far the larger branch has been decidedly utilitarian, looking for practical insights into how best to organize programs the value of which is taken mostly for granted. The smaller, more critical branch has sounded alarms about social control, hidden agendas, and harmful and/or unintended consequences. The first group of writings has tended to adopt a positivist tone and to be basically atheoretical; the second has been more frankly polemical, but often short on valid or compelling data. The present collection begins to bridge the gap between the two branches and to adumbrate what sociology can bring to the study of health promotion on the job. More than answers, the worksite health promotion field urgently needs a more self-conscious approach to the posing of answerable-and fundamental--questions. This question posing is what the authors of these eight new papers are struggling to do, with varying degrees of success because the field is so new. Nevertheless there is much we can learn from these papers: from what they say or neglect to say and from difficulties they encounter. Rather than try to canvass all the terrain they collectively cover, I will dwell on the two issues they raise that seem to me most salient. They are intertwined and can be thought of as issues of meanings and questions of motives.
The search for meanings is a central enterprise in most if not all of the papers here, a reflection, it would seem, of the protean nature of the field and the felt need for some standardization of vocabulary. Several of the studies wrestle with an operational definition of worksite health promotion as a construct that plays a role here as both independent and dependent variable. Others seek to look beyond
MA 02215,
U.S.A.
surface definitions for deeper meanings-manifest or latent motives-that may explain the behavior of program sponsors and/or participants.
This
MEANINGS
Boston.
What is worksite health promotion?
What is most striking about the initial definitional task is how complicated it quickly becomes. Conrad begins with a broad definition, elastic enough to stretch around an elaborate menu of program possibilities. Hollander and Lengermann then report having altogether finessed the definitional issue; they left their survey respondents “free to answer on the basis of their own perceptions whether such a program exists in their organizations”. Roman and Blum, by contrast, see the resolution of definitional ambiguity as the first-order task in laying the groundwork for future research in the field. And their idea of refining the definition of health promotion by comparing and contrasting it with employee assistance is a helpful one. More remains to be done, though, in drawing out the essential distinctions between two types of company-sponsored health program with very different origins, but now following trajectories that seem in many ways to be blending them into one. The primary versus secondary prevention distinction needs closer analysis. For example, some EAPs try to do primary prevention by looking for stressors in the workplace or by training employees to manage their own stress [ 11;and when health promotion programs screen for hypertension, they are engaged in secondary, not primary prevention. Historically, what has been different about EAPs is the centrality of job performance as the linchpin in both their administrative and therapeutic rationales [2]. The specific role supervisors and of the importance of confidentiality-two other distinctions Roman and Blum make-relate to this job performance issue because EAPs, unlike health promotion programs, are often working at a precipice where an employee’s job is in jeopardy. Should health promotion come to look more and more like employee assistance, the implications for social control merit closer sociological analysis. The opportunities for coercion become especially worrisome, as Roman and Blum suggest and as some of the Kotarba and Bentley data poignantly attest, if Conrad’s ‘cultural wellness’ has a mean streak, where ‘zealots’ can exclude and stigmatize nonconformists. If simply defining a health promotion program seems inordinately complex, among the chief challenges to taxonomic consensus are the idiosyncracies 569
570
DIANA CHAPMANWALSH
of different programs rallying under the same banner. Several of the papers remark on this variation, which bespeaks an underlying lack of clarity concerning what such a program minimally entails. Conrad draws a distinction between health promotion programs and activities traditionally carried out under the orthodox rubric of occupational health and safety. Yet, on closer examination, it appears that many of the ostensibly new ‘wellness programs’ in American industry scarcely expand things that occupational health physicians and nurses have been doing for years. An element of old wine in new bottles has entered the promotion of health promotion. In line with that, it is interesting to wonder, in response to Conrad’s observation about the apparent absence of formal health promotion programs in European and Pacific companies, whether American industry is ‘ahead’ in its sponsorship of stand-alone health promotion, or ‘behind’ in the fragmented and distorted view of health (as acute-care medicine) that requires a special effort to give simple preventive activities the attention they clearly warrant. In the Scandanavian countries, particularly, this would be an interesting question to pursue. Also related to the peculiarities of the American health care system, a second definitional imprecision arises out of the problem of standard preventative medical services-periodic medical examinations, prenatal and well-baby care, Pap smears and other routine screening conducted by personal physicians. Such services are often covered in third-party payment programs financed in America through the employment relationship. Certainly these services are part of classic preventive medicine and they are covered to one degree or another in some, but by no means all, employee benefit plans. Whether this coverage should confer ‘credit’ in a tally of worksite health promotion programs is a question survey researchers have yet adequately to address. Finally, and more complicated still, survey researchers have done little so far to take account of the intensity or scope of a given effort. Most sizeable employers do something to promote healthy lifestyles: they hand out materials provided for free by voluntary health agencies, or support the Great American Smoke-Out every year, they run occasional health tips in the house organ or sponsor a health fair once in a while. In a 1985 national survey of a probability sample of all private sector worksites with 50 or more employees, the federal Office of Disease Prevention and Health Promotion found at least one health promotion activity at nearly 66% overall, with substantially higher rates at larger installations [3]. At what threshold any one or any combination of these activities begins to weigh in as a genuine health promotion ‘program’ is a judgment call that research to date has generally left the respondent to make on his or her own. Hollander and Lengermann do raise the issue of “the nature and extent” of programs, but lack the finely-grained data on the inputs to specific initiatives that would be required to array respondents’ programs along any kind of intensity scale. The next generation of survey research on the extent of health promotion programming in industry will be able to build on the work reported here and sharpen the precision of operational definitions.
What is ‘risk’? When they do, one of the constructs badly needing greater clarification is the notion of ‘risk’ taken up by Alexander and glancingly mentioned by others here. Alexander seems to be writing mostly of the company’s risk, although her major point is that the model of disease etiology that puts individual risk factors at its center is a narrow and, for corporations, in many ways a self-serving one that blames victims, shifts costs to employees, and ignores the social production of disease. While raising some important questions, she leaves ample room for others to follow up, defining much more clearly the ideological construct of ‘risk’ and the role it has played historically and will continue to play in the evolution of worksite health promotion programs. One distinction that may shed some light on notions of risk has been made by Perry and Jessor [4] among others [5]. They argue that, ideally, health promotion should be more than disease prevention, just as health should be more than the mere absence of disease. Disease prevention, or health conservation, involves a search for those at elevated risk, usually through some kind of screening process. Once identified, these high-risk individuals are discouraged from continuing their specific health-compromising behavior (smoking, drinking dangerously, ignoring their hypertension). The program seeks to increase their knowledge, teach them new skills, instill and reinforce motivation. Health promotion, or health enhancement, by contrast, focuses on a population as a whole, not just those whose risk is elevated in some measurable way. It seeks to encourage health-enhancing behaviors (regular aerobic exercise, a health-conscious diet, defensive driving and seatbelt use). Ideally, it should be amplifying feelings of mastery and control. Health-enhancing interventions, theoretically, are directed not just at the individual level, but also at the environment, both physical and psychosocial, where an effort is made to remove any noxious agents that may be harmful to health and to influence values and norms in the workplace as they relate to health, to mobilize role models and social supports, to provide opportunities for pursuing health and to make sure support structures are in place. As Alexander properly points out, the risk factor approach has limitations. a case Syme has argued elsewhere in cogent detail. Years of good epidemiological research has established three principal risk factors for coronary heart disease: hypertension, smoking and cholesterol. Yet only a small proportion of the people who have all three risk factors actually develop heart disease, and of all who do develop the disease fully a quarter have had no risk factors or only one [6]. What this says, as Syme points out, is what Alexander is bringing to our attention: important though known risk factors may be, other factors come into play in the etiology of disease. Risk factors do increase the probability of becoming ill, but a risk factor approach overlooks the environment: physical, social and cultural. Diseases are socially produced, and risk factors are too; they are not a function simply of individual choice. One of the ways we know this is that gender, marital status, and social class are
Toward a sociology of worksite health promotion among the most robust variables social epidemiologists associate with patterns of disease. These variables need to be explained (and influenced) in terms of group (not individual) experiences and processes. Because of these social factors and how important they are, placing responsibility for personal lifestyle just on individuals tends to burden them with something that may be less a choice than a response to social constraints. Alexander correctly observes that it is unusual to find a corporate manager who thinks in these broader terms, but some do; and few that I know see the world in the narrow cost-benefit terms that she seems to impute to them. This brings us to the question of motives. MOTIVES
That motives are mixed and splintered among interest groups in the worksite health promotion world seems self evident to all the authors here (and to anyone who bothers to look). Two kinds of motives or interests emerge as preeminent concerns: those of corporations in the decision to sponsor programs and those of individual employees in the decision to partake of them or not. Both merit close attention, as survival issues for the worksite health promotion ‘movement’, and as sociological questions harboring real complexity. What motivates
corporate sponsors?
From the corporate perspective, these authors repeatedly assert, there are strong incentives on employers to act, because promoting health promotion is in the long-term economic self-interest of American companies, beset as they are by a persistent upward trend in the costs associated with health benefit plans. The extent to which health promotion can realistically be expected to affect health care costs is the subject of increasing debate, as several of the authors here grant. Both Conrad and Alexander emphasize how thin the available evidence truly is, although neither cites the recent work of economists like Russell [7], Warner [S], and Schelling [9], each of whom has, in different ways, mounted a forceful attack on the evidence that investing in health promotion will serve the narrow economic self-interest of a business firm. Parenthetically, it is worth noting a small but telling mistake that several of the authors in this collection and many others in the field inadvertently make. To actually ‘reduce’ health benefit costs through a health promotion strategy is a possibility few sophisticated corporate managers seriously entertain: what they aspire to do to costs is at best to ‘contain’, or ‘stabilize’, or ‘manage’ them. Behind this semantic nicety lies a more worrisome doubt about how completely the authors in this collection have actually captured the nuances of corporate thinking about investing in health promotion. For example, Hollander and Lengermann make a somewhat offhand assertion that has become a shibboleth in the field, namely that there is something not quite rational about the way companies go about deciding to invest in health promotion and that this irrationality stands in stark contrast to decision making “techniques. . typically [applied] to production
571
and other service activities”. This claim has become part of the folklore of worksite health promotion. To its credit, the Hollander paper does begin to question one of the underlying assumptions, and begins to ask what goes into corporate planning of health promotion initiatives. Someone now needs to take the same critical approach to the other element in the putative equation. It does not go without saying, in my view, that companies are any more purposeful in their planning for other kinds of investments that they make on a comparable scale. We have no data in any of these papers on how much companies are actually investing in health promotion, but for many, I submit, the cost is little more than a rounding error in the context of their total human resource investment. There is doubtlessly much we can learn by examining corporate decision making in health compared to other decisions, but we need to pay more attention to the selection of a valid comparison set. No one, to my knowledge, has thought very deeply about what kinds of other corporate pursuits would be truly comparable to health promotion programs, and why. Is the decision to implement a health promotion program like the one to continue an employee’s health insurance coverage after s/he retires? The latter is a far more expensive benefit than health promotion is, and has grown like topsy in recent years, with no evidence of systematic planning. Does the health promotion innovation resemble a dental plan? Many companies instituted those in the seventies and were soon publicly lamenting large unanticipated costs. Is health promotion decision-making so much less ‘rational’ than this? The high-tech versus low-tech dichotomy in the Hollander and Lengennann paper seeks to bring some empirical data to bear on their question of corporate ‘rationality’. And that dichotomy implies (although this is my interpretation, not theirs) that worksite health promotion is analogous to a product investment. They stratify companies according to an index of investment in research and development, as a proxy measure for a company’s innovativeness. There are serious validity concerns about the index itself and what it may represent. As one of many possible examples, consider some implications of the fact that workforces in high R&D companies are markedly more likely than those in smokestack industries to comprise disproportionate shares of employees who have already adopted a ‘wellness’-oriented lifestyle. Moreover the relevance to health promotion of this index is questionable: it relates to what Thompson [lo] would call an organization’s ‘core technology’. If health promotion initiatives are to be compared to product investments designed to yield future profits, the connection needs to be made more closely, and the comparability of the two types of decision should be argued, not simply asserted or assumed. To my knowledge, no one has explored this question, perhaps because it is highly complex. To argue that corporate health decisions resemble those shaping product development, one needs a sophisticated understanding of corporate resource allocation decisions [ll]. One also needs to know how much money is really at issue, in light of Simon’s [I21
572
DIANA CHAPMAN WALSH
insight that corporate decisions are not ‘maximizing’ but ‘satisficing’, that the search for another increment of information is generally called off when the search costs outweigh the potential benefits that the additional information could bring in uncertainty averted. For a low-cost program like health promotion that everyone seems to like, how much uncertainty (in downside risks or hidden costs) is really at stake? If the potential costs of an incorrect decision are negligible, what rational justification is there to engage in expensive purposeful planning? There are a number of empirical questions here that someone with some data could begin to resolve. Roman and Blum find their analogies closer at hand, in comparisons that, for me, have more face validity than extrapolations to product investments. They seek to place worksite health promotion in the larger context of corporate culture in the management of human resources. But, again, our understanding would be enhanced if, alongside of the somewhat subjective ‘culture’ variables, we had some harder measures of the nature and scope of the range of different activities different companies support in human resources. Still, in contrasting health promotion to employee assistance, Roman and Blum do broach the interesting question of boundaries around separate programs. More can be done with the concepts from organizational theory of boundaries and boundary spanning, but the notion of distinct organizational entities vying for influence within a business firm suggests a deeper way of thinking about our ‘rationality’ concern. The rationality which many observers seem to find lacking in corporate decisions about health is evocative of the ‘rational actor’ model in Graham Allison’s book, Essence of Decision [13]. A rational actor model holds that nations (in Allison’s case, or in ours, organizations like corporations) maximize utilities. They are driven by incentives, carefully calculated self-interest, and make rational decisions. The point of Allison’s book is to show that at least two competing explanatory models can fit the data just as well. The second is an ‘organizational process’ model, in which decisions grow out of bureaucratic imperatives, standard operating procedures, and the outputs of organizational subunits, characterized by inertia, or inevitability, that limits options and information and shapes the course of events. In the third model, decisions are produced by individuals as political actors, positioning themselves, using power, jockeying for advantage, and influencing the direction of change. When we shift from the rational actor lens through which many observers seem to look, we move from a world where economic self-interest is the decisive factor (the hope of money to be saved), to one in which worksite health promotion programs emerged willy nilly, as outputs of organizations going about their business. Our focus accordingly shifts to organizations and organizational subunits and their vested interests in the health promotion game. The Alexander paper has alerted us to the centrality of vested interests, and when we take them as a point of departure, we turn our attention to: (1) government, retreating from and seeking to dismantle the welfare state, as too expensive; (2) insurance carriers, trying
hard to survive in a newly turbulent environment, a more hostile and competitive environment than in the past; (3) hospitals, competing for a share of a shrinking market, positioning themselves to attract patients, now in short supply; (4) other vendors of health promotion services, proliferating rapidly in a dynamic and competitive market; (5) employers. both as buyers and as sellers of health promotion services. Looking through an organizational lens, just at the employer sector, compels attention to organizational subunits of business firms, each, again. with a distinct purview on the functions of health promotion programs: (1) Human resource professionals. charged with attracting and holding the best possible employees, see health promotion as a kind of magnet to compete in labor markets and perhaps even to draw especially high performers. (2) Benefit specialists. struggling to contain health care costs. want to accomplish this goal without appearing to renege on old promises from the 1960s when companies felt more expansive about what they could do for employees. Health promotion programs, as Conrad points out, are a low-cost way (a ‘symbolic exchange’) to sugar-coat the pill of ‘take-aways’ from the benefit package. (3) Corporate physicians have long been a medical subspeciality in search of a pursuasive mission, and the urgency of that search is intensifying as American industry strips away a layer of middle management and demands tighter justifications for nonproductive expenditures. This puts new pressure on medical departments to quantify an impact, and health promotion is one of the areas to which their attention has turned [14]. (4) Legal and risk management staffs within corporations are contemplating malpractice and other torts, for example, from nonsmokers who are exposed to secondhand smoke. Offering a health promotion program may become a defense against that future liability. (5) Finally, corporate image specialists have noted Conrad’s phenomenon of ‘cultural wellness’ and see in it a chance to capitalize on a broad secular shift, reinforcing the message that theirs is a caring and modern company. It seems more than coincidental that many of the leading firms in the corporate health promotion field are companies that try very hard, in their corporate advertising, to project a youthful, vital image. When we shift, finally, to Allison’s third explanatory model, we find events occurring because individuals who have power, resources, influence and persistence decide, for their own reasons, that they want to invest the energy into making them occur. The worksite health promotion field is replete with anecdotes in which committed individuals (a chief executive or other senior officer, a medical director or benefits manager or a health educator at the grass roots) are believed to have made singular contributions, influencing decisions to support companies’ innovative programs. Doing so has repaid some well, advancing their own careers or self-esteem, enhancing their organization’s prestige, or serving some other latent function. Is this behavior so ‘irrational’; I believe not. The notion of irrational decisions comes from a narrow view of health promotion as being ‘about’ cost containment, first and foremost. The Allison
Toward a sociology of worksite health promotion approach alerts us to the idea that these innovations are about widely differing utilities, depending not only on the circumstances but also on the conceptual model we apply. Health promotion at the workplace is about employee satisfaction, about morale and productivity, about humanitarianism, about fitness, about health, about personal career ambition, competition in many forms, corporate public relations, about all these desiderata, and no doubt others too. A thorough empirical study of these different motivations would yield fascinating results. We must be careful not to simplify the complex. When the question of the program’s meaning is being framed in limited utilitarian or cost-benefit terms we need to ask ourselves, as Alexander begins to do, who is casting it thus and why: whose interests are being served, what are some alternative formulations, how does one achieve hegemony over the others? My own experience of the evolution of worksite health promotion (as one who has been on the sidelines for the past decade) differs markedly from the historical account that Alexander has pieced together. First of all, ‘overutilitization’ as an ideological construct originated not with industry but with the state. It was when certification of need programs and professional standards review organizations were being introduced in the late 1960s and early 1970s that the logic of overutilization reached the published literature [ 151. Because HMOs used many fewer hospital bed days per capita than did unstructured fee for service (with no evidence of different outcomes), it was asserted that there must be substantial overutilization throughout the health care system. Only later did private industry take up the cudgels against ‘excessive utilitzers’. Moreover, the argument that industry’s interests would be served by promoting health promotion emanated, again, from the state and some public health activists, who sought to secure industrial support for wellness programs at the worksite. They conceived a worksite strategy as an integral part of a ‘second public health revolution’ they wanted to rally, and viewed the workplace as a complex sociotechnical system, where, in theory, employers have the full range of change mechanisms at their command: education, incentives, social values and norms, even coercive power in the form of corporate policies and rules, backed up by implicit or overt sanctions. The deeper questions Alexander raises about the ideological functionality of worksite health promotion are fascinating and important ones. To advance them we now need a combination of Alexander’s critical and historical perspective with a much closer and more richly textured account of what it is that corporate managers and representatives of the other vested interests (especially the state) are really thinking, saying and doing. What motkates
employee participants?
Rich texture and close touch with the perspectives of participants make the two ethnographic studies my personal favorites in this collection. John Naisbitt, in his bestseller Megatrends [ 161 conducted content analyses of media outlets and identified the ‘wellness movement’ as one of only ten broad-gauge ‘mega-
573
trends’ that he predicted are here to stay. The evidence is all around us, but the interesting question is why and why now: what new need in the psyches of some contemporary men and women is the wellness megatrend tapping into and how; and who are those who manage to resist its appeal? Some speculative thoughts on these questions of meaning have been published in the past [17], but Conrad’s study of Medical Technology Company and Kotarba and Bentley’s of Wellness Inc. go beyond speculation and take the position of those whose behavior we are trying to understand. They do not claim to have full answers yet, but do provide some intriguing leads. Fitting in is a crucial factor in the decision to join a program, indeed the quest for ‘fitness’ that Conrad sees as the driving force in these programs seems in the Kotarba and Bentley study to be broader than physical fitness; it is people looking for a place to fit, a place to belong, a new, more comfortable or more ‘fitting’ sense of self. Conrad’s distinction between fitness and health needs more elaboration, I believe. Whitbeck [IS] has observed that fitness is “a significant component of health, so that, other things equal, a more physically fit person is more healthy”, that is, has a greater “psychophysiological capacity to respond appropriately to a wide variety of situations”, which is her definition of ‘health’. By this definition, smoking is an indication of being less healthy (because it diminishes physical lung capacity), whereas not wearing seatbelts, or having a dangerous job do elevate risk but do not compromise health. Achieving physical fitness does improve health (by enhancing muscle tone, circulation, and cardiac reserve, and the density of bones) but a more fit person can be less healthy than a less fit one, for example, if the latter is “so ridden by phobias and neuroses that, in many situations, the most appropriate responses would be blocked by an anxiety reaction” [18, p. 6191. I will not attempt further elaboration here, but simply want to suggest that we need more refined descriptions of participants’ own definitions of both ‘fitness’ and ‘health’, before we can accept the assertion that they are pursuing one to the exclusion of the other. I suspect that most would say, as one of Conrad’s subjects did, that they are pursuing fitness as one avenue to greater health. It may be significant, moreover, that of all the risk factor interventions on the standard menu of health promotion programs, aerobic exercise produces the most immediate feedback: exercisers perspire, feel their pulses race, and sometimes get an ‘endorphin rush’, in short they directly, physically experience Kotarba’s “health-asaccomplishment”. No such immediate physical rewards attach to the accomplishments of dieting, cutting down on cigarettes or alcohol, or buckling a seatbelt. But, again, it would be instructive to hear in greater detail how participants and nonparticipants in programs answer these subtler questions. If worksite health promotion programs are really about fitting in or belonging, about alienation from a sense of community and a perceived need for social support, then it is interesting to wonder about the social costs of the wellness movement. Bellah et al. argued that Americans are retreating into homogeneous “lifestyle enclaves”, and that this trend is
DIANA CHAPMANWALSH
514
undermining communities, where public and private life come together in heterogeneous mutual support groups (191. Could it be that health promotion is a lifestyle enclave in the worksite and if so is it deflecting energy from collective efforts to improve the quality of workhfe for all? Is it possible that the positive health outcomes, now being reported by some worksite health promotion programs, could be achieved by very different approaches to building a sense of mutual support and community on the job-for example ‘workplace democracy’ or ‘quality circle’ programs without any ‘health’ trappings at all? These are some of the many questions that these provocative papers raise. Finally, on the question of motives, we come to the issue of gender differences. Kotarba and Bentley discuss it in passing and Spilman attacks it frontally. Health promotion on the job seems to signify something different for women than for men. The difference is no doubt a complex interaction of different social locations, intermingled with different experiences, both of work and of health. There is wide terrain here for more intensive explorations of gender and other demographic variables (especially job status) and of the interplay that Zimmerman and associates highlight between life at work and life at home. SUMMING
UP
The eight papers collected here provide much food for thought on social factors in the success or failure of wo’rksite health promotion programs, from the separate perspectives of program sponsors and participants. They position worksite health promotion as a problem area opening to questions germane to the sociology of organizations and professions, of health and of work, of communities and families, even the sociology of knowledge and theories of social change and deviance. Conrad, in his introduction, lays out an agenda for future research, so I will simply conclude with a brief comment on design and methodology. A number of these studies are admittedly exploratory and are recognized by their authors to suffer severe methodological limitations related to small samples, low response rates, inadequate or missing baseline measures and/or comparison groups, uncertain reliability or validity of measures, and the construct validity issues implicit in the definitional ambiguities belabored above. For the immediate
future, as the field matures, two investigative approaches will bear the most fruit. The first will be tightly designed intervention studies (ideally using randomization or else rigorous quasiexperimental designs) that compare two or more fundamentally different strategies seeking to achieve the same result. These studies should be theoretically informed, but will address narrowly circumscribed questions about what works best for whom. The second kind of investigation that will advance the field will tackle some of the broader and more sociological questions the writers here have begun to pose. But these studies will need to attend more closely to middle-range detail. to use a combination of qualitative and quantitative techniques in designs that conform better to accepted methodological stan-
dards, and to build much more securely on established sociological literature. In particular, there are two bodies of research that the studies here inadequately plumb. The extensive body of organizational theory and research needs to be brought more squarely into future investigations of corporate motives, goals, decisions and behavior in the health promotion arena. Even more striking, however, is the relative absence here of grounding in the substantial literature on disease prevention and health promotion. Systematic theories have been developed and tested to explain preventive health behaviors, the influence of social supports, of selfefficicacy and locus of control, of values, and of structural variables, among many contingencies [20]. Future research on worksite health promotion will have to concern itself with a wider range of explanatory variables than are introduced here, and with complex interactions among a web of predisposing, enabling, and reinforcing factors that contribute to health behavior. In this way, the field can progress toward the development of encompassing theoretical frameworks that will permit the specification of causal relationships between a broad range of mutually-interacting explanatory variables moving through time. A thorough review of the relevant sociological literature, leading to specific recommendations for future research on worksite health promotion, would be a useful contribution at this time. Meanwhile, we have a good start here, despite limitations that the authors themselves grant, and with it what amounts to an open invitation to a field which will certainly benefit from the application of sociological theory and methods, and which as surely will repay the debt in new insights into a slice of the social world that is variegated, perplexing, tightly bound up with larger social forces, and imperfectly understood. AcknowledgPmenu-The research on which this commentary draws was funded in part by the Pew Memorial Trust, the General Electric Foundation, the Commonwealth Fund, the National Institute on Alcohol Abuse and Alcoholism, and the W. K. Kellogg Foundation.
REFERENCES
I. Walsh D. C. and Kelleher S. Preventing alcohol and drug abuse through programs at the worksite. Work&e Wellness Media Report, Washington Business Group on Health and Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, 1987. 2. Walsh D. C. Employee assistance programs. Milbank Meml Fund Q.lHlth Sot. 60(3), 492-511, 1982. and Health Promotion. 3. Office of Disease Prevention National Survey of Worksite Heath Promotion Activities Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services. P.O. Box 1133. Washinaton, DC 20013-I 133. Unpublished manuscript. 4. Perry C. L. and Jessor R. The concept of health promotion and the prevention of adolescent drug abuse. Hlrh Educn Q. 12(2), 169-184, Summer 1985. 5. See Collings G. H. Jr. Managing the health of the employee. J. occup. Med. 24, 15-17, 1982. 6. Syme S. L. Strategies for health promotion. Preuenf. Med. 15, 497, 1986.
Toward
a sociology
of worksite
7. Russell L. Is Prevention Berter than Cure? Brookings Institute, Washington, D.C., 1986. to corporate 8. Warner K. E. Selling health promotion America. Hlth Educn Q. 14, 39-55, Spring 1987. and cigarettes. Prevenr. Med. 9. Schelling T. Economics 15, 549-560, 1986. J. Organizations in Acfion. McGraw-Hill, 10. Thompson New York, 1967. II. Bower J. Managing the Resource Allocation Process. (R.D.) Irwin, Homewood, 111. 1970. goal. Ad12. Simon H. On the concept of organizational min. Sri. Q. In press. 13. Allison G. Essence of Decision. Little Brown, Boston, Mass., 1971. 14. Walsh D. C. Corporafe Physicians: Berween Medicine and Managemenf. Yale University Press, New Haven, Conn., 1987. of need: 15. Bicknell W J. and Walsh D. C. Certification the Massachusetts experience. New Engl. J. Med. 292, 1054-1067, 15 May, 1975. J. Megatrends: Ten New Directions Trans16. Naisbitt forming Our Lives. Warner Books, New York, 1982. 17. Gillick M. R. Health promotion, jogging and the pur-
health
promotion
575
suit of the moral life. J. Hlth PO&.. Policy & Law 9, 369-387, 1984. 18. Whitbeck C. A theory of health. In Concepts of Health and Disease : Interdisciplinary Perspectives (Edited by Caplan A.. Engelhardt H. T. Jr and McCartnev J. J.). pp.. 661626. Addison-Wesley, Reading, Mass.: 198 1: 19. Bellah R. N.. Madsen R.. Sullivan W. M.. Swidler A. and Tipton S. M. Habits of the Heart. Harper & Row, New York, 1985. 20. See Mechanic D. Medical Socioloav. Free Press. New York, 1978; Green L. W., Kreuter M. W., Deeds S. and Partridge K. B. Health Education Planning: A Diagnosric Approach. Mayfield, Palo Alto, Calif: 1980: Hambrug D. A., Elliott G. R. and Parron D. L. Health and Behavior. National Academy Press, Washington, D.C., 1982; Behavioral Health: A Handbook for Health Enhancement and Disease Prevenrion (Edited by Matarazxo J., Miller N. E. and Weiss S. M.). Wiley, New York. 1984; Promoting Adolescent Health: A Dialog on Research and Practice (Edited by Coates T. J., Peterson A. C. and Perry C.). Academic Press, New York, 1982; Handbook of Medical Sociology (Edited by Freeman H. E., Levine S. and Reeder L. G.). Prentice Hall. Englewood Cliffs, N.J., 1979.