How do employees feel their health is valued? a descriptive case study

The purpose of this study is to examine the perceived effectiveness of worksite wellness programs based on employee perceptions. Relying on the CDC HSC, the study attempts to understand how worksite wellness programs encourage employee health and well-being. First, the study proposes to identify the prevalence of worksite wellness programs, policies and benefits as recommended by CDC HSC in organizations. Second, the study describes to what extent these programs are perceived by employees as effective toward creating a climate and community of support that encourage the adoption of health promotion behaviors. We believe this adds additional significance to the research effort. This two-step approach helps build research partnerships with health-care organizations, incorporates employee feedback and overall encourages academic-practitioner collaborations and encourage ways for implementing the research findings in practice.

Two research questions were used to guide this research:

A descriptive case study approach was used for the study (Merriam, 2002). According to Merriam (2002), case study approach helps in “understanding the meaning people have constructed, that is, how people make sense of their world and the experiences they have in the world” (Merriam, 2002, p. 6). The literature emphasizes the importance of linking worksite wellness programs and promotion of health behaviors among employees. Therefore, it is necessary to examine the experiences of employees with wellness programs, activities and interventions in organizations. Furthermore, employee perceptions of the effectiveness of such interventions plays a crucial role not only in promoting health behaviors but may also increase the participation and involvement of their peers. Thus, how employees make sense of and perceive the value of wellness programs would be crucial for the success of wellness initiatives.

According to Merriam (2002), a general qualitative approach is appropriate when there are opportunities for investigating the experiences of individuals and understanding how they make sense of, value or perceive the effectiveness of organizational interventions. Furthermore, a general qualitative method can enable the researcher to co-construct the meaning participants make of the topic under investigation. A qualitative study provides a holistic approach to studying complex meaning making, through the examination of beliefs and social interactions that occur in natural settings.

More specifically, we adopted a descriptive approach in designing the case study (Yin, 1994). Descriptive case studies require analyzing cross-sectional data of a certain program or case and involving collection of data on individuals. We were interested in collecting aggregated data from different worksites on their overall assessment of wellness programs. The CDC HSC offers an assessment template to evaluate the prevalence of different wellness programs and strategies adopted by organizations and also provides comparative assessments of worksite programs with other organizations of similar size. To some extent, the cross-sectional data would provide a snapshot of the characteristics of wellness programs prevalent in a defined sample of organizations. This step would be helpful in assessing the frequency of wellness programs offered across worksites (and organizations). Descriptive case studies also emphasize data collection from individuals, which was important for the study as we wanted to capture the experiences of employees using different wellness programs and their perceptions of program effectiveness.

Relying on the CDC HSC as a framework and assessment tool, the study examines the perceived impact of organization-specific support factors (e.g. organizational structure) using cross-sectional worksite/organizational data on specific wellness prevention/promotion approaches such as tobacco control for promoting health-related behaviors. The first goal of this study was to develop a macrolevel understanding of how organizations enable effective wellness activities. The second goal was to identify evidence-based organizational wellness practices by ascertaining the actions, involvement and perspectives of the participants. Thus, the descriptive case study method was most appropriate to describe employee stories and understand “how” organizations were able to develop effective wellness practices and “what” evidence-based wellness practices help employees and organizations to improve performance and learning.

To identify the perceived impact of worksite wellness programs, we relied on two sources of data collection. Using a sequential data collection strategy, participating organizations first completed the CDC HSC survey to identify current worksite wellness programs. Second, the organizational assessments or scores in each wellness category were compared to the CDC HSC national average (see Table 1) of all participating organizations. Participant organizations were then contacted and invited to identify employees who could participate in one-on-one interviews with the primary researcher to elaborate on the significance of those wellness categories where their organizations scored higher than CDC HSC national average. Specifically, we were interested in their perceptions of how wellness approaches in their organizations supported the adoption of health promotion behaviors among employees.

A pilot test of the CDC HSC survey was conducted to improve the face validity of the questions with participants from five organizations. The primary researcher relied on convenience sampling and reached out to several local technology organizations that were a part of a higher education-and-industry consortium. The primary researcher approached 25 managers, at 25 organizations. Of these 25 individuals, 20 agreed to participate in the study. These individuals had a variety of roles in the organizations but were not in the human resources functions for their organizations. The study was approved by institutional review board (IRB) committee.

We also wanted to use the CDC HSC to examine, compare and contrast the state of health and wellness programs of the participating organizations (Centers for Disease Control and Prevention, 2014). The study adopted the CDC HSC as a framework for evaluating the effectiveness of organizational approaches to wellness programs. Furthermore, the CDC HSC also offers a way to compare and contrast multiple organizations on their approaches to wellness programs and policies and potential linkages to improving health and well-being of employees. The study was also focused on exploring the extent to which organizations were purposely engaging in choice architecture to make healthier options more easily available than unhealthy options for their employees.

First, participating organizations were given the CDC HSC that would allow the organization to have a baseline data on how it was performing on the various wellness categories. Comparison with the national CDC HSC scores would help in the evaluation of “how” well the organization was performing. During the answering of the survey questions, organizations were encouraged to elaborate on their wellness programs or lack of programs.

The Emory University Institute for Health and Productivity Studies, in partnership with the CDC, developed the CDC Worksite HSC, which lists 15 categories of workplace wellness. HSC helps employers conduct assessment of their existing wellness promotion policies and programs, identify gaps in their approaches and outcomes to develop customized and high-impact interventions and improve employee health and well-being (Roemer, et al., 2013).

The current study compares scores received by participating organizations to scores in the validation study by Emory University. In line with the CDC HSC framework, the results are organized by wellness program type. The 125 questions have a weighted amount and are broken into 16 major categories of workplace wellness (Centers for Disease Control and Prevention, 2014). These categories include the following:

1. Organizational Supports (18 questions), 33 points.

2. High Cholesterol (6 questions), 15 points.

3. Tobacco Control (10 questions), 19 points.

4. Diabetes (6 questions), 15 points.

5. Nutrition (13 questions), 21 points.

6. Signs and Symptoms of Heart Attack and Stroke (4 questions), 4 points.

7. Lactation Support (6 questions), 15 points.

8. Emergency Response to Heart Attack and Stroke (9 questions), 17 points.

9. Physical Activity (9 questions), 24 points.

10. Weight Management (5 questions), 12 points.

11. Occupational Health and Safety (10 questions), 22 points.

12. Stress Management (6 questions), 14 points.

13. Vaccine-Preventable Diseases (6 questions), 18 points.

14. Depression (7 questions), 18 points.

15. Community Resources (3 questions), not scored (this domain was not included in the survey we shared with participants.

16. High Blood Pressure (7 questions), 17 points.

A team at Emory University tested the reliability and validity of the CDC HSC at 93 worksites across organization sizes, business types and US geographic areas, examining question responses and conducting interviews to refine the instrument for general distribution (Centers for Disease Control and Prevention, 2014). They concluded that the CDC HSC offered a comprehensive worksite wellness assessment tool that is based on evidence-based approaches for helping organizations confront the challenges facing increasing costs due to health care (CDC, 2014). In creating and validating the CDC HSC, the Emory team partnered with the National Business Coalition on Health, the National Safety Council and 32 state health departments (Roemer et al., 2013). We relied on reliability and validity of CDC HSC as reported by Roemer et al.’s study.

First, the CDC HSC survey was distributed to the organizations and scores on different wellness categories were identified. Then, at least one employee representing each one of the 20 organizations was invited to respond and to describe, in their own words, their organizations’ health and wellness programs. The participants were not in charge of these wellness programs. They were participating in our study as employees who were employed in the organizations that reported high scores on different categories of the CDC HSC study. The questions during the interview allowed the participants to discuss any thoughts that were not shared during the survey portion of the interview. A sample of the questions is included below:

These interview questions were developed from the research questions and presented to the participants.

In this study, 20 participants from 25 organizations were interviewed for 40–60 min each. The small number of participants helps provide a deeper understanding of participant experience and develop a thick and rich description of that experience. In-person interviews were conducted in a neutral location, such as the participants’ private office, conference room or a place that the participant chose, so they felt comfortable in that location. Enough time was given to allow the participant not to be rushed. The interviews were tape-recorded. The transcription was completed by the primary author and no computer program was used in the coding process.

Interviews were the primary source of textual data. The data analysis phase of the project relied on the constant comparative analysis as recommended by Strauss and Corbin (1990). The transcribed data was read several times to develop familiarity with the participant data. The transcriptions of the interviews were read and reread for interesting themes, recurring themes and outlying themes and coded for similarities, trends and triangulation. We relied on inductive coding to first develop codes and then grouped codes into different categories. The coding process was iterative and this process helped identify plausible relationships among the categories (Schwandt, 1997). The categories provided an interpretive framework for contextualizing the participant’s experiences and the extent to which they perceived the effectiveness of different wellness interventions.

We used member checking as a reflective experience to capture perceptions of not only the effectiveness of wellness programs but also how managers and leaders are critical for promoting a culture that enhances health promotion behaviors. Thus we maintained validity for the qualitative portion of the study. To strengthen credibility, we use the constant comparison method. This method helped with coding of the data initially. Post capturing codes, the primary author summarized the content and organized codes into categories. Boundaries between different categories were established to refine category development and uncover patterns in the data.

This section presents cross-sectional snapshot of data on how participants and their organizations reported on wellness programs and the extent to which these programs and policies were perceived as effective in supporting and sustaining health behaviors in employees. The findings primarily focus on summarizing the organizational scores received from participants in the 25 organizations and comparing the summarized score for each wellness category with the national averages as reported in the CDC HSC. The highlighted cells in Table 1 below are for CDC HSC study organizations. The CDC study scores represent the average score of all participating organizations controlling for size and industry.

Table 1 provides a comparison of companies tested in the CDC HSC (gray columns) and companies where our participants worked for (reflected in last two column titles “Our Study Scores” and “% of Our Study Scores”). We grouped the wellness interventions into three major classifications. Group 1 wellness interventions received scores greater than the CDC wellness scores. Group 2 wellness interventions received anywhere between 1% and 20% lower than the CDC scores and Group 3 wellness interventions reported anywhere between 21% and 30% scores lower than the CDC scores.

In what follows, we review and present wellness best practices in each of the CDC-identified areas. We also discuss challenges in the effective implementation of wellness best practices and programming activities.

Our first major finding identified four wellness categories in which the participating organizations reported higher scores than the CDC HSC averages. These categories were tobacco control, lactation support, emergency response to heart attack and stroke and occupational health and safety. We relied on the interview data to further contextualize the high-performance scores and to what extent and how participants perceived the effectiveness of these wellness interventions.

The highest-scoring organizations in our study are taking steps to improve tobacco control by reducing barriers to cessation counseling. An automobile parts manufacturer stated that over 50% of company employees over 21 admit to smoking. One interviewee participant (corporate care manager) recognized the need for adopting health-promoting behaviors to address smoking. According to them:

These statistics are particularly interesting when one considers that this organization received the highest score among all the organizations participating in our study. They only missed three points overall on the entire CDC HSC. They went to great lengths to celebrate successful cessation and provide free resources for tobacco users, including an Human Resources (HR) director dancing the Texas Two-Step with an employee that completed a cessation program. However, they still note tobacco use as one of their biggest challenges. Tobacco control could potentially be viewed as an important wellness investment that organizations cannot simply ignore.

Lactation support, including providing a private space, a breast pump and flexible break times, can demonstrate organizational support for nursing mothers. One of the most telling statistics from a study in 2004 concluded that there was a 94% return-to-work rate after maternity leave for women participating in an employer-sponsored lactation program. (Ortiz et al., 2004). Two organizations in the highest-scoring category addressed lactation. The engineer in the 25-employee manufacturing firm stated, “we have a room set aside for that. The nursing room has another room in it where you can go breastfeed. There is a breast pump in there and it‘s a paid break time.” The third-largest organization in the study had two lactation rooms and paid maternity leave and recently began offering fathers a week of paternity leave. The “extra-mile” level of action was demonstrated by a company that paid for breast milk to be shipped back home to an employee’s baby while she was working out of town. Another organization incentivized participation by providing employees with a free breast pump if they participated in a prenatal program. A more basic but still important level of engagement was shown by high-scoring organizations that gave all employees breaks that can be used for lactation support, providing a lactation room set aside with a breast pump and offering maternity and paternity leave. However, participants in general did not report as much on these supportive interventions other than the instances shared above.

The highest-scoring organizations had emergency response teams in place that conduct intermittent training with CPR and defibrillators throughout the year. A high-scoring small organization provided all 25 of its employees with CPR training. A large manufacturer touted several trained first responders on staff who all carry radios and a medical kit. Many organizations in the high and medium categories stated that everyone in management from supervisor and up received emergency response training and were trained in CPR at the facility during working hours.

Workplaces should have an emergency response plan, a team in place and prior training on CPR and AED usage. Herbert et al. (2007) studied 158 recreational service departments (health and fitness facilities) and found that almost all had “written emergency plans, but only 50% posted their plans and only 27% performed the recommended quarterly emergency drills” (p. 128) and 73% had an AED, but only 6% reported using it in an emergency.

One very high-scoring organization instituted the “Save Award” when CPR was used on the job to save someone’s life. One of our informants shared:

In another instance, the results of their extra-mile emergency response training helped the community. The corporate care manager reported, “they just saved a sixteen-year-old girl over at (a local high school). She fell playing volleyball. She collapsed. She was having a heart valve problem and the janitor at the school was trained by our company. He ran over and got the defibrillator, hooked her up, and saved her life.”

Our participants mentioned that they have several occupational nurses at every facility. The organizations used industry standards to guide safety programs, and, at every facility, emergency response teams on staff were available daily. They also had policies in place to never blame an associate for workplace injury. Safety committees were active in these organizations, meeting at least on a weekly or monthly basis. A participant described his organization’s monthly safety meetings, where many of the issues in the CDC HSC are covered with the entire group of employees: “the managers stand up and go through everything in the department. They also bring up stuff that they heard about on the news or something that happened at another company, and how can we prevent that at our company.” A participant who worked at a social services organization stated that their funding was tied to certain levels of government where required safety standards had to be met.

A trend among more office-related organizations was to ignore or have less of a focus on occupational health and safety. However, there were organizations in the office setting that also provided standing desks and headphones for telephone usage to reduce or prevent repetitive motion injuries. Another very small organization used part-time traveling nurses that go from company to company in order to provide an occupational nurse without the cost of a full-time nurse employee. One organization provided high-quality footwear for employees who were on their feet all day. This may seem like a small expense, at approximately $200 per year per employee, but the interviewee who mentioned it beamed with pride that his organization cared so much about his daily needs and commented that he thought about it regularly.

Overall, even though our data suggests that the organizations scored more than the CDC HSC averages, the interview data reveal more insights on the bigger issues facing leaders and employees. Occupational health and safety, as well as emergency response interventions receive organizational investment and support. In addition, our interview data also suggests that investment in tobacco control and lactation support address key workforce related demographic groups – millennials and women who are important for organizations.

In our second major finding, we identify a next tier of wellness intervention categories where the participating organizations received 1%–20% scores lower than the corresponding CDC averages. In this group, the wellness interventions featured physical activity, stress management, depression and vaccine-preventable diseases.

The participants reported that their organizations engaged in several activities to increase employees’ physical activity. Group stretching time in the morning and in the afternoon helped employees move, take their minds off their work and prevented injuries. One participant noted that their company included posters of all seven stretches that the employees were encouraged to exercise at the beginning of each day. Another participant reported that their organization also offered classes in tai chi, yoga and workstation movement trainings on site. Participants also reported that when organizations offered several socially coordinated physical activities, it strengthened employee participation. Multiple participants reported that their organizations offered organized yoga and Pilates classes for stress reduction, physical movement and social activity. Others offered portable basketball hoops, memberships at a gym within walking distance and basketball as a weekly group activity for employees. Other organizations used walking as a social, physical movement activity. Several had walking routes around the lake and woods near the company’s campus and employees formed walking groups around a route called the “Mayor’s Mile” in the industrial park. One organization teamed employees with “comrades” or buddies and encouraged or required them to walk together each week. This helped with physical activity as well as team building and stress management, according to the interviewee. While organizations were certainly not short of ideas to enhance physical activities, more work was needed to help improve employee participation.

Participants in this study consistently mentioned that they were provided dedicated stress-free zones, such as fitness rooms or break rooms, “phone booths” where employees could have privacy and temporary stress-free zones. One organization provided onsite resources for employees with post-traumatic stress disorder symptoms. A workplace study on online support and stress management found that participants who reported consistency in their weekly meditation practices with group were able to manage their stress more than others (94% versus 54%).

Participants in our study appreciated being included in the decision-making process for issues that impacted job stress, such as changes in work schedules, time-management demands, specific work practices and work processes. Employers adopted a variety of ways to encourage work-related feedback from their employees. Morning meetings allowed employees to provide feedback and suggest improvements regarding issues from the previous day and for the upcoming day and week. Some organizations provided counselors or HR members to whom employees could speak to about workplace issues. In the construction industry, it was common for employees to take unpaid time off when they needed to. This allowed them to navigate issues more easily in their personal lives.

One participant who worked for this organization cited tension between production employees and nonproduction employees. The participant mentioned that a lot of the tension was related to unclear expectations and misunderstandings about what each group was doing or expected to be doing. He felt that 95% of people were complaining about something. If there were formal mechanisms for communicating about these feelings before the tensions escalated, it could likely help reduce the amount of tension. It is clear that in addition to individual or employee related health and wellness, the workplace environment also is a likely cause for increasing stress for employees.

Employees suffering from depression can impact the organization through loss of productivity, absenteeism and other hard-to-quantify ways. The World Health Organization (WHO) ranks depression (i.e. major depressive disorder) as a leading cause of disability in the world (Murray and Lopez, 1996). Participants said that their companies had no way of reporting or recording whether their employees suffered from depression. The topics of mental health and depression were left to the discretion of the individual employee, whereas physical activity, tobacco control and even stress management had specific programs where organizations were involved proactively to help address these issues. Depression can be difficult to diagnose for multiple reasons. Employees are likely to avoid diagnosis because of stigma, denial, lack of physician skill or knowledge. Furthermore, lack of availability of providers and treatments, additional limitations due to coverage and restrictions on receiving expert care (Goldman et al., 1999) compound the problem. Past research has underestimated the link between burnout and depression. Treatments for depression may help workers identified as burned out (Schonfeld and Bianchi, 2016) and has the potential to improve not only the quality of life but also reduce costs due to turnover, burnout and other workplace disruptions for employers (Macy et al., 2017).

Organizations in this study demonstrated multiple times that the treating and screening of depression was the responsibility of the employee. For instance, a participant stated that “the employee assistance program (EAP) information on depression is posted on the bulletin board.” According to our participants, when depression is not discussed openly, employees are likely to have limited choices and must ask for additional support and resources. Unfortunately, several participants also suggested that their workplace culture encouraged employees to treat depression as something that the employees needed to fix on their own. In contrast, other organizations had hotlines for reporting drug use and seeking help for depression.

Several participants in the study reported that they encouraged employees to see the chaplain for depression and other emotional issues. One of the more progressive organizations in the study offered free resources for every other wellness category in the CDC HSC except when it came to their approach toward depression. This employer wanted employees to have “skin in the game” and asked employees to pay something for using depression services. Even as they were willing to support other employees who could not afford to pay for their depression treatment, this is an interesting distinction because the company spent a lot of money on all kinds of wellness resources other than depression.

Other organizations focused on depression in various ways. A very small manufacturer offered a quarterly health review with a nurse. This wellness approach is not common (Roemer et al., 2013), even though it is recommended by the CDC. On similar lines, we also note the importance of training managers in the workplace on topics concerning depression in the workplace as a way of transforming the work culture. As noted by our participants, the work climate was not conducive for tackling mental health issues.

Our participants had very little to say about vaccine-preventable diseases. They either said “yes, we offer those” or “no we do not.” One classic workplace example of the benefits of vaccination comes from a study of the 1983 to 1985 rubella outbreak in the financial district of New York City by Goodman et al. (1987). In the study, it was reported that there were 57,686 cases of rubella in the USA when the rubella vaccine was introduced in 1969. As a result of vaccination efforts, a 99% decline was reported by 1985. However, the trend reversed when 186 outbreaks and cases were reported in the workplace shortly after the decline (Goodman et al., 1987). The rubella immunization efforts had been aimed at school children but had not eliminated the disease in young adult women, which was the population of greatest concern (Goodman et al., 1987). In the context of the COVID-19 crisis, we recommend that more efforts be put in place to prevent the spread of preventable diseases like vaccination programs at work.

Group 3 wellness interventions reported anywhere between 21%–30% scores lower than the CDC scores. The wellness categories were organizational supports, nutrition, weight management and high blood pressure, high cholesterol and diabetes.

The organizations in this study offered a variety of incentives for participation in their health and wellness programs. According to participants, their companies offer cheaper insurance premiums for certifying as a nonsmoker. One company offered employees a nonwellness plan and a wellness plan to save 30% on insurance premiums. Others offered lower but more frequent incentives, such as $10 for participating in wellness screenings, regular lunch and learns and watching health-related YouTube videos. Furthermore, one company provided employees 6 h of extra flex-time to use at participating organization’s onsite wellness center for checkups, a health assessment or anything relating to an illness. Providing flexible work hours can demonstrate organizational support and most of the best-scoring organizations had methods for providing flexible work environments for their employees. Perhaps the most unique program was the “school day program,” that allowed parents to match their children’s’ school schedule in the summer, on weekends, during the weekday and even on inclement weather days.

Our participants emphasized organizational supports as crucial for sustaining the long-term and cumulative effects of wellness programs. As one participant noted, a health clinic onsite offered a variety of free wellness programs. These types of organizational supports are likely to facilitate the promotion of health behaviors. However, as noted before, the overall scores were much lower than the CDC scores. One key best practice would be to use a bundling approach, where health risk assessments are offered as a baseline requirement for participation in wellness programs (Baicker et al., 2010) as the participants reported. Furthermore, when these baseline approaches were bundled with nutritional strategies such as making a majority of the available food in the vending machines healthy (Childress and Lindsay, 2006), these efforts were more likely to result in promoting health behaviors.

The very best practices in this study included active communication with vending companies to provide healthy options and a corporate garden onsite that provides salad materials for employees. One of the companies provided a salad bar at the company cafeteria every day, which was attributed to dramatic weight loss as reported by one participant. Another remarkable program was subsidized meal preparation; for $150 a week, prepared meals were delivered to the employee’s house. The interviewee discussed this much-loved program because of the health benefits, ease and convenience. The participant also appreciated that the company would take the time to care enough to help them in this way.

Our participants noted that their companies were supportive of inducing changes in the food options that were available in the workplace, including work meetings. Some organizations tended to buy healthy food and beverages. For instance, one company would give out bottled water for free but charge for soda. Other organizations offered healthy food options for lunch meetings. These options have fewer calories, lower sodium and higher protein. A participant also reported that their company provided free and healthy snack options in the workout room. The company also provided free fruit in the break rooms. One of our interviewees, a wellness trainer shared:

Giving away fresh fruit and vegetables was a common theme throughout the study, whether it was from the corporate garden, employees with gardens or just as a kind gesture. One interviewee felt that the only healthy nutrition the company stressed was staying hydrated. In the employee’s opinion, this was seen as a negative, but it can also be seen as a vital part of nutrition in a hot warehouse where people were fainting on a weekly basis. Proper hydration can be a fundamental building block of nutrition and a great starting point for organizations that are just beginning a wellness program.

One industrial manufacturing organization took further steps to limit and even prohibit unhealthy food. For instance, the HR Manager said, “It's not a written policy, but it is part of our meetings. Our owners said, “No cake.” They promote the “no cake” at certain functions and when we just did the dinner for the safety award, we made sure that we didn’t have any brownies. We were originally going to give brownies and I’m like, “No, you can’t do that.”

Businesses can be more effective when employee inputs are considered to encourage buy-in and to continuously evaluate the effectiveness of worksite wellness programs. For instance, communication of appropriate incentives to help support healthy food options might be necessary and viewed as a business priority. However, the real benefits are from having policies that engage, promote and support a healthier lifestyle for all employees.

Interviewees reported that chaplains, nurses and other mental health professionals addressed issues related to overeating, linking the symptom to deeper emotional issues. A key feature in these programs was maintaining confidentiality and building trust with employees to increase their participation. Our participants also mentioned other services through their EAP concerning emotional issues, overeating, drug use or other areas. Even though the EAP service was supported by the employer, employees’ information was protected.

Other organizations use additional methods for helping employees with weight management. One organization used body mass index (BMI) testing as part of an annual health assessment self-management program. Others used BMI testing at any time of the year. One company attempted to incentivize BMI testing by offering to pay for 50% of the costs associated with the testing if the employees were willing to match the remaining 50%. Many participating organizations in the study implemented Weight Watchers groups at their facility or encouraged employees to join these groups, depending on the number of interested employees. January was repeatedly mentioned as a prime month for starting Weight Watchers or gym-based programs for employees. “Biggest Loser” competitions were common, but not viewed as healthy by leaders. For instance, one participant reported that leaders in their company felt uneasy as they suspected employees were “bulking up” right before for the “Biggest Loser” contest and then starving themselves just so they could win the contest. The company stopped the contest altogether after the unintended harm caused by such programs. As the Centers for Disease Control and Prevention (2016) report recommends, contests and competitions are effective only when combined with additional interventions to support behavioral changes.

Organizations in the study provided long-term treatment and education to help employees with chronic conditions. Their methods ranged from using biometric weight loss initiatives to address high blood pressure to focusing on the high cost of bad habits in educating employees. For instance, one company worked to educate employees on the daily cost of cigarettes and energy drinks. Participants cited an instance where several of their employees were spending $15–$20 per day on energy drinks. Another organization had a four-month long wellness program that dealt with stress and high blood pressure issues. This length of program helps drive positive behavior change, according to the employee. Some organizations also had affiliated hospitals and primary care facilities either as another facet of the organization or even wholly owned by the organization.

One organization had blood pressure monitoring devices in every break room and in the safety office. Their wellness trainer organized “Wellness Wednesdays,” where I try and rotate what break room I‘m at to help aid and to track blood pressure for them and then one of the nurses goes into the safety office and helps with that every Wednesday. A corporate care manager in the study shared:

“We have all the (bad) food joints around here, but a lot of places have bad food joints, you know? A lot of those bad food joints sometimes have healthy options, it’s just the decision that we make in those situations.

The team at the company where the corporate care manager worked discussed the nutrition of field employees. It was difficult to support this group of drivers and salespeople in supporting changes to their dietary behavior as they traveled and were far from the home office.

Overall, Group 3 wellness interventions suggest opportunities for the participating organizations to make some of the biggest improvements in their worksite wellness programs. Combining incentives and interventions with other strategies is more likely to increase participation in wellness programs and health promotion behaviors for employees.

Certain organizations receive higher CDC scores than others on the following wellness categories: tobacco, signs and symptoms of heart attack and stroke, emergency response to heart attack and stroke and occupational health and safety. Our findings suggest that because these wellness initiatives are legally mandated (e.g. occupational health and safety) or identify high-risk behaviors that can mean life or death situations for the affected employee and others in the workplace. Thus, these wellness areas received additional organizational supports from employers and effective programs were in place to prevent health and safety issues from occurring at all. Not surprisingly, the CDC scores were high.

The analysis of our data from the HSC report and employee interviews suggests that when companies are mandated to ensure workplace safety and occupational health standards, additional systems are put in place as required. For example, participants reported that care teams were trained in CPR to ensure the workplace was compliant with regulatory mandates. However, greater persuasion and buy-in are needed to create and sustain a wellness culture that can promote nutrition, physical movement and other habits to prevent sickness in the workplace. The literature suggests that the future of workplace wellness will require organizational leaders to be more understanding and responsive to the needs of their employees (De Libero, 2013). A variety of wellness programs should be offered to meet employees at their level of interest.

The literature illustrated the important connection between different areas of the CDC HSC. Specifically, seven of the categories of the HSC can work together to increase the health of the workforce (Baicker et al., 2010). Four preventive categories (Physical Activity, Weight Management, Nutrition and Tobacco Control) can help three of the chronic disease-related categories (High Blood Pressure, High Cholesterol and Diabetes). This interaction is important in this study because smoking and chronic diseases were challenges for all organizations, even those that scored very high on the CDC HSC.

Most organizations struggled with smoking, even high-scoring organizations. The use of tobacco can be extremely detrimental to employee health and wellness as it is an indicator for a variety of chronic diseases. Chronic disease management was lower for the organizations in this study compared to the CDC validation study. The organizations in the study offer only a few programs to address chronic conditions related to high blood pressure, high cholesterol and diabetes.

A one-size-fits-all policy might not be a useful approach for employers. As wellness programs mature, more and more employers might seek to customize the programs to suit the individual needs of their members. For example, providing high-quality footwear for employees who were on their feet all day made a strong impact on an individual employee. These types of policies are likely to motivate and engage employees and also demonstrate that the organization cares about their health and well-being.

Some organizations may have scored highly on the CDC’s instrument but could go much further in the effectiveness of the wellness-related communications they provided for their employees. For instance, organizations in the high-scoring category rely on mass communications to share health information. An interviewee who works in the educational services industry indicated that their company’s wellness communication is “pretty much generalized. There’s general e-mail sent out at least monthly on wellness program and there’s also flyers, so it’s pretty much kind of a mass email.” The CDC HSC guidelines do not recommend such an approach. The literature also recommends a more individualized and customized approach for communicating wellness initiatives.

In terms of our second research focus, we identify different types of managerial supports and organizational interventions that were implemented. An important challenge moving forward is examining the roles and responsibilities of organizations and employees related to wellness initiatives. For instance, it appears from our analysis that placing individual responsibility on employees to take charge of certain illnesses (e.g. depression) might emerge as a continuing trend. However, placing the burden of establishing health-enhancing behaviors fully on the employees would be unfair and also likely to increase burnout in the workplace. It is also likely that some organizations might adopt a “carrot and stick” approach and use surveillance to force employees to adopt a healthy lifestyle. Even though we identified organizational support such as completing health risk assessments and engaging with medical professionals as high-impact wellness practices, these efforts can be viewed as providing “carrots” to ensure that employees sign up for health promotion plans every year. It is also likely that when employees choose to opt out of participating in wellness competitions or programs, they might be penalized by their coworkers or immediate supervisors as not being good corporate citizens. The ethicality and legality of some employer decisions in such instances need to be debated and discussed.

There are findings in this study that are contrary to conventional practice. For instance, weight-loss competitions are still common in the workplace. However, in this study, one organization stopped them after monitoring the bloodwork of participants in these challenges which showed poor health outcomes because employees were “bulking up” before the challenge and then engaging in crash diets to lose as much weight as they could as fast as possible in order to win the competition.

According to participants, there is also a prevailing notion that spending money on wellness is an expense, rather than an investment because employees will leave the organization before the organization realizes a financial return on its investment. Future research should explore the outcomes of investing in health programs. One interviewee stated that the thinking might change if leadership “could see that (health and wellness) is an investment, instead of a cost […] you have to pay for it today, but you don’t always see the benefit. And you may never be able to put a number on it.” Future research can look at the return on investment of health programs, particularly if employee turnover negates the investments in health when employees leave the company.

The CDC HSC asks many optional demographic questions that help to paint a picture of the people in the organizations in our study, including racial/ethnic groups, work status (including full-time, part-time and temporary), job type (including salaried or hourly) and education levels. This information labeled “optional background information” is not required for completing the CDC HSC and the overall workplace wellness score is not dependent upon the answering of these demographic questions. In alignment with critical wellness scholarship, we recommend future researchers to capture demographic information about race, gender and ethnicity to enhance the rigor and relevance of wellness assessments and evaluations.

Future researchers might examine health metrics, in terms of dollars, doctor visits or biometrics before and after the implementation of a wellness program or paid wellness coordinator. Because this study interviewed employees and not members of executive leadership or finance and accounting, financial metrics were not available or the focus of this study. The inclusion of leaders and directors of wellness initiatives would offer additional ways for examining the impact of wellness initiatives on employee behaviors on organizational outcomes.

Workplace wellness is a complicated and emerging topic. We suggest that when high-impact wellness practices are linked to organizational support in the workplace, these efforts are likely to have more positive effects on both employee outcomes and organizational outcomes. A regular routine of checking on wellness issues can help keep potential problems from going unnoticed. An example of this is a reminder to stretch at a morning meeting, for a population that has ergonomic issues.

Our participant organizations in the study seemed to nudge employees into health screenings during orientation or regularly. This can be a valuable practice, as participation in health screenings results in cheaper health insurance, financial incentives or even a substantial contribution to the employee’s health savings account. The information in this study can help organizations build, expand or continue their wellness programs or specific aspects of their wellness programs. The different ways organizations “nudge” their employees toward making better decisions as it related to health and wellness can enrich our understanding of nudge theory.

Most importantly, employees benefit when they can be healthier and reduce their health risk behaviors to be contributing members to their workplace, families and communities.