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We thank Drs Safeer and Allen for their thoughtful comments. We agree with the authors’ position that building and sustaining a culture of health at the workplace is core to the success of workplace health promotion programs. The essence of corporate culture is grounded in the underlying assumptions, values, and beliefs that are jointly applied and taken for granted by the organization and its employees.1 That ethos is inspired by forward-thinking leaders who establish a framework for health promoting actions that, over time, become the unspoken basis for this culture. To achieve an organizational culture of health, companies must indeed consider how to establish shared values, healthy norms, peer support networks, multiple “collision” touch points, and a positive social climate. Excellent wellness programs are but one visible manifestation of a good company culture that each day illustrates to employees that they, and their well-being, matter to the organization. For culture to be developed or changed, there still must be appropriate health and well-being structural supports in place that define the employee experience.
Where we disagree is on the notion that efforts to address individual health run counter to a culture of health framework. Individual and organizational health improvement efforts are complementary, not contradictory. Effective programs are built on mutual trust and respect between workers and leaders, which includes health promoting messaging that is consistent and constant. As Dr Peter Wald at USAA describes it, a healthy culture is one that offers “surround sound”—sending communications throughout the workday that the company cares about its employees’ well-being and safety.2
Over two-thirds of Americans are overweight or obese3; 14% smoke4; heart disease and cancer are the leading causes of premature death and lost productive years5; about 40% of adults aged 45 to 64 have hypertension6; most adults do not exercise enough7; and very few people follow healthy diet recommendations.8 The American Heart Association estimates that fewer than 5% of adults have none of the seven risk factors leading to heart disease.9 In addition, the United States is experiencing increases in psychosocial malaise that include substance use disorders, social isolation, high levels of stress, and depression, which may lead to antisocial behaviors and suicide.
Given the prevalence of these health risks, employers have a critically important role in communicating in a constant drumbeat that “your health and well-being matters.” That message is most potent when backed by concrete health and well-being initiatives in the form of policies, programs, social, and environmental supports.
Building a culture of health requires paying attention to individual, organizational, and community health. Knowing this, we have worked with various organizations, including the Centers for Disease Control and Prevention, Robert Wood Johnson Foundation, Health Enhancement Research Organization, American Heart Association, and the Samueli Institute to develop and field test various organizational health assessment tools. These include the CDC Worksite Health Scorecard,10 the HERO Health & Well-Being Best Practices Scorecard in Collaboration with Mercer,11 the Samueli Institute's Optimal Healthy Workplace Assessment,12 and the American Heart Association's Workplace Health Achievement Index13—survey tools that address individual, organizational, and community health. The items included in these instruments emphasize the importance of peer support networks, wellness champions, senior leadership engagement, and clear commitment to employee health and well-being that is written into organizational mission and vision statements. These actions, when aggregated, represent the critical ingredients that coalesce with insurance benefits, health promotion programming, company-wide policies, and environmental supports to build and sustain what may become a true culture of health at the workplace. By design, these scorable tools incorporate the evidence from best and promising practice literature reviews, along with individual studies, that employers use to gauge the extent to which evidence-based practices are in place at their worksites.
The CDC Worksite Health ScoreCard, which we adapted for our study, includes 18 modules and 154 items that cover the wide range of individual, organizational, and community activities designed to promote healthy cultures. The first module, entitled “Organizational Supports,” incorporates many of the culture of health factors mentioned by Drs Safeer and Judd. For example, the survey asks whether in the past 12 months worksites have:
- Demonstrated organizational commitment and support of worksite health promotion at all levels of management?
- Included references to improving or maintaining employee health and safety in the business objectives, core values, or organizational mission statement?
- Had an employee champion or network of champions who actively publicize health promotion programs?
- Promoted and supported employee volunteerism?
- Extended access to key components of the program to all workers, including hard-to-reach workers (eg, telecommuters, contract workers, night shift workers, part-time workers)?
- Provided and supported flexible work scheduling policies?
- Made company-specific health promotion programs available to family members?
- Coordinated programs for occupational health and safety with programs for health promotion and wellness?
Other modules ask whether employers:
- Sponsored or organized social activities designed to improve engagement with others, and provide opportunities for interaction and social support?
- Provided opportunities for employee participation in organizational decisions regarding workplace issues that affect job stress?
- Provided opportunities for employee input on hazards and solutions, and implement these solutions when appropriate?
To support a healthy company culture, employers must take actions as noted by the examples listed above. Employers cannot effectively establish a culture of health without having a thriving and robust wellness program in place, which includes changes to the physical and social environment that enable healthy choices. The opposite is also true: one-off programs (eg, websites, screenings, incentives, challenges, pamphlets), when done in isolation, are not likely to create a culture of health or lead to meaningful results.
We agree that assessing employees’ perceptions of the culture, health or otherwise, is important and central to validating management's assertions. We encourage investigators to recruit a cross section of employers and facilitate employee surveys to measure culture of health based on employees’ views on workplace culture. This approach was not feasible for us given the limited resources, and we suspect recruiting a robust group of employers to administer an employee survey may be difficult. A previous study sought to compare employer and employee perceptions14; however, the task of matching employer to employee responses was not possible given the data set. Regardless, we would be very interested in comparing results from future employee-level assessments with organizational health scores and perhaps constructing a more robust measure of culture of health that combines both perspectives.
We are on the same page with Drs Safeer and Allen that assessing the value-on-investment (VOI) from organizational and individual health programs is needed. Ultimately, we are all working toward the same common goal: a better quality of work–life and improved organizational health. Two sides of the same coin.
1. Schein E. The Corporate Culture Survival Guide. Jossey-Bass: San Francisco, CA; 1999.
3. Flegal KM, Kruszon-Moran D, Carroll MD, Fryar CD, Ogden CL. Trends in obesity among adults in the United States, 2005 to 2014. JAMA
6. National Center for Health Statistics. Health, United States, 2017: with special feature on mortality. Hyattsville, Maryland. 2018. Available at: https://www.cdc.gov/nchs/data/hus/hus17.pdf
. Accessed February 22, 2019.
7. Blackwell DL, Clark TC. State variation in meeting the 2008 federal guidelines for both aerobic and muscle-strengthening activities through leisure-time physical activity among adults aged 18-64: United States, 2010–2015. Natl Health Stat Rep
9. Lloyd-Jones DM, Hong Y, Labarthe D, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction. Circulation
10. Centers for Disease Control and Prevention. CDC Worksite Health ScoreCard: An Assessment Tool to Promote Employee Health and Well-Being. Atlanta: U.S. Department of Health and Human Services; 2019. Available at: https://www.cdc.gov/workplacehealthpromotion/index.html
. Accessed February 22, 2019.
11. Health Enhancement Research Organization. Waconia, MN: The HERO Health and Well-Being Best Practices Scorecard in Collaboration with Mercer (Version 4); 2014. Available at: https://hero-health.org/hero-scorecard/
. Accessed February 22, 2019.
14. McCleary K, Goetzel RZ, Roemer EC, Berko J, Kent K, Torre H. Employer and employee opinions about workplace health promotion (wellness) programs: Results of the 2015 Harris Poll Nielsen survey. J Occup Environ Med