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To Harness the Power of Cultural Support, We Must Differentiate Between the Culture of Health Concept and Traditional Wellness Programming

Safeer, Richard Scott MD; Allen, Judd Robert PhD

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Journal of Occupational and Environmental Medicine: May 2019 - Volume 61 - Issue 5 - p e232-e233
doi: 10.1097/JOM.0000000000001576
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To the Editor: Improvements in an Organization's Culture of Health Reduces Workers’ Health Risk Profile and Health Care Utilization, Journal of Occupational and Environmental Medicine. Rachel Mosher Henke, PhD, Michael A. Head, MS, Karen B. Kent, MPH, Ron Z. Goetzel, PhD, Enid Chung Roemer, PhD, and Katherine McCleary, MS. DOI: 10.1097/JOM.0000000000001479.

Developing Two Culture of Health Measurement Tools, Examining Employers’ Efforts to Influence Population Health Inside and Outside Company Walls. Kent K., Goetzel R., Roemer E., et al. JOEM 2018 (60);12:1087–1097.

The Correlation of a Corporate Culture of Health Assessment Score and Health Care Cost Trend. Fabius R., Frazee S., Thayer D., et al. JOEM 2018 (60);6:507–514.

During 2018, the Journal of Occupational and Environmental Medicine (JOEM) published three articles related to measuring culture of health in the workplace. We congratulate the authors for their foray into examining the impact of culture on workplace health and wellbeing. As the authors noted, there has been a lack of empirical evidence in support of creating a culture of health. Unfortunately, we do not believe these recent studies actually examine employee health culture. At its core, we fundamentally disagree with the culture of health definition provided by the authors and hence the Center for Disease Control and Prevention (CDC). We also believe the methodology the authors deploy to measure culture of health is flawed.

The CDC defines culture of health as a working environment in which employee health and safety are valued, supported, and promoted through worksite health and wellness programs, policies, benefits, and environmental supports. In contrast, we view a culture of health as the complex web of social influences supporting health beliefs and behaviors (including such factors as shared values, norms, peer support, and social climate). In our view, a culture of health would align informal and formal policies and procedures such as traditions, modeling, resource commitment, and communication with healthy lifestyles. While intentional implementation of health and wellness programs, policies, etc, by the employer supports a healthy workplace culture, it does not necessitate the transformation of the social milieu which ultimately determines the culture.

Cultural influences (particularly the informal influences) are not adequately measured directly in the current studies. Instead, the studies examine the impact of wellness programming at the organizational and community levels. The current studies do not measure the impact of culture change, but rather, the impact of following the wellness programming recommendations of the CDC, the Health Enhancement Research Organization, the Wellness Councils of America, and other organizations that have fostered the growth of the workplace wellness community. Most importantly, the current studies do not measure the employee perception of the health culture (eg, norms, peer support, and shared values).

It is difficult to see a direct link between culture change and wellness programs in their current form. In our experience, the vast majority of wellness initiatives are directed at individual transformation. The primary foci are personal motivation and skills. In addition, many programs remove barriers by subsidizing wellness activities and making changes to the physical environment. These are important efforts, but they are not culture change per say. It is likely that a useful measure of the impact of culture change would require those involved to address cultural influences directly. An effort to improve the quantity and quality of peer support for achieving healthier lifestyles (at work and at home) would be an example of culture change. A company's systematic initiative to change an unhealthy norm for inadequate sleep among shiftworkers would be another example.

Perhaps the clearest cases of a culture of health at work can be seen in cultural support for safety. Norms for wearing safety gear, maintaining safe workspaces, and learning from accidents have changed over the past 50 years. A concern for safety is also evident in the community with new norms for improved safety features in automobiles and the development of cycling and pedestrian paths. Much could be learned from this change to the culture of health. The study of the safety culture as a building block of a culture of health may be a fruitful direction for research. The culture change techniques deployed in achieving safety norms could be deployed to address other health behaviors.

There are employers actively engaged in culture building (in addition to implementing policies, environmental changes, etc). For example, Johns Hopkins Medicine1 and Ohio State University are building out wellness champion networks knowing that behavior is more often influenced by peers than by employers. However, there is a dearth of research methodology available to effectively measure the impact of enhanced peer support and other cultural influences in the workplace. Nonetheless, research by Christakis and Fowler2 make it abundantly clear the importance of our social networks in making health choices and thus employers and researchers in this space must create a path for intentional utilization of this strategy.

We would like to thank the authors for their effort to add visibility and credibility to the goal of achieving a culture of health. We need to address the valid criticisms of many of the current wellness initiatives. Creating cultures of health should reach those not currently involved, increase long-term lifestyle improvement success rates, and reduce the likelihood that employees will adopt unhealthy behaviors. In short, creating a culture of health will make it easier for members of that culture to have a healthy day. We believe that the capacity to create a culture of health will greatly enhance wellness program outcomes. Culture of health research is important to the advancement of effective approaches to supporting employee health and wellbeing.


1. Safeer R, Bowen W. Creating a culture of health at Johns Hopkins medicine. Am J Health Prom 2018; 32:1821–1823.
2. Christakis NA, Fowler JH. Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives. New York: Little Brown and Company; 2009.
Copyright © 2019 by the American College of Occupational and Environmental Medicine