Reprinted with permission from the American Journal of Health Promotion, March/April 1999

Great News: Every year approximately 70 percent of employees attempt to adopt a new healthy   lifestyle practice (Allen 1998). Our Greatest Challenge: Less than 20 percent are successful in maintaining those changes. The Poisoned Well of Unhealthy Cultures The village well was poisoned and the people fell sick. Unbeknownst to the villagers the poisoned well water had impaired their capacity to adopt healthy lifestyle practices. Health promotion professionals raced madly about pleading with the villagers to exercise, stop smoking, eat right and balance work, rest and play.

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The villagers heard the message and set goals for a better life. Try as they might, few villagers achieved their lifestyle improvement goals. So many failed that a great sadness fell on the land. The health promotion professionals were asked to go elsewhere to seek their fortunes.    

The Poisoned Well of Unhealthy Cultures

The village well was poisoned and the people fell sick. Unbeknownst to the villagers the poisoned well water had impaired their capacity to adopt healthy lifestyle practices. Health promotion professionals raced madly about pleading with the villagers to exercise, stop smoking, eat right and balance work, rest and play. The villagers heard the message and set goals for a better life. Try as they might, few villagers achieved their lifestyle improvement goals. So many failed that a great sadness fell on the land. The health promotion professionals were asked to go elsewhere to seek their fortunes.  

Our cultures are poisoned wells today. They do not encourage people to be healthy. With some notable exceptions¾for example, new norms for not smoking and for buckling seatbelts¾family, workplace and broad community norms undermine efforts to adopt healthier and more productive lifestyles.  In some areas¾stress, exercise and nutrition¾the culture has become so toxic that few escape unscathed.

Fortunately, people can learn how to create healthier and more productive cultural environments. This edition of the newsletter offers a brief history of the culture-based approach. Then key culture change concepts are defined. Strategies for jump-starting a new program and for established health promotion programs are discussed. A culture-based program at Union Pacific Railroad helps illustrate key strategies. Finally, we offer our thoughts about the future of culture-based health promotion.

Born Out of a Quest for Sustained Results

In the early 1960s a team of psychologists received a grant to help court-appointed delinquent youths (Allen, Dubin, Pilnick and Youtz 1966). The results seemed promising until the participants graduated from the program and returned to the street. One of the psychologists, Robert Allen, recognized that individual psychotherapeutic approaches to behavior change were ineffective in helping children break free of their illegal and frequently life-threatening lifestyle practices (e.g., drugs, robbery, vandalism, etc.). Allen found that the street culture was overwhelming young people’s efforts to adopt healthy lifestyles. Allen’s solution was to teach kids how to create non-delinquent subcultures.

Allen extended his work to hundreds of different organizational and social problems ranging from litter reduction, to corporate productivity, to educational reform (Allen and Kraft 1980). Allen formed a behavioral science organization¾the Human Resources Institute¾to advance culture-based approaches to change. In the 1970s the Human Resources Institute developed the first culture-based health promotion programs at two pharmaceutical firms: Johnson & Johnson and Hoffman LaRoche. These projects led to the Lifegain model of culture-based health promotion (Allen and Linde 1981).

The Building Blocks of Culture

Five cultural factors work together to shape long-term individual behavior. Assessing the impact of these cultural dimensions is the first step in empowering members of your workforce to choose healthy and productive cultures.

Discovering Wellness Values

A value is a heartfelt belief about the appropriate way to approach living. Values develop at all levels of the organization. The concept is most familiar on an individual level. For example, "My friend values honesty, frugality and compassion." Organizations also adopt values. The value theme for the 1980s was "lean and mean." In the early 1990s, it was “quality.” In the later part of the 1990s, it's turned to "speed of innovation." Just as organizational development values such as innovation are gaining attention in the workplace, health promotion values such as self-care need to become part of the way companies do business.

Your job, as a worksite health promotion professional, is to identify health-enhancing values and translate them into the language of the corporate culture. Here's how:

• Describe past health promotion efforts and then ask people’s opinions about these initiatives. Examine this input to identify desired values. 

• Ask leaders how health promotion themes might fit with their vision for organizational growth.

• Ask members of the culture to list goals for the health promotion effort. Then, identify values that encompass those goals.

• Describe programs and activities that can be used to support employee wellness. Then ask people to determine principles and values that will be important for delivering successful programs.

• Describe wellness and health promotion. Then determine what aspects are the biggest motivators. Choose your values to highlight those qualities.

• Once you have a preliminary list of four or five themes, ask people to translate the themes into the language of the culture.

Using these techniques, some organizations have adopted highly innovative value sets that match the organization's vision. Conoco, for example, organized its efforts around healthy pleasure and self-understanding. The YMCA strives to work with the whole person¾mind, body and spirit.

Core program values such as these provide needed direction for culture change. They enable employees to decide how health promotion matches their personal values. Such a match fosters commitment and enthusiasm. This positive attitude toward shared values is the cornerstone of a corporate culture that supports health.

Demystifying Cultural Norms 

One common misperception is that people and organizations always behave in accordance with their values. It is far more likely for the behavior of organizational members to be guided by cultural norms. A norm is an expected and accepted behavior: "It's the way we do things around here." For example, most people value eating healthy diets, but norms rarely support a balanced diet that is low in fat and sugar and high in grains, fresh fruits and vegetables.

For better and for worse, norms guide most health behavior. There are social standards for everything from when to seek help with an alcohol problem to whether or not to exercise during lunch breaks. Now that it is a norm to wear car safety belts, it has become much easier to buckle up. Changing norms for adult smoking made it easier for adults to quit. In contrast, cultural norms for long work weeks, fast-paced lifestyles and two-income households make it extremely difficult to manage stress.

Organizational Support: The Backbone of Culture

Each workplace develops its own mechanisms for defining and perpetuating its culture.  Formal personnel policies dictate such things as hours of work, employee benefits and procedures. Informal structures such as “the grapevine" and leadership modeling are equally powerful. In order to bring about lasting changes in the culture, both informal and formal organizational support systems need to be brought into alignment with health promotion values.

There are a variety of ways to measure organizational support. Strategies include a review of job descriptions and performance evaluations. An evaluator might attend a company orientation for new employees or training sessions. Focus group interviews can reveal how friendships develop and determine rituals, symbols, celebrations and company myths. Reading the company newsletters and email bulletins can also reveal how the culture works. Observing how space is used and how employees interact is another strategy

Peer Support: Acts of Kindness that Work

People often think of peer support in terms of special health promotion programs such as Alcoholics Anonymous or Weight Watchers. But natural support systems provided by family, friends and coworkers are also important sources of support. Ideally, such support systems provide both emotional support (in the form of kind words of encouragement) and instrumental support (such as money and time off).

Research on the benefits of peer support has been inconclusive (Terborg, Russell and Glasgow 1995). One likely explanation of this finding is that our culture provides insufficient training in how to effectively support lifestyle change. The most common forms of support for lifestyle change taught in our culture are nagging and listening. These two forms of support appear inadequate, and can undermine personal change.

Workplace wellness programs can offer training specifically designed to increase the effectiveness of support provided by coworkers and supervisors. For example, training can be organized around primary support skills (Allen 1997):

Peer Support Skills

• Goal Setting¾Helping to establish meaningful and specific goals using the “Stages of Change” framework (Prochaska, Norcross and DiClemente, 1994).

• Identifying Role Models¾Finding someone who has successfully achieved a similar goal.

• Eliminating Barriers to Change¾Developing strategies for obtaining needed time, equipment and other resources.

• Locating Supportive Environments¾Helping to find people and places that support lifestyle improvement goals.

• Working Through Relapse¾Helping to get back on track.

• Celebrating Success¾Cheering someone on and acknowledging accomplishments.

Climate: The Cultural Equivalent of Yeast in Bread Making

Three work climate factors¾a sense of community, a shared vision and a positive outlook¾are the cultural equivalent of yeast in bread making (Allen and Allen 1987). Where they are noticeably absent, individual and organizational growth grinds to a halt. Where a sense of community, a shared vision and a positive outlook are abundant, cooperative action and individual transformation proceed smoothly.

A sense of community is present when people feel as if they belong and they trust one another. This sense of belonging includes an awareness that others "care" and that the individual, in turn, has a responsibility to care for others. Furthermore, when a sense of community exists people tend to know one another beyond familiarity with job roles. What does this mean for health promotion? People are more receptive to advice about lifestyle if they believe it is given in a spirit of caring. In addition, community provides a level of comfort needed to try new behavior. Physiological addiction also appears less pronounced when people feel a sense of community (Horn 1972).

A shared vision inspires peak individual and organizational performance. When people have a shared vision, they are enthusiastic about the organization's goals and have a common view about how to achieve them. When no shared vision exists, people end up working at cross-purposes. There is little common agreement about what the organization is trying to achieve, and it is hard to figure out why people should work together to achieve health promotion goals.

Shared vision emerges when people have a chance to integrate their own personal goals and approaches with those of the organization, program or project. This is particularly important in health promotion because people are working with a variety of personal and organizational goals.

With a positive outlook people look for opportunities rather than obstacles and for strengths rather than weaknesses in one another. In health promotion, it is our strengths rather than weaknesses that enable us to move forward. For example, with a positive outlook, the feedback from a health risk appraisal will be seen as recognizing many lifestyle strengths and a few opportunities for lifestyle enhancement. In a more negative culture, the same health risk appraisal feedback might leave employees feeling inadequate and many believing that survey results will be used to weed out unhealthy employees.

Tools for Tapping the Organizational Unconscious

Most members of groups and organizations are blind to the influence of culture. For this reason, it is necessary to measure culture and its impact on behavior. Cultural anthropologists and other behavioral scientists have developed a variety of cultural analysis techniques. Strategies include focus group interviews, participant observation, the examination of organizational documents, field experiments and surveys.

One cultural analysis tool, the Lifegain Health Culture Audit, was designed specifically for health promotion program planning and evaluation. Versions of the survey have been used by hundreds of companies, schools and government organizations. A “short form” illustration of the Lifegain Health Culture Audit survey is available on the back page of this newsletter.

Jump Starting a New Health Promotion Program

Cultures are complex systems that respond best to a systematic change process that empowers organizational members to consciously choose their cultural environments. New health promotion programs can get off to a great start by organizing the program vision and processes to assure long-term success. The following four-phase Normative Systems Culture Change Process was developed specifically to change complex cultural environments. The four-phase approach for changing culture should be part of the strategic planning process.

Normative Systems Culture Change Processs

Phase I: Start-Up

The first phase involves analyzing the culture, setting objectives and gaining leadership commitment. Leadership "ownership" is achieved by acquainting leaders with health promotion goals and the culture change process that will be used for achieving them. Leaders are also encouraged to develop their own personal plans for modeling lifestyle improvement. As part of this first phase, baseline data are gathered from which later progress can be measured, and the program is tailored to meet the specific needs of the organization.

Phase II: Involvement

The second phase introduces the health promotion effort to the wider organizational community. A letter from the president and articles in the company newsletter provide an overview of program goals and strategies. It is often highly beneficial to kickoff the program by inviting employees to attend a wellness workshop. Company-sponsored games and contests have also been used to share the overall program vision with employees. For example, one university held a wellness contest. The contest manual introduced the philosophy of the wellness program. Individual participants and university departments won prizes for taking part in a variety of wellness activities.

Phase III: Integrating Change

Support for healthy lifestyles needs to become a part of the fabric of organizational life. Day-to-day organizational functions should be adjusted to reflect a commitment to health. Phase III efforts address organizational supports such as communication systems, rewards, employee orientation, training, leadership modeling, policies and procedures. Changing smoking policies is a highly visible example of such a policy change. Smaller changes in the way the organization conducts its business can also reinforce new health values and norms. For example, it may be possible to include healthier food choices in vending machines and the company cafeteria.

Phase IV: Sustaining Change

The final phase is ongoing evaluation, renewal and extension. The evaluation should encompass three broad categories of assessment¾performance, programmatic and cultural.

• Performance evaluation examines the “bottom-line” results. Performance evaluation includes assessing the program’s economic impact, illness avoided, productivity improvements, morale changes and health behavior changes.

• Programmatic evaluation examines how well the initiative was implemented. For example, a determination can be made of participation rates, participant satisfaction and the pace of changes in organizational policies and procedures.

• Cultural evaluation examines changes in values, norms, peer support, organizational support and climate. Frequently the evaluation includes re-administering the cultural assessment survey (see Lifegain Health Culture Audit) as well as conducting focus interviews and field experiments.

Celebrate your successes. Picnics, banquets, retreats, annual reports, award ceremonies and shareholders’ meetings are appropriate venues for celebrating health promotion outcomes. Celebrating is an important rite of passage to a new culture. During such activities, leaders can acknowledge how the culture has improved. Celebrating success provides participants with an opportunity to fully appreciate the value of their efforts. In addition, such celebrations further clarify the vision of a healthier and more productive culture. They enable participants to further commit to individual and organizational health. Such celebrations also reinforce project principles (such as approaching change systematically or being results-oriented).

Renew and extend your program. This may involve the commitment of additional resources to areas that are particularly resistant to change. One nice thing about culture change is that problems really do go away. For example, new norms for regular exercise reduce the need to offer special enticements for trying out exercise. Fitness just becomes “the way we do things around here.” For this reason other health and productivity concerns would become the focus of your renewal and extension efforts. Build on your successes by approaching other areas such as self-management, teamwork, quality, customer service and speed of innovation. The same systematic culture-based approach can be applied to a broad range of organizational objectives.

Finally, get people involved in bringing changes to new settings. Program extension is critical; employees who become the "teachers" are often the most successful in maintaining personal lifestyle changes.

Individual responds to new and compelling

health promotion message

Adding Culture Change Components to an Established Program

Those involved in mature programs may find it difficult to restructure their overall program design around the four-phase Normative Systems Culture Change Process. For these programs, traditional health promotion elements can be adjusted to address cultural issues.

Conduct Periodic Cultural Assessments

Mature programs should conduct a periodic assessment of their cultures. Such assessments can either focus on a broad range of wellness goals or focus on those aspects of the culture that are the current focus of program interventions. For example, a program that is emphasizing medical self-care could look specifically at norms, values, peer support and organizational support factors that influence self-care behavior. Is it a norm, for example, to consult a self-care book before seeking non-emergency medical care? In terms of organizational support, are people being rewarded and recognized for their medical self-care efforts?

It is recommended that a broad cultural assessment, such as the Lifegain Health Culture Audit, be conducted every three to five years. Broad cultural assessments keep programs on track. Program priorities can set to address large gaps between the current and the desired culture. For example, in one hospital’s audit it was determined that norms related to financial wellness and weight management had the largest gaps. As a result, health promotion managers are emphasizing these norms in their program design. 

Periodic cultural assessments reveal shifts in employee needs. Many organizations are finding that mergers, downsizing and changes in employee demographics require modifications in their program design. For example, work-family life balance issues may have become the priority for a workforce. As a result, health promotion programs must accommodate family members and housemates. Or maybe the cultural assessment will determine that your organization has a very unhealthy work climate. As a result the first priority in your program design would be to foster a sense of community, a shared vision and a positive outlook.

Develop Leadership Support

Culture is the link between traditional health promotion activities and leadership. CEOs, vice presidents, managers and supervisors need to be able to define their roles in supporting wellness.

• Leaders can share a vision for a healthier and more productive workforce. Translating health promotion goals into business terms and philosophy is an important leadership function. Almost all management initiatives (such as customer service, learning organizations or quality) are fertile ground for sharing about the importance of a healthy workforce. Leaders can articulate their vision in written and verbal statements about how business goals can best be achieved by supporting employee wellness.

• Leaders can serve as role models. Their healthy lifestyle choices and participation in health promotion activities inspire employees.

• Leaders can assist in setting budget and human resource priorities that reflect a commitment to employee health.

• Leaders can recognize individual and organizational progress. For example, leaders can acknowledge cost savings and overall reductions in employee illness achieved through the wellness program.

Develop Peer Support

The support of family, friends, coworkers and supervisors can be a force for individual and cultural transformation. Mutual support for healthy lifestyles can be nurtured through work team discussions, mentoring programs and support groups. At one university, for example, a “Well Department Awards” program was introduced to foster department discussions of mutual support for health. Departments competed to achieve high scores on an anonymous survey designed to measure support for wellness. At an oil and gas company, work groups participated in the Game of Lifestyle Change. Work groups earned game points by participating in individual and group activities designed to enhance mutual support for healthy lifestyles. 

Develop Organizational Support Systems

Traditional health promotion programs frequently offer new forms of organizational support such as health newsletters and classroom experiences designed to promote employee health. These new health promotion programs are added to an existing array of organizational rewards, communication systems and training (see Organizational Support section). In order to cut organizational clutter, examine existing organizational policies, procedures and programs (outside the health promotion program) to see if they can be adjusted to better support healthy lifestyle choices. For example, a system can be established for rewarding healthy lifestyle choices with reduced employee insurance premiums. In this way, health promotion can be more fully integrated into day-to-day operations without adding a new layer of programs and activities.

Develop a Healthier Work Climate

Without a sense of community, a shared vision and a positive outlook, productivity, innovation and morale suffer. Health promotion activities can be retooled to build a healthier work climate.  For example, fitness classes can include “get-to-know-you” activities before and after the workout. To better nurture a shared vision, wellness mentoring programs can include a discussion of how personal goals fit with the overall direction of the company. To foster a more positive outlook, health newsletters can emphasize individual and organizational achievements.

The Future of Culture Change Approaches

Common sense says everyone wants to be healthy. Common sense assumes that given the knowledge that smoking is harmful, alcohol overuse is destructive, or being overweight increases the chances of cancer and heart disease, people will change their health practices. Unfortunately, the common-sense approach to change doesn't work because it focuses exclusively on individual motivation and because the common-sense approach lacks a strategy for modifying the underlying culture.

Companies have a long history of offering a single solution to complex behavioral problems. Companies turn to the usual solutions: conduct a survey; create a new department; write a new policy. Unless organizations modify their approach, it is easy to see how one failure could be followed by an endless series of failures that might lead a company to abandon health promotion entirely.

A more systematic culture-based approach will enhance individual lifestyle improvement efforts. State-of-the-art individual change programs now embrace a process approach to change. For example, James Prochaska and his colleagues have identified six stages of individual change that are necessary to lasting self-improvement (Prochaska, Norcross and DiClemente 1994). Unfortunately, it is not a cultural norm to approach personal or organizational change as a process. It is normal to see change as a question of personal revelation or a function of picking the right goals. To improve success rates, health promotion practitioners will need to change this "quick fix" culture to one that embraces systematic ongoing change.

The Future of Culture Change Approaches

As the field of health promotion matures, it is likely that companies will begin to adopt approaches that focus simultaneously on individual change processes and culture change processes. Benchmark studies are presenting compelling evidence concerning the need to create supportive cultural environments (O’Donnell, Bishop and Kaplan 1997). Working with cultural values, norms, peer support, organizational support and work climate will greatly enhance the likelihood of sustained positive results. 

The future and spirit of the culture-based approach is summarized in the words of the late Robert F. Allen: "We must transform our cultures so that our need for one another is not an obstacle to overcome, but rather a virtue to be celebrated."

References

Allen, J.R. (1998) “Lifestyle Change attempt and success rate findings from Lifegain Health Culture Audit surveys conducted at over 50 companies,” Research Report from the Human Resources Institute, Burlington, Vermont.

Allen, J.R. (1998) “Wellness mentoring can help rebuild the corporate culture,” Worksite Health, Summer, pp. 27-30.

Allen, R.F. and Allen, J.R. (1987) “A sense of community, a shared vision, and a positive culture: Core enabling factors in culture‑based health promotion efforts.” American Journal of Health Promotion, Vol.1 No. 3, pp. 40‑47.

Allen, R.F. et. al. (1981) Collegefields: From Delinquency to Freedom. Irvington Publishers, New York.

Allen, R.F. and Linde, S. (1981) Lifegain: The Exciting New Program that will Change Your Health¾and Your Life, Human Resources Institute, Burlington, Vermont.

Allen, R.F. and Kraft, C. (1980) Beat the System: How to Create More Human Environments, McGraw-Hill Available from Human Resources Institute, Burlington, Vermont.

Horn, D. (1972)  “Determinants of change.” In J.C. Stone, F. Cohen and N.E. Adler (Eds.), The Second World Conference on Smoking and Health, London: Pitman Medical.

Levering, R. and Moskowitz, M. (1994) The 100 Best Companies to Work for in America, Plume, New York.

O'Donnell, M.P. et. al. (1997) “Benchmarking best practices in workplace health promotion,” The Art and Science of Health Promotion, March/April, Vol. 1, No.1.

O’Donnell, M. (1989) Definition of health promotion: Part III: Expanding the definition. American Journal of Health Promotion, Vol.3 No. 3 p. 5 

Prochaska, J.O, et. al. (1994) Changing for Good: A Revolutionary Six Stage program for Overcoming Bad Habits and Moving Your Life Positively Forward, Avon Books, NY,.

Terborg, J et. al. (1995) “Behavior change at the worksite: Does social support make a difference,” American Journal of Health Promotion, Vol. 10, No 2, pp. 125-131.