HEALTH: GLOBAL NETWORK

Studies in behaviour change to improve the health of the world

Powered by MAKING WORK A HEALTHIER 4 PLACE 2015

CONTENTS INTRODUCTION

On behalf of the Global The breadth, depth and variety of thought demonstrated here is simply astounding and worth reading in full. Chief Medical Officer We are privileged to have been able to call on such a wide Network I would like to variety of world-leading experts from a range of disciplines, thank the contributors backgrounds and contexts. Each of these pieces includes 8 36 a challenge or recommendation to our network on how of this seminal collection we can radically improve the health of the world through IMPROVING workplace health and behaviour change. We are united WORKPLACES EMPLOYEE in our recognition of the unique opportunity we have to OF THE FUTURE ENGAGEMENT make a difference in the workplace and through that, public health, as employers operating in health systems and communities across the globe.

Working together we will develop and take forward these recommendations to achieve a global impact; going far beyond what we could have achieved individually and proving the power of partnerships to transform the health of the world. 74 A NEW ROLE FOR CMOS

Dr Paul Zollinger-Read Bupa CMO On behalf of the Global CMO Network 98 120 PUBLIC AND With thanks to our contributors, the Global Chief Medical Officer Network and our secretaries: COMMUNITY DIGITAL Caroline Stanger, Gareth Lyon and Sarah Mullin HEALTH OPPORTUNITIES

2 3 INTRODUCTION

Health systems under strain The Global CMO Network To that end we have asked 32 Our mission is to It has been widely remarked that The Global Chief Medical Officer of the world’s leading experts in the world faces a “health crunch”. Network has been established workplace health and behaviour improve the health The happy advent of rising life to make a unique contribution change to take part in our and wellbeing of expectancy across the board is to this goal – harnessing the research project. adding demographic pressure to experience, energy and inspiration The contributors come from a less welcome blend of rising of clinicians in senior decision the world a wide range of backgrounds healthcare costs and growth in making roles in some of the – small innovative business, non-communicable diseases which world’s biggest companies. respected academics, charities, are already straining the capacity Our mission is to improve the specialists in particular conditions and resources of healthcare health and wellbeing of the and Chief Medical Officers systems around the world. world, working with others. themselves. It is this breadth of This crisis cannot be averted We are motivated to combine contributors which has helped through business as usual and the experience, energy and us to avoid relying too heavily on hoping that “something will inspiration of a committed any one conventional approach. come up”. network of clinicians in commerce with global reach. Radical new approaches, partnerships and delivery models We are driven by the belief that need to play a role alongside and the private sector has a role to in support of existing systems. play in tackling the biggest health Together we will challenges in the world, working push the boundaries with other civil society players, governments and UN Agencies. of possibility and

Together we will push the innovate through boundaries of possibility and collective action innovate through collective action.

Having met and agreed on this mission we have decided to commission research in order to discover what the greatest opportunities are in workplace health.

We were of the view that in order to bring about significant, scalable and sustained improvements in workplace health, we would need to focus on behaviour change. 4 5 Each of these contributors collection to which the Global But in reality each of these pieces have been asked to identify CMO Network is proud to put touches on two or more of So what’s next? what they see as being the key its name to. For ease of reference these themes. recommendations for sustainably we have categorised these We believe that all of the ideas in the research are worthy What is particularly noteworthy improving workplace health research pieces into five themes: of pursuing, scaling and developing for more people. is the broad consensus on through behaviour change and 1. Workplaces of the future the critical success factors for As a network we have agreed that we will take some of to issue the Global CMO Network – shaping the work environment interventions in workplace health. these ideas forward collectively. We are however equally with a challenge for how we to promote health. We have made an effort to distil could practically implement determined that the range of thinking here should be these down into a form which can their recommendations. 2. Improving employee made as widely available as possible to anyone who engagement serve as a basis for the network’s would wish to build on it. Research – enabling good choices. future initiatives in this area and for the individual initiatives of our We are therefore making a commitment to promote We have received a wide range 3. A new role for CMOs member companies, as well as this research and to help make connections for any of high quality, insightful and – shifting corporate mindsets. creative responses to this project. any other organisation which organisation interested in pursuing any of these ideas. Each of these contributions are 4. Public and community health wishes to adopt them as follows: To that end we will be disseminating this research - looking outwards. worthy of significant consideration widely and would welcome contact from any in their own right and has helped 5. Digital opportunities organisations wanting to build partnerships to develop to shape our thinking. Together – making it personal. and implement these ideas. they constitute a seminal research As a network we will be meeting regularly to determine which challenges or combination of challenges we will take forward.

Critical success factors for workplace health behaviour change By the end of our meeting we will have an outline of the work we will be undertaking as a network in the future, 1. The use of behaviour change techniques to 6. The use of digital channels as a key enabler and our plans for reaching out to and partnering with motivate and genuinely involve people in for scaling, personalising and segmenting other organisations to improve the health of the world. decision making i.e. co-creating solutions interventions. with them, often at large scale and using Thinking of health in a holistic way, incorporating We are certain that the research contributors we have social networks. 7. psychological and physical health. worked with to date have a valuable role to play in developing and implementing these projects. Some of 2. Employees are empowered to take control, Appreciating what matters to employees on to get involved and make a difference, 8. them will be joining us at the meeting. Others will be a broader level, including the health of their especially through volunteering. working with us on the delivery of aspects of our future families and communities as well as broader work. All of them will be invited to be Friends of the 3. The use of appropriate incentives to change population health. Network and recognised as allies and ambassadors for behaviour. These might include financial, improving the health of the world. Taking action early, enabling and supporting competitive or reputational incentives. 9. people to be healthy every day. This report is therefore both a manifesto for future action 4. The environment and context needs to and a catalyst for things to come. Our network is open, 10. Leadership matters – visible ownership be structured so that choices are made growing, collaborative and ambitious to act. It is also and participation by CEO, CMO and senior automatically (nudge theory). Small changes therefore an invitation to anyone out there who would leadership teams. can have a big impact, recognising that 90 join us on this journey. percent of decisions are made using ‘fast, 11. The ability to demonstrate measurable return instinctive and emotional thinking’ (system 1). on investment that brings value to the company We will make a transformative impact on the health of and improves health, wellbeing and productivity the world. We understand the scale of the challenge 5. Connecting people to a bigger purpose beyond of employees. before us and the need to move on from words to work. themselves and enabling them to be recognised

for doing so. ‘Happiness lies in serving others’. That work starts today.

6 7 Workplace health. CMO or CHO? Culture as context. And unintended consequences WORKPLACES by Alan Newman 10 Creating dynamic workplaces: OF THE FUTURE a pathway to healthier workers and productive businesses by David Dunstan 14 shaping the work environment

Theories and techniques for influencing to promote health health behaviours in organisations by Ivo Vlaev 18

Occupational health interventions for developing and developed countries by Paul Dolan 22

Health improvement in the workplace by Richard Jenkins 28

Minimalist, oblique and non-obvious by Rory Sutherland 30

Workplaces and the self-management of co-morbidity by Stephen Bevan 34

8 9 WORKPLACES OF THE FUTURE

Consider the example of a school Item 4 women were smokers. Today it’s Workplace health where a small number of parents If we want to change behaviour about 22 percent for both sexes and were consistently late dropping we have to change the context. has been for the last four years or CMO or CHO? Culture as context. their children off. This irritated the Supermarkets are behaviour so. The steepest decline coincided teachers and the other parents and savvy. They know that our decision with smoking being banned from And unintended consequences fines were introduced for lateness. making and buying behaviour most public places. This is a good Lateness subsequently increased. are influenced by the layout of example of changing context to What explanation do you have for the store. I have not been to the change behaviour. by Alan Newman this unintended consequence? supermarket that you use but I’d bet that at the main entrance Item 5 Nagging is counterproductive and we encounter fresh produce and As this article is aimed at is likely to produce unintended flowers. (Subconsciously this hits a corporate audience in This article is a response to a Item 2 Item 3 consequences. Because we know our ‘feel good’ button and so we generaland since the request request for a ‘thought piece’ on Psychologist and Nobel Prize The Hawthorne Effect is a we have good intentions when we develop a more positive frame of came from Bupa I have considered behaviour change. It is written winner, Daniel Kahneman, points good example of unintended seek to influence other people’s mind when we shop.) Bupa’s purpose and the role that behaviour (“it is for their own with two things in mind - out that we have two decision consequences. In the 1920s and behaviour change projects might making systems. System 1 is 30s when ‘scientific management’ good”) we arrogate to ourselves Special offers are piled high and have in achieving it. A number Bupa’s purpose, which is longer, fast, intuitive, subconscious and ‘time and motion’ were new authority we do not have. True seem too good to ignore. And if of problems are immediately healthier, happier lives and the and effortless. System 2 is slow, ideas, Western Electric conducted consent is missing. The impact of there’s baking on the premises apparent. Consider this: Global CMO Network’s intention calculating, conscious and effortful. studies at their Hawthorne plant this is not neutral. Resistance is then bread and cakes will be far • (Batteries and UHT milk aside) to be transformative in its As we go about our daily lives we in Illinois to see how lighting levels increased and it becomes more from the entrance. At the checkout Which brand do you associate use System 1 more than 90 percent might influence productivity. difficult to achieve the intended, chocolates, snacks and sweets efforts to improve the health most strongly with long life? positive outcomes. and wellbeing of the world. of the time. But when we are in Whether levels were raised or will be at a child’s eye level so • Which brand do you associate corporate-management mode lowered, productivity improved. increasing the likelihood of pester- (The phenomenon is not new. most strongly with health? Item 1 we are often using System 2. Once the experimenters left, power and impulse buying as we C S Lewis noted that “Those who We focus on objectives (ie. productivity declined. queue. This phenomenon, ‘Choice • Which brand do you associate Behaviour change is difficult. It is torment us for our own good will most strongly with happiness? difficult to bring about not only in intended outcomes) that are Architecture’, is now so well known Here are two good examples of how torment us without end for they other people but also in ourselves. ‘SMART’ (specific, measurable, that there’s even a Simpson’s System 2 thinking misses the point. do so with the approval of their Different answers to each question? Why is this? The short answer is achievable, relevant and time cartoon about it, Homer is at the Millions of pounds have been spent own conscience.”) That tells us that longevity, health that brains are habit machines. related). We use Key Performance Kwik-E-Mart and sees that he has to around the world, and continue and happiness might not be as They make thousands of micro- Indicators. We rarely consider go to the other end of the counter to be spent, telling people of the closely related as we think. ‘Longer decisions every day and we’re not unintended consequences. But to buy a doughnut so he decides dangers associated with smoking lives’ is a weak link. It matters to even aware that they’re doing it. if we’re to succeed in a world to buy some prominently placed or bad eating habits. Have these actuaries, understandably, but it’s Over time these micro-decisions dominated by behaviours based on fresh fruit instead. But the fact that campaigns had the intended effect? a tricky message for the rest of become the basis of habits which, System 1, we first need to change we know what’s going on doesn’t If the intended effect is to influence us. Longer than what? How many to a large extent, define us. our own corporate behaviours that protect us from our subconscious. behaviour the answer is, “No”. people want to live until they Consider the people using focus too much on System 2. If the intended effect is to show that There is clearly a fine line between are 100? We want to be younger escalators at Victoria Station. Government ‘is doing something’ influencing and manipulating but longer: we don’t want to be older Most, if not all, know that it would then the answer is, “Yes”. for the purposes of this article we longer. ‘Longer lives’ dilutes the be better for their health if they set that issue to one side. However, health-and-happiness message. took the stairs but not one of them in the case of smoking and its made the micro-decision to do reduced incidence we can see that so. It is probable that each one of it is the change of context that has them was thinking about something had most impact. The 1951 (Doll) else when he/she subconsciously paper that demonstrated a causal ‘decided’ to take the escalator. link between smoking and lung (The fact that other people were cancer was not properly acted also using the escalators and not upon for many years. In the UK in the stairs had an effect too.) the late 1940s about 80 percent of men and about 50 percent of 10 11 WORKPLACES OF THE FUTURE

Item 6 Building on the points in item 5, we see that the Global CMO Network seeks to be transformative. One step on the journey to achieving this is to consider what the job description and metrics might be of a Chief Health Officer or Chief Happiness Officer as opposed to a Chief Medical Officer. (Outcomes in corporate world often have a strong link to measurement).

This headline from an October 2014 FT article emphasises the remedial aspects of workplace health – in this instance British Gas saw a 43 percent reduction in engineers’ back-related absence and got £31 back for every £1 spent on back-care workshops. Worthwhile but not transformative. Alan Newman So what’s the bottom line? What is our call-to-action? Alan Newman’s early years were spent in Kuwait before 1. Two groups of CMOs (‘competition’ adds a bit of spice) write the job he came to a military school description and performance measures for the role of Chief Health in the UK. After graduating Officer (CHO). What can we infer from the differences between the with an Honours degree in CMO role and that of CHO? Then repeat the exercise this time with Psychology from UCL, he spent the focus being Chief Happiness Officer (CHO). What insights do we 3 years in Kenya on VSO as a have now? science teacher. He worked for a number of software 2. Well intentioned and mainly-well-designed behaviour change projects companies before joining DEC can be derailed easily and early by unintended consequences. as a software services manager, A “we are okay but you’re not okay” stance may do this, or poor where he worked in the UK empathy. To minimise the risk of unintended consequences, ask some and Middle East. He attended trusted third parties to be devil’s advocates. Why might employees the International Management by the water cooler criticise the project and not engage? What have Programme at INSEAD in 1987- we said or done that could alienate or irritate our audience? 89 and became a freelance (To assist us, let’s build a database of stories that highlight consultant in 1992. unintended consequences). Clients with whom he’s worked 3. Context is critical – and culture is context. Brains are ‘Bayesian’. include Ageas Protect, Aviva, They automatically contextualise information, judgements and British Friendly, BT-Syntegra, decisions. The Global CMO Network, by virtue of its membership, Hannover Re, LV, the National can contribute a good deal to understanding how culture (corporate Consumer Federation, and and national) provides the context in which behaviour change takes Swiss Re. He is an established place (i.e. is a facilitator) or does not (i.e. it is an inhibitor) and it is conference speaker and has written for several publications proposed that this be a specific research stream. including FT Finance and The Journal of Brand Management.

12 13 WORKPLACES OF THE FUTURE

Creating dynamic workplaces: a pathway to healthier workers and productive businesses by David Dunstan, Genevieve Healy, Nyssa Hadgraft and Duncan Young

Prolonged sitting – a modern What do we mean by dynamic How to promote dynamic Cleverly designed spaces that workplace health hazard working environments? working environments encourage increased movement, With increasing computerisation of Dynamic (or activity permissive) Environmental-based strategies combined with supportive job tasks (and longer work hours), working environments are those aimed at encouraging employees organisational policies and cultures, it comes as little surprise that that encourage more movement, to sit less and move more are can use behavioural insights and sitting now predominates our more often. Shifting thinking away more likely to be effective on nudge workers towards healthier working lives. As awareness grows from the idea that the productive a larger-scale than individual- behaviours. By integrating dynamic about the harmful health effects worker must be chained to their focused, educational interventions. working strategies into the of too much sitting, it is becoming desk, dynamic workplaces facilitate Long term change requires habit everyday environment, the aim is more and more apparent that the and support opportunities to modification through a multi- for moving more to be the default modern workplace environment be active throughout the day, interventional approach and option, rather than a conscious may be a ticking time bomb including frequent transitions social norms to embed these new behavioural decision. These subtle for workplace illness and injury. between sitting, standing and behaviours. Modifications to the changes reinforce the ‘social norm’; Strategies for reducing sitting time walking. Consistent evidence workplace physical environment, the more people who are displaying are needed if we want to reduce indicates that these frequent coupled with a supportive culture positive new habits, the more likely the risk for future chronic diseases. postural shifts are beneficial for for change, should therefore be other people will also try them. both heart and musculoskeletal integral components of a healthy A move to this new way of working Rather than focus on structured health. In addition to reducing workplace strategy. will depend on engagement and workplace physical activity sitting time and promoting participation by all levels of an programmes, we contend that a improved health, dynamic Height-adjustable workstations organisation. If workers cannot more achievable, and potentially workplaces have further potential (allowing movement from sitting envisage the benefits of modifying more sustainable, step to getting to improve communication and to standing) are becoming existing work practices, success workers more active is to embed collaboration between co-workers, increasingly popular and have rates will be low. Additionally, more movement and less sitting increase energy levels and reduce been shown to lead to reductions while leadership in health does throughout the day via the creation fatigue. Dynamic workplaces could of over two hours in workplace not always begin at the top, senior of dynamic working environments. therefore boost productivity within sitting time when part of a multi- leadership support and alignment workplaces in two interrelated component approach. However, with company values is critical. ways – by improving worker health modifications to desks are only one A whole-of-organisation approach and safety and encouraging greater option – there are many low cost Organisations that emerge as that integrates dynamic work collaboration and engagement. and easily administered strategies leaders in dynamic working that can also be pursued. For practices within existing health environments could even A dynamic workplace is not example, walking meetings have and safety, human resources and promote themselves as just about creating a physical been shown to increase divergent change management frameworks, employers of choice to attract environment that facilitates thinking outcomes, while standing will increase the potential the best and brightest talent movement, but also shaping a meetings are often shorter with for sustainability. workplace culture that supports no detrimental productivity effect. it. Organisational “buy-in” is thus Rethinking how the working day is critical for the promotion and scheduled could also facilitate more support of these spaces. light to moderate physical activity. 14 15 WORKPLACES OF THE FUTURE

Evaluating change using supportive technology How the Global CMO Network Wrist-worn activity tracking can take the lead devices have become an The Global CMO Network increasingly popular way for is uniquely placed to take a tracking physical activity levels leadership role in advocating through the day. These devices, dynamic workplaces. and other types of supportive The network can facilitate technology, could also be used resource and knowledge sharing, to monitor the effectiveness of including solutions to common dynamic work environments. barriers to change. The network can also foster links with Supportive technology organisations with expertise (including activity trackers and Professor David Dunstan Dr Genevieve Healy in behavioural change, such as apps) can help workers gain an David Dunstan is an NHMRC Genevieve Healy is a Senior health promotion organisations, awareness of their own behaviour Senior Research Fellow and the Research Fellow at the School of universities and research Head of the Physical Activity Public Health at the University of (eg. monitoring sitting time institutes. In addition, as global laboratory within the Division Queensland. Her research focuses throughout the day) but also leaders, the network could use of Metabolism and Obesity at on understanding how much we could be useful for evaluating and their influence to put this issue the Baker IDI Heart and Diabetes sit and how this influences our tracking activity behaviour at an on the international agenda. Institute. He is an Adjunct health, as well as the feasibility organisational level. Increasingly, Professor in the School of Sports and acceptability of reducing organisational performance in Similar to initiatives such as Science, Exercise and Health at this behaviour in key settings, employee health and well-being The University of WA, an Adjunct including the office workplace. the Global Corporate Challenge, is being incorporated into Key Associate Professor in the Her work has influenced policy the Global CMO Network could Performance Indicators (KPIs). School of Population Health at and guidelines regarding the initiate the Sit Less, Move More In line with this, the Global CMO the University of Queensland, importance of reducing prolonged Global Challenge, encouraging Network could drive the inclusion an Adjunct Associate Professor sitting time, and has been teams around the world to set of reporting on employee activity the School of Exercise and featured in >1200 online, print or goals to reduce their daily sitting Nutrition Sciences at Deakin broadcast media articles. levels, such as sitting time, into time. Supportive technologies University and an Adjunct Senior regular reporting to boards and could be used to measure Lecturer in the Department of Dr Healy co-leads the Stand Up potentially, to external networks. Australia program of research: a behaviour, and motivate Epidemiology and Preventive program which aims to investigate employees to achieve set goals. Medicine at Monash University. Effective use of supportive the benefits of reducing At an organisational level, technologies in combination David’s research focuses on prolonged sitting time in the benchmarking against other with social media provides the role of physical activity workplace, and includes multiple companies can provide opportunities to share learnings and sedentary behaviour in the industry and government partner the healthy competition prevention and management and achievements on implementing organisations. The quality of her needed to sustain commitment of chronic diseases and he is dynamic workplaces. Organisations work has been recognized by to initiatives. the author of 130 peer-reviewed that emerge as leaders in dynamic over 20 awards, including the papers. His research outcomes 2014 Research Australia Griffith working environments could even Overall, dynamic activity have been recognised extensively University Discovery Award, promote themselves as employers permissive work spaces in the international/national media, and the 2012 Scopus Young of choice to attract the best and as indicated by more have the potential to reduce Researcher of the Year (Medicine brightest talent. than 350 media features in chronic disease risk, encourage and Medical Sciences). 2013, including interviews for greater collaboration and lead substantial featured print articles to productivity gains. As an (The Economist, New Scientist, emerging area of occupational Wall St J, NY Times) and health, the Global CMO Network television (60 minutes, Catalyst). can be forefront in setting the dynamic workplace agenda.

16 17 In contrast, many interventions Human behaviour is an interacting Opportunity is defined as all the Theories and techniques approach behaviour change from system in which capability, factors: social – afforded by a specific perspective, being either motivations and opportunities, culture encompassing sets of for influencing health a traditional approach relying on interact to generate behaviour, shared values and practices - rational choice theory - providing which in turn influences these and physical – the infrastructure information and incentives to components (see Figure 1 below). or technology available. behaviours in organisations employees so they reflectively steer towards more healthy courses of Capability is defined as the In summary, this theoretical by Ivo Vlaev action, or more recent alternatives individual’s psychological and framework for conducting focus predominantly on ‘nudging’ physical capacity to engage in the behavioural analysis ensures that new behaviours by changing the activity concerned, which includes the most appropriate intervention context or the environment in having the necessary knowledge is implemented once we have Designing effective interventions to motivate change among which choices are made which and skills and also possessing better understanding of the role employees in organisations requires two key components: is known to produce often the capacity to engage in the of specific determinants in health necessary thought processes. behaviour in each organisation. overarching theory of behaviour that enables understanding unconscious effects on motivation and action. So to maximise the For example, some employees may Motivation is defined as all those of the specific barriers and drivers to behaviour change in chances to change health-related have the capability (knowledge brain processes that energise and such settings; and also behaviour change techniques that actions requires integration of and skills) to exercise but lack the direct behaviour, which are often are likely to be particularly effective in this context. those approaches. physical or social opportunities interpreted as two distinct sets due to structural and cultural of systems: evolutionarily older Utilising a theoretical approach, barriers (lack of gyms, time, ‘System 1’ processes described rooted in sound evidence-based understanding boss); or they The importance of theory as automatic, uncontrolled and theory usually leads to long-term may be capable and have the In the words of Kurt Lewin effortless, and more recent, There is nothing effectiveness and sustainability of opportunities but lack motivation. (considered the father of modern characteristically human ‘System 2’ the proposed policies. Additionally, social psychology) “there is processes described as reflective, so practical as complex interventions should nothing so practical as a good controlled, and effortful. The ‘dual work on several levels – structural a good theory theory”. Meaning, we cannot process’ model has often been or environmental, psychological, make significant advances in proposed as a theoretical basis and behavioural – which will understanding and changing for targeting automatic health enable employers to implement behaviours unless we have a behaviours with ‘nudges.’ multifactorial interventions, theory of what causes behaviour. targeting several levels at once. This includes all necessary and sufficient conditions that make it possible for an individual to Figure 1: A theoretical framework for understanding behaviour change perform a specific behaviour. In order to act, the person needs enough knowledge and skills, Psychological conscious will or unconscious

desire, optimal physical conditions Physical and favorable cultural institutions. Capability Therefore, our position here is that employees’ health behaviours in Reflective

organisations are subject to the Motivation Behaviour same wide range of influences, Automatic like any other human action. Opportunity

Social

Physical 18 19 WORKPLACES OF THE FUTURE

Techniques to motivate change It is also important to inform and This is in line with theories of which include techniques such To conclude, influencing Reflective motivational techniques reinforce to people that they are behavioural economics which as ‘providing information about employees’ behaviours is a key such as ‘providing information on not only behaving in ways that are predict that messages will be most others’ approval of current/new area that needs to be addressed consequences’, ‘prompting barrier desirable, but continue to be similar effective in eliciting behaviour behaviour’, ‘expert models or as more field interventions identification, specific goal setting to others just like them. change when information is demonstrates the new behaviour’, are needed. The suggestions and review of behavioural goals’ presented in way that is consistent and ‘providing opportunities for made here apply to all kinds of should be encouraged. Influencing However, as it turns out, the devil with how it is mentally processed. social comparison’. Specifically, the behaviours and organisations, automatic motivation is also a key is in the detail of how information This is due to a large body of last technique is usually defined because the underlying lever that has been a relatively is presented. Recent research has recent work which suggests – in this literature as “drawing behavioural principles are the neglected area in health behaviour revealed that a minor reframing in line with recent models of attention to others’ performance same (for example, social norms change; which is why this section of relative information in a social judgment – that people are to allow comparison with the can affect choices in dieting, briefly describes a specific norms intervention greatly influenced by how they rank, person’s own performance”. Here exercise, alcohol, smoking, and intervention that has potential to increases its effectiveness. or believe they rank, amongst it becomes obvious how the other health domains). Professor Ivo Vlaev have a lasting and powerful impact Most social norms interventions others, not by how they differ cognitive theory of rank-based The generic theoretical framework on automatic motivation and health involve telling recipients how from the average, across a variety judgment provides deeper insight can also be applied universally Ivo joined Warwick Business School as a professor of behaviour in work places, assuming they compared to the average of domains, including judgments into how this technique actually across all work environments; Behavioural Science in 2014. all other essential determinants are person, which may have mixed of crimes and punishments, works at a psychological level thus revealing the way towards He received his DPhil in in place of course. efficacy. However, when people financial debt, employees’ of analysis. The ‘rank’ effects truly innovative organisations Experimental Psychology from are told the position in which wages and well-being, student demonstrate how such fine-grained promoting employees’ health and the University of Oxford before they rank amongst others, and satisfaction, income and health, understanding of the underlying ultimately their subjective well- There are some obvious working as a researcher at especially their work colleagues, exercise, anxiety and depression, mental computations allows us being. Crucially, more research is applications of this framework University College London behaviour change is more to changing employees’ health pain, income and mental distress, to optimise the effectiveness of needed on interventions that target and lecturer at Imperial behaviours in organisations. likely to occur. Therefore, more gratitude, alcohol consumption, the technique; which is one of the the automatic motivations, as this College London. Organisations are very social consideration should be given and personality judgments. most promising contributions of is the least understood factor in spaces. Therefore, the set of as to how interventions can be behavioural economics to health the behaviour production system Ivo is interested in decision making and behaviour change. shared values and practices that improved through presenting This intervention shows how behaviour change. presented in Figure 1. Conducting He approaches this from the characterise institutions and information in ways in which it understanding of the underlying such interventions promises to convergence of psychology, groups can also influence is naturally processed. cognitive mechanisms can create more effective tools for neuroscience and economics. be utilised to improve the changing behaviour and improving behaviours. This is known as the In 2010, Ivo co-authored the effectiveness of ‘behaviour change automatic effect of ‘social norms’ employee’s health across different Mindspace report published by techniques’. There has been a (or norms in the mindspace work settings and industries. the UK Cabinet Office, advising framework). Using norms as cues recent initiative within health local and national policy makers for behaviour change is often psychology, which attempts on how to effectively use reported in the literature and is to develop a comprehensive behavioural insights in their usually based on telling people taxonomy of behaviour change policy setting. He has also acted what others are doing in a similar techniques used in interventions. as a reviewer for a wide range situation. Norms motivate us to This is important, because thus we of journals and research funding organisations. act, because of evolved human can common language describing impulses to belong and seek the ‘active ingredients’ of complex affiliation with groups and similar interventions, which in turn can others. Therefore, testimonials facilitate theory development. from people most similar to the For example, a broad class of target audience, especially work behaviour change techniques is colleagues, should have powerful, encompassed by the category yet automatic influence ‘social influence’ techniques, on motivation.

20 21 WORKPLACES OF THE FUTURE

Table 1 More than half of the participants Occupational health had failed to notice a large gorilla Messenger We are heavily influenced by who communicates information walking directly through the teams interventions for developing Incentives Our responses to incentives are shaped mental short-cuts passing the basketball back and forth. In workplaces, attending to and developed countries Norms We are strongly influenced by what others do around us one thing whilst failing to attend to Defaults We “go with the flow” of pre-set options another can result in injury.

by Paul Dolan, Laura Kudrna and Kate Laffan Salience Our attention is drawn to what is novel and seems relevant to us Inattentional blindness is an important cause of errors in airline Priming Our acts are often influenced by sub-conscious cues cockpits and emergency rooms Affect Our emotional associations can powerfully shape our actions in particular. In order to reduce There is now a general consensus that changing people’s these errors, airline and health Commitment We seek to be consistent with our public promises minds about their health is not enough to change their workers use checklists, which Ego We act in ways that make us feel better about ourselves robust research shows save lives. lives. Landmark research has found that people’s intentions MINDSPACE is deliberatively in to change their behaviour explained only one-quarter of The two challenges we focus on are workplace safety and sedentary the form of a checklist to help their actual behaviour change, leaving the other 75 percent behaviour in the context of developing countries and office workers in policy makers better attend to the to be explained by other factors, including the context and developed countries, respectively. Workplace injuries are particularly principles of behaviour change, and checklists can be used to help situations within which behaviour takes place. prevalent in developing countries and sedentary behaviour in workplaces in developed countries. Our interventions to address these challenges workers better attend to safety. focus on changing context rather than cognition - operating on System In a well-known study of nearly 1, rather than System 2 – and are delivered using the elements of 4,000 patients across eight The last couple of decades of The 2010 MINDSPACE report MINDSPACE. Again, these are illustrative examples; the elements of hospitals in Jordan, India, the US, research in behavioural science on “Influencing behaviour MINDSPACE can also be applied to other types of interventions. Tanzania, the Philippines, Canada, have taught us a simple yet very through public policy” focuses England, and New Zealand, a important lesson: much of what on changing context rather Whether or not any intervention is deemed to be effective depends surgical safety checklist reduced we do simply comes about, than cognition to bring about upon the method used to assess its efficacy. We recommend that, when any patient complications by over rather than being thought about. behaviour change. It presents possible, any proposed intervention be tested in natural field experiments. a third and deaths by nearly one As Nobel Laureate Daniel key design tools, which Natural field experiments use randomisation in real-world settings to half. Although this study was not Kahneman describes, a simplified operate largely on automatic assess the causal effect of an intervention on changes in health and causal in design, other more recent model of the mind divides it effects, and which have behaviour on the target populations without their knowledge that they research using causal designs have into two distinct parts. System been consistently found to are participating in a trial, thus providing assurance that any change in an demonstrated similar benefits of 1 is the hardwired part of our robustly influence behaviour. outcome from pre to post-intervention is due to the intervention and not medical checklists. brain that processes information These effects are arranged another factor. Indeed, multiple interventions could be tested - instead of automatically and unconsciously. in the acronym MINDSPACE building one large ship that could sink, test many smaller ships, and then What is remarkable about the System 2 is the part of our brain (See Table 1). Our general invest further resources to scale-up those that float. efficacy of medical checklists to that processes information recommendation is that the reduce injury and death is that the deliberatively and consciously. Global CMO Network promotes Intervention 1: Checklists in developing countries to reduce checklist approach was imported It is now understood that System the use of the mnemonic – workplace injuries from its use in airline cockpits to 1 drives most of our behaviour. MINDSPACE – as a checklist prevent pilot error. As checklists Every 15 seconds, 160 workers have a work-related accident. Providing facts and information to for designing interventions have been effective in reducing Why do these accidents occur, and what can we do to reduce them? convince System 2 of the benefits to target occupational health injury and death in two separate of behaviour change can only outcomes. One cause of workplace accidents is inattentional blindness, contexts suggests that they will get us so far. In order to bring a cognitive phenomenon that results from not attending to one thing generalise to other workplace about extensive improvement in whilst attending to something else. In a famous demonstration of this contexts where accidental injury occupational health we need to phenomenon two teams of students, dressed in either black or white, is common such as agriculture, focus on influencing System 1 by passed a basketball back and forth between themselves. After the fishing and mining. designing the context within experiment, the volunteers were asked if they had seen anything unusual which people act. or odd during the video, or if they’d seen anyone other than the players.

22 23 WORKPLACES OF THE FUTURE

There is also evidence that they are Table 2 Intervention 2: It would seem, therefore, given the software on the computer used cost-effective: the implementation Tackling sedentary behaviour serious health consequences of at work, which aimed to reduce Messenger Instead of having mangers communicate the benefits of long uninterrupted sedentary costs are offset by a reduction checklists to mid-level employees, consider using a mid-level using prompting software sedentary behaviour, that there is in the number of complications employee from another office in a similar industry that already As a result of advances in reason to further intervene, beyond periods and total sedentary time that they prevent. Importantly, uses checklists. For other mid-level employees that need to technology in general and email provision of information about the at work in conjunction with a checklists don’t require changing use the checklists regularly, this person will likely appear to be in particular, modern office life is risks, in order to encourage more brief information session on the trustworthy and an expert - because they already use checklists people’s minds to change characterized by long hours of activity amongst workers. Recently importance of reducing long sitting - and as similar - because of their position and type of work. their behaviour (e.g. about the there have been trials to investigate periods at work. They have shown These are the three key attributes of an influential messenger. sedentary behaviour sitting at a importance of safety); instead, they computer. There is now strong various forms of interventions in the that prompting from software plus Incentives We know that people are more sensitive to losses than to automatically make salient features evidence that multiple adverse workplace, which aim to increase the education session was more gains, and so a health insurance discount could be offered to of their environment that may not the number of steps a worker takes effective when compared with workplaces that use the checklists in a loss frame, e.g. “lose out health outcomes, including otherwise be focussed upon. on saving £60 annually if your workplace does not use increased risks of type 2 diabetes, during their workday. These have information alone. a checklist.” cardiovascular disease, certain included interventions based on In implementing a checklist This is good causal evidence of forms of cancer and premature sit-stand workstations, increasing approach to reducing injuries Norms Let workplaces know (factually) how well they are doing to the effectiveness of this prompting mortality, are associated with the number of breaks and using in workplaces, we strongly reduce injuries relative to other workplaces and that checklists software in reducing both the can help. E.g. “Your workplace has 50 percent more injuries than prolonged and uninterrupted bouts software prompts to encourage recommend adopting a ‘System 1’ length of sedentary periods and other workplaces like yours. Checklists reduce injury” or “90 of sedentary behaviour. Office- people to stand up at interval. approach to compliance instead their frequency, but there percent of workplaces that start using checklists reduce their based workers are one of the single of relying on workers’ intentions to injury rate by 50 percent” Taking in to account the results are likely to be differences in largest occupational groups in implement them. Table 2 of these various trials and the its efficacy across contexts. We Defaults Any new insurance customers should be automatically developed countries such as the below provides examples of how Global CMO Network’s ambition therefore recommend that further opted-in to use checklists and must opt-out if they do not UK, the US and Australia. On this the elements of MINDSPACE could or will not use them. to achieve a high compliance rate field experiments are carried out basis we suggest that offices are be used to encourage workplaces in the intervention to improve to test the efficacy of this software Salience Checklists can be provided on brightly coloured paper to a key setting in which to measure to use checklists. workplace health, we propose that in different contexts and to attract attention. and implement changes to reduce the adoption of computer based investigate what other interventions workplace sitting with a view to Priming Checklists can be placed in easily accessible and often-used software - which prompts office the software could be bundled workplace areas, such as the break room, on desks, at improving population health. workers to stand up and walk with in order to achieve further reception, or in vehicles. However, the provision of around - should be promoted by reductions in sedentary behavior, Affect People are more likely to do something if it feels worthwhile. information alone may not be the network. This recommendation with the overall goal of establishing Providing task feedback makes tasks feel worthwhile. Provide is based on evidence from a the best strategy to bring about feedback on whether the checklists were done well/properly sufficient to motivate behavioural behaviour change in the targeted and people are more likely to do them. change in sedentary office workers. number of trials which have Indeed, in one study, when office demonstrated the effectiveness population. We again recommend Commitment People are more likely to enact behaviours if they publicly of this approach. adopting a ‘System 1’ approach to commit to doing them, and so posters within the workplace workers were provided with a range of recommendations in relation to encourage workplaces to reduce with signatures indicating a commitment to complete and Studies of the effectiveness of send the checklists to the insurance company are likely to their sitting patterns at work, only sedentary behaviour. Table 3 hourly prompts from workers’ increase compliance. eight percent of the total sample overleaf provides examples of how computers to stand up, and achieved the target goals. the elements of MINDSPACE could Ego Make people feel good about themselves when they do prompts to walk 100 steps or checklists with messaging that plays on their ego, e.g. Moreover, those eight percent be used to encourage workplaces more upon standing found that “Checklists save lives. Be a lifesaver by using them.” represented individuals who had to reduce sedentary behaviour. both groups significantly reduced been randomly assigned in to the the duration and frequency of least stringent of three targets, all their average sitting bouts of 60 of which were based on medical minutes or more. Though both recommendations. were successful in affecting the behaviour of the individuals in the trial, the stand up prompt brought about a greater reduction in sitting, while the stand and walk saw a greater increase in workday physical activity. Similarly, studies have used prompting 24 25 WORKPLACES OF THE FUTURE

Table 3

Messenger Instead of having managers or health professionals communicate the benefits of reducing sedentary activity companies could consider providing health training to a mid-level employee from each department and letting them trial the software. These people could then be tasked with the job of communicating the benefits of decreased sedentary behaviour and how best to use the software. This person is likely to be an influential messenger as they will appear to be trustworthy and an expert - because they already use the software and are knowledgeable about the health benefits – but also as similar - because of their position and type of work.

Incentives Activity could be monitored through pedometers and Professor Paul Dolan individual or office teams could be offered incentives to Paul Dolan is an internationally increase their activity levels in a loss frame, e.g. “Lose out on renowned expert on happiness, a new coffee machine for the office if your team fails to reach behaviour and public policy. the target of an average of x number of steps per day.” He is currently a Professor of Norms Office workers could be made aware of their performance Behavioural Science in the relative to other office workers in their department or in the Department of Social Policy at company. Workers could be provided with descriptive norms, the London School of Economics which factually report their performance relative to others, and Political Science and Director or injunctive norms, which reports how they are performing of the new Executive MSc in relative to how they should be performing. Behavioural Science. He was recently a seconded Defaults The prompting software could be installed on all office member of the Behavioural computers and the default frequency of prompting should Insights Team in the Cabinet be set at a level which ensures that compliance would lead to Office, and is currently Chief sufficient activity to hit targets laid out by health professionals. Academic Adviser on Economic Appraisal for the Government Salience The prompting software itself works on the basis that it makes Economic Service. He is author salient the importance of regularly disrupting sedentary activity. of “Happiness by design: Though people can be aware of the need to do so it can often Finding pleasure and purpose in become back of mind - the prompt addresses this by drawing everyday life”, published Penguin. attention to need to stand up and move around regularly.

Priming Pictures of people stretching in sports clothing could be placed in office areas to subtly encourage movement.

Affect The delivery of the prompt could be designed to evoke an emotional response in the targeted individual. One example would be to have a creaky skeleton deliver the advice to stand up and move around. Another would be to have a picture of a worker’s child accompany the message.

Commitment People could be asked to publicly commit to increasing their sedentary behaviour by signing a pledge hanging in a communal area of the office to hit a targeted number of steps.

Ego People could be made to feel good about themselves when they perform well in terms of step per week/month. For example they could be sent a personalised email to congratulate them on high levels of activity.

26 27 WORKPLACES OF THE FUTURE

David had never considered warnings on the packet, reads the joy, passion, humour and spectacle Health improvement variety of fruit before and starts Surgeon Generals message on with others in the workplace. with a fruit he recognises. Later in the bottle. It doesn’t change his Because this is what will make a the week his interest is provoked behaviour. Then he finds a message difference. Understanding from in the workplace by more unusual fruits, all with on the intranet advising of the senior leadership of the value notes on how to eat and what fishing club. David loves fishing, of health and wellbeing in the the taste will be leading to a it brings him joy and a break from workplace and that physically by Richard Jenkins journey of new sensations and new life but he hasn’t been for years, and psychologically enlightened experience. Further, the company has lost his kit and can’t afford and supported staff to deliver is sponsoring a farmers market the cost. But, all is not lost and on better results and live better lives to be in the foyer every Thursday contacting the club discovers they both in work and out of work. offering the fruits and also were sponsored some rods and We know what people should do Let me tell you a story about David. This morning, in the lift, David of the stairs to the tenth floor, vegetables, fresh and at a better kit by the company Chief Medical to be healthier, more productive David has diabetes, is overweight meets Libby. Libby is wearing a David wants to give it a go and price than the local store allowing Officers team to support people and happier. The evidence is and he smokes. He lives with his bright orange T-shirt and sporting encourages his friend to join. David to share his new knowledge back to the sport. Next Saturday, undeniable around smoking, family who are all overweight and the banner of ‘stairs supporter’. It’s fun. They get caught up in knots and experiences with his family. David is at the riverside, casting a obesity, exercise, alcohol, stress has recently lost his father to a She makes for quite a spectacle. and find out just how inflexible they Eating has become linked with line with new friends who share his reduction, etc. The future isn’t in heart attack aged 56. David spends Libby is 22 and a volunteer from both are. They are soon laughing positive sensations, emotions and passion for angling and the stress reworking the evidence, telling two hours a year with his doctor the local college studying nursing. at each other’s efforts to replicate family bonds, not the previous and anxiety ebbs away allowing people the same message over and 1,800 hours at work. During Doing all he can to avoid eye the leader’s moves. David hasn’t guilt and negativity. the ability to cope and make good and over again. The future is those two hours with his doctor he contact David gets in and presses laughed so much for weeks. decisions to return over time. delivering the messages in a is repeatedly told to stop smoking, the tenth floor. ‘Surely she can’t Two colleagues see them laughing David still worries about his His psychological wellbeing is way that people engage with lose weight and improve his diet. expect me to take the stairs to and investigate, soon joining the mother and his family. He is finding improved not through counselling and that is with stories, fun, joy He knows what he should do to the tenth?’ Libby presses nine and group of haphazard men, many of life stressful and this is beginning or medication but by a hobby and emotion. improve his health and wellbeing. gives her elevator speech: ‘get out whom are enjoying exercise for the to erode the great improvements he loves. During the 1,800 hours at work he with me on nine, we will take the first time in many years. Laughter he has been making to his physical That is the challenge and smokes, eats poorly and does stairs together to ten and I will tell and humour rather than exercise health. He knows he needs to David has since volunteered to opportunity of the CMO and little to no exercise. you a story.’ and weight loss the motivators stop smoking and also reduce his be a champion for health the senior leadership teams. for engagement. alcohol but they are the things he and wellbeing in his business, His health impacts on his life and David found it very hard to say no, reaches for most when stressed supported by the CMO team and work. He snores and his sleep exited at nine and walked up one All this activity makes David and feeling down. He sees the encouraged to share his stories, his apnoea leaves him fatigued and flight of stairs whilst Libby gave her hungry and he heads for the lacking concentration. He has story of being obese as a teenager, vending machines for a candy bar repeated periods of short sickness meeting a stairs supporter in her but things have changed. absence due to repeated bronchitis local shopping mall and being Next to the machines is an offering Dr Richard Jenkins and the worry of his widowed inspired to change. It only took of fresh fruit and it’s free. Inside Richard Jenkins is Vice President for Primary Healthcare and Family Medicine mother has meant he has failed to 30 seconds to tell her story. Libby the machine are the candy bars at Emirates Airline where he leads and manages a portfolio of clinical services finish important tasks on time or gave David a sticker to wear on his but they cost money and money including Primary Healthcare, Aviation Medicine, Occupational Medicine, with the desired quality. He is sent uniform: ‘today I took the stairs’. is tight. Also, all the non-diet Industrial Injury Rehabilitation, Family Medicine and Clinical Psychology which to the Occupational Health Clinic Amazing how proud a grown soda cans are gone, replaced by are delivered to eligible staff and their families. who advises him to lose weight, adult can be of a sticker and the a free water fountain or diet soda A previous Group Medical Director and GP Partner, he has experience and eat better and stop smoking. emotional connection was made in the machine. David still has a expertise in board and operational governance, clinical systems improvement, He knows that already. It’s between stairs and a good feeling choice, the fruit is not mandated patient safety and clinical leadership. Previous roles include member of the UK not working. inside. He thinks he will take the and the candy is still there but the Improvement Faculty, a founder member of the Faculty of Medical Leadership stairs again next time. opportunity to choose the better and Management and Deputy Chair of the BMA Medical Managers Committee. option is improved. Making the At lunch, David and a colleague right choice has got easier, the He has several years’ experience of presenting to health care audiences nationally and internationally plus written notice a group of men in the wrong choice harder. There is also discussion documents for The Kings Fund and RCGP. Richard lives in Dubai, UAE with his family. foyer. They were being taken an information sheet giving advice through a short tai chi class. and tasting notes on the five types Feeling motivated by his ascent of apples available. 28 29 WORKPLACES OF THE FUTURE

Because they are minimal, they As an instance of the MONO You see when you issue an Minimalist, oblique offend people’s sense of self­ solution in medicine, I would immediate prescription to a importance. People might advance the idea of the deferred patient, there is a very strong grudgingly accept that small prescription. For years, thousands tendency (a “latent bias in the and non-obvious nudges of this kind might change of perfectly intelligent doctors choice architecture”) which will people’s behaviour when it is assumed that there were only two prompt them always to take the a matter of choosing a free options when a patient came with, pills immediately. They will almost by Rory Sutherland promotional spoon, but they are say, a respiratory tract infection: certainly go to a pharmacy soon highly reluctant to believe the after leaving the GP’s surgery 1. prescribe antibiotics same techniques might have any (if the surgery does not have its bearing on “serious” policy areas 2. don’t prescribe antibiotics own pharmacy). Once they have Recently a large cereal company began a promotion where you could such as education or health. paid the £8.10 prescription charge, The third, new, oblique option there is a strong sunk­cost bias collect codes from three packets of breakfast cereal and redeem them where the GP can issue a deferred Finally, because they are oblique, to take the pills. It feels wrong to prescription for antibiotics, online for a free spoon. You could choose between a large spoon and they may require a little more spend £8.10 on pills you then delayed by anything from one a small spoon. effort to implement and to justify do not use. within an organisation. Logical, to seven days, was a perfect economic or legal minds lean example of a MONO idea. This is often the case with MONO towards the kind of mechanistic, Minimalist, Oblique and (clearly, ideas. The pre-­existing problem And, from the start, everyone So they did this. And the problem direct solution that gets nodded since so many people had never only becomes apparent when Why aren’t schools, districts wanted a large spoon. In fact the went away. Labelled like that, through as “obviously sensible”. even considered it) Non­Obvious. you have come up with the and states rushing to set company was worried that they people’s preferences were Changing the names of a spoon is new solution. It seems to make patients no might run out of large spoons completely different and much up these measures? Maybe more lateral; it may cause a little less happy than if antibiotics were and end up with a surplus of the more evenly spread. because the programs have no more headscratching:­ you may I am quite often asked for prescribed immediately. And yet small ones. natural constituency. There are well need to perform a test to recommendations on books which it reduces the number of people This is a very simple example of not labor-or-capital-intensive, justify your intuition. everyone should read on the At this point, had they consulted a solution which is what I call so they don’t create lots of jobs taking antibiotics by over 50 subject of behavioural economics. an economist, they would have MONO Minimalist, Oblique and or lucrative contracts. They Lastly, because such solutions are percent. The percentage reduction There are, in truth, about 20 I learned that the solution was Non­Obvious. don’t create a big, expensive nonobvious,­ it is quite often that in the unnecessary prescription of would happily recommend: Daniel simple. You would need to reduce initiative that a politician they lie in areas where people do antibiotics is, I suspect, even higher. Kahneman’s Thinking Fast and the price of the small spoon or I don’t claim that a MONO solution can point to in a stump not think to look. Slow, Thaler & Sunstein’s Nudge As with the problem of the spoons, increase the price of the large always work or that you will be speech. They just do their job, and Dan Ariely’s Predictably the original problem is only spoon. Perhaps you could demand able to find one to solve every effectively and cheaply. Irrational would always appear on obvious in retrospect. If offered a only two codes for the small problem. However they are always this list. These books all make the large or a small spoon, who would spoon, or four for the large one. worth looking for. And one thing Susan Dynarski, point that we do not always act in choose a small one? And who, Or perhaps the new choice could I can confidently assert: you should writing on educational policy accordance with the theories of when given an immediately valid be “one large spoon or two at least try to find a MONO solution nudges in the New York Times mainstream economics. prescription, would not start taking small spoons.” first, before trying something more drastic, more elaborate or the treatment immediately? Fortunately they did not consult more costly. an economist. Someone from their media agency had a better Unfortunately organisations are idea. “Why not simply re-label heavily predisposed to do the them large spoon and small opposite. They either leave the spoon as “Adult Spoon” and small tactical tweaks until last “Children’s Spoon.” almost as an afterthought or they don’t even look for them at all. Everything in the structure of large organisations works against small solutions.

30 31 WORKPLACES OF THE FUTURE

But there are three books less often read which Between them, they contain three vitally important So, if you can happily accept the You might also like to consider are vital to understanding ideas which are: principles in how to intervene in any complex system. idea, undignified as it may seem, different names for such tests. 1. Small that there is value in borrowing small First of all, the idea that small things can have large nudge ideas from marketing and The conventional view is that 2. Oblique effects. It is perfectly possible to change the level seeing if they apply in the far more these small behavioural biases 3. Non Obvious.­ of consumption of antibiotics by more than half by serious world of medicine, allow me “may well apply in trivial matters simply adding to a GP’s range of choices. to advance two suggestions I would such as choosing a spoon” but love to see tested. disappear when people are Second, the idea that successful interventions are considering being tested for often oblique. The deferred prescription does not First of all, if you want people to cancer. You would think that, change anything about the availability of antibiotics, complete a course of antibiotics, wouldn’t you? I thought it for it operates in a different dimension by changing the try building in a little variability many years. timing (simply adding a buffer). into the prescription. Don’t give people 48 white pills; instead give The surprising truth is that, if Rory Sutherland Thirdly, in Timothy D Wilson’s book, Strangers to them 40 white pills and eight anything, these effects are even Rory has worked at Amex, BT, Ourselves, Wilson explains why many solutions in blue ones. Instruct them to finish greater when people are making Compaq, Microsoft, IBM, Bupa, human behaviour will always be NonObvious. It is the white pills and then take the big decisions than when they easyJet and Unilever. He was simply because most of our decisions are in effect blue ones. My contention is that make small ones. appointed Creative Director of made unconsciously. Even with the best efforts in the number of people who don’t OgilvyOne in 1997 and ECD in 1998. In 2005 he was appointed the world, we cannot always use introspection to complete the course will drop Vice Chairman on the Ogilvy understand why people behave the way they do. In dramatically. many cases experimentation is the best we can do. Group in the UK.

Secondly, if you would like more He was President of the Direct If everyone in medicine understood these three people willingly to submit to tests Jury at Cannes in 2007, and was principles, and simply resolved to search for one for prostate cancer, for instance, elected President of the Institute new MONO idea every year, the transformative effect borrow a lesson from credit ­card of Practitioners in Advertising in could be immense. and loan companies. Tell people 2009 for two years. Rory is also how quickly they can expect a a visiting professor of Warwick result. People hate uncertainty. University and was recently (2012) awarded an honorary doctorate An uncertain duration of (D. Litt) by Brunel University, uncertainty is something they hate he is also the Technology even more. Promise them to text a Correspondent of the Spectator. preliminary result in 24 hours and a final result three days later, and see how much more willing people may be to be tested.

32 33 WORKPLACES OF THE FUTURE

However, a lot of work is needed techniques (delivered face-to-face, Workplaces and the to help many people reach this online or through peer support) level of confidence and self- for pain management, coping with efficacy. This should be the goal fatigue and identifying the early self-management of co-morbidity of self-management interventions. signs of depression or anxiety.

Recent research by The Work The success of interventions by Stephen Bevan Foundation has found that several focusing on the self-management behavioural interventions aimed of co-morbid health conditions at at workers with long-term work is based on empowerment, conditions can play a significant self-confidence to ‘lead’ the Many people of working age with long-term physical health conditions also have co-morbid part in improving clinical development of workplace mental health problems – especially depression and anxiety. These can lead to significantly outcomes and supporting both accommodations and self- poorer health outcomes, reduced quality of life and reduced work productivity. The costs to job retention and return to work. awareness of the development Professor Stephen Bevan the health care system in the UK are also significant – by interacting with and exacerbating The interventions included patient of the early symptoms of Stephen Bevan is Director education, intervention to improve psychological distress accompanied of the Centre for Workforce physical illness, co-morbid mental health problems raise total health care costs by at least 45 self-confidence and develop self- by early support-seeking behaviour. Effectiveness at The Work percent for each person with a long-term condition and co-morbid mental health problem. advocacy skills, online support, There is growing evidence that Foundation and an Honorary Research evidence consistently demonstrates that people with long-term conditions are two and peer support such as ‘buddy’ online approaches can be especially Professor at Lancaster University. Stephen has conducted research schemes among cancer survivors effective as they can be accessed to three times more likely to experience mental health problems than the general population. on high-performance work or people recovering from at a time when they are most practices, employee reward mental illness. needed by the employee and can strategy, staff engagement and be used to reinforce behavioural Overall, the evidence suggests is impeded significantly by poor help their managers and co-workers retention and Good Work. He is Behavioural interventions in coping techniques learned in that at least 30 percent of all mental health, which can reduce to understand what support they an advisor to a number of UK workplaces to support employees face-to-face education or training. people with a long-term condition the motivation and energy needed need to remain productive at work government departments and with co-morbidities to self-manage Several studies attest to the also have a mental health problem for self-management, and lead to can help reduce sickness absence has advised employers and policy their health need to focus on growing body of evidence here, makers in Europe, Asia-Pacific, and that, by 2030, close to 40 poorer adherence to treatment and undermine the pressure to several areas. First, awareness with many showing strongly Australasia and North America. percent of the working age plans. There is strong evidence struggle on when ill (‘sickness training among line managers elevated levels of job retention In 2014 he was named the 6th population in many developed that people of working age who presence’). This support can of the need to support early and return to work among workers most influential HR thinker in economies will have at least are confident to self-manage their include flexibility in work schedules referral to occupational health whose self-management skills have the UK. one work-limiting long-term long-term condition in the (start and finish times), technology- and occupational therapy support been improved. condition. Co-morbid mental health workplace experience less lost enabled homeworking, job rotation Stephen is a reviewer for several for employees and the need to problems have a number of serious working time and can play a more to avoid strain, fatigue or anxiety, academic journals, including The encourage employees to play a The Global CMO Network implications for people with long- active part in managing workplace adjustments to performance Lancet and is Chair of the UK Fit leading role in the management can play a very practical part for Work Coalition and Director term conditions, including poorer adjustments and phased return targets, graduated or phased return of their conditions at work. in the development, testing, of The Work Foundation’s Health clinical outcomes, lower quality of to work. to work. Some of this focuses on Second are education and evaluation and dissemination of at work policy unit. Stephen has life and reduced ability to manage practical adjustments to working coaching/mentoring interventions a range of behaviourally-focused recently been given the 2014 physical symptoms effectively. The biopsychosocial model of care time or to tasks. Some is about which support employees to interventions to support the GAMIAN-Europe Personality A significant part of the explanation and rehabilitation tells us that, culture, climate, team working improve their self-confidence and growing number of employees award for his research on mental for poorer clinical outcomes is that many people with long-term health and a supportive environment. self-efficacy in managing their who will develop co-morbid illness and work across Europe. co-morbid mental health problems conditions need support from Often a confident worker with conditions at work. These need mental illnesses alongside chronic can reduce a person’s ability to Occupational Health professionals, a health problem can suggest to have a psychosocial focus and physical health conditions. Some actively manage their own physical Occupational Therapists or Clinical adjustments which help them will need to emphasise coping of this effort will include collating condition and are associated with Psychologists if they are to play remain productive at work and strategies in relation to physical existing educational and online unhealthy behaviours such as an active part in the confident help the team meet its targets symptoms and psychological material. Further effort will be smoking. Self-management is at self-management of their health. – a mutually beneficial solution. distress. These may include needed to ensure that a core set the core of effective treatment for Specifically, help to improve their education and behavioural of evidence-based material is long-term conditions – but this perceptions of self-efficacy and to available to employees in large and small organisations.

34 35 Preventing psychological ill health Corporate and Social Responsibility by Bill Mitchell 38 (CSR) strategies providing high quality employee supported volunteering IMPROVING Implementing a common standard opportunities can significantly improve to measure ideal cardiovascular workplace health health in the workplace by Phil Veasey 60 EMPLOYEE by Eduardo Sanchez and Chris Calitz 42 Creating a ‘blue print’ for intervention Targeting the underlying issues development and implementation to have a transformative impact by Robert West 64 ENGAGEMENT on employee health by David Halpern 46 Setting clear goals for behaviour enabling good choices change interventions Use behavioural economics to by Steve Haynes 68 achieve wellness goals by Kevin Volpp and David Asch 48 Interview with Professor Susan Michie on workplace health Why you need an by Susan Michie 72 ‘employee-centric’ approach by Mark Cobain and Holly Whelan 52

A global mass participation movement by Mike Standing 56

36 37 IMPROVING EMPLOYEE ENGAGEMENT

Observable signs in the workplace Figure 1: Recognising the signs of going off-track Preventing include: changes in behaviour such as irritability, withdrawal or Wellbeing moodiness, mistakes which are Feeling overwhelmed out of character for that individual, psychological ill health Less in control signs of fatigue and low mood visible on the face or posture, Anxious by Bill Mitchell sustained or becoming worse over Difficulties a few weeks. Sleep disturbed These signs would suggest the Reduced resilience person might have moved into Tired, struggling Preventing psychological Other major illnesses – heart We are used to thinking about the stress pathway leading toward Mood low, less decisive disease, cancers, diabetes – tend behaviour changes which could mental ill health. ill health is one of the to affect those who are over 55; reduce the risk of heart disease; Feelings of failure biggest challenges in psychological ill health is the we are less used to the idea of Depression, ill health the medical arena today. biggest threat to health in the behaviour change that could late teens to fifty-five age group. reduce mental ill health. According to the World It is estimated that in the UK the Tools for behaviour change Health Organisation business cost of mental ill health Before a person goes from Employees are provided with tools to encourage The core areas we focus on for maintaining optimal psychological wellbeing to (WHO) psychological amount to over 15 billion pounds behaviours that make it less likely that the person will good psychological health are represented in the due to reduced productivity at mental ill health, he or she travels slip into the stress curve culminating in psychological diagram below. ill health accounts for 38 work. Approximately 70 million down a very gradual pathway of ill health. This is an application from the questionnaire percent of all ill health in working days are lost a year due behavioural and cognitive changes used on the Performance Energy courses to motivate Figure 2: Psychological fitness to mental health problems. The which makes them less and less participants to commit to sustainable changes in areas high-income countries. WHO estimate parallel figures able to deal with the pressures of such as exercise, sleep routines, optimal nutrition, for middle-income countries but life. Early identification of stress relaxation approaches, reduced alcohol consumption acknowledge that the data sets are signs, the recognition that one and social and relationship time, all of which relate to often unreliable or non-existent. is on the pathway is critical to stronger mental wellbeing. In addition to the economic costs, prevention. Intervention in the psychological ill health takes an workplace could have a key role The Performance Energy course was introduced Energy enormous toll on the ability of in prevention of psychological to Bupa at the end of 2013. So far, over 700 people to lead happy, productive ill health. leaders and managers have gone through it. lives. But, in many cases time off for psychological ill health could be Building self-awareness through The aims of the course are to encourage behaviour peer group support changes in three core areas to reinforce mental prevented by earlier identification Busy-ness and by reinforcing behaviours The practical proposal here is energy, resilience as a protection against stress, which could have a preventative that employees commit in small work effectiveness and cognitive changes to • Behaviours that reinforce the physiology of mental effect on the development of groups, to look out for one another, reinforce positive healthy mindsets toward change health include: exercise, sleep, nutrition, low alcohol, psychological ill health. to have open conversations about and challenges of life. Adopting positive attitudes relaxation time, social life and relationship time. identifiable signs that indicate that and mindsets have been linked to the adoption someone has moved into the stress of health related behaviours such as diet and • Behaviours which related to making good choices, curve and that they encourage exercise. Better health outcomes and positive include any behaviour which allows the person behaviour change and support for mindsets have also been associated with improved to feel he or she is marginally more in control of the sustainability of the intervention. work performance, effectiveness and psychological complex life circumstances rather than feeling well-being. helpless or done to. This pathway from potential well- • The way we see things refers to ways of seeing being to ill health may take many one’s life circumstances and also attitudes about months before clear symptoms of oneself which could have a positive effect on psychological ill health develop. mental wellbeing.

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Complexity of life Prioritising resilient behaviours Cognitive exercises Throughout the programme, To encourage engagement with Clinical practice tells us that Intervention in When work demands become we would enlist workplace peer the programme the message is complex life circumstances overwhelming or when life support to encourage the use personalised depending on the can lead to a person becoming the workplace becomes more complex and of these tools and reinforce person’s score on a complexity of overwhelmed which in turn leads potentially stressful there is also sustainable behaviour change life questionnaire. For example, them to give more and more to could have a key a tendency for a cognitive shift to making it more likely to engage a person working 40 hours a the demands and reduce time occur whereby the person tends a sizeable proportion of week with two preschool children, for behaviours which could role in prevention to think in a more negative way the target population. who is also looking after elderly reinforce their resilience and mental which undermines effective Measurement instruments to relatives and has started a new energy creating a dysfunctional of psychological coping. It is not unusual for assess the impact of the job in the last year, would score in spiral. An online questionnaire normally confident people to ill health intervention would include: the highly complex life category. assesses what participants are start to undermine themselves the Performance Energy Such a person has a high potential prioritising in key behaviours with self-doubts, anxious thoughts questionnaire and performance Dr Bill Mitchell for stress and exhaustion which that reinforce mental energy and and beliefs that they are failing stress measures, the Hospital could lead to ill health even though resilience. They are encouraged others. This type of cognitive shift Bill Mitchell is a clinical Depression and Anxiety Scale at that time they might not be to prioritise time for one or two can move towards depression. psychologist working on and Beck Depression Inventory. showing any stress signs. behaviours which could have a Online tools encourage short contemporary cognitively based preventative effect. cognitive exercises to reinforce psychological approaches to The proposal The questionnaire would assess resilient attitudes and help the treat anxiety states, depression, complexity of life through asking The questionnaire scores the person maintain a stronger mindset The proposal is that we would stress reactions and chronic questions about: individual on how frequently and towards themselves and their assess the viability of this peer fatigue states. He has a particular group led approach to preventing interest in treating work related • number of hours worked regularly they use behaviours coping ability. psychological difficulties which are associated with good psychological ill health in relevant per week recognizing that many people mental health including: These cognitive exercises come divisions of the Global CMO • ages of children work in circumstances that can from research on wellbeing and Network member companies • exercise easily lead to the loss of any • the extent to which the happiness as well as from cognitive where there is already support • relaxation time balance to life which increases person feels supported by at a senior level to do something therapy and our own clinical the potential for them becoming partner, friends, family • sleep practice. Examples of five minute proactive about improving health exhausted or ill. • whether or not the person is • diet from a blood sugar cognitive exercises include: and wellbeing. He also works as a consultant supporting elderly relatives stabilising perspective • short mindfulness exercise to a number of companies and or chronically sick members • low alcohol consumption involving slow diaphragm of the family professional service firms; he • social time breathing with one’s mind in leads workshops on such areas as • recent changes such as • relationship time the moment Managing Yourself, Resilience, and change of job, house move, Managing Personal Change. • time for them mid-week • reflect, visualise things you relationship breakdown feel grateful about today He lectures on the Kings College London MSc programme on Individuals should score themselves • visualise something that gave It has been our experience that Mental Health Studies and he is on a regular basis, the information you a sense of accomplishment complexity of life is a major risk a visiting lecturer at the London is presented in a motivating way recently – think about what you factor for psychological health Business School. and how they are doing on a in non-managerial front line are good at that allowed you to month-by-month basis could be employees while struggling to achieve that result. shared with members of their peer manage work demands, significant group to encourage sustainable work changes and difficulties behaviour change. balancing life are risk factors for managers and knowledge workers.

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Implementing a common standard to measure ideal cardiovascular health in the workplace by Eduardo Sanchez and Chris Calitz

The American Heart To achieve impact at scale, the mortality rates are declining in the “Lieutenants” from each company, a 50-year old with ideal An online risk assessment and AHA has convened the CEO US because of effective treatment senior leaders who are typically cardiovascular health has health promotion tool – My Life Association|American Roundtable, a group of 23 CEOs and prevention, but the prevalence Chief Medical Officers or Vice- substantially lower lifetime Check™ - and a composite heart Stroke Association from Fortune 1000 companies of obesity and diabetes in adults Presidents of human resources risk for cardiovascular disease health score (range zero to ten) (AHA|ASA) is focusing committed to promoting Life’s remains high. Adult smoking or benefits. Both groups meet and markedly longer survival. based on Life’s Simple 7 has Simple 7 as an evidence-based rates have declined, yet roughly independently on a quarterly basis Unfortunately, several surveys been developed. This scoring on the workplace to common standard to measure 42 million adults (18 percent) still to review progress and reestablish have demonstrated that very method is more “salient” than reduce the high burden and monitor workplace health. smoke. High blood pressure affects goals. Webinars addressing few Americans have ideal basing it on seven metrics and of chronic disease in Together, these CEOs are one in three adults, yet less than specific topics, such as tobacco cardiovascular health. Only 18 is easily understandable. leading by example to help meet half have their blood pressure control strategies, are arranged percent of Americans have five or Several studies have shown a the US by promoting AHA|ASA’s goal of improving controlled. Comprehensive on an ad hoc basis to share the more metrics with ideal levels, strong linear association between the adoption of Life’s the cardiovascular health of all workplace health promotion latest research and best practices. with lower prevalence among men this heart health score and Americans 20 percent by 2020. programmes grounded in science Together, these companies have (11 percent) compared to women cardiovascular disease incidence Simple 7, a scientifically Global organisations can adopt and fully implemented have been an estimated reach of ten million (25 percent). Studies have also and mortality, which makes Life’s validated measure of Life’s Simple 7, which is simple to shown to improve employee health, employees and their dependents. shown that people who meet three Simple 7 and My Life Check™ a cardiovascular health. understand and easy to measure. reduce absenteeism and generate The CEOs are focusing on the to four of Life’s Simple 7 measures potentially effective framework Doing so will allow firms to savings from reduced healthcare AHA|ASA prescription for reduce their risk of heart-related for individual and public health monitor the cardiovascular health costs and increased productivity. health called Life’s Simple 7 death by more than half. However, interventions, including workplace of their employees and compare – a scientifically validated an AHA|ASA Nielsen study showed health promotion programmes. improvements with peers. To improve employee health and measure of cardiovascular health that most people do not know increase the implementation and and a pathway to achieve ideal their Life’s Simple 7 numbers The workplace is a promising evaluation of comprehensive cardiovascular health. It comprises and most US adults overestimate setting to promote health and workplace health programmes, the four modifiable behaviours - not their heart health: 39 percent of prevent chronic diseases: there are AHA|ASA has convened the CEO smoking, healthy weight, eating people surveyed thought they roughly 156 million working-age Roundtable, a group of 23 CEOs healthy and being physically active were in ideal cardiovascular health adults in the US; more than 80 representing some of the country’s - and three important biometric whereas studies show that roughly percent of annual US healthcare biggest employers. Together, these measures - blood pressure, one percent of Americans have costs are spent treating people CEOs have committed to form a cholesterol and blood sugar. ideal levels for all seven metrics. with chronic diseases such as learning collaborative and actively These seven metrics are classified Therefore, employers can use the heart disease and high blood serve as role models for healthy into three clinical strata: ideal, science of Life’s Simple 7 to assess pressure, and two-thirds of these living in order to enable and intermediate and poor. Individuals the heart health of their employees costs are incurred by working- sustain a culture of health in their with ideal levels for all seven and monitor progress towards age adults younger than 65 years. workplaces. The vision of the CEOs metrics are considered to have improved heart health. Cardiovascular disease and stroke is operationalised by designated “ideal cardiovascular health”; 42 43 An enhanced version of My Life To provide an additional external Recommendations for the Global Studies have also Check™ will launch during 2015 incentive to improve employee CMO Network and contains activation strategies health, AHA|ASA will be announcing Organisations can adopt the shown that people which encourage employees to a new national recognition and Life’s Simple 7 construct as who meet three to choose lifestyle behaviours based award programme for workplace a validated measure of ideal on their specific risk factors. It health. This award programme cardiovascular health. It is a four of Life’s Simple also provides them with health will build on AHA|ASA’s existing science-based measure that 7 measures reduce communications and links them Fit-Friendly Worksite recognition has relevance for healthy people, to resources to adopt healthier programme by adding a greater people in pre-disease states and their risk of heart- lifestyles. The updated version also emphasis on performance measures those with cardiovascular diseases. allows employees to synchronise using My Life Check™ as a validated, related death by The composite score of My Life their wearable health monitoring standardised measure of ideal Check™ offers a compelling more than half devices, which enhances tracking cardiovascular health. This platform starting point that is “simple” to Dr Eduardo Sanchez Chris Calitz health behaviours. The data provides an objective and consistent understand and relatively easy Eduardo Sanchez serves as Chris is the Director of Health platform will enable longitudinal assessment over time of workplace to measure using existing health Chief Medical Officer (CMO) for Programs and Evaluation for the assessment of cardiovascular wellness programme’s achievements risk assessments used in the Prevention for the American Office of the Chief Science and health at the individual and in cardiovascular health. workplace. As more organisations Heart Association (AHA). He Medical Officer at the American aggregate company levels, as know their baseline aggregate brings an interest and experience Heart Association (AHA). He is well as multilevel benchmarking. heart health score, they can track in prevention and population primarily responsible for health The CEO Roundtable companies improvements, and compare their health to AHA. Prior to joining strategy and policy for the AHA are working towards the performance with their peers. AHA, he served as Vice President CEO Roundtable, twenty-three implementation of My Life Check™ Organisations can also use the and CMO for Blue Cross and Fortune 1000 CEOs committed Blue Shield of Texas (BCBSTX) to creating a culture of health during 2015-2016 and represents heart health score to educate where he focused on worker to improve employee health a large sample to assess the use employees about the gap between and worksite wellness, clinical and productivity. Previously, of this tool in the workplace. their perceived and actual health, prevention, and chronic disease Chris was a policy analyst for and tailor wellness programming management, particularly The Vitality Group, a joint to further motivate healthy diabetes and cardiovascular venture between Humana and behaviours and reduce the disease. Discovery Health. burden of chronic disease. Eduardo currently serves as Chair Chris had served as an expert of the Partnership for Prevention panelist on workplace wellness Board of Directors, the National for the Center for Disease Control Commission on Prevention and Prevention and the national Priorities, and the Texas Public advisory board for the Corporate Health Coalition. He also serves Health Leadership Program on the Institute of Medicine’s convened by the Robert Wood Roundtable on Obesity Solutions Johnson Foundation. Chris and on the Board of Directors co-founded the MEND Program, of Trust for America’s Health, an evidence-based childhood Academy Health, the Public obesity prevention program. Health Institute, and the CATCH He led the multidisciplinary team Global Foundation. that successfully adapted and disseminated the program in the US and Canada. A member of the Alpha Chapter of the Delta Omega public health honors society, Chris graduated with a Masters of Public Policy (with honors) from John Hopkins University.

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Targeting the underlying issues 79 percent of young employees want to to have a transformative impact work for an organisation that cares about how it affects society and 64 percent on employee health said that it would inspire loyalty by David Halpern, Veerle Snijders and Michael Hallsworth

Around half of US There is now extensive literature acknowledging an employee’s a bigger effect than the givers the opportunity to volunteer during work, even if the employee employers offer wellness on the correlation between strengths and allowing employees themselves anticipate. There are job engagement and stress: to spend time on what they find two conditions which are necessary does not take advantage of it, promotion initiatives, but disengaged employees have double interesting and important. Involving for this benefit to be felt: the is associated with higher life evidence suggests that the risk of being depressed, higher employees in making decisions contributor must see the difference satisfaction; higher employer these interventions only stress levels and higher risk of heart (even small ones) increases job their actions make, and they must identification; and better job disease. In this light, it is worrying satisfaction. More broadly, a critical feel that they freely chose to make performance. Several organisations have minimal effects. that a 2013 worldwide Gallup factor for wellbeing is the quality the contribution. that have an official volunteering study found that only 13 percent of of the relationships between the scheme in place confirm One limitation is that most employees were engaged at work, employees and their managers: Examples of how organisations these findings. programmes only target physical costing the US alone between $450 a one point increase in trust in can implement these findings health, and thus fail to address an billion to $550 billion each year in management (on a ten-point scale) include: offering small rewards Therefore, our recommendations underlying cause of poor health: lost productivity. has the equivalent effect on life (e.g. coffee cards) that employees for members of the Global CMO employee mental wellbeing. satisfaction as a 36 percent are advised to spend together with Network are to review their Dr David Halpern What can we do to address these change in income. a colleague; having a fund from working practices to stimulate The seminal Whitehall studies David Halpern is the Chief problems? There is an increasing which employees can make small trust, engagement and friendly provided some of the first evidence Executive of the Behavioural body of evidence that shows Perhaps the more innovative option donations to another colleague; relationships between employees of how psychological factors in Insights Team - often known as that relatively small changes to is to help employees help others. and donating money to a charity and management; restructure the the UK Government’s ‘Nudge the workplace could harm physical organisations can raise the mental Employees who had donations of the employee’s choice. The latter reward and incentive schemes Unit’. He has led the team since health. The Whitehall studies wellbeing of employees, and made on their behalf were happier has shown to lead to a 20 percent to take full advantage of the its inception in 2010. Prior to that, showed that employees in lower thereby also improving physical and more satisfied with their rise in productivity, independent of benefits of prosocial rewards; David was the founding Director clerical or manual jobs had triple health. This evidence boils down jobs, which can lead to increased whether the donation was related and introduce a (health focused) of the Institute for Government the odds of poor general health to two principles: be nice to productivity. Additionally, people to performance or the size of employee volunteering scheme. and between 2001 and 2007 was and double the odds of poor your employees, and help your who were randomly assigned to the donation. Because, as the above examples the Chief Analyst at the Prime mental health than more senior employees to be nice to each other. spend a certain amount of money show, it might be time to change Minister’s Strategy Unit. Before grades, which could not be entering government, David held While these principles may sound on others were not only happier Increasingly, businesses recognise the way we look at employees’ explained by baseline health or tenure at Cambridge and posts glib, they are underpinned by some but also experienced lower blood that staff engagement goes health. Of course, we should risk factors. at Oxford and Harvard. He has hard-edged evaluation. pressure and had lower levels beyond the office doors. Survey still support healthy eating written several books and papers data suggests that 79 percent of of cortisol than those who were and exercise by making these on areas relating to behavioural Let’s start with some relatively young employees want to work for assigned to spend the money on behaviours as easy and attractive insights and wellbeing, including small things. Allowing employees themselves. A dual pathway to an organisation that cares about as possible, but we also need Social Capital (2005), the Hidden to design their own job title can these fascinating results appears how it affects society and 64 to target underlying issues, like Wealth of Nations (2010), and co- significantly reduce emotional to be that giving to others (a) percent said that it would inspire a lack of engagement and low author of the MINDSPACE report. exhaustion. Making the end result promotes communication and loyalty. One way of increasing levels of wellbeing, to have a truly of employees’ work clearer and social connection within the this social impact is by allowing transformative impact more visible significantly increases organisation, and (b) giving makes employees to volunteer during on employees. wellbeing. So does explicitly people feel better – and with work time. Although this may seem counterintuitive, having

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Money has its limits as a carrot An enormous industry in sent automatically. This changes Use behavioural economics The next step beyond education wellness is devoted to this the architecture of the selection to has been the use of financial highly transactional approach of that of an enhanced active choice: incentives, which target behaviour delivering points, badges, miles, It highlights the disadvantages to achieve wellness goals rather than knowledge. The implicit or dollars to encourage good of the lesser alternative while argument is that if we pay people behaviour. Section 2705 of the retaining individuals’ freedom Affordable Care Act increases the to decide. When we tried this by Kevin G. Volpp and David A. Asch for health-promoting behaviours, they will engage in them. It works amount of money employers in approach with CVS Caremark to a certain extent, but typically the US can put at risk for members, the number of people not as much as programme improving these behaviours choosing automatic refills more or outcomes. The transactions than doubled. Conventional wellness programmes rely heavily on education and transactional financial sponsors would like. are more effective at changing incentives to encourage employees, insurance plan members, and patients to lose weight, If we lower the co-payments behaviour than education alone, Or consider an employer who stop smoking, and manage their chronic health conditions. Those programmes, though on medications, as value-based but the premise underlying these is unhappy with the completion intuitively appealing, achieve less success than new, practical approaches derived from insurance design suggests, programmes is that people rate for employee health-risk assessments (HRAs). Instead of behavioural economics, which help us identify and overcome some of the psychological adherence does go up, but not by make decisions rationally. enough to matter. The landmark However, several decades of merely doubling the incentive from barriers that undercut our health goals. The first step in benefiting from behavioural MI FREEE study, which made research reveal that many of our $25 to $50, use existing groupings economics is getting past our reliance on our old ways. medications free after a heart decisions don’t reflect rational within the workforce and randomly attack, increased medication choices, but rather irrational pick one group each week to win adherence from a disappointing 39 thinking that occurs in predictable at each worksite. Anyone within that group who has completed Why education alone Larger still are factors related to percent at baseline to 44 percent ways. Experts in behavioural his or her HRA wins $100; if more doesn’t work social position. But how we live — better, but still disappointing. If economics have been able The first step in to harness this predictability than 80 percent of group members On April 12, 2007, New Jersey our lives — whether we smoke, we pay employees for completing and lead us to the healthful complete the HRA, each member benefiting from Governor Jon Corzine was in exercise, take our medications, health-risk assessments, some behaviours we seek. The state of of the group gets a $25 bonus. the front passenger seat of a and wear seatbelts — substantially fill them out, but most don’t. behavioural the art in wellness programmes The odds can be structured to car involved in a motor vehicle determines how long we live and Increasing the payments improves moves beyond education yield the same overall cost as the economics is accident. The accident lacerated the health we enjoy. Everyone participation, but that gets and transactional incentives basic doubled-incentive approach. flesh and broke bones, and he is interested in wellness, yet expensive as costs quickly outpace getting past our toward behavioural economics But the design harnesses the required mechanical ventilation in everyone’s first suggestion for diminishing returns. If the savings approaches, which are simply strong effects of social norms and reliance on our a trauma center before eventually achieving it is education. or rebates for desired behaviour better at getting people to do avoidance of regret: People hate recovering. Corzine had been a are buried in other payments — old ways what naturally they want to the idea that their team might be highly paid CEO of Goldman That approach seems reasonable, as when employers reduce health do anyway. selected, other members of the Sachs and a US senator before until you think through its implicit insurance premiums for workers team get a prize, and yet they becoming New Jersey’s Governor. assumptions: If we tell people who meet certain health standards Putting behavioural economics themselves lose out because of He was a controversial figure that smoking is dangerous, they — the rewards are hidden among to work something they didn’t do but that politically and financially, but no will stop. If people are informed other paycheck deductions and Let’s say you want to improve was easily within reach. The result: one would ever call him stupid. about the benefits of exercise, become less salient. The results medication adherence among your The HRA completion rate rose Nevertheless, he wasn’t wearing they will go for a run. If only are often disappointing. employees, the members of your from 40 percent to 64 percent, a seatbelt, and reports suggest someone had told Jon Corzine pharmacy benefit plan, or your compared with the 40 percent to he never had. that seatbelts save lives. Health education is critically important, patient population (depending 44 percent increase yielded by merely doubling the incentive. Employers, health insurers, but if we devote resources to upon whether you are an employer, doctors, and health systems educating people about what they an insurer, or a provider). increasingly recognize that already know but don’t do, we may You start by offering an automatic everyday behaviours are among overlook more practical solutions. prescription-refill program, but the most important determinants instead of a traditional opt-in of health. The care we receive for programme, present a required cancer or heart disease makes a choice: (1) the inconvenience of huge difference. refilling prescriptions manually each time or (2) having the refills 48 49 IMPROVING EMPLOYEE ENGAGEMENT

Putting behavioural economics Here are some specific • Turn repetitive activities, like within reach suggestions for the Global CMO taking medication, into a daily Professor Kevin Volpp The aim of behavioural economics Network for implementation: game in which people are Kevin is a Professor at the School of eligible to participate only if is not just faddish games that • Instead of giving a reward Medicine and the Wharton School of they took their medication the the University of Pennsylvania, where work one time to achieve a minor (such as a cash payment previous day. Such an approach he is also director of the Center for health goal. Its techniques have for completing a health-risk effectively pairs the routine Health Incentives and Behavioral been used to significantly increase assessment or for not smoking) Economics. Kevin’s work focuses on weight loss, smoking cessation, with engaging and emotionally only to people after they meet developing and testing innovative and diabetes management. positive experience. a goal, give it to everyone in ways of applying insights from Behavioural economics approaches an account that they can see These approaches derive from behavioral economics in improving sometimes involve what is called (like an online bank statement patient health behavior and provider science. Increasingly, technology automated hovering, whereby or even a physical gift card performance. He has done work with platforms can help deploy these wireless data from internet- that isn’t yet activated). And a variety of employers, insurers, health systems, and consumer companies designs to put them within reach enabled scales, blood pressure take it away only if success is in testing the effectiveness of different behavioral economic strategies in of organisations and their people. cuffs, glucometers, or pill bottles not achieved. This approach addressing tobacco dependence, obesity, and medication non-adherence help large numbers of patients in private and public entities around the world. He is a principal of the makes the reward tangible and This article is adapted from a stick to health-promoting activities. behavioral economics consulting firm VAL Health and an elected member within reach today, when the version previously published at Substituting technology for of the Institute of Medicine, National Academy of Sciences. action needs to happen. It also Harvard Business Review otherwise expensive personnel takes advantage of our natural December 1, 2014. helps achieve scale. We are aversion to loss (people work currently running a large trial of harder to retain something than Professor David Asch automated hovering, funded by the to earn it). David is a Professor at the School of Centers for Medicare and Medicaid Medicine and the Wharton School • Use separate checks or gift Services Innovation Center, that of the University of Pennsylvania, cards to deliver benefits that aims to reduce rehospitalizations where he is also Executive Director would normally be buried in and new cardiovascular events in of the Penn Medicine Center for a paystub. In short, make the patients after a heart attack. Health Care Innovation. David’s work smaller incentives easier to see aims to understand and improve how and, therefore, more influential. physicians and patients make medical How can we encourage the choices in clinical and financial adoption of behavioural economics • Construct teams so that settings, including the adoption of approaches? The first step is individual efforts are reinforced new pharmaceuticals or medical by their peers. For example, getting employers, insurers, technologies, the purchase of insurance, and personal health behaviors. rather than merely encouraging and providers to reconsider His research combines elements of economic analysis with psychological individuals to walk more, create the assumptions that underlie theory and marketing in the field now called behavioral economics. conventional approaches like teams and augment individual He is a principal of the behavioral economics consulting firm VAL Health points, miles, and other traditional rewards with bonuses for and an elected member of the Institute of Medicine, National Academy incentives. A key lesson from each team member walking a of Sciences. behavioural economics is that minimum amount (say, 7,000 the size of an incentive matters steps a day). Teams would also far less than how it is framed compete against each other and messaged, how it travels for prizes or bragging rights. along existing pathways of social By enlisting social norms, you networks, and how it connects capitalize on the most powerful to individuals emotionally. of human motivators.

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Why you need an ‘employee-centric’ approach by Mark Cobain and Holly Whelan

We believe in the theory of “workplace wellness” and all the great benefits that it can bring to employees, employers and society. However the problem in practice is that good quality initiatives delivering tangible results are rarely seen.

The first question is what makes a ‘wellness’ So what’s the answer? For us it’s about This approach is good for ‘consumer engagement’ equates 3. Business commercial practice initiative a success? From the employer’s ensuring that workplace wellness is truly employers because its good to success or failure. We spent to ensure that good market perspective, financial savings on healthcare cost “employee-centric”. That means building cost for business (costs, health over 20 years delivering behaviour penetration is achieved in a is important. Health care professionals however effective initiatives based on proven health and employee engagement change programmes to improve cost effective and scalable will be looking for real health improvement of science in a way that engage employees at and productivity), but its also people’s heart health in many way that is measurable. both the individuals and the overall company. both a rational and emotional level. importantly good for employees. different settings, including direct Without this, initiatives are not Finally, business leaders will be keen to ensure Given how much time we all spend to consumer, via Health Care commercially sustainable. that what their company is spending its money More of that later, but science backs this at work, its important for us to feel Providers and also employer on will translate into increased employee up. For example, our own research has good and be part of something “health and wellness” programmes. A great example of this working in engagement and productivity (in other words, demonstrated a person’s emotional response that we can relate to and be practise is a concept we developed employees working better to deliver better to information about their own risk is the proud of. In the end, we believe its During this time we learnt that some years ago called ‘Heart Age’. company results). only mediator between risk perception and OUR “health and happiness” that the best interventions fused the smoking cessation and functional imaging counts, and none of us want to feel following three things: The issue is that workplace programmes tend studies show increased activation of that ‘workplace wellness’ sounds to be developed with only one (or maybe ‘emotional’ neural pathways are associated like something done to us, but 1. Fast Moving Consumer Goods The Heart Age two) of these goals in mind, with the bottom with the desire to quit smoking. In the end, rather something we want to do (FMCG) company marketing line usually being savings on healthcare the most effective interventions can only and ‘engage with’. techniques to persuade and initiative engaged costs. Although this is financially desirable, be based on initiatives that people will be target different population more employees the evidence for workplace health actually emotionally motivated to do and that work. So that’s enough of the “theory”, segments to take a personal delivering this is controversial. how do we practically create these interest in their health than any other “employee-centric” initiatives? and support them to make the We believe that despite large amounts of right changes. initiative money being spent, too few initiatives inspire This first thing is to bring in the enough of the “right” people in the workforce right skillsets and experience. 2. Proven behaviour change to actually engage, even if the programmes Our personal and professional methodologies and public health themselves are effective once they do. backgrounds mean that we science to ensure programmes This results in lower ‘dose’ intervention and both intuitively and practically are evidence based. a reduction in overall efficacy. understand how to deliver engaging health and wellness initiatives that work. We both have strong academic backgrounds in biological sciences and spent most of our careers in the global ‘consumer goods’ industry where 52 53 IMPROVING EMPLOYEE ENGAGEMENT

Heart Age was designed to simply effective and scientific way to So, Heart Age is an example of a b. Understand what employees d. Follow up with a pilot including The Global CMO Network can translate the complex medical allocate resource to prevention ‘employee-centric’ platform that with differing risk profiles and initiatives that are testable and play a crucial role in oversight of concept of cardiovascular risk into in those populations who need it not only can drive workplace attitudes to their health see as measure their impact on all the pilots - identifying diverse an “age” of your heart. For years, most. Most recently we deployed health, but also start conversations the most important personal relevant outputs, using those workforces and sites to properly doctors had talked to their patients Heart Age in a multinational with employees to generate and environmental factors results to generate momentum test the approach and comparing about their ‘risk’ without any real company across 95 countries using ideas on what would be most for their own wellness. Use all amongst employees, business it with traditional methods of success, no matter how credible a bespoke Heart Age website. helpful to support them and these factors (not one alone) to unit managers and leaders and workplace wellness. It will also be and evidence based it was. Most As well as the tool the site included involve stakeholders including generate powerful insights on therefore cost effectively scale crucial in defining the metrics on people don’t understand the global ‘maps’ of all the company suppliers and optimise our work developing the overall strategy in the company. which to judge the effectiveness concept of risk (neither do most sites and we reported ‘interim environments. This information within a company for those at of interventions and if successful doctors!) but everyone knows they findings’ back to employees during is important not only for the greatest risk. identify the route through which don’t want to get ‘old’ before their the campaign. We worked closely Medical and Occupational Health dissemination and scale can occur. time. This global insight works with the Medical and Occupational function, but also for many other c. Use the data generated to everywhere such as in Spain, Health department, but also departments, allowing the business identify the potential ecosystem * We would be happy to make physicians experienced women Corporate Communications and case to be broader to include of interventions (environmental, the Heart Age platform we dragging their husbands to see Brand Teams. The data showed optimisation of employee services behavioural and health checks) used available for this purpose. them a week after they were told that the Heart Age initiative such as the workplace canteen, that best represent the needs of their Heart Age. In South Africa, engaged more employees than gym and even how this works with the different risk groups as well the Heart Foundation said their any other initiative during the supporting local businesses in the as the potential impact a highly Heart Age campaign was the most year (not just Occupational Health area surrounding the worksite. engaged workforce could have effective they had ever run, and initiatives but also corporate on health and business metrics. recently in the UK, Heart Age was employee engagement ones), Our proposed challenge to the adopted in the NHS Health and collected a huge amount Global CMO Network is to set up a Check programme. In addition, of business critical data as pilot in one to three very different the health impact of Heart Age has well as supporting traditional companies using a bespoke been proven in an independent Occupational Health initiatives. Heart Age (or similarly proven Mark Cobain and Holly Whelan randomised trial, but just as Some countries and work sites engaging)*platform to prove how importantly, since launch over had Heart Ages that were ‘older’ “employee-centric” approaches Mark Cobain and Holly Whelan both worked at Unilever (in marketing and R&D respectively) for many years. During seven million people have taken on average than their real ages, can be used to: this time, they delivered health & wellness programmes in our test online. while some were younger. a. Stimulate employees to become several settings, including Global Consumer Brands, the Unilever Corporate Brand, Workplace Health & Wellness and even In the workplace environment, We mapped those Heart Age interested in their own personal Corporate Startups. Heart Age also works extremely values to the environment in health, and then importantly, well. The scientific algorithm which the employees worked and identify and engage employees During their final four years at Unilever they worked in the New underpinning the ‘Framingham their behaviours. Some of the to propose areas where they Business Unit, developing new business models in Health & Risk Score’ accurately classifies results were surprising, and gave all feel they can take action Wellness. During this time, they built up a huge knowledge and populations into ‘high risk’ and good initial indications of where together and identify the insight base as well as adding to their already strong global ‘low risk’ categories. We use this employer money might be spent perceptions they have about networks in the academic, public and private sector. Mark and Holly also set up Heart Age as a stand-alone brand and business, and others, such as the Q-Risk more wisely. For instance, while their environment and level which was in turn adopted by charities and the public sector as a algorithm to ensure we are employee perceptions of the of support. These are ‘low novel way to communicate health to consumers. The two continue scientifically sound. For a disease healthiness of workplace food was hanging fruit’. to operate Heart Age under license today (www.ukheartage.com). that is the biggest killer, and the related to Heart Age, perceptions largest financial drain, it’s an of provided physically activity Upon the closure of the New Business Unit in 2014, they decided spaces did not. Despite this, not to return to the Unilever core business, but instead continue employees who ate healthily and what they had started and felt passionate about, and so set up were physically active themselves their own independent behaviour change company – regardless of workplace provision Habit Partners Community Interest Company. still had lower Heart Ages.

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A global mass The programme demonstrated a meaningful and sustained lifestyle change in the participation movement members through long-term reductions in alcohol consumption by Mike Standing and Elizabeth Hampson

Alcohol abuse is a substantial In 2012, an English Health and Social Care Information Centre survey is a growing body of evidence Social media has provided a One example of a successful reported that of those who had consumed alcohol within the last that this harmful behaviour can new instrument for facilitating social media behavioural change burden to public health. week, 55 percent of men and 53 percent of women drank more alcohol be changed. The science behind movement through these stages program is Alcohol Concern’s There are about 3.3 million than the recommended limit, with 31 percent of men and 24 percent the study of behaviour argues of change as it provides easy “Dry January”. The campaign deaths attributable to alcohol of women drinking more than twice the recommended daily amount. that directed change is possible access to information and sharing seeks to raise awareness and This high incidence of harmful drinking leads to serious chronic health through deliberate strategy and of information from friends reduce harmful drinking behaviour worldwide, representing conditions, disability, and mental illness and the economic burden is course of action planning. Studies and other subscribed links. by challenging people to abstain 5.9 percent of all mortality. equally substantial, with the estimated cost to society of alcohol-related show that it takes anywhere from The e-messenger delivering the from alcohol for the month of harm in England some £21 billion per year. This includes £3.5 billion in 18 to 254 days (with a mean of information is also more likely to January. Results have been NHS spending, £11 billion in crime-related costs, and £7.3 billion in lost 66 days) of actively pursuing a be trusted. This, in turn, makes impressive. During the 2014 productivity. behaviour to form a new habit. people more receptive to the campaign, 17,312 people took part One model commonly referred to message, which can serve to online, there were 25,077 likes on A 2009 Omnibus survey report on drinking asked respondents whether in discussing behaviour change is help increase contemplation for the Dry January Facebook page, they had heard of measuring alcohol consumption in units, 90 percent the Stages of Change Model which change. Indeed, it seems norms 3,461 followers of the programme’s had, an increase from 79 percent cent in 1997. Likewise the percentage assigns five stages to the process. are increasingly driven by what Twitter account, and ten online of people who had heard of daily drinking limits had increased from 54 In this scheme people move from a is seen online as social media advice sessions with over 10,000 percent in 1997 to 75 percent in 2009 in. Awareness of safer drinking pre-contemplation phase of either allows for tracking of friends’ participants. In addition to the levels is not sufficient to drive behaviour change and despite rising unawareness or lack of interest in posted activities and thoughts. large participation rate, the awareness alcohol-related deaths have risen by 19 percent between 2001 change; to a contemplation stage Therefore, programmes promoting programme demonstrated a and 2012 (with 6,490 deaths in England in 2012). Nevertheless, there with increased appreciation of behaviour change would be meaningful and sustained lifestyle problems where thoughts about expected to have a higher uptake change in the members through making a change begin to form; where friends and other social long-term reductions in alcohol 35 to a third or preparation stage media contacts are also involved. consumption. Six months on where a decision is made to act Finally, the act of making an online, from Dry January, four percent of 30 and planning for the change is public commitment to change surveyed participants were still 25 strategised. The fourth stage in the a behaviour (whether through a alcohol-free and 23 percent of model is the action stage, where posted statement committing to participants who had “harmful” 20 the planned change is carried a change or through a more formal rates of consumption prior to the out. Once action has been taken, online participation) is, in essence, programme were in the “low risk” 15 the focus shifts to maintenance seen as a social contract. Once classification. Although those

10 and prevention of relapse. a commitment is made there is a responding to the survey will be Unfortunately, it is common for drive to succeed in order to satisfy self-selecting and more likely to 5 people to cycle through the prior one’s ego, thus a commitment to have completed the programme, stages as part of a pattern of action that is easily made online this shows that despite the percentage of the population at risk (%) at of the population percentage 0 regression and procession. becomes an effort to sustain relatively short length of the Dry 1998 2000 2001 2002 2005 2006 2008 2009 2010 a period of positive January programme, sustainable

Source: Deloitte analysis based on NHS Information Centre data 2012, ONS behaviour change. change has been achieved for some.

Increasing Risk Men Higher Risk Men

Increasing Risk Women Higher Risk Men 56 57 IMPROVING EMPLOYEE ENGAGEMENT

The Dry January Facebook page The Global CMO Network is ideally placed to build on these insights. shows in the posted comments the Collectively you could decide to focus on a specific risk behaviour feelings of many that completed and launch a collective mass participation movement to reduce it. the challenge and the positive This would motivate and engage employees at members companies change in attitude and behaviour and could serve as a starting point for a broader global mass it is brought to them: participation movement.

“I had some alcohol on Saturday night and had a huge discovery. I don’t like me when I am drinking. Foggy head, no memory, and more abrupt personality than normal. Can’t really see a reason to return to drinking. Thanks Dry January for the help this has given to make my life so much better.

Now into Feb and was so pleased I made it through dry January after thinking that I was getting into a bad habit of drinking every night Mike Standing Elizabeth Hampson more or less and having alcohol Mike is a strategy Partner Liz is a health strategy and in the house. But that’s it! it was a inMonitor Deloitte. Over the policy consultant with 14 years habit and I shall continue as I did last twenty year period, he of commercial experience. in January, I don’t need alcohol has delivered transformation She has consulted across all to boost me or get me through programmes across the organisations involved in the things, I feel great, my memory pharmaceutical industry. UK health economy: central is much improved, my skin looks government, pharmaceutical, His areas of expertise are: great and I feel good about myself. med tech, charities NHS commercial strategy, commissioners and providers healthcare analytics, innovation Well I have done dry January advising on policy development and organisational change. and strategic challenges in health. and managed to lose 1 stone 3lb!!!! I am not stopping either!!! His clients include Bring on February!!! Governments, seven of the top ten pharmaceutical I have been fine and dandy with companies, hospitals and it and having learned a bit about healthcare charities. why I am prompted to have a Previously Mike was co-leader drink, and how nice it feels to find of Monitor group’s global life alternatives. I am set to carry on sciences practice and global with it, so thanks!” head of life science at Cap Gemini.

Mike was a founder member of the UK’s Global Medical Excellence Cluster (GMEC) Advisory Board, a graduate of Durham and Cambridge Universities and is based in London.

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Health benefits for employees At least five of these seven measures may be high Corporate and Social Responsibility Emerging but limited evidence suggests health on the list of desired outcomes for workplace health benefits for employees taking part in high quality programmes, further emphasising the applicability (CSR) strategies providing high quality employee volunteering opportunities. and relevance of employee supported volunteering. Many employers realise benefits can be gained from Defining high quality volunteering employee supported volunteering encouraging employees to volunteer. They help High quality volunteering can be defined as regular local schemes, engage with the wider community volunteering sessions where skills and resources opportunities can significantly improve and gain new skills. For example, ‘’we selected really offered by the volunteer match the requirements great community activities (many focused on young of the recipient organisation or individual. people) that have dual benefit. We see they have workplace health an incredible social impact. There’s a business Examples include the development of employability, benefit, and a learning opportunity for staff’. computer literacy and reading skills in disadvantaged by Phil Veasey communities, or capacity building of charities by What’s not widely understood or recognised, providing skilled trustees. however, is how valuable volunteering can be in terms of improving an employee’s health. What’s essential is that there is a coming together of the skills of the volunteer and the needs of the A report by The City of London and Corporate recipient. After all, ‘Why send an accountant to Executive summary Evidence on the health benefits of volunteering Citizenship into the benefits of employee supported paint walls when their financial skills would be Emerging research demonstrates that high quality Health can be defined as ‘a state of complete physical, volunteering found, ‘the majority of respondents more valuable?’ employee supported volunteering can have a positive mental, and social wellbeing and not merely the reported their experience of volunteering made effect on the employee’s health. It’s recommended absence of disease or infirmity’. And volunteering as them feel more positive across a range of Case studies that a Corporate Social Responsibility (CSR strategy ‘an unpaid activity where someone gives their time measures including: We interviewed six employees involved in two providing high quality employee supported to help a not-for-profit organisation or an individual programmes, plus two senior managers responsible volunteering opportunities should be a credible who they’re not related to’. But what are the links • self confidence for supporting the schemes, to see if they could part of workplace health strategies. between the two? • a sense of wellbeing/happiness identify and articulate the health benefits • understanding of and empathy with others from involvement. This thought-piece sets out to explore: Past research on volunteering has primarily focused • awareness of wider social issues • evidence on the health benefits of volunteering on benefits received by recipients of volunteering action. However, we can confidently state the case • job satisfaction • evidence on the health benefits for employees for improved health of employee volunteers too. • pride in and commitment to the company taking part in high quality employee supported Volunteering, for example, ‘increases self confidence, volunteering opportunities • motivation combats depression and helps you stay physically • defining ‘high quality volunteering’ healthy’, and ‘those who volunteer have lower A compelling part of this report captures how • employee supported volunteering case studies mortality rates, greater functional ability, and lower volunteers feel they gain from volunteering. rates of depression later in life than those who ‘One of the big benefits highlighted by respondents don’t volunteer’. was the opportunity to do something worthwhile that’s of real benefit to others. This was mentioned Studies suggest, ‘those who give support through time and again: “It gave me a sense of wellbeing, volunteering experience greater health benefits than contributing actively towards a social cause.” those who receive support through these activities’. In one study for example, ‘volunteering was In addition, it’s important to recognise that it’s not associated with halved mortality risk by more than just the individual who benefits from the intrinsic four years, with the effect strongest for those who value of helping others. Several respondents volunteered regularly’. reported the “feel good factor” transfers positively into the workplace – something that will surely appeal to employers.

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Legal and general Until our discussion, a senior Volunteering roles are all children Conclusions Ultimately, this appears to be SMaRT programme: member of staff working for and young people focused – Based on current research and a viable and achievable health ‘The Senior Managers as Recruited Career Volunteer hadn’t made the we interviewed five employees employee experiences of the six intervention and could successfully Trustees’ programme identifies link between the programme and and roles varied from teaching corporate volunteers that we extend to all workplaces. and supports talented employees the potential health of employees, children to read, to becoming a interviewed, we conclude there’s a to become trustees in charities. but was enthused by the notion. school governor, to mentoring strong link between involvement in “CSR/HR people aren’t making students in years 12 and 13. employee supported volunteering The SMaRT programme enables the links, but we shall start telling Volunteering is actively supported schemes and experiencing positive A Corporate Social legal and general’s most promising them now there’s an additional and encouraged and employees health and wellbeing in the leaders to gain skills reason to start a scheme.” are awarded one day off per year workplace. Additional research is Responsibility (CSR) and experience outside of the to undertake their volunteering needed to fully explore the benefits, strategy providing usual leadership development A volunteer described gaining a role – although it’s acknowledged but it seems highly probable that high quality employee courses. They are encouraged “wider perspective” from employee that most employees go the ‘extra this approach will be effective. to take the necessary time to supported volunteering. Plus, he mile’ and volunteer for hours well supported volunteering Phil Veasey support their duties as Trustees. experienced a “good, positive beyond this. Workplace Health and CSR opportunities should Phil has a track record of They are trusted to manage their feeling” as a result of volunteering professionals should therefore creating and scaling high impact, be a credible part sustainable strategies and own time and to show that skilled and felt it helped put his life Volunteers at Morgan Stanley consider collaborating to provide programmes in local communities volunteering is a normal part of in context. further emphasized how employee high quality employee supported of workplace including: ‘Building Powerful the working week. Employees supported volunteering gives them volunteering opportunities. If this health strategies Communities’ in partnership Morgan Stanley: employee a sense of perspective and reduces collaboration leads to increased engaged on the programme with Bupa, the Tower Hamlets supported volunteering as part stress in the workplace. commit for somewhere between levels of employee supported Public Health Team and MEND, of Morgan Stanley’s ‘Giving Back’ 50 - 100 hours per year over a volunteering and the subsequent which influenced up to 6,000 strategy. The firm’s community “It’s very humbling. One of the minimum period of three years building of capacity in ‘third sector’ local residents to adopt healthier affairs programme provides biggest benefits is that it teaches and, to date, around ten senior organisations and disadvantaged eating habits and become more employees with opportunities to you perspective and brings you managers have enrolled on the communities who need support, physically active and is now volunteer in a variety of ways, down to earth…I feel more relaxed programme each year. Feedback this can only be a good thing in being replicated as part of the supporting charities that focus and more focused (on work),” shows palpable improvements in contributing to alleviating global Commonwealth Games legacy in on improving children’s health commented one volunteer. engagement with CSR principles, health inequalities. Scotland; the community element and education. of the National School Sport engagement with legal and general Volunteering was also described Strategy, including ‘Sportivate’, as a business, and engagement as backing-up workplace health a £36m project that attracted with their own professional and messages. “The firm is encouraging 900,000 ‘unsporty’ young people personal development. Internal people to have a better work-life into sport in a three-year period research also shows that people balance, but it doesn’t have the and is now a major 2012 Olympic on the programme have a better same impact as figuring it out legacy programme; and the work life balance by six percent National Mini Tennis Programme, for yourself (through employee more than those who are not. This for the Lawn Tennis Association, supported volunteering).” all contributes towards legal and that is now the way in which general’s key CSR goals around children are introduced to and promoting good governance, learn the sport globally. helping people achieve financial security and live healthy and active lives.

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Smoking is not the only behaviour When developing a campaign Creating a ‘blue print’ for that is causing a major problem an important consideration across the board. Addiction is is whether to have it running about to publish a major review continuously or mounting a series intervention development concluding that the global of time-limited campaigns such as prevalence of ‘alcohol use disorder’ Stoptober (a mass quitting event is about 5 percent in the adult in the UK which runs throughout and implementation population (higher amongst men October), or indeed a hybrid of than women) which means that in the two. It is also important to be any significantly sized organisation aware of national and international by Robert West there will be a sizable proportion campaigns which a company of employees with a serious can time their own campaign alcohol problem. The proportion to run synergistically alongside of the workforce who drink such as World No Tobacco Day excessively leading to impaired or No Smoking Day in the UK. The most obvious of these that For example, tobacco smoking is I think that there are quality of life and lost productivity, Furthermore, a company may applies to companies pretty one of the main contributors to probably quite a few but do not necessarily qualify as consider timing their campaign to much across the board is tobacco loss of productive working time. having a ‘disorder’ is even higher. coincide with times of year when important behaviour smoking. Smoking is the number In fact a study which recently It is important to bear in mind the people are more likely to change patterns affecting two cause of disability and published in the journal for which ‘alcohol prevention paradox’: at their behaviour, such as New Year. premature death globally and I am Editor-in-Chief, Addiction, health that could be the population level, by far the It is worth making these alliances one of the most important showed lost days at work and usefully addressed in most harm generated from alcohol so that company campaign causes of lost productivity. the cost to industries to be the workforce. consumption comes not from the approaches can benefit from the significantly higher than had people who are severely alcohol leverage which come with regional, A very natural question for any been previously thought. dependant but from a much larger national and international drives. employer is ‘To what extent group of the population who are should I be getting involved in The relatively quick return from just drinking too much. This latter behaviour change to promote reducing smoking in the workforce group is a potentially valuable health in the workforce?’. More is often overlooked. This is not target for behaviour change specifically, ‘To what extent only because of the immediate Tobacco smoking programmes in the workplace. do I have the right, duty and reduction in time lost to cigarette is one of the main commercial interest to get breaks but also because of the The opportunities for companies involved?’. I suggest that the high susceptibility of smokers to contributors to to address workplace health issues answer to all three of these respiratory illnesses. This includes vary enormously depending on the loss of productive questions is ‘yes’. common respiratory infections country, the kind of company, the and the fact that a substantial working time nature of the workforce, and the Employers are well placed to proportion of employees who level of employee engagement. support behaviour change within smoke will start suffering from Unless programme participation their workforce because of the chronic obstructive pulmonary is mandatory or incorporated into amount of time people spend at disease over the age of 40 which routine activities, any behaviour work and because of the structures will lead to days off work change initiative that employers already in place for the delivery and hospitalisation. want to implement amongst their of initiatives. I also think most workforce has to be attractive and companies now recognise their demonstrate how it is going to duty of care in relation to their benefit those taking part. workforce, even if they do not yet know how best to discharge this. It can clearly also be in a company’s best interest to be involved in behaviour change.

64 65 There is a common misconception It seems to me that the Global that behaviour change CMO Network has huge potential interventions consist of merely for taking this agenda forward. applying common sense. This has First of all there are economies led to huge waste of resources of scale in implementing global and a substantial opportunity cost. behaviour change programmes. What is required is harnessing Secondly, harnessing the expertise that enthusiasm and applying within this network will lead to it to the accumulated evidence innovative solutions to the practical base to ensure interventions are issues faced in this implementation properly designed and focused. that may not have been arrived at It is important for a company to by companies working in isolation. be familiar with the evidence base I would love to see the Global around the behaviour type they CMO Network creating a ‘blue Professor Robert West are aiming to address. print’ for intervention development Robert West is Professor of and implementation – including Health Psychology and Director When considering what kind both content and delivery – which of Tobacco Studies at the Cancer of approach is most likely to can be accessed and adapted Research UK Health Behaviour Research Centre, University yield dividends (literally and by businesses according to their College London, UK. Professor metaphorically!) one of the key specific needs. It will not be re- West is also Editor-in-Chief of the differences between smokers inventing the wheel but applying journal Addiction. He has authored and people who drink too much a solid set of principles to create more than 500 scientific articles, is that most people who smoke that match between the supply books and book chapters. do actually want to stop whereas side (Global CMO Network) and He was co-founder of the English most people who drink too much demand (businesses), to help Stop-Smoking Services. do not think there is a problem. underpin an efficient strategy for His research includes evaluations Therefore, support for these two companies to achieve their goals. groups of people will require very of methods of helping smokers to stop and population surveys of different approaches. Smoking smoking and smoking cessation cessation programmes are going patterns. He advises the English to be more focused on building Department of Health on a wide capability – helping people to range of policy initiatives including achieve a goal they are already social marketing campaigns. He is engaged with – whereas with author of ‘The SmokeFreeFormula’ people who drink too much, the (Orion) which aims to bring the approach will be more focused science of stopping to smokers. on motivating people to make For more information see a change. www.rjwest.co.uk.

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Campaigns with an element Finally, initiatives must be genuine These include: Setting clear goals for of enforcement are generally and owned throughout all levels • a clear understanding of more successful than those within the organisation. the workplace context and without. Indicatively, workers Line management engagement psychosocial risk factors behaviour change interventions having immediate access to to reinforce and actively from the outset personal performance data is also encourage behaviour changes is • a clear understanding of the important – enabling people to vital. This is backed up in numerous by Steve Haynes health risk profile of workers see improvements in real time studies which demonstrate the • provision of choice is proven to engender greater, role that line managers play (combining physical activities sustainable improvements in in employee engagement and with volunteering, local healthy behaviours. behaviour change. For example, community and fund raising a recent Gallup survey showed When considering Equally, when should behaviour The scientific evidence that activities for example) From what I have experienced, that line managers account for change within a workplace demonstrates the impact behaviour change in employee involvement in the around 70 percent of variance in • social engagement environment commence, and workplaces can have in improving initial and ongoing design of employee engagement scores – workplace settings, it is (if at all) end? Impact will also health behaviours is limited. • inclusivity initiatives is important. Whilst the and engaged workers are almost important to be clear on vary depending on the desired Many of the studies focus on scientific evidence to demonstrate 30 percent more likely to outcome. For example, are we participants who are already the desired goals from the importance of employee participate in wellness initiatives. looking at cessation of existing motivated to change their involvement in the design of the outset. Is workplace behaviours, adoption of new behaviour, for example, people initiatives is limited, parallels can What follows is a case study which behaviour change an behaviours or prevention that are already physically active. be drawn from a recent study of evidences an organisation that of undesirable behaviours? Additionally, those people that initiative, a policy, part stress management interventions in recent years has achieved an Furthermore, it is essential to perceive themselves to be at in a medium sized organisation 80 percent participation level in of the organisational clearly define what health and/ risk are more likely to modify in a metal forging company – workplace health activity. Whilst it culture or employee or wellbeing means to the their behaviour. Programmes again, an area where few studies is not possible to identify the exact organisation. What is it that that focus on health education value proposition? have been conducted to assess contribution that each initiative/ the organisation is seeking to are not proven to be generally its role. Primary interventions element made to the overall address? What are the underlying effective in terms of participation were based around Participatory impact, and a lack of funding objectives? At a very basic level, levels or sustained behaviour Action Orientated Training (the meant that the analysis of health it can be argued that North modifications. However, the focus on the practical actions outcomes was not possible, it American programmes grew evidence points to programmes of participants), which included does highlight the importance of out of a desire to control direct which tailor materials to individual management and employee a number of key factors in design healthcare and disability insurance needs and those which promote workshops focussed on improving and management of workplace expenditure, whereas by contrast ‘incidental’ participation through the work environment and health programmes that influence in the UK for example, they are choice architecture approaches personal interviews targeted positive behaviours. growing out of a number of factors – initiatives which enable healthy at those with high [stress]-risk relating to the overall employee/ behaviours to be adopted through scores. The interventions resulted employer value proposition workplace design (for example, in a reduction in various adverse (i.e. attract and retain healthy better signposting of stair use, psychosocial factors and stress and productive workers, healthy food and drink options). responses and were successful lower absenteeism). in reducing work-related stress in a short period of time.

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Findings from this case study Initial staff health assessments also suggested that it was the identified that perceptions of organisation’s ‘capacity for fitness vastly differed from the continual adaptation’ that enabled reality and only a small percentage sustainable behaviour change and of workers were physically identified certain qualities in the active. Knowledge of and access organisation’s workplace culture to activities were also limited. that create these conditions. Furthermore, it showed higher These are: than average levels of • A culture of opportunity and raised blood pressure, poor learning drives a learning diet choices and low levels of culture, fostering inclusivity nutritional awareness. and equality. Today, Ginsters’ workplace health Steve Haynes • Opportunities that increase programme currently offers Steve is the global head of diversity of relations within the 59 different activities to staff wellbeing at the British Council. company and wider community. and achieves an average of 80 He has designed and implemented • Qualities of trust and openness. percent participation levels (with some of the first fully integrated • ‘Perpetual emergence and approximately 1,000 staff per workplace health programmes in the UK and set up the first uptake of adjacent possibilities month attending at least one integrated workplace health enabled the programme activity). There are numerous management company, Navigator to continually make small direct financial cost benefits of Health working with various adaptations in response to the programme, for example, they organisations in the development ever changing conditions’. saw a reduction in recruitment of their workplace health costs, and lowered private provision from health benefits Case study - Ginsters: health insurance. to wellbeing strategies. He is the Achieving 80 percent co-founder of the C3 Workplace engagement Health Movement, a nationwide networking body of workplace A pilot programme amongst Line managers account health professionals. Cornwall based food manufacturer, for around 70 percent Stephen is also a member Ginsters, in conjunction with of variance in employee of the Mayor of London’s the University of the West of engagement scores – Healthy Workplace Charter England set about to identify and engaged workers are Advisory Group as well as an the effectiveness of a campaign assessor of London based to improve and sustain physical almost 30 percent more employers seeking Charter activity and positive health choices likely to participate in status in workplace health. among staff and their families. wellness initiatives Furthermore, he is a member It identified which interventions of the Time to Change Learning affected behaviour change and Peer Network where he is involved how best to communicate health in the sharing of good practice amongst organisations on issues messages to workforces. Ginsters surrounding mental health. is the largest private sector employer in Cornwall.

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we know from psychology that approach which not only relates Interview with Professor Susan positive reinforcement is so much to minimising ill health but more effective than punishment or maximising good health and blame. Even very minor changes to wellbeing. It should involve the Michie on workplace health language, for example, rephrasing idea of giving people time. “you didn’t do this well” to “I’ve For example, there should not identified room for improvement” be a culture of skipping lunch by Susan Michie can turn phrases around to get a breaks or staying late at work much better result. to show your commitment. Instead, employers should focus The top-down approach applied on maximising their employees in this workplace was successful working efficiently and effectively and the stress management when they are at work. This is The Karasek Model shows that As a result staff would be found There are significant course which we ran specifically achievable through managers Professor Susan Michie mental strain is influenced by three eating their lunches in cupboards for senior managers was adapted setting clear roles, responsibilities Susan Michie is Director of the economic and social dimensions. The people who fare or under the stairs. for different groups of staff. and goals as well as giving Centre for Behaviour Change at pressures that affect worst are those who experience all For example, it became evident that clear feedback and consulting University College London, UK. three – high workloads, little social Taking the Karaseck Model, we people outside of porters were suffering from stress employees on decisions that will She completed her undergraduate support at work and a lack control knew it was beyond our reach to and doctoral education in but because they were mostly ultimately affect them. work which cannot be over what they can do. A study reduce work load but what we psychology at the University of tough men, they would never go I conducted at a workplace with could do was influence the control Oxford and her clinical psychology divorced from what on a ‘stress management’ course. Recommendations to the Global 19 percent absenteeism amongst and support available to the training at the Institute of happens within. These Therefore, renaming the course CMO Network its domestic staff highlighted the domestic staff. A large common Psychiatry, University of London. ‘handling difficult situations’ made Firstly, the team needs to be pressures can come disparity between what managers room was negotiated for staff to She is a chartered clinical and it more accessible to this particular multi-disciplinary and not just health psychologist and a and staff members perceived as eat their lunches in and a clock-in, from having more than group. This example emphasizes restricted to medicine. Often Fellow of the Academy of Social the root cause of the problem. clock-out system was introduced the need to be flexible in adapting there should be psychologists or Sciences, the European Health one job, working long Whilst managers viewed absent to give staff the opportunity at interventions to fit a company’s nurses in charge, especially given Psychology Society and the British hours and working to staff as skivers not taking their the start of the day to report culture and values in order to have the issue around mental health Psychological Society. work seriously, a closer look at the faulty equipment and at the end zero hour contracts. influence at multiple levels. at the moment. Secondly, CMOs situation provided an alternative of the day to report any abuse. Susan’s research is in health In addition, a consultation was as part of a senior management psychology and health services, explanation – poor job satisfaction. In summary, the greatest organised to see if there could be team should educate the senior focusing on the design, delivery, Whilst working in the Occupational Outsourcing had disrupted the challenges facing health in the more staff involvement in decision- managers about the low cost uptake and impact of behaviour ward teams which before then workplace are the people, the Health and Safety Unit at the initiatives that can help staff. I change interventions related had provided staff with familiarity making such as when choosing the Royal Free Hospital I saw staff resources and the interaction strongly believe it is important to health. and a support system into which colour or design of new uniforms. members who could no longer between the two. How does one, to work from the top of the they could report faulty equipment All of these initiatives cost next to cope under the pressures they with limited resources, motivate organisation down – targeting and abuse. Furthermore, having no money. were experiencing outside of work and inspire people to look after key individuals in order to get a permanent workforce on a alongside pressures from within. both their own health and the key committees and groups on particular ward had resulted in Another issue which we addressed health of those around them? board. And lastly, the Global CMO staff taking pride in keeping it was poor management. When The greatest challenges managers were asked, “when Network must ensure that their clean but one consequence of When looking at opportunities was the last time you called work is multi-disciplinary which facing health in the outsourcing was a loss of this for health and wellbeing in a someone into your office just to means pursuing preventative sense of pride and support system workplace, context is essential. workplace are the tell them they had done a great initiatives as well as detecting built around the ward teams. One of the 2007 NICE behaviour job?” it was received with nervous and treating illnesses – a holistic people, the resources Other factors contributing to low change principles for effective laughter, because it was not done. approach, with psychology at job satisfaction included culturally interventions states that operating and the interaction Therefore, we suggested that its heart. inappropriate food offered in the at various levels simultaneously between the two managers used the ratio three canteen as well as the lack of time and consistently is an effective to one when giving someone and space allocated to staff for approach. Furthermore, there constructive criticism – three lunch breaks. has to be a long term, strategic, positives to one negative because evidence based, peer informed 72 73 How to solve the Chief CMO health related Medical Officer’s dilemma behaviour change by Eric Lowitt 76 by Paul Chadwick 90 A NEW ROLE

Workplace health On purpose and the future and behaviour change of workplace health and FOR CMOS by Eric Silfen 80 wellness programmes by Vic Strecher 94 shifting corporate mindsets The social value of work by Jon Miller 84

Keeping the workforce healthy in a large pharmaceutical company by Murray Stewart 88

74 75 A NEW ROLE FOR CMOS

Relevance Levers of individual’s behaviour Quick wins and the power How to solve the Chief Polar bears floating on melting ice So then why would individuals do of self-financing caps aren’t particularly relevant to something they normally don’t do? Designing sustainability programs the average worker’s daily choices. The relevance programs helped for employees to carry about Medical Officer’s dilemma So we surveyed employees to learn us better understand the drivers based on relevance and behaviour more about their most closely of individuals’ behaviours. We levers yielded a growing flow of by Eric Lowitt held beliefs, dreams, and learned that people really would ‘quick wins’. We ran contests to frustrations. Informed by take a specific action when that see which group of employees employees’ own views, we broke action provided at least two of the could save the company the most sustainability down into bite-sized following benefits: money, per employee, in a way chunks. We explained how simple that had a positive environmental/ Let’s define your challenge. On the Solving chief medical officers’ • Financial benefit (save or make As your company’s Chief behaviour changes (eg. unplug social impact. Frankly, employee one hand, you are tasked with and Maytag Repairman challenge the individual money) Medical Officer, you face phone charger wires at your participant rates in these contests capable of equipping employees comes down to affecting behaviour • Convenience (save or give a dilemma: how can you home when not in use) could save were higher than my clients and to live healthier, happier, and better change among individuals. the impression of saving the employees money (while reducing I forecasted. That’s because we affect large-scale behaviour lives, while saving your employer Over the past decade, person time) the environmental impact of energy designed the contests to ask for change when armed with millions in wasted expense each I’ve partnered with numerous • Limbic (make the person’s life use). Then we launched a series of employees’ knowledge (feeling year. Through your thoughtful Fortune 500 companies to better in a way that appealed to limited power and control? challenges among employees to needed) and provided a slice of guidance, millions of non- accelerate behaviour change their reptile portion of the brain) History, in the form of take action that would again yield the cost savings back (financial employees can also be positively among executives who were both personal and environmental • Take one for the team benefit). The more contests we ran, business’s gradual decision affected by designing products and skeptical about another corporate benefits. Over time, these efforts (lessen the burden on others the more the savings added up. to pursue sustainability, services that promote better health. pursuit: sustainability. Said took on a life of their own as who the person cared about) Usually within 18 months (shorter On the other hand, you are among simply, sustainability is a state provides an insightful clue. employees were energised to • A feeling of being needed on two occasions) we generated the least powerful executives of development where today’s save money (for themselves, and (the person’s views and enough savings to finance our own today. With limited budget, few generation is able to meet its more often, for their group of knowledge were asked for sustainability initiatives. No CEO or to no direct reports, and minimal needs without adversely impacting work colleagues) and improve and valued) CFO would say ‘no’ to an initiative control over any corporate business tomorrow’s generations to do their environmental and/or social that delivers benefits and is decisions, how can you affect the same. The business case to impact. The Maytag repairman A quick word on these levers of self-financed. the lives of your work colleagues, ‘become sustainable’ was clear: would have received more calls if behaviour: they are not equal in their families, and their save money and improve lives. he had been more proactive about impact or appeal. Nor are they A few companies have begun communities? I call this the Yet sustainability’s place on the showing consumers how to use the listed in any particular order. to dismantle their sustainability Maytag Repairman challenge. corporate agenda was constantly appliances to deliver benefits that programs. Not because they in peril as political views, pressing were specific and relevant to them. weren’t successful…but because Remember the Maytag repairman corporate needs, and the sustainability action is now a part commercials? A highly trained, constant demand to achieve The media is littered with of employees’ daily actions. highly capable person hired and returns for shareholders examples of companies telling How can you affect intent on doing good sat alone coloured what should have their employees to ‘lose weight’ the lives of your work If we could do this while starting in a room waiting for a customer been a straightforward decision. or take other such action. from a point of polar bears on to call to fix a Maytag appliance. colleagues, their Employees won’t take action to melting ice, then why can’t we The phone never rang; the repair Turning the tide of executives become ‘healthier’ (whatever families, and their do this with more visceral and person’s ability went untapped. and employees’ attitudes and ‘healthier’ really means, beyond personal evidence that action is behaviours toward sustainability communities? the absence of active disease) if in individuals’ best interests? took years. What my clients and they are told by their boss to do I learned can shorten the amount so for the company’s sake. of time it takes for you to do the same with health and wellness. Among these lessons are:

76 77 Call to action – challenge for CMOs In how much detail can you describe what’s relevant to your employees, what drives your employees’ behavioural decisions, and your untapped capacity to create self-financing quick wins that are able to finance (monetarily and politically) your health and wellness ambitions? Are you working with your natural partner – the global head of HR – to Eric Lowitt commission an employee research program to begin to answer these Eric Lowitt is the CEO of Nexus Global Advisors, a leading questions? Without opening the advisory firm to senior executives kimono too much, are you willing on issues of sustainability, to share your successes and failures health and wellness programs, toward this end with the Global and renewing the life of a CMO Network? company by embracing volatility. Eric advises CEOs, senior Let us know where you are in public officials, and leaders of your journey, what roadblocks nongovernmental organizations are preventing you from achieving in the fields of strategy, your performance objectives, collaboration, and sustainability. and what you are willing to share A sought-after speaker, Eric with your peers. was named one of the Top 100 Thought Leaders in Trustworthy Business Behavior in both 2012 and 2013. He has worked for nearly two decades with Accenture, Fidelity Investments, and Deloitte Consulting and earned his MBA from The Wharton School.

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Workplace health and behaviour change by Eric Silfen

For the Chief Medical Although a recent flurry of Workplace health programmes The Chief Medical Officer must be Operationally, for workplace 6. Analysis of performance Officer community peer-reviewed literature has are well received by employees certain that workplace health and health and behavioural change such as weighted or adjusted described numerous challenges when they are preventative in behaviour change programmes, programmes, the Chief Medical comparisons of baseline to post discussing the significance associated with workplace health, nature, non-threatening and like any other company endeavor, Officer should be responsible for: programme trends in health care (racial/ethnic discrimination; proactive, speaking to personal demonstrate productivity; that expenditures or productivity of workplace health and 1. Programme design including bullying; psychological health; issues which employees and is, demonstrate effectiveness costs for employee participants behaviour change for metrics such as financial impact communicable and non- their families are struggling with, in enhancing employee job and nonparticipants relative to as well as evaluation of the optimal organisational communicable illnesses) defined thereby diminish the impersonality performance and/or satisfaction programme investment change in health risks and metrics for accurately and reliably of the company. However, these and efficiency in delivering health performance is like behaviours discussing the value quantifying what are often programmes will remain a priority care and other work-life cost 7. Results reporting to senior detrimental organisational effects for senior leadership only as savings relative to programme 2. Programme setting including leadership describing the overall of motherhood and presents questions going forward. long as they mitigate perceived investment, (ie. positive return worksite implementation return on investment; in what aspect(s) of the programme apple pie to cultural significant financial consequences, on investment). 3. Choosing the employee Often, as part of their role, Chief were most of the savings norms – they are workforce performance or legal population participating in Medical Officers actively engage In addition, the Chief Medical realized (e.g. HRA/wellness; risks to the organisation. the programme as well as indisputably necessary, in various programmes supporting Officer must shoulder a dual lifestyle management), and what developing the processes for but difficult to quantify. employee health and well-being. As a physician, the Chief Medical responsibility. He or she must benefits to the employees were enrollment Such “company-wide public Officer possesses cache with act on his or her Hippocratic associated with those savings, health efforts” can include both and the respect of employees. obligation to maintain the vision, 4. The interventions and incentives (eg. high employee participation specific interventions such as Therefore, his or her leadership effectiveness and viability of including health risk appraisals per se; significant health preventing absenteeism, nutrition responsibility in the domain of workplace health programmes. As (HRA/wellness), lifestyle risk improvement). counseling, smoking cessation, workplace health is to act both employees are the life-blood of any management and disease and rehabilitation as well as as a stalwart employee advocate organisation, these programmes management coaching general services such as walk- as well as a steward of solid are vitally important for individual 5. Measures of success such Chief Medical Officers in clinics, wellness physicals, corporate performance. as well as company health and as medical, pharmacy, and employee assistance programme well-being. short-term disability pre/post actively engage in (EAP) counseling, and health expenditure trends adjusted Conversely, the Chief Medical various programmes plan selection and advice. for demographics, health Officer must assure management status, and baseline costs or supporting employee that these programmes are improvement(s)in self-reported health and well-being. financially rigorous, insure against health risks from repeat organisational risk and are legally health risk assessment as well as ethically compliant, (HRA) completers and that this “soundness” is communicated to and understood by senior leadership.

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Overall, the Chief Medical Officer has the opportunity to deliver an on-going, quantifiable, incentive-driven, well-managed comprehensive corporate health management programme that can continually achieve significant health improvement while promoting health care and productivity cost savings in an employee population thereby cementing his or her dual role as employee champion and corporate steward. Dr Eric Silfen Eric Silfen is an international In conclusion, corporate expert on the implementation workplace health and behaviour of information technologies in change programmes present a the medical setting; hospital multi-dimensional opportunity and health plan clinical affairs; disease and care management for the Chief Medical Officer programs; and clinical quality to proactively and positively and performance improvement. engage with the employee During his time as Chief Medical population as well as embed a Officer for Philips Healthcare, medical consciousness into the Eric led the Office of Medical organisation thereby refining and Health Affairs and worked to company performance. By taking inform and communicate Philips the reins of workplace health Healthcare thought leadership leadership, the Chief Medical around the world. Operationally, Officer can proactively own the he was responsible for embedding robes of corporate sustainability a “medical consciousness” in and social responsibility, serving Philips Healthcare by developing the clinical and econometric as the best advocate for medical evidence that helped differentiate and health plan services offered to the company’s products, employees, establishing personal services and solutions in the visibility and cache within the global marketplace. organisation, and demonstrating to employees that senior leadership firmly “practices for the company what it preaches to its customers”, thereby substantiating that the company is in tune with its health care customers’ value propositions making the firm a more respected business partner.

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The social value of work by Jon Miller and Lucy Parker

Businesses today are under “It’s infectious,” one senior themselves valuable to more than Point of view: what is your Based on these experiences, In conclusion, there may be many increasing pressure to executive told us, “people love just shareholders. business’ perspective on the we offer some hypotheses on benefits to making sure that the benefits of having a strong people feel connected to the social explain how they deliver the sense their work is connected world’s big challenges? We found to a big picture, that they’re Products: what positive role in this to be the secret ingredient narrative on social value, in value of their work – benefits for social value alongside making a difference and it’s the world does your business that distinguishes the leading terms of workforce engagement them individually, and for their financial value. Public good for the business”. This will play through the goods it takes companies from the rest: taking and wellbeing: organisations. A radical professor confidence in the corporate not surprise those in the field of to market? Successful products a clear stance on the most of education called Edgar • First, they may have a greater workplace health – researchers deliver value to people’s lives, significant issues that are relevant Friedenberg, writing in the 1970s, world remains low, and sense of personal agency and have repeatedly linked work and many also see a market to the business. said that ‘what we all must decide too often it seems that confidence – bolstered by the engagement to organisational opportunity addressing global is how we are valuable rather than companies are taking more feeling that the work they do is performance – but it highlights challenges through new products We find these questions to be a how valuable we are’ – and we value out of society than making a difference. the importance of having a clear or services – energy efficiency very useful way of untangling the believe this applies to businesses, • Second, their motivation gives they are putting in. It stands narrative about the social value of solutions, for example, or conversations about the impact as it applies to individuals. them greater stamina – they are to reason that this applies to the business. affordable water purifiers. of a business on society. Often, employees too: people feel people miss each other in the less prone to exhaustion, anxiety The Global CMO Network could and burnout. better about their work if We wanted to look at the ways Practices: how does your business dark, because they’re talking at play a valuable role by committing use its operations to create value? they see that the companies that businesses can have a positive cross-purposes: someone may • Third, employees who feel to a programme on social purpose, impact on the world around There is much focus on reducing be questioning the environmental connected to the social impact whereby its member companies they work for are themselves them, and so we spent time with ‘negative externalities’ – waste, damage of operational practices, of their business are likely to explicitly identify their social value productive members of companies operating all over carbon emissions, etc – but and they’re answered by the social be more resilient, more able to narrative and develop channels to society. the world, across a variety of companies can consciously create contribution of philanthropy. withstand setbacks, hardier in effectively engage their sectors – engineering, technology, ‘positive externalities’ too, such as For businesses seeking to difficult times. employees in it. Whilst doing the research for mining, pharmaceuticals, food developing skills in the supplier communicate effectively about • Fourth, they may be more able our book, Everybody’s Business, and drink. This led us to a simple base, or supporting jobs social value, this model brings to undertake ‘negative tasks’ we found that today’s leading framework, the Prism, which has in distribution networks. a little clarity. – a positive social impact may companies are increasingly five dimensions: purpose, products, offset the effects of work they sophisticated at communicating Philanthropy: what philanthropic practices, philanthropy and point Many of the companies we may find boring or unpleasant. with employees about the role of view. Companies looking to activities does your company feature in our book have become • Fifth, they may be less likely to their business plays in society. clearly articulate their social value choose to engage in? These days recognised leaders in contributing leave the organisation if they They understand that people are can start by asking the following this often means more than writing social value, and have developed have a sense that the things more motivated when they can five questions: big cheques; it means harnessing clear narratives around this. During that matter to them are also make a connection between the the core skills and capabilities our research, we encountered important to the organisation. activities that fill their working Purpose: is your business of the corporate to have a more plenty of hugely motivated teams days, and the impact upon the motivated by more than the meaningful impact, and applying and individuals, energised by the • Finally, we find they are not wider world – and can only blind pursuit of profit? The the same imagination and rigour recognition they are generating destabilised by public criticism bolster a sense of wellbeing in companies we researched all they apply to their business. value for society hand-in-hand of the company, e.g. in the event the workplace. have a healthy track record of with financial value. Crucially, of a crisis: they are less likely profitability – and they see this as each of them were articulate on to feel undermined and may be a natural consequence of making the dimensions of social value able to talk authentically about described in the Prism, above. the company’s position. 84 85 Jon Miller Lucy Parker Jon Miller is co-author of Lucy Parker is co-author of Everybody’s Business: the Unlikely Everybody’s Business: the Unlikely Story of how Big Business Can Story of how Big Business Can Fix The World. He is a partner at Fix The World. She is a partner at Brunswick Group, working with Brunswick Group, advising senior companies to promote the positive leadership in business and helping contribution they can make in the them get to grips with their role world, and helping them connect in society. She has more than with broader society. Jon has twenty years’ experience with worked all over the world with global corporates across a range global corporates in many sectors, of sectors, from pharmaceuticals from the US to Asia and Africa. He to engineering, from retail to was Strategy Director for Mother, telecoms. Lucy began her working one of the most awarded creative life making documentaries for agencies in the world – including the BBC, before moving into the Campaign’s Agency of the Decade. business arena helping companies Jon has created campaigns for communicate with critical many NGOs, including Amnesty, audiences. In government, from Greenpeace and WWF, as well 2008-2010 she led the UK Prime as developing government Minister’s Taskforce on Talent and health campaigns. Enterprise.

People are more motivated when they can make a connection between the activities that fill their working days, and the impact upon the wider world

86 87 A NEW ROLE FOR CMOS

Education is followed up by Improving the health of the work “I liked that it featured three Keeping the workforce screening programs. Although force in a large pharma company patients at different stages of the there is all round health screening can take advantage of its main disease. Very interesting to hear available to employees the uptake aims to improve health. With what it’s like from the patient’s healthy in a large of screening for heart disease internal disease area experts the point of view. Diabetes runs in and diabetes is noticeably company can focus on disease my family so this was very increased after education and awareness and education with relevant to me.” pharmaceutical company awareness sessions. targeted screening and follow up. Further improvement in the “I’ve worked in the metabolic There is also a difference in uptake area for years so I understand the by Murray Stewart health of its employees is made in screening programs related to with cheaper and easier access to disease of diabetes but not the local access and cost of external medicines and vaccines. extent to which it can affect screening. This means that in patients’ daily lives. This seminar countries where the employee Quotes from the patient seminars: made quite an impact on me.” would have to pay for screening “Very emotive and engaging. It In a large global pharmaceutical company to explain the effect of the drug and how they have themselves there is greater internal made me feel proud to be working benefited from the new treatment. If the drug is with over 100,000 employees in over 150 uptake in USA than in UK. for the company leading the way approved we will explain the process and thank the countries it is a challenge to maintain and in therapies for melanoma. Having regulatory team and others involved we will thank Another way to ensure improved improve the health of the workforce. recently had moles removed the manufacturing team for making and supplying health of the workforce is cheaper myself, I was particularly alarmed the drugs and then inspire the commercial team how and easier access to medicines However, given that the focus of the company is to know that there may not be to understanding the benefits of the medicine and and vaccines. All employees are on developing medicines to help the health and any signs that you are developing who will go on to provide the drug to physicians entitled to free flu vaccinations wellbeing of the individual there is a great deal of the disease and how quickly it and patients. which are provided at work and attention on education, access to health care facilities, can develop. I feel I’ve been very screening for diseases and also access to medicines costs the uptake is high. There are Following the broadcast there are questions and lucky!” that can help motivate the employees. also reduced cost to employees of answers about the disease, and medicine with the pharma companies own drugs. personal stories from patients and employees. In general there is a lot of attention to get employees to understand that in all aspects of the business from In addition to education, awareness These sessions have created disease awareness and and screening it is important for a Research and Development to manufacturing that Dr Murray Stewart understanding and motivated different parts of the large health care pharmaceutical they should be putting the patient first when doing Murray Stewart is Chief Medical organization to take care of their health. company to provide healthy their work. The motto of the company is “do more, Officer for pharmaceuticals at options for eating and exercise. feel better and live longer”. This is also followed up by visits to the manufacturing GSK where he is responsible for Healthy eating options are and sites where the medicines are made. Workers on the efficacy and safety of GSK There are regular monthly sessions on disease need to be available for employees the production line like to know the benefit of the pharmaceuticals globally. education and medicine development that are done and simple things like at meetings medicines they are handling and to interact with the live on one site but relayed across the globe to all changing options from biscuits and Murray joined GSK in 2000 as team who have developed the drug. Associate Director for Clinical sites and then recorded for access by all employees. cakes to fruit is important. Research & Development in the These are attended by a large part of the workforce Education is also targeted at high risk groups. UK and since then has held senior and are not only educational but motivational and Exercise is encouraged in the Internally disease area experts will give presentations positions in the Cardiovascular and workforce - most if not all large inspiring. The aim is to make the session topical where appropriate. For example diabetes and heart Metabolic therapy area. sites have gyms which are open and relevant. So when a new drug is approved for disease presentations have been given to the African and accessible before during and Before joining the pharmaceutical industry, Murray worked as a diabetes a certain disease such as diabetes the session will American society which has significantly higher after work hours. There are outside consultant and senior lecturer and was Consultant Physician/Honorary start with experts within the company explaining incidence of diabetes, hypertension and stroke paths/trails for walking and Senior Lecturer and Head of Clinical Services at the Diabetes Centre, about diabetes the disease and clinical complications compared to Caucasians. Newcastle upon Tyne in the UK. His research was in lipid metabolism in and need for new therapies. The R&D team will then running on sites. Employees are encouraged to do meetings such type 2 diabetes he did his medical training at Southampton Medical School describe the new medicine they have developed and External experts are also invited to give presentations as one to ones where they walk in the UK and is a Fellow of the Royal College of Physicians. the clinical trial data. We will then invite a few patients on the science and disease to a wide audience. who have been in the trials and taken the new drug and talk.

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CMO health related behaviour change by Paul Chadwick

After the home, the The intervention or approach Psychological theory holds that that is most likely to have the behaviour is governed by context. workplace is the greatest health impact is one that This means that acontextual environment where is best answered empirically on aspirational targets are not adults spend the the basis of careful modelling of something that sits comfortably a range of specific behavioural within a behavioural framework. majority of their time interventions. Nevertheless, after Targets for any attempt to thereby presenting work-based smoking cessation change behaviour should be set organisations with services, I would suggest that with reference to its baseline interventions that target physical occurrence, and based on what ample opportunity activity have great potential for evidence suggests is possible to influence multiple health impact given the prevalence given the constraints operating and consequence of sedentary to limit its performance. This will health-related behaviour generally, along with be different for different areas behaviours. the physical, psychological and of health-related behaviour. It is economic costs associated unlikely that any one behavioural with work-acquired intervention can produce a musculoskeletal disorders. compliance rate of 80 percent. It is more likely that such It is helpful to make a distinction demanding targets will be met by between behaviour change the systematic application of a interventions and the methodology co-ordinated suite of interventions of behaviour change. The former that have been optimised for a relates to the specific techniques particular context, and which or collections of techniques within tackle the multiple barriers a programme of intervention whilst to change. the latter relates to the systematic process by which one arrives at understanding the specific levers and barriers influencing a behavioural target and the design of the intervention to influence this. It is the application of the methodology of behaviour change that offers the greatest potential for impacting health in the workplace.

90 91 A NEW ROLE FOR CMOS

The COM-B Model provides a Programmes and initiatives that Finally, whilst specialist behaviour This approach is likely to be In order to raise standards framework and methodology for have proven success in one change expertise is often effective because it is based on in this area the CMOs should understanding the determinants organisational context may have a required to design and optimise a scientifically credible synthesis promote Behaviour Change as of a particular behaviour and a limited impact in others. Successful interventions to improve health, of current behaviour change an applied science which needs systematic way of going about the behaviour change initiatives it is also the case that the greatest approaches, and allows for to be practiced by professionals process of designing interventions understand that organisations impact will be achieved by targeted interventions at multiple who have the requisite academic to change it. A behaviourally that fulfil the same function may behaviour change interventions levels of influence ranging from training in the core scientific competent approach will deliver nevertheless be very different at that are delivered at scale by the individual to the socio-cultural. discipline of psychology along the following: the level of operational procedures non-specialists. Such interventions There is a wealth of evidence with a professionally accredited and culture. It is vital to understand need to be tightly prescribed in now emerging that shows that course in the practical and/ 1. A systematic analysis of the these contextual differences when operational terms to make sure interventions based on this or clinical application of this factors influencing the target bringing interventions from one that they are implemented in approach have been successful in discipline. Successful health- behaviour that draws from organisation into another. the manner in which they were areas that have previously resisted related behaviour change what is known in the empirical The methodology of behaviour intended, along with clear guidance change, for example, in the areas interventions often require the Dr Paul Chadwick literature and takes account of change takes this as a given on what aspects of service delivery of compliance with hand washing application of insights from Paul Chadwick is a Consultant the potential variation in local and allows for the exploration can be flexed and what needs to guidance and the implementation diverse ends of the explanatory Clinical and Health Psychologist. contexts of delivery. of the unique culture of an stay the same. The use of clear of patient safety alerts. spectrum. For example, changing He is the Clinical Lead for Psychological Service for Diabetes 2. A comprehensive programme organisation as part of the process standard operating procedures for dietary behaviour may require at the Camden Integrated Practice of co-ordinated behaviour of behaviourally optimising an the delivery of behaviour change There is a great deal of variation interventions that simultaneously Unit and Associate Consultant intervention for a specific context. interventions is what has enabled in the way that organisations draw from theories concerning change techniques organised in the UCL Centre for Behaviour us to create a community weight understand behaviour change the physiological underpinnings into intervention programmes Change. Paul has been at the The degree to which an and the competencies required to tackle the identified barriers management programme that of behaviour (e.g. appetite forefront of developing, evaluating to design and deliver such and facilitators to change. organisation understands achieves comparable effects regulation) as well those explaining and disseminating evidence- behaviour change will have a big when delivered at scale by non- interventions. One potentially the socio-economic influences on 3. An implementation plan based approaches to obesity in impact on the success of any important role of the Global CMO detailing the ways in which specialist staff to the effects behaviour (e.g. the mechanisms by the UK and provides training and venture to improve workplace Network is to promote the use the organisation goes achieved under trial conditions which low socioeconomic status consultancy to individuals and health. The application of of evidence-based approaches in organisations wishing to integrate about delivering the various with specialist delivery agents influences health through food behaviour change methodology relation to behaviour change. behaviour change interventions components of the intervention. (MEND PLEMM Study). choice). Psychology is the only will have the greatest possibility professional discipline that has into their work. of success if there is a high level the competencies to deal with this He co-founded the MEND of behavioural competence within complex modelling of behaviour. Programme, currently the world’s the organisation generally. Ideally It is the application largest community-based pediatric this requires having an individual CMO’s can also make sure that weight management programme who possesses the requisite of the methodology psychologists with behaviour and is the Clinical Director of depth of understanding of the of behaviour change change expertise are located DiscoverMomenta, an organisation core discipline of psychology as at the heart of organisations, currently delivering evidence- well as the specific training in that offers the greatest making sure behavioural know- based adult weight management behaviour change at the heart of potential for impacting how is embedded at all stages of programmes across the UK. He organisational design, from the holds teaching positions at most the organisation, preferably on health in the workplace the senior management team. design of organisational values of London’s major universities and has published widely in the area This individual should be working and principles, to understanding of behaviour change for physical towards threading insights from the specific needs of the activity and eating behaviour. behavioural change research individuals who are the ultimate and practice into the operating targets of behavioural change. procedures of each successive In this way whole organisations layer of management. can be optimised to support the desired behaviour change.

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Another way to see reality more commitment to, their corporate which provides our risks of disease On purpose and the future of clearly is to rise above – to purpose, found a seventeen-fold and death 30 or 40 years in the transcend – our ego. We can return on investment from 1998 to future, what if we had a tool that do this by focusing our life on 2013, compared with a threefold predicted, like a weather report, workplace health and wellness a purpose that is bigger than return among so-called “Good- to- our energy or willpower over the ourselves. Cigarette smokers who Great” companies, and a doubling next few days? What if this tool are asked to consider core values of return among S&P examined over time the influences programmes important to them also begin to 500 companies. not just of our health behaviours, think about love, compassion, and but of news and sports events, other transcending concepts. Another relevant question is, the weather, the day of the week, by Vic Strecher As they transcend, they lose their “Can we help employees season of the year, the economy, defensiveness to the prospect of become better aligned with their and how our partner was doing? quitting smoking. purpose?”. Two human factors that And what if we were furthermore can generate this alignment are able to look at how our energy and On a research team I was recently energy and willpower. Energy willpower influenced alignment In his book Megatrends, hatchets. We’re now left to ask: If we encourage the frog to jump involved in from the University (or vitality) provides the “wind with our purpose in life? John Naisbitt wrote: “The most “How do we engage employees out of the water, he might say: of Michigan, the University of in the sails” that improves exciting breakthroughs of the in our tomahawk-and-hatchet “What do you know? Are you Pennsylvania, and the University performance, presenteeism, and In time this meaningful technology 21st century will not occur surgery?” and “How much do we an expert on boiling water? This of California, Los Angeles (UCLA), engagement. But even given a – employing a thorough but careful because of technology need to pay them to undergo it?” water isn’t so hot. I know other the brains of physically inactive destination and wind in the sails, integration of mobile phones, the frogs in much hotter water.” This but because of an expanding adults were scanned using one also needs a rudder, Web, biometric devices, big data, We are asking the wrong defensiveness is a function of the concept of what it means functional magnetic resonance or willpower, to control executive and the most advanced forecasting questions ego – a kind of “castle wall” which imaging (fMRI) while they affirmed functioning and behaviour. science – could help us become to be human.” To quibble a bit with Naisbitt, protects our identity and self purposeful core values. Compared Willpower (also termed “self- better “researchers of ourselves.” esteem, but which also prevents Wouldn’t that be more motivating Workplace health and wellness I would suggest that the most with a control condition, we control” in the research literature) us from seeing reality. (By the than 1970’s-era forecasting models programmes will become more exciting breakthroughs of the 21st found greater activation in a part is related to greater performance, way, organisations face the same of disease and death? Nearly engaging and effective as we century will occur as we better of the brain related to the self. presenteeism, engagement, injury issue. The C-suite is often the last everyone makes observations redefine what it means to be integrate technology with what This activation, in turn, predicted prevention, and self-care. to see that their employees are about what’s behind their bad and healthy. The idea of health being it means to be human. Let’s call significant increases in physical disengaged.) Which behaviours influence good days – it’s part of human the absence of disease and death it “meaningful technology” – activity over the following month. energy and willpower? Many nature, and is essential to survival. is still prevalent in our society and, combining the best of technology So how do we see ourselves in Two thousand years ago the studies have shown that both The attributions of causality we continues to be the doctrine of with the best of humanity to help a more realistic way? ancient Stoic philosopher Seneca are boosted by improvements make, however, have significant our medical and public us become our own researchers wrote, “When a man does not in sleep, mindfulness, physical biases, inaccuracies, and other health professions. and philosophers. And let’s start Sometimes the castle wall breaks by asking the right questions. open. We suffer a heart attack. know what harbour he is making activity, and diet. If motivated by shortcomings. We don’t typically The widely used tools of We get a bad review from our for, no wind is the right wind.” A a strong purpose and a desire for notice multiple days of behaviour workplace health and wellness One such question might be, boss. The organisation goes harbour, or purpose, in life and at more energy and willpower, one and their interactions with other programmes – particularly the “Why are people so resistant to through a layoff. Our ego is work is a meta-goal that engages could envision greater effort and behaviours (e.g. lack of physical ubiquitous health risk assessment change?” The metaphor of the damaged. While potentially focus and greater performance. persistence given to improve these activity combined with poor (more accurately a death risk boiling frog seems to fit health harmful (our ego also serves many Organisations express this purpose and other behaviours. This is where eating), or with environmental assessment) – reflect this approach issues in the workplace: if you put positive functions), such a break through mission statements, our meaningful technology may factors (e.g. poor sleep combined and provoke defensiveness and a frog in boiling water it jumps also presents an opportunity to but those missions must be play a role. with a declining economy). suspicion. They fail to engage right out, but if you put it in cool see clearly . . . to become engaged authentically lived. We may often wonder by midday meaningful conversation about water and gradually turn up the in a new direction . . . to change. Is the true mission of corporations why we have no energy, or why we health behaviour change. Our field heat the frog gets sleepy, rolls over, only to return value to feel out of control. Perhaps it’s a has been attempting to perform and boils to death. Most of the shareholders? If so, it’s likely that poor night’s sleep, a snowstorm, surgery with tomahawks and problems we face in the workplace – such as sedentary behaviour they’ll return less value to their an overindulgent breakfast, or a or poor communication among shareholders. A recent study of 28 heartbreaking loss by our favourite colleagues – are slow, incremental “Firms of Endearment,” primarily football team. Instead of a “boiling-frog” problems. selected for the strength of, and traditional health risk assessment, 94 95 A NEW ROLE FOR CMOS

Meaningful technology to help us In conclusion, what I’m suggesting better understand ourselves would here is a new definition of health – likely lead to greater motivation one that focuses on living a to improve those behaviours that fulfilled life rather than just trying most influence our energy and to steer clear of disease and death. willpower. Traditional health and Under this redefinition, purpose wellness programmes typically in life becomes a meta-goal that offer classes or self-help materials can motivate us to develop and to change health behaviours. harness greater energy Yet this isn’t the way we typically and willpower. seek help. A more relevant way to do so is by looking at others like Meaningful technology can ourselves who have successfully make us better researchers and changed their behaviour. philosophers of ourselves through: Dr Vic Strecher (a) developing an authentic Strecher is Professor and Director In the world of technology, this purpose; (b) using mobile phone, for Innovation at the University of is called “collaborative filtering.” web, biometric devices, and big Michigan School of Public Health. Recommender systems, such as data collection to monitor purpose, In 1995, he founded the University those used by Amazon or Netflix, energy, willpower, and a range of of Michigan’s Center for Health Communications Research, a employ collaborative filtering behavioural, environmental, and research-focused organization of algorithms to identify others temporal factors; (c) providing health and behavioral scientists, similar to you who have used a forecast of future energy and educators, software engineers, and a product that would be likely willpower; and (d) providing a artists. Through this Center, he has to appeal to you. recommender and rating system been a leading investigator on over of advice from similar, $45 million in grant-funded Through meaningful technology, successful others. studies of computer-tailored we can for example identify others health programs. similar to ourselves who have All of this could provide employees improved their diet, and their a truly engaging, useful service Vic founded HealthMedia, an Ann Arbor-based company that strategies could be recommended in their daily lives. At the same has created digital health coaching to us. The tips that work the best time, employers could – without programs for millions of users could receive high ratings, just any information about individual which was purchased by Johnson employees – better understand as the mobile app Yelp allows & Johnson in 2008. us to rate restaurants and the best predictors of productivity, other establishments. absenteeism, engagement, and Currently, as Director for health-related costs. Employers Innovation, he is working to create could also identify sections of their an environment that promotes organisations that exhibit more more direct dissemination of research efforts to improve or less energy and willpower over We found greater the public’s health nationally time and better understand the and globally. He is also Visiting activation in a part behavioural, environmental, and Professor at the Peking University’s temporal factors influencing these of the brain related School of Public Health. critical factors. to the self Vic’s latest research and book is related to the importance of developing and maintaining a strong purpose in life.

96 97 Taking up the challenge – What can the Global CMO catalysing an effective Network do to improve the and scalable response to health of people everywhere? PUBLIC AND non-communicable disease by Nalini Saligram 114 in low-and middle-income countries A systems approach to COMMUNITY HEALTH by Christine Hancock 100 worksite wellness programmes in addressing obesity Creating workplaces as hubs by Terry Huang 116 Looking outwards for healthy ageing by Graham Stokes 104

Prevention may be cheaper than we think by Jeff Sturchio 108

Re-evaluating current interventions by Mike Loosemore 112

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• target each unique workplace Taking up the challenge – catalysing and cultural setting – decentralising and adapting an effective and scalable response to local need • undertake baseline testing to non-communicable disease in and ongoing follow-up to evaluate and monitor the low-and middle-income countries programmes, and allow for employee feedback to improve programmes by Christine Hancock • comprehensive multi-modal programmes including personalised and behavioural elements give the best results. The challenge The opportunity Evidence of effectiveness and In addition, organisations that Non-communicable diseases But there is good news. Tackling lessons learned currently run successful HIV/ (NCDs), including cancer, diabetes, three major risk factors – tobacco There are many publications AIDS programmes in LMICs can heart disease and lung disease, use, poor diet (including misuse linking workplace-health initiatives take advantage of the lessons accounted for 68 percent of the of alcohol) and lack of physical with improved employee health learnt and build on these existing 56 million deaths in 2012 – double activity – can prevent or delay the and productivity, but relatively platforms, partnerships, models the number of deaths from all majority of NCDs. The workplace few scientific peer-reviewed and resources. infectious diseases (including HIV/ is a crucial arena for health studies of their effectiveness. AIDS, TB and malaria), maternal promotion, as it is where many However, a review of current The Global CMO Network: and perinatal conditions, and adults spend so much of their time literature (scientific and grey), catalysing global action nutritional deficiencies combined. – but many employers, especially case studies, toolkits and The Global CMO Network can There are particular challenges to in economies hit by global self-reported studies identifies learn from existing initiatives with preventing and treating NCDs in recession, are reluctant to invest key success factors for an effective demonstrable outcomes, and low- and middle-income countries in health, even when potential workplace-health programme: leverage its reach, resources and (LMICs) because of increasing returns can be 5:1. • target multiple risk factors, convening power to deliver exposure to behavioural health especially those that drive the greater impact and innovation. risks, and under-resourced and The Global CMO Network brings disease burden in the region under-funded health systems. together the expertise, resources, where the workplace is located Of the 40 percent of deaths global reach and scale of some • combine multi-component from NCDs that occur in the of the world’s largest companies. health education with changes under-70s, four-fifths are in It is uniquely positioned to to the physical and social developing countries. catalyse a transformative response workplace environment to to the NCD challenge and establish encourage behaviour change a global health strategy to deliver real, measurable impact. Its • group support enhances membership of the Clinton Global outcomes Initiative facilitates the opportunity • competition and incentives for a multi-sector approach, in often deliver better engagement partnership with business, NGOs, • take an interdisciplinary governments and the public- approach health community. • obtain management buy-in and employee ownership

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Case study: IBM Proposal: wellness hubs This model brings together IBM’s workplace health programme is a global The Global CMO Network can take the elements existing assets, resources and framework that allows a unified strategy to be of a successful workplace health programme expertise to position participating combined with local innovation. It is continuously (as demonstrated by IBM) to develop its own workplaces as ‘wellness hubs’ evaluated, and its programmes have been approach to enable employees – and suppliers within communities. Programmes implemented in IBM workplaces including Australia, and communities – to lead fitter, healthier lives. could also be offered to suppliers, China, Europe, Japan, India, South Korea, and local small businesses and partners North and South America. Member companies of the Global CMO Network at reduced cost (or at no cost). would create wellness hubs in up to ten member Small informal businesses account The principles of IBM’s approach are a population organisations. These pilot sites would deliver for one third to one half of GDP approach (focused on reducing high-risk employees modular, scalable health and wellness services to in LMICs and account for over 50 and keeping low-risk employees’ low risk) and complement and enhance existing workplace-health percent of employees. By creating facilitating small actions over time for lasting provision. They will support behaviour change, a ‘healthy business enabling behaviour change – all supported by targeted and be accessible to employees, suppliers and environment’, in which direct costs Christine Hancock engagement, trust and evaluation. communities. Initiatives should be based on and risks of smaller employers Christine Hancock is the founder behaviour-change principles and carefully are reduced, the potential and director of C3 Collaborating for Health, which she founded in The programme covers occupational health and monitored/ evaluated, and could include: impact on health – and therefore health promotion, providing health care, and with productivity, reduced absenteeism 2009. She is an experienced nurse and health service manager. extensive health benefits (dental, mental-health, 1. Evidence-based, multi-component weight- and improved morale – could be She was CEO of the NHS in pharmaceutical and other services). The health- management programmes providing individuals significant. Waltham Forest, a disadvantaged promotion framework includes: with the skills and resources to lose weight and area of north London and for Final thought • monitoring health status/risk (including screening); maintain weight-loss; 12 years the CEO and general • creating healthy workplaces that foster healthy Sustainable health-behaviour secretary of the Royal College 2. Health-promotion outreach – harnessing the behaviours, supplemented by strategic change requires individual of Nursing before becoming enthusiasm and skills of volunteers (champions), president of the International behaviour-change programmes (eg. stress empowerment within a health- equipping and empowering them with training/ Council of Nurses where she was reduction, smoke-free environments supported by supporting environment. This is tools to inspire others and become a movement involved in policy-making through smoking cessation, and healthy cafeteria options complex and requires partnership of healthy-living advocates; WHO and other UN bodies, and as well as weight-management programmes); and working at scale – but this is an opportunity to be proactive visited 50 countries looking at • comprehensive health-care plans that support Online ‘healthy-living tools’ providing information their health care. In the UK she 3. in targeting NCDs in low- and healthy lifestyles. to educate and empower employees to make is a governor of De Montfort middle-income countries before healthier choices; and University, and a trustee of a they become an epidemic. From 2004–8, the health of the workforce improved, charity for homeless people. and the number of people with four or more risks fell Promotional activities and incentives – including 4. Are you up to the challenge? by more than half. signposting to existing community and workplace programmes and initiatives, and perhaps partnering with a retail partner to provide healthy discounts. We found greater activation in a part of the brain related to the self

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Collectively, the private sector has Smart and progressive businesses What we would like to explore Creating workplaces as hubs a significant role to play in driving are investing time and resources with the Global CMO Network is transformative change on a global in improving their employees’ a consensus that this opportunity scale in health and ultimately health and managing wellness in space and target audience is a for healthy ageing saving lives. When we talk about the workplace, with demonstrable fertile area to continue with. workplaces, we don’t just mean benefits to their bottom lines. And if so, identify possible high rise office settings, we mean These organisations at the effective interventions to drive by Graham Stokes and Claire Baker everything from agriculture to forefront of workplace wellness real change, and mechanisms factories to small advertising recognise that employee health for delivering these successfully agencies and all that’s in between. and wellbeing is not just a ‘nice throughout different types and With approximately 65 percent to have’, but that it makes great sizes of organisations. As CMOs of the global adult population business sense - with organisations with varied workforces and Meet Anika So how can we help Anika, and As the world’s population continues in the workforce; employers and that promote workers health workplaces we have a unique Imagine Anika. She’s 49 and the millions of other working to live longer, it then translates that workplaces have the unique being among the most successful set of connections to draw is a seamstress in a clothing age people in a similar situation we will be working for longer, be ability to create health-enabling over time. experience from and possibly manufacturing company in New around the world to be healthier? this through choice or necessity. environments and promote trial interventions. Delhi. She enjoys spending time A part of the answer may lie in the Meaning employers, more than behavioural change to healthier We’ve identified that: with her family and proudly workplace.... ever, have a vital role to play in lifestyles for the majority of the • The workplace is a unique has four children and six grand their employees’ health – for world’s population. fertile opportunity space to children. Her father passed away Context immediate and long term benefits make ageing (and dementia five years ago. Anika’s mother Ageing is a global phenomenon: for all involved: the individual, the In conclusion, designing risk reduction) relevant to a As the world’s who is 70 and is showing signs of In the year 2000 there were 605 employer and society. A healthier interventions to target those in younger audience, which is population dementia lives with Anika and her million people aged over 60 in working age person is more likely the work force aged 35-60 we previously untapped. believe will be the approach which continues to live husband in their family home the world. This will rise to two to continue to be so in older • Many people in the workforce will have the greatest impact on along with their son Arjun. billion people aged over 60 by age too, they won’t experience aged 35-60 have both senior longer, it then workplace health. 2050. That will be 20 percent of as much ill health. This is called and junior dependants reliant Anika works for around 40 hours the population (WHO). Where morbidity compression. And health on them. translates that we By enabling employees to make a week, and is also responsible for these people live will not be evenly in older age is the main factor in healthier choices and reduce • They are motivated to help will be working the household shopping, cleaning spread around the world: 80 determining where the balance lies exposure to major risk factors for their dependants, meaning and cooking. She informally cares percent of older people in 2050 between the costs and benefits of for longer, be this dementia and non communicable they inadvertently neglect for her mother, and often looks will live in low and middle-income an ageing society. their own health. through choice after her grandchildren too. Her countries (WHO). diseases, businesses incentivise priority is keeping everybody else There are things we can do employees to be more fully • Dementia is often looked or necessity well and earning enough money This presents some great across our life course which may engaged, committed and at as a reserve of old age. to help keep the family a float. opportunities....and challenges. reduce our risk of developing ultimately more productive. However research suggests Her family are the most important It means that the workforce will dementia, contrary to popular belief Organisations also benefit from it could be connected to the thing in the world to her. She’s be older than ever before. it is not the reserve of old age. an enhanced ethical reputation, life course. This new research their backbone. The consequence For example: As the World Alzheimer Report creating a competitive advantage, has the potential to make and are more likely to attract dementia relevant to a younger for Anika of putting her family first • In the EU the working age group 2014 highlights; the strongest and retain workers. More broadly, generation. Empowering the is that she inadvertently neglects between 55-64 will expand by evidence for possible causal healthy workplaces also mean 35-60 working age population her own health. This puts her at 16 percent by 2030. All other associations with dementia are healthy communities, which have to be healthier could reduce risk of ill health both now and in age groups will show a declining those of low education in early a tremendous influence on the the incidence of dementia over the longer term, meaning that if trend. This is due to higher life life, hypertension in midlife, and environment in which a business time. And of course other non something happens to Anika, then expectancy and lower fertility smoking and diabetes across the operates and is able to contribute communicabled Diseases. those around her suffer too. Her ill rates. life course. The report calls for older health impacts the whole family. adults who are often overlooked to broader economies. • In China, by 2022 the average in prevention programmes to be age of working farmers is targeted. Increased physical activity predicted to be over 50, or and reduction in levels of obesity even over 60. are also highlighted as being important. 104 105 Professor Graham Stokes

Graham Stokes has over 25 years of experience in specialist dementia care and is an internationally recognised authority on dementia care practice and policy. He is Global Director of Dementia Care at Bupa where he oversees Bupa’s dementia policy and practice around the world.

Graham also holds a number of academic posts including being Visiting Professor in Person-Centred Dementia Care the University of Bradford. He is also Co Chair of the Board of the Dementia Action Alliance. Prior to his Bupa appointment, he was a senior consultant clinical psychologist at an NHS Foundation Trust in the UK where he was Head of Psychology Services for Older Adults and Adults with Neurodegenerative Diseases.

Claire Baker

Claire Baker is currently the Healthy Ageing and Wellbeing Adviser, covering strategy and advice for healthy minds, workplaces and environments.

A firm believer that businesses have the ability to catalyse change in the world Claire is managing a partnership between Bupa and Alzheimer’s Disease International, together advocating for governments to develop adequate national policy plans which enable people to live well with dementia today, and reduce the risk of dementia in the future.

Claire also has experience across Facilities Management and award winning Sustainable Business projects – ranging from an employee behaviour change campaign which resulted in 100,000 people around the world getting walking to improve their health, to driving carbon reduction through a global carbon measurement system which resulted in Bupa being the first private healthcare company to achieve the Carbon Trust Standard.

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Behavioural economists like abstinence than smokers in the for the week is likely to have Prevention may be cheaper the University of Pennsylvania’s control group. After 12 months healthier eating patterns during Kevin Volpp would argue for of enrollment in the programme, that time period. Likewise, social the latter. Volpp supports the nearly 15 percent of individuals in norms cannot be underestimated. than we think idea that people are irrational the incentive group had remained People are less likely to start in their decision-making and smoke-free, compared to only five smoking if it’s not acceptable to thus require a bit of additional percent in the group that did not do so in their community. by Jeff Sturchio incentive, or “nudging,” to make receive incentives. healthier choices. However, human A Population Services International behaviour is predictable and Researchers have also employed (PSI) project in Lusaka, Zambia can be evaluated in consistent, behavioural economics to help used social capital, as opposed systematic ways. For instance, improve health outcomes and to money or food, to secure similar results. The researchers Everyone’s familiar It’s no secret that rising health change around eating healthy we tend to gravitate toward reduce health care costs in the care costs are a growing challenge foods, staying active, avoiding activities that will grant us developing world. In India, where randomly assigned more than 1,000 with the old adage, for many countries, in large tobacco use and alcohol abuse, immediate gratification, such immunisation rates are usually hairdressers in 200 areas to four “an ounce of prevention part because of the growing have the great potential to delay as indulging in an ice cream abysmally low in rural areas, groups: one control group, two sundae, rather than a longer-term Abhijit Banerjee and colleagues financial reward groups, and one is worth a pound of epidemic of non-communicable the onset, mitigate the severity, diseases (NCDs) such as cancers, and prevent the development of aspiration of living healthier. divided 134 villages in rural “social recognition” group, in cure.” But what does cardiovascular disease, asthma chronic disease. Udaipur into three groups: a first which barbers would earn stars on that ounce of prevention and diabetes. In the US alone, In his 2012 book, The Power of experimental group enjoying a thermometer poster in their shops Anyone who has tried to stop Habit: Why We Do What We Do the presence of regularly open, representing condoms distributed – cost? The answer may chronic diseases were a major contributor to the country’s $2.9 smoking or lose a few pounds in Life and Business, author and well-publicised health facilities; and, by extension, lives protected be less than you think. trillion in health expenditures in knows that changing bad New York Times reporter Charles a second experimental group in from HIV/AIDS. 2013 – about 17.4 percent of its behaviours is not easy. Helping Duhigg asserts that identifying which such facilities were located At the end of the study, researchers GDP. Yet only three percent of people adopt healthier behaviours the triggers for unhealthy habits and parents received a kilogram of found that the hairdressers in the the US health budget is allocated is often both challenging and as well as the incentive for lentils when they brought a child social recognition group had sold for disease prevention. Without costly. How, for example, do changing behaviour are critical in for immunisation; and a control twice as many condoms as those in adequate intervention, estimates you use incentives to encourage factors in one’s ability to break group for which no intervention any other group. indicate that between 2013 -2023, individuals to eat locally grown a bad habit. Finding what social was applied. At the experiment’s US health care spending will fruits and vegetables as opposed cues go into changing the habit of conclusion, the rate of complete further increase an average of 5.7 to a candy bar? How do you driving a short distance rather than vaccination was 38 percent in percent each year if the rate of successfully convince people walking and exploring what the villages with the lentil incentive, NCDs continues to accelerate. it’s better to take the stairs and “reward” for the better choice is, as opposed to just 17 percent in CMOs are perfectly not the elevator on their way to can foster the adoption of a new, villages with just the clinics and six These statistics highlight the need the office? Are the promises of healthier habit. percent in control villages. positioned to enable for policymakers to focus priorities a healthier and likely longer life and drive change around prevention. But companies sufficient, or do individuals require Other research in behavioural But material gain is not the only and foundations also have an other material or social incentives? economics supports the power motivating factor. Behavioural important role to play in reducing of incentives. In one randomized, economic theory has also been risk factors and fostering healthier controlled trial studying the successfully applied to improve behaviours. Indeed, increased effectiveness of financial incentives health by using social triggers investment in disease prevention, for tobacco cessation, researchers (as opposed to the ambiguity of embedded in a new culture of discovered that the experimental health or “wellness”) to incentivise health, presents an opportunity group, whose members received better health behaviours. Nudge: to improve health outcomes in $100 for the completion of a Improving Decisions About Health, more affordable and effective smoking-cessation programme, Wealth, and Happiness by Richard ways. Facilitating behaviour $250 for cessation of smoking H. Thaler and Cass R. Sunstein, within six months after enrollment, offers interesting insights into and $400 for abstinence for social cues that can influence an additional six months, had better behaviour. For instance, significantly higher rates of someone asked about their diet 108 109 PUBLIC AND COMMUNITY HEALTH

As these and other studies increasing efforts to prevent in the first place. Investing in demonstrate, what we learn disease by transforming the innovative and pragmatic solutions from behavioural economics has way their respective companies that foster better health on a tremendous potential to improve approach improving health population level will pay dividends health outcomes. With the growing outcomes. CMOs are perfectly in the long run, bending the population affected by chronic, positioned to enable and drive cost curve for health care and preventable disease, decision- change in this area. helping people to live longer, makers should consider leveraging healthier lives. The reality is we these findings to shape more Prevention is not perceived as a cannot afford to continue as we effective policies. The private sexy topic. Monitoring progress are today. NCDs do not have the sector has an opportunity to help toward keeping people well frisson or the urgency of a disease shift the paradigm to increase on a population level can be outbreak, but the economic impact dramatically the focus on primary difficult to quantify, particularly in of chronic illness on families, and secondary prevention of systems where the metrics centre communities, companies and disease. Companies can leverage around incidence of illness. But countries is affecting productivity the findings of behavioural the management and treatment and growth globally. It’s not economics to bring to bear of a chronic illness and its sustainable for any country, their considerable expertise and complications will almost always rich or poor. resources to explore incentives cost more than its prevention that most effectively motivate people to break bad habits and adopt healthier behaviours. Jeff Sturchio Jeff is President & CEO of Rabin Martin, The seismic shift required to a leading global health consulting firm. foster greater emphasis on A respected global health thought prevention requires leadership leader, Jeff is a trusted counselor from companies themselves. to senior leaders in the private Our experience shows that sector, multilateral organizations, companies best positioned to governments, NGOs and foundations. influence change in healthy Jeff has contributed to numerous behaviours demonstrate several publications in global health, most characteristics: a clear vision of recently, Noncommunicable Diseases the change they want to achieve, in the Developing World: Addressing Gaps in Global Policy and Research products and services that (Johns Hopkins University Press). align with this vision, continued Previously, Jeff was President & CEO of the Global Health Council and Vice engagement with stakeholders, President of Corporate Responsibility at Merck & Co. Inc., President of The visible champions that can Merck Company Foundation and Chairman of the U.S. Corporate Council advance policies and practice, on Africa. He is a Visiting Scholar at the Johns Hopkins Institute for Applied strong public policies and good Economics, Global Health and the Study of Business Enterprise; a Principal internal governance. Nor is of the Modernizing Foreign Assistance Network; a Fellow of the American leadership in promoting prevention Association for the Advancement of Science; a member of the Council on is not limited to companies in the Foreign Relations; an Advisor to the Clinton Global Initiative and a member health sector. As the responsible of the NCD Alliance Expert Advisory Council. He holds an AB from Princeton leaders within their companies, University and a PhD from the University of Pennsylvania. Chief Medical Officers can play an important catalytic role in

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Active MovementTM is a new kind Active MovementTM ‘s unique Re-evaluating current of health intervention constructed perspective is causing many precisely around these criteria. businesses, health organisations Each client business is evaluated and government authorities interventions independently so a dedicated to re-evaluate their current programme can be constructed; interventions. I am delighted to followed by a three-stage, 6 – be able to share this pioneering by Mike Loosemore 12 month activity programme programme with the Global CMO that integrates non-sedentary Network to instigate across their behaviour and low-level activity own businesses, from individual into everyday routine. Such an departments to specific buildings undemanding, easily attainable to their entire company network. The continuing trend of British It is clear to me that if a major shift This requires, of course, the programme creates the most Dr Mike Loosemore children towards ever greater in the country’s physical activity is creation of a very different kind important element of the Active In this way, we can extend levels of obesity (currently one in to take place, the focus must move of programme. If we are to gain MovementTM intervention – awareness and implementation Mike Loosemore is a pioneer in TM Exercise Medicine. He is Lead four entering secondary education away from the clichéd methods traction with such an uncommitted its accessibility to all. It was of the Active Movement Consultant in Sports and Exercise at 11 years old are defined as such) of free gym memberships, audience, anything we might deliberately designed to cater for concept to make a different not Medicine at the Institute of and the increase in Type2 diabetes encouragement to play sports or propose must be relevant to everyone. No age profile, ethnic only in the general health of all, Sport, Exercise and Health. the way they lead their lives – and group, gender, physical ability, but in each individual’s perception from two percent of the population office exercise routines. Corporate He is one of the foremost sports sport experience, lifestyle or of their own well-being and the in 1991, six percent of the wellness programmes that pander empathetic to their current mindset. physicians for elite athletes disability type is excluded from opportunities to improve it. population in 2011 with a predicted to no-one but those already into reflected in his recent role as increase to eight percent in 2020, their own physicality need to be So it’s time to forget treadmills, enjoying its benefits, as seen Chief Medical Officer at the are testaments to the poor state of re-examined. Self-help techniques tracksuits and trainers, or exercises in the outstanding results from Commonwealth Games. Yet Mike this country’s health. and other formulaic interventions and stretches. Forget trying to programmes already carried out is also a primary advocate of will fail to gain any leverage promote hard sessions at the amongst adults in the workplace, Exercise in Medicine, applying the Successive British governments with the vast majority of the gym, punishing runs or exhausting pupils in school and even children power of activity to improving have looked for new ways to population as long as they remain aerobic lessons. Instead start at a as young as a year old in the health and long-term well-being. encourage the population to disinterested, disillusioned level that all can understand and nursery. In the case of the young This has been the inspiration be active, though their current or un-convinced. achieve. Any activity must begin and the elderly, we add a further behind Active Movement, a minimum weekly guidelines of 30 by both reversing the growing dimension by creating Active new behaviour change health minutes exercise a day plus two The key is to stop trying to get epidemic of sedentary behaviour MovementTM communities where, intervention designed to reduce resistance activities are ignored. people to run before they can walk and encouraging only low-level for example, the children, staff and sedentary lifestyle and low-level Latest figures suggest barely (both literally and figuratively). activity; it must be tailored to the parents all participate together activity across all age groups. seven percent of British men get The only way that the population audience and location it inspires; so not only benefiitting from near this level, with over six million will review their own physicality is it must be a long-term process; the health gains personally but people completing no physical if it is part of a behaviour change there must be continual adding the vital ingredient of role activity whatsoever. process that positively affects encouragement, motivation and modelling. The concept of a family Ever-increasing evidence shows their views on activity, health and support to continue; it should be Active MovementTM is also being that sedentary behaviour has long-term well-being. This is what collegiate; and evaluation should tested with the creation of an become a critical problem as we makes Active MovementTM different not be about goal-setting and Active MovementTM Home Kit. continually engineer activity out of from any other health intervention. analysis, but about participation, our lives - and nowhere is this truer Its start point is about reshaping enjoyability and achieving than in the office environment. peoples’ lives not their bodies. collective behaviour change. Active MovementTM’s unique perspective is causing many businesses, health organisations and government authorities to re-evaluate their current interventions

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2. Champion the use of mobile mHealth- based prevention What can the Global CMO technology to improve health efforts have much potential outcomes or mHealth in short, for impact and should be to encourage people to eat championed by the Global CMO Network do to improve the right, exercise regularly, Network. Even if they get used stop smoking and prevent by just their own employees, health of people everywhere? chronic diseases. the impact can be significant. mHealth holds much promise, 3. Assess the impact a company especially in developing is having on the health of by Nalini Saligram countries where cell phone use its employees, families and is widespread. For example, communities. Create a global there are 900 million cell Health Impact Index and rank phone subscribers in India. companies. And ensure that Dr Nalini Saligram mHealth has shown some the Index is taken into Nalini Saligram is Founder & At Arogya World we are We are deeply invested in the formula viable in India, we would success in behaviour change in consideration as the world CEO of Arogya World, a US committed to changing the implementation of large, scalable use it to convince companies several fields – HIV and malaria implements the post-2015 based non-profit organization diabetes prevention programmes that employee wellness medicine adherence, diabetes Sustainability Development committed to changing the course of chronic disease, course of chronic disease through in India – in schools, workplaces increases productivity, decreases management etc. In smoking Goals. The Global CMO one community at a time. advocacy and prevention. and by leveraging mobile absenteeism, and improves the cessation, text messages have Network members can write Nalini is engaged with a major We strive to do our work technology. We believe we have bottom line. Industry bodies been shown to double the thought pieces on the Index, mobile health diabetes prevention helped 150,000 people improve would also see the value, and quit rate. by changing the health speak at industry conferences effort and an ambitious workplace their health, and that kind of support workplace wellness. behaviour of individuals, and persuade companies the wellness initiative in India. But more evidence is needed measurable impact spurs us on. world over, not just their own She has lived and worked the culture of workplaces, This can be a much needed and to establish the use of mHealth members, to comply. in many parts of the world, and the health policies As a global health practitioner, practical contribution from the for chronic disease prevention. including Merck in Philadelphia, of governments. I would look to the Global CMO Global CMO Network. They can Arogya World’s mDiabetes We must ensure that we leave Glaxo Wellcome in London, Hill Network to: get a few smart young people is adding to the evidence the world a healthy place for & Knowlton in Hong Kong and from their companies (ROI Task base. mDiabetes, our first the next generation. This is, Merial in Atlanta. She has also Establish a formula for Return on 1. Force) to work with NGOs like us CGI Commitment, a ground- quite simply, our responsibility. been active with several non- Investment (ROI) from workplace and with HR folks in companies breaking one million person The Global CMO Network profits such as United Way and wellness, which is easy to execute US Fund for UNICEF. She serves in different geographies, to text messaging effort in India, can genuinely advance our and validated, the world over. on the Dean’s Council of Emory validate the ROI calculations. has shown exciting results – generation’s efforts to fight non- University’s Rollins School of 35 percent of a subset of communicable diseases (NCDs). Public Health. As we have gone about getting the text message recipients companies to become Healthy compared to 21 percent in a Workplaces in India, one of our mHealth holds much control group (who did not Clinton Global Initiative (CGI) receive the text messages), commitments (our goal is to promise, especially in reported positively changing reach 100 by end of 2016), a developing countries two or more health behaviours key challenge has been finding known to prevent diabetes . ways to convince company where cell phone use CEOs to invest in workplace is widespread Building on the success wellness. If we had a simple, easy of mDiabetes, we are now to implement, fully endorsed developing an mHealth2.0 platform for smart phone use in India, with Cigna Foundation funding.



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The biological and environmental Worksite wellness programmes elevators. Many companies are A systems approach to forces together make it highly typically involve a combination looking to these ideas where difficult for individuals to of preventive screening, health environmental cues for behaviour rationally make healthy choices – education, behavioural are more conducive to healthy worksite wellness programmes a phenomenon behavioural counseling, and sometimes versus unhealthy practices. economists call bounded rationality disease management. – despite awareness and knowledge However, the literature suggests The incorporation of friendly in addressing obesity of the health consequences of being that programmes that have competition within wellness overweight. It is not surprising, the greatest participation and programmes can also spur then, that the vast majority of outcomes are ones that include individual and organisational by Terry Huang public health interventions to a financial incentive. There is still change. For example, there is date, with an emphasis on health debate as to what kinds of financial evidence from other domains that education and behavioural incentive work best, but they competition can be leveraged to counseling, has led to little can include rebates on insurance create innovation. In the case of success in long-term weight loss. premiums, discounts on gym wellness, teams of employees can Obesity is now a Obesity is a complex problem The public health challenge of memberships or cash rewards. compete for awards by striving to resulting from myriad social and halting and reversing the obesity achieve certain health behaviour global epidemic among In light of these challenges, the The Vitality programme from lifestyle changes in the age of epidemic lies in the interplay World Health Organization has insurer Discovery South Africa or wellness goals. This has the both adults and children. globalization, which accelerated between human biology and an called for a whole-of-society, has taken this one step further potential benefit of engaging a Despite significant starting in the last quarter of the obesogenic environment. multi-stakeholder approach to by partnering with large grocery broad spectrum of employees 20th century. Technology, while Humans are innately driven to obesity. Similarly, the Institute of chains to offer discounts on and allowing for the organic public health efforts indispensable in the modern seek pleasure from food and to Medicine in the United States has healthier foods. formation of support networks to date, the prevalence era, has led to a more sedentary store energy in the body. Research also called for a systems approach among employee groups. Such of obesity remains lifestyle. In addition, and perhaps in neuroscience has shown to obesity. In this framework, it Successful programmes are also social support and interpersonal more importantly, it has also led that fats and sugars trigger the is recognized that employers ones where company leadership accountability have been shown in persistently high to an increase in the availability, reward pathways in the brain, and workplaces can play a major sets the tone for health by the literature to be important for in developed countries accessibility and affordability of similar to other pleasure-inducing role in the fight against obesity. supporting and enacting company weight loss behaviours. fats and sugars. These are manifest substances. In addition, our bodies However, a systems approach is policies that make it easier for and continues to in the increase in the production are designed to conserve energy not simply adding up changes employees to adopt healthy increase in developing of meats and packaged foods and because that is an evolutionary at the individual, institutional, behaviours. For example, a The public health countries. beverages. Not coincidentally, advantage in times of food environmental and policy levels. flexible work schedule encourages there has been a parallel increase scarcity. Unfortunately, the Rather, it is important to examine employees to exercise during the challenge of halting in portion sizes, both in terms human biology is a mismatch to what motivates and sustains day, especially when gyms are of commercial packaging and the current environment of food change at each of these levels. readily available on site. Some and reversing the normative expectation in society, abundance. Our environment is In other words, the incentives for companies, such as Google, have as a result of cheaper fats and obesogenic because its social, change must be aligned across also begun to practice “choice obesity epidemic sugars. To translate these changes physical, economic and marketing these levels. As noted earlier, architecture” by creating a default into quantitative significance, both dimensions all favor food health may not be a sufficiently physical and food environment lies in the interplay epidemiological and clinical data productivity and consumption motivating factor, for employees that nudges employees to adopt between human from the US, where obesity first over energy expenditure. or employers. At the same time, healthier eating and engage in reached epidemic proportions, it would be shortsighted to treat more physical activity. Examples biology and suggest that an increase of workplaces as independent of include making fruit, vegetables approximately 200 kcal/day in the communities in which they and water more accessible than an obesogenic food intake is sufficient to explain are embedded. This commentary less healthy items (eg. on shelf environment the rise in obesity over the past highlights a few systems-oriented displays or at check-outs) in the four decades. insights that can further enhance design of cafeterias and vending the impact of worksite wellness machines or making stairs more initiatives in addressing obesity. accessible and attractive than

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Collaboration is another key To achieve the greatest and most Obesity is complex and requires Ultimately, the vision that companies should strive for ought not only be systems insight that has not sustainable impact, companies a set of multi-pronged strategies making the healthy choices the easy choices. Rather, companies should been well applied to wellness should consider themselves as fully that reinforce each other. apply what they know about changing organisational culture to the programmes. To increase employee integrated in the communities from The Global CMO Network, and creation of a culture of health, where the healthy choices are the preferred participation in and compliance which they draw their workers. indeed the private sector at- choices within workplaces and throughout society. with wellness programmes, Given the complexity of obesity, large, has a real opportunity to individuals must feel greater incentives for behaviour change respond meaningfully to the call ownership in them. Too often, must go beyond the workplace for a multi-stakeholder, systems wellness programmes are designed and into households and the approach to obesity. To do so, Professor Terry Huang as top-down strategies imposed broader community. As such, there incentives not only need to be Terry Huang is Professor at the City on employees. Rather, we know is a real opportunity for companies re-prioritized at the employee University of New York School of Public from pubic health literature that to extend wellness programmes level but also at the managerial Health. Previously, he served as a senior community-engaged approaches to dependents of employees. level. Company managers should leader on pediatric obesity research at yield better results in the long This ensures that what companies be held accountable to health- the U.S. National Institutes of Health. run. Companies should facilitate ask of the employees at work related performance benchmarks He is Co-Founder and Senior Advisor a process where employees can, would be consistent with practices within a company and be rewarded of the U.S. National Collaborative on on an ongoing basis, identify the at home. Limited data show that when benchmarks are met or Childhood Obesity Research (NCCOR) and is a global leader on creative needs and barriers for health as high as 20 percent of employee exceeded. Globally, there are key solutions for obesity and chronic behaviour change, and design and absences may be due to children’s lessons from indices that rate disease, systems-oriented prevention test solutions to overcome these health needs, and we know and rank companies on a range strategies targeting both the supply of and demand for health, cross-sectoral barriers. This process has a certain overweight and obese children of social good indicators, such partnerships, and the translation of science to policy. He has published and parallel to how companies treat miss school significantly more as environmental sustainability. lectured extensively on these topics and has served as a consultant or their market audiences whenever than average weight children. A similar benchmarking tool expert for the Institute of Medicine, Global Alliance for Improved Nutrition, a new product or service is As such, childhood obesity can on wellness programmes may Access to Nutrition Foundation, EPODE International Network, MEND being designed. directly affect the productivity further private sector innovation Program, Healthy Weight Commitment Foundation, Johns Hopkins Global of companies in addition to in this regard and help companies Center for Obesity Prevention, among other notable organizations. increasing healthcare costs. educate and bring along their Besides taking whole families board members and shareholders into consideration, companies to embrace wellness as a company The public health must become champions of value. Given obesity’s complexity, community health. The private employees’ health and productivity challenge of halting sector can influence public policy are determined by what happens and reversing the by encouraging the development both inside and outside the of health-promoting urban design, workplace. As such, the next obesity epidemic food policies, and marketing generation of worksite wellness practices. Short of doing so, any programmes would see greater lies in the interplay benefit of the best-designed alignment with health-promoting between human worksite wellness programme strategies extended to employees’ can easily be overwhelmed by family life and communities. biology and the dominant obesogenic forces outside workplaces and in the an obesogenic broader community. environment

118 119 Scaling up using digital technology by Alan Payne 122 DIGITAL Slim.In for good by Navin Pareek 124 OPPORTUNITIES Making health personal – changing behaviour through technology making it personal by Shaun O’Hanlon 128

120 121 DIGITAL OPPORTUNITIES

to millions of people but it is also The second area of opportunity Scaling up using extremely economically efficient. from the Global CMO Network is So that is an example of how we that we can consider employees can change a behaviour trait to as research subjects. We can digital technology help people lead longer, healthier, explore the concept of evidence happier lives and at the same time base to prove that interventions save a colossal amount of money, are working within a workforce. by Alan Payne both on Bupa’s claims but also on If we can apply this evidence secondary health care systems. base at the behavioural level to a company’s performance or even a The components of the technology division within a company we can are already there so all we are start to build causal links. Does doing is bringing them together in us providing behavioural change Non-communicable diseases It can also adapt to how you that very quickly. There are a lot a unique way to change behaviour digital interventions, at a very Alan Payne (NCDs) like heart disease, cancer want to be spoken to – the tone of ways now to use technology and provide preventative low cost, offer an opportunity to Alan Payne is the Digital Director and diabetes have been declared of voice and style of approach. to unobtrusively provide us with healthcare. That is why we increase a company’s or even a at Bupa responsible for the a global health emergency by For example, nagging works for insight providing that there is a created our Global Institute for country’s GDP? So the Global CMO growth in the e-enabled agenda, the World Health Organization. some people but not for others. trusted relationship. Digital Health Excellence or Network offers an unparalleled supporting the businesses to achieve the vision of “longer, Causing 36 million deaths a year, This is hyper-personalisation. GLIDHE, which is a joint venture opportunity not just as a channel healthier, happier lives”. these diseases are almost entirely Some have likened it to a virtual An example of a digital initiative between Bupa and University but also as a platform to derive His work includes expanding preventable through reducing Jiminy Cricket at one end of the at Bupa is our Bupa Quit app College London’s Department of evidence base where people feel the mHealth capabilities risk factors: smoking cessation, spectrum or the virtual mother which is already about 20 percent Behavioural Science and Computer a part of creating that evidence. augmenting the considerable physical activity, and eating a in law on the other! In marketing effective at stopping people from Science. Behavioural Science tells person to person services already smoking by tracking their cravings healthier diet – which employers terms you would call this us what works and Computer My final thoughts to the Global offered, driving social media and responding with distraction can help their employees manage marketing to a segment of one. Science helps us scale it up to CMO Network are – consider awareness and enhancing the at work. We would traditionally put you therapy. This includes socially deliver it to millions of people. this a learning experience because overall health solutions. into segments according to your sensitive videos which correspond we will not get it right straight Combining the reach of workplaces sex, demographic, age group etc. to the users’ demographic and The Global CMO Network offers away, so please persevere. Alan’s experience includes with the scale of digital health And what we want to do is create stage within the programme. firstly, an unparalleled opportunity The opportunity to succeed is over 25 years, across four technology, there is a clear a cluster whereby the data tells us For example, on day four of their to create channels to make vast. This is a long term task and continents, in healthcare, imperative for trying to evidence how you behave, what cluster you programme they will be able companies more productive in it will take time to get the evidence insurance, banking and capital markets, bringing innovation, base digital interventions as we are fit into, what behaviour you have to view a three minute video of their workplace, but also have we need. Allow for re-calibration, vision, knowledge, drive and the doing at Bupa - tools that we can then what behaviour intervention previously successful participants them lead longer, healthier, consider this to be a research ability to deliver globally across scale up to reach millions of people will more likely work for you. talking about their experience happier lives, whilst they are initiative first and foremost to get multiple businesses and support to help them live longer, healthier, The more we understand you, on their day four. At the moment doing it. It is, therefore, about the insight we need to get better functions. Alan additionally holds happier lives. there are four people that we being more present at work. the more likely we are to create and better tools, services and an Honorary Senior Research attach to you as a profile so if interventions which will work The vehicles for us to be able to products. And finally, partnership Fellowship at UCL specialising Technology allows us to scale up for you. If you want to offer a you want to watch the video four do that are traditionally very – the key for us is that we cannot in intelligent systems and and replicate what humans can programme to a company with times you can watch four different difficult but if a company is do this alone. The opportunity digital health. do at a low level. Furthermore, 50,000 employees and adapt the people – it rotates, keeps you offering those services, we have to have the quality of the CMOs it can then produce a very high programme to cover the multiple interested and distracts you. got an institution that you already involved gives us access to millions response rate. Technology allows traditional demographics it is The app also has challenges for work within and trust to a large of people in a demographic who programmes to be interactive impossible to interview them all. you so you can meditate or play extent. And because you already are more likely to take impacts of and personalised, it allows the But what if you could achieve this a game with an average playing have that trusted relationship, these interventions. This makes intervention to work for you by just carrying a phone around time of three minutes. This 20 some of the behavioural barriers it a truly a great opportunity and rather than someone like you. and answering a couple percent rate of effectiveness is that would prevent us offering we hope that it will make your of questions in your hand? achieved through moving electrons these change cycles have companies in turn more profitable. In addition, through the use of which not only means that the already been broken. So the first Let’s evidence that. digital tools we can re-calibrate programme can be scaled up easily opportunity is one of reach - the ability to get to such a large number of people in one go. 122 123 DIGITAL OPPORTUNITIES

Make sustainable changes in lifestyle Slim.In for good Unlike some online programmes, slim.in prioritises lifestyle changes to ensure sustainable weight loss. We target 14 behaviours that, if changed, can help on A weight loss behaviour change a weight-loss journey. These include the usual suspects (breakfast every day, two to three snacks, increased programme for South Asian adults exercise, reduce alcohol and the like). In addition, this includes culturally relevant behaviours like encouraging by Navin Pareek the use of spoons and bowls since it will help reduce high carbohydrate intake among Indians.

Lifestyle change leverages recognised tools such as SMART (Specific, Measurable, Achievable, Relevant, Time-bound) goals, goals and rewards, planning for change and 21 day habit formation, all wrapped in gamification. Slim.in is a weight management Programme components for not continuing on a diet: intervention that aims to achieve hunger pangs. Everything else is wide reaching behaviour change Reduce calorie intake tracked on the site’s easy-to-use An important point to note is that these help users in other aspects of towards permanent weight loss. Slim.in aims to achieve a interface. To aid tracking, slim. Manage barriers to change their life too. The website has been under active 25 percent reduction in daily in has slim values of ~10,000 Managing lapses development for more than a South Asian recipes, thousands calorie intake while nudging the The site tries to anticipate the year and we expect to launch by of restaurant menu items and Increasing behavioural flexibility user towards healthy and filling typical problems dieters face that April 2015. Post launch, an offline hundreds of exercises/household Research shows that some overweight people have low behavioural foods. There is no restriction on lead to non-adherence and gives programme will be developed in activities. The recipes only have flexibility. Slim.in will include a component to help increase this as it has what users can eat. Based on simple ideas to overcome them. association with leading clinical ingredients and are editable to been shown to make a difference to weight loss efforts height, weight, gender and age, The intention is for dieters to feel psychologists from India and the allow for variations. each user is allocated a daily they are not alone in facing these UK. These programmes will be Peer to peer learning and mentoring and weekly allowance of slims, a issues (normalising) and encourage delivered in various venues such To aid the larger goal of behaviour Slim.in uses a combination of a Facebook-like interface for interaction measure of satiety-adjusted calories. them back to their diet. The sub- as corporate meeting rooms and change and attitudinal shifts, there and a twitter-like follower mechanism to make it easy for people to share This allowance is recalculated every sections include: community halls. time the user records their weight. are articles around a wide variety their reasons for success. Slim.in makes it easy to give followers access • Motivation and Expectation Fruits, vegetables and low-fat milk/ of topics like how to read labels, to users posts, favourite foods/recipes and even their daily food diary. (benefits and sacrifices, working yogurt count as ZERO slims thus ideas on managing external There is a HelpWall where users can ask for help from the community if on motivation, understanding eliminating one of the main reasons triggers, myth busting, etc to aid they are facing a specific issue. the user’s weight loss journey. what is success on a weight loss programme) • Attitude (negative self-talk, self-compassion, imperatives, impossible dream thinking i.e. solving my weight issues will fix my life) • Thoughts and Feelings (internal triggers, binge, cravings) • Skills (examining patterns in your eating, assertiveness, stress management, behaviour chain analysis) • Relationships and Support (will a weight loss partner help, choosing the right partner, dos and don’ts for the family) 124 125 DIGITAL OPPORTUNITIES

Individualise and personalise User-created groups Programme highlights Motivation Use of technology How the Global CMO intervention This functionality allows users the Some examples of how motivation • Technology allows slim.in to Network can help Culturally appropriate Tagging and flexibility to create groups that are is built in to the fabric of the easily answer to the questions recommendation engine specific to their social, professional Slim.in has been made culturally programme are given below: “What should I eat?” and • The Global CMO Network can or family groups. appropriate for South Asians in “How much should I eat in a help by spreading awareness All content on the site is tagged • Learning from people you its tone and approach. Some day?”. This is particularly helpful about slim.in and funding to show relevant content for each • A sense of belonging arises follow is as easy as looking up examples are given below: in a South Asian context as programmes in their workplaces user depending on where they from joining a group of like- their feed of posts, favourite people tend to cook from scratch or local communities. are on the website. For example, minded people: for example, • Nutrition information for the recipes, and even their food with wide variation in similar if she is viewing Lifestyle change people in the same profession largest number of Indian recipes. diary for today (if they have • Slim.in can easily be adapted for sounding dishes. to Increase resistance training, the (technology, accounting, Recipe ingredient quantities are enabled access). other cultures and backgrounds • It helps ‘automate’ the role of the (yummly.com API gives access to right reading pane could show her hospitality), age groups, stage editable to ensure all variations • The SuccessWall feed showcases dietician to some extent, allowing one million recipes). The Global Strength and Flex from Challenges of life (new mum, bride-to-be), of the recipe can be catered for. user’s success in weight-loss, us to run the offline programme CMO Network’s support can and Precautions to take when similar taste in entertainment • Since milk is the only important lifestyle changes and any with the help of psychologists. help spread this easy-to-access starting resistance exercises from (Bollywood, TV serials), interests source of Vitamin B12 for a lot of other parameter they wish concept to users globally. Wellness. Based on the user’s (cricket, knitting). vegetarian Indians, low fat milk to track (like quality of life, • It allows for including performance, we could even • Private groups for people who is zero slims to ensure it is not self-esteem, health parameters psychology-based concepts trigger messages in their newsfeed. would like to harness the power substituted by something else. like cholesterol). This has like SMART goals and 21 day For example, if she has not lost habit formation without making of a group, but only among peers • One of the recommended multiple objectives: weight in the past couple of weeks them sound too academic. of their choosing. lifestyle changes is to encourage – Ending obsession with after losing some before, we could use of spoons and bowls. Indians weighing scales which play recommend an article on Weight Changing people’s attitudes Improve physical activity tend to use the carbohydrate a disproportionate role loss plateau. • It presents research-validated Slim.in gives significant importance staple – chapatti or rice – as a in motivation to physical activity due to its material to help separate fact substitute for spoons, which – Motivating with frequent Artificial Intelligence to plan from fiction. accepted role in helping maintain results in disproportionate personalised seven day menu success stories and a few weight loss. amounts of carbohydrates in • It carries articles that bust (in future) interviews (if so many people specifically Indian myths like • Three of its 14 lifestyle changes their diet. can do it, I can too) Customisation for each user “Drinking honey and lemon relate to physical activity • Journeys of sub-ethnic groups – Celebrating small successes is currently implemented water in the morning helps (including topics such as raising (Punjabi, Tamilians, etc) on as slim.in recognises weight using the algorithm described lose weight”. your heart rate, Increasing slim.in to help people identify above. Once we have enough loss is not easy resistance activity and reducing with the programme and give • It uses “Behind the Headlines” data to train a model, we will • Using HelpWall to get support on sedentary behaviour). them confidence. from nhs.uk to better explain Navin Pareek implement an artificial intelligence specific problems. the sometimes incorrect and/or Navin is CEO and Co-founder of recommendation engine to present • Slim values for hundreds of • A section on Motivation and exaggerated headlines. Slim.in, a company dedicated to common physical and household each user with a unique experience. Expectation as explained above. • It uses social media to not only developing a behaviour change This will also help us recommend a activities. educate but also take a more based weight loss programme menu for the next seven days that • Activity related challenges, for South Asian adults. He was activist role in a culture where is healthy, filling, personalised and for example: Couch to 5K, previously Director of Technology big brands are not challenged within their slims allowance. Increase strength and Flexibility, and Finance at MEND, a pioneer the way they should be. 10,000 steps a day, along with in child weight management comprehensive, validated • It provides education (label interventions. Navin has a resources to help achieve them. reading, harmful effects of background in IT, operations and obesity) via online and strategy, and has worked with offline campaigns several global companies like CNBC, BT and MCI.

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Information sharing Myth vs Reality: The Internet and now mobile Online Patient Services Making health personal – The NHS@75 report said that patients need to become active partners in their healthcare if the NHS is to devices have powered the survive. Do online services such as Patient Access help patients become more involved in their health?

information revolution. Citizens Patients Health Professionals have real time access to more Only young IT savvy people will Doctors don’t want online changing behaviour use online patient services patient services information than any one person 64% of users are over 35, Almost 1 in 4 users are 55+

can ever consume or understand; Age of healthcare professionals 18-24 17% % support online record viewing in health there has been a rise 74 for long term conditions through technology 25-34 19% 35-44 21% of trusted information resources support asking a 45-54 19% % healthcare professional a by Shaun O’Hanlon (Patient.co.uk*, NHS Choices, 55+ 24% 79 question online WebMD etc.) that provide the People don’t trust online patient citizens with high quality, peer services - it’s a fad that will fade support the use of online services % such as appointment booking The use of Patient Access has 77 and repeat prescriptions reviewed health information and increased by 63% (Jun-Sep 2013) signpost more granular, trusted https://secure The traditional model of healthcare Changing behaviour is complex Consumer markets such as retail, resources. Our experience at % JUN 60 SEP of EMIS practices in England 2013 :( provision is based on a doctor/ and certainly a detailed view is insurance and banking have been Patient.co.uk shows an exponential 2013 intend to enable Patient 20,285 33,085 Access in the near future patient relationship which puts outside the scope of 1000 words revolutionised first by the Internet rise in consumption, increasingly visits visits :( the clinician at the centre of both however it is clear that healthcare and latterly by connected, smart on mobile devices. the decision-making and taking provision needs to become personal devices. A massive 16% Online services will only catch of practices say responsibility for the optimal increasingly personalised and behavioural change in the In behavioural change terms, lack of time is the on in big cities biggest obstacle for implementing outcome. relevant to the individual whilst population has been observed access to information is a key Almost 1 in 6 users live in online patient services small towns or villages precursor to initiating and then It can take as little also being economically viable. in these markets as citizens as 3 minutes to set up For many patients this created To do this we need to empower now have more information, effecting a change. The axis moves what Berne would call a Parent GP practices think their patients and expect our employees and choice and interaction. Take the from the physician being the won’t use online services – Child interaction, which results citizens to take a much greater banking system where consumers’ custodian of information to the 9 in 10 GP practices think their patients would use in a culture of abdication of online services ownership of their health and behaviour has changed profoundly citizen frequently knowing more Those less well off won’t use

internet services of GP practices recognise responsibility and an over- wellbeing. They need to interact with organisations putting them at about a subject; this can change % that patients would use 1 in 5 users are low income, 96 online services dependency on healthcare services with clinicians as equals in the centre as the sector has moved the transactional analysis model social housing residents as a whole. For others, it has led to the decision-making and take from a relatively inaccessible, immediately as an adult-to-adult disaffection and disengagement responsibility for some of their bricks and mortar business to a communication is necessary. with health services, as they health. Equally clinicians need to 24-hour, service driven paradigm. are either not entitled or not accept and seek to engage with As a result, citizens generally We should not limit ourselves comfortable with the clinically a patient centric model where perceive they have a better service to be thinking about static, centric paradigm. For employers they can have adult-to-adult from their banks and take more published information either. this creates significant workforce interactions with their patients. responsibility for their Technology is not only giving us Will the future Really be online? challenges both for short-term personal finances. the ability to know more about You’ll never get patients to take a more active role in absences and longer-term There are many facets to enabling what out healthcare providers their own healthcare employee health. this change including employer/ How then can technology drive say about us, to treat us as equal

public health policy and patient a change in behaviour in the in terms of our medical records It’s predicted that by 2020 % of healthcare % of Patient.co.uk and professional education about healthcare market? Let’s look but it is now giving us the ability will be online visitors want 40 61 to find out about a which there is much literature. I at Blanchard’s three elements to gather far more information medical condition. And 23% want to find out about would like to focus on the role of of empowerment about our health and wellbeing in a healthy lifestyle

% of patients would like to personal technology in healthcare real time. Wearable technology, add their own self recorded Patients will always want to see their • Information sharing 71 medical values to their doctor face-to-face empowerment for both the citizen/ activity monitors, connected record • Autonomy employee and the clinician. body analysers, consumer blood % • Self-management pressure monitors and home % of patients support viewing records online for long 57 of patients want 85 term conditions online GP blood testing (e.g. glucose) give consultations citizens access to huge amounts of information about their body Find out more about Patient Access at http://patient.co.uk/patient-access

Sources: Patient.co.uk annual survey (October 2013) [22,785 respondents] and immediate feedback when Emis practice survey [625 respondents] they make a change. 128 129 DIGITAL OPPORTUNITIES

We have plenty of data to show Self-management there is a public appetite for this Information and autonomy will health information (see panel) and not improve outcomes unless they this is increasingly driven from facilitate change - this is where mobile devices. technology has its biggest role. Clinicians and patients can not only Autonomy use data derived from wearable Autonomy is the capacity of a technology to jointly make better- rational individual to make an informed decisions but they can informed, un-coerced decision. also create a feedback loop to enable the patient to meet targets Whilst this may appear at first in a shared care plan. One example to be a logical extension of the may be using activity data from a Dr Shaun O’Hanlon information enablement, it is fitness tracker linked into a mobile more than that. In healthcare this application that reminds the unfit EMIS Group’s Chief Medical Officer. Shaun started with EMIS in 2005 is about the individual making or overweight patient to exercise and was responsible for the clinical a decision rather than asking a certain amount per day, coupled architecture of EMIS’s flagship the clinician to do it for them. with gamification and a simple product EMIS Web, overseeing the The clinician will be seen as a reward program this will be able roll out to GP’s and the inception component of their decision to effect lifestyle changes which and delivery of EMIS Mobile as making however increasingly significantly improve heath. The well as the community product. people will use other media advent of new platforms, such as available to them through Apple HealthKit, when integrated With the expansion of EMIS Group technology such as social media to EMR’s will provide the vital link to include Pharmacy, Hospital care (e.g. Facebook and Twitter) and between interesting technology and service provision, Shaun has more specialist forums where and healthcare improvement. taken group wide responsibility expert patients, other consumers for product and clinical strategy. and even healthcare professionals Public Health authorities and He is passionate about citizen converse, discuss and inform Employers can play an active role healthcare and how technology participants. With mobile in all aspects of the empowerment can empower the citizen through technology this will increasingly though technology, not only access to quality healthcare happen real time, especially when through active promotion of information, access to their own aligned with information from information sites and even health record and the ability to various monitors discussed above. provision of technology devices share their personal health data but also through the creation of with those caring for them. Shaun’s As employers we should be reward programs which are linked advanced work on EMIS Web has encouraging appropriate use of to personal achievements set pioneered the next generation social media, even whilst people through clinical encounters which of clinical management tools are working (in moderation). empower and enable the patient. within the UK healthcare market. He trained at Cambridge and St The result is a healthier, happier Thomas’ Hospital, becoming a GP and more responsible public principle in 1994. Shaun is also a and workforce. director of Qresearch.

*Patient.co.uk is part of EMIS Group

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