Expert Interview

Q: What is Personal Return on Investment (PROI)? How should PROI be used in promotional and marketing campaigns?
Mr. Pfeiffer: PROI can be defined as the perceived value (e.g., benefits) received weighed against the personal investment required (e.g., time, money, inconvenience, effort, competence, sacrifice) to commit, act on, and maintain a specific health behavior. Unless the individual believes that his or her investment creates a greater value of personal wellbeing, the chance of long-term success is questionable. 

When developing and marketing health management programs for the employee rather than the executive or C-Suite, it's important to develop communications and key messages that resonate with the PROI concept. Therefore, positive health practices need to be connected with the abilities and possibilities of today, not with the nebulous threat of infirmity at some time later.

Communications should promote and position personal effectiveness on and off the job, rather than just productivity at work. For this reason, marketing communications need to promote the relative features, attributes, and benefits provided by a specific program and show how they outweigh the barriers to change created by the assessed personal investment required. 

Q: What is the difference between soft and hard communications applications? What are some examples? How should employers use these applications?
Mr. Pfeiffer: Soft communications are low-tech approaches to messaging that are delivered at the work site. People make up the first component of soft communications. This involves creating a communications and distribution network that integrates professional staff, management, and lay leadership social networks to convey and reinforce key messages, promote the brand, provide information and support, and reinforce a culture of health.

The second component is traditional media such as books, newsletters, booklets, flyers, posters, video, e-mail, and signage that are used to create awareness, improve knowledge, teach skills, motivate, and reinforce positive health behaviors.

A third soft communications component comprises gadgets that not only will promote the brand, but also are used as incentives for participation. These include t-shirts, sportswear, water bottles, and pedometers.

 When branded, promoted, and distributed properly, soft communications applications are a point-of-service strategy that can be very effective at engaging the target population and reinforcing a culture of health.

Hard communications are high tech communications tools that deliver content, resources, and social support—virtually. With the evolution of the Internet and delivery devices such as smart phones and electronic tablets, people have 24/7 access to tailored health content, coaching platforms and tutorials, and peer-support groups. In addition, with the explosion of social media such as Facebook, Twitter, and Second Life, the creation of health-related affinity groups or communities provide an information and support network that connects employees virtually.

A major advantage of virtual communications is the scalability of health content and support (e.g., coaching, disease management) in connecting geographically dispersed populations.

However, while these hard technologies provide great opportunities for engaging a larger percentage of individuals in health management initiatives, the jury is still out on the long-term effectiveness of virtual programs. I believe that high tech is not necessarily "high touch" and is not more effective than point-of-service programming. In other words, a program should not be limited to a screen or a telephone receiver—hard and soft communications tools need to be integrated.

Q: Can you discuss the importance of branding your program?
Mr. Pfeiffer: I was very fortunate to work for Xerox Corporation in the 70s when we were acknowledged as one of the leading marketing organizations in the world. Being part of this culture provided me the opportunity to work with a number of highly creative people who viewed selling health in much the same way as selling a copier or large duplication system. Through our marketing, we were articulating a solution(s) to address a specific need or problem. In the same manner, health promoters need to think more like "Madison Avenue."

As health promotion professionals, we often ignore the importance of promotion within our job description. We need to view work site health as we do any other product or service, and market it as such. Every day your target audience is being exposed to brand messaging that is competing with your health message.

Thus, an important component of promotion is establishing a brand identity with your program name, logo, slogan, etc., that is used not only to build and reinforce identity, but also create brand loyalty over time. Brand loyalty in this sense is building an adoption rate that creates a critical mass of participants who not only identify with your products and services, but also use them because they have perceived value. This is not to say, that sticking a logo on a banner, newsletter, web portal, or a water bottle is a beat all to end all, but it's important to promote your unique brand and its related benefits to your target audience.

I like to say that as health promoters, we are "massaging attitudes." People tend not to be open to engaging unless they truly understand that a product or service exists, addresses personal needs, provides personal benefits, and they trust the message. Branding helps plant seeds of awareness (and acceptance) within your target audience and provides opportunities to promote your services.

Q: Why is it important to keep management informed of the business case for investing in work site health promotion? What are some effective approaches to engaging company leadership?
Mr. Pfeiffer: The simple reason is that management accepts the responsibility of "the buck stops here." Management is constantly faced with making hard decisions regarding resource allocation. Health promotion usually will take a back seat to other business continuation initiatives, especially during economic downturns. It's very important that management (the C-Suite), middle management, and line supervisors understand the business rationale for health promotion as a productivity strategy, not just an exercise in containing healthcare costs.

Some effective approaches for keeping management informed about the value of health promotion include the following:

• Incorporate language into the organization's mission and core values statement about the value of employee health to the health of the business.
• Provide key leadership with news releases, white papers, or other publications on a periodic basis that demonstrate the value of health promotion. For example, Leading by Example, published by the Partnership for Prevention is a respected peer-to-peer communications program designed to engage the C-Suite in the business case for health promotion.
• Provide executive health promotion programs during executive retreats or meetings. For example, do a health screening, health risk assessment, and a health coaching or interpretation session. This strategy personalizes health within the context of a "peer environment" and hopefully reinforces the value for the broader work population. Other initiatives that resonate with executive groups are "stress management" or "energy management" workshops that focus on the unique challenges among managers.
• Develop a health and productivity management dashboard that is presented to management on a semi-annual basis. Create the ability to provide the same index on a division or operating group basis—this creates competition and accountability among managers. However, be careful. The objective is to get managers to allow access and encourage participation in sponsored programs rather than intimidating employees to change.
• Nurture executive champions who "get it" and are not afraid to justify and reinforce the value of employee health to the organization.

Q: How can social networks be used to promote work site wellness programs? What are some examples?
Mr. Pfeiffer: We've learned from the work of Nicholis Christakis and James Fowler that social networks seem to have a significant influence on risk factors such as smoking and obesity. On the basis of the Framingham Study data, an individual was more likely to become obese if his or her spouse was obese; if a friend was obese as well, the chance of obesity was exponentially greater.

In the case of tobacco, the same social network associations applied. However, those smokers who quit, usually quit in groups. The bottom line? Social networks are a powerful tool for influencing individual behaviors both good and bad.

When examining best practice organizations in health promotion, most likely you'll find that they have a strong culture of health. This seems to indicate that these organizations have created significant social networks from the top down and from the bottom up. They not only have articulated the value of healthy employees to a healthy organization, but also have walked the talk in supporting and engaging their entire populations in healthy practices.

Thus, when we talk about creating a culture of health, we really are talking about "cultures of health" that are nodal and socially unique. For example, when you talk to Bill Baun at M. D. Anderson Cancer Center, he will tell you that he tailors his message and programs to the unique subcultures of his organization. In other words, to be effective, he needs to understand these unique social networks and leverage their communications channels as well as their formal and informal leadership circles.

Some approaches include the following:

• Create lay leadership networks. One important strategy is developing a lay leadership network of employee volunteers that act as local ambassadors of your health promotion program. For example, we developed a "team leader" concept at Xerox. We trained more than 200 employees to act as our local marketing representatives at their respective work sites. They received three days of formal training on the program, which included presentation skills. Each team leader was given a "launch kit" that was used for employee orientations and follow-up programming. The team leader acted as our local liaison and provided the professional staff with input on pertinent needs and assessment of current initiatives. We also encouraged team leaders and their work site team to get involved with local community health groups and initiatives.
• Develop affinity group programming. Developing unique programming specific to operating groups (e.g., back care for service technicians) not only addresses special needs, but also leverages formal and informal communications channels to promote your efforts within and outside of that social network.
• Encourage the development of affinity groups or clubs. Many organizations support the development of social groups or clubs that share common recreational pursuits (e.g., groups for running, cycling, skiing, triathlons), hobbies, and health and life concerns (e.g., weight management, single parents, retiree, AA, specific disease states). Depending on the organization, affinity groups can meet regularly and connect through electronic bulletin boards and other social media platforms.
• Other soft approaches to creating social networks can include the development of team challenges, buddy-up promotions, and mentoring programs.
• Get into the home. It's important not to neglect the family when marketing and implementing health promotion initiatives. It makes both business sense and program sense to leverage positive health practices through the example of family members. A prime target should be the female of the household who typically is the primary health care decision maker and caregiver.

Finally, it's important to understand that building social networks should not be limited to the use of social media, such as Facebook and Twitter, although these media platforms have significant value in keeping social networks "glued." There needs to be a healthy balance, a hybrid model combining the virtual and the local to create and leverage social networks that fit the communications style and culture of the organization.

Q: What advice would you offer employers who wish to effectively market their work site programs?
Mr. Pfeiffer: While not inclusive, I would suggest the following:

• Understand your organization's formal and informal communications channels. How do your employees currently receive information? What are the most effective? Are there any other channels you can use?
• Make sure your communications are targeted to your needs, reflect the nuances of your culture, and are consistent in design and key messages.
• Create and market your brand on an ongoing basis.
• Stay visible. Create a marketing and communications plan that leverages your organization's communications channels and exposes your target audience to key messages, program offerings, and success stories on an ongoing basis.
• Be transparent with information. Provide an annual "health report card" based on such instruments as a health risk assessments. Compare data (e.g., health score, participation rates) across operating groups and divisions. This can instill friendly competitions and motivate outliers to participate.
• When appropriate, cross-market your health promotion offerings within other programs and communications such as benefit descriptions, recruitment communications, new hire orientations, and safety information.
• Do not ignore the power of word of mouth. Employees (and managers) can make or break your program. Like any product or service offering, a positive experience normally will be communicated to two or three people, whereas a negative experience normally will reach ten. Quality is important.
• Leverage your leadership at all levels through periodic communications that promote their support and encourage participation of your employee base.
• Highlight employees,  who have succeeded in making positive health changes, through company publications. This not only personalizes the program, but also reinforces self-efficacy to other coworkers—"Well, if Jane can lose weight, so can I!"
• Market success by marketing life, not risks. Make sure that your message is consistent and aligned with your business goals, while understanding that an employee's "gut" reacts more to his or her PROI than to the company's balance sheet.
• Be creative!
• Inject the element of fun into your messaging and programming!
• Take your time. Crafting your message (and brand) takes time; do not expect employees to be knocking down your door when your first promotion is launched. Consider testing your messaging and content through pilot testing.
• Measure effectiveness. Establish well-defined goals and objectives around your communications and measure accordingly. Use your data to refine your communications strategy.

Q: What are the best ways to achieve high participation and engagement?
Mr. Pfeiffer: That's a very tough question with no easy answer. First, we need to define what participation and engagement mean from a total health management perspective rather than a singular program focus. Is taking a health risk assessment (HRA) once a year the definition of a participant or is it three total activities per year? We know there seems to be a dosage effect on health risks and costs, but we don't know if this has been tested or is merely observational?

Is engagement merely the completion of a "course" or is it demonstrated competencies that are aligned with desired outcomes? The bottom line is there is no commonly accepted index to measure either participation or engagement from a total health management perspective. As such, it's difficult to measure how a communications campaign or promotion affects these measures.

In lieu of this fact, we need to identify what organizational and personal barriers prevent employees (and family members) from participating in work site health promotion programs. For example, time constraints are a major barrier—on the clock or off the clock—especially for hourly employees. In other cases, though organizationally sanctioned, there are managers who will not be flexible in allowing their employees to take the time to participate. In these cases, policies need to be developed, communicated, and reinforced to encourage participation.

Another barrier is the amount of conflicting health information that consumers are exposed to regarding nutrition, physical activity, health screenings, and treatment options. Helping employees improve their health literacy is an important success factor for engagement.

The lack of motivation—even with open access—is a recurring barrier to participation and engagement. Today, incentive programs in the form of benefit credits or cash have taken the front seat in trying to motivate employees. Yet, outside of tobacco cessation programs, there is little evidence that incentives drive engagement and most importantly produce sustained outcomes. Yet, I am amazed that some incentive plans are more expensive than the per employee cost for the interventions themselves with little to show for it over the long-term.

Again, PROI should not be ignored when developing a promotional strategy to drive participation. No doubt, financial incentives will improve a person's PROI—at least in the short-term—and drive participation. It is a great "kick start" and a means, initially, to get employees engaged—especially with outliers. But, when does the individual realize the intrinsic value of health and the importance of staying engaged? That remains the "$64,000 question."

My hunch is that investing in a culture of health and creating strong social networks at all levels of an organization is a better long-term engagement strategy than providing monetary carrots on a long-term basis.

Also in This Section

• Establish employee communication channels
• Plan the marketing strategy
• Determine incentives and rewards
• Launch the program
• Expert Interview - David Anderson, PhD

The opinions expressed in these interviews are those of the interviewee and do not necessarily represent the official views of the Center for Disease Control and Prevention (CDC), the Department of Health and Human Services (DHHS), or the U.S. Government.  The placement of these interviews on the Center for Disease Control and Prevention's website does not imply the endorsement of one particular organization, author, product, or service over another. 

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