Abstract
Until recently, SDoH were viewed largely as a public health construct, most often discussed in the context of government-sponsored health benefits. Defined by the World Health Organization as “…the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life,” 1 social determinants of health contribute significantly to each individual’s health status. Although debate continues as to the relative significance of SDoH to overall health, there is broad consensus that these factors play an important role. In support, the past 2 years have yielded a plethora of research studies, including recognition of the importance of SDoH on the health of employees and family members receiving employer-sponsored health care. As a contributor to individual health status, SDoH represent a largely untraveled path for employers to improve workforce health, well-being, and business performance. Additionally, meaningful employer attention to SDoH may also support employer health-care cost containment efforts.
Why now? A confluence of several factors has triggered growing interest in SDoH. Employers have yet to find an impactful and lasting solution to lowering health-care costs that also results in improved employee health and well-being. Cost-shifting to employees in the form of high-deductible health plans has failed to yield the hoped-for health-care consumerism behaviors. In fact, many low-wage workers are choosing to simply avoid using health care. 2 Complicating the issue is the fact that raising health-care costs have limited employers’ abilities to provide meaningful wage increases, particularly for lower wage workers, creating the need for many to have to choose between spending money on health-care expenses and basic living needs. As a result, stress levels due to financial concerns for many employees is near an all-time high.
For most employers, full recognition of the significance of SDoH—and the employer’s role in the issue—hasn’t been fully appreciated. The fact is that wage disparities have only increased in recent years, and despite current near-record low levels of unemployment, low-wage workers haven’t seen the earnings increases that their more highly paid counterparts have received. 3
Yet, there is hope. Financial well-being as an important social determinant has been identified by most employers as a priority concern for many employees. A number of vendors have introduced new marketplace offerings, with services that include one or more of the following, along with others: Student loan repayment support Basic money management techniques More timely pay/advances on earnings Low-cost loans Retirement readiness counseling Installment purchasing
While helpful, these offerings don’t get at the root problem of socioeconomic disparities. Some employers have taken a broader view of SDoH as a foundational component of workforce health and well-being. From this vantage point, opportunities exist to take a closer look at organizational roles and responsibilities in supporting employees and their communities as part of broader corporate social responsibility considerations.
Opportunities to Improve Social Determinants of Health via Worksite Health Promotion and/or Well-Being Initiatives
Worksite health promotion and/or well-being initiatives can play a significant role in helping to improve SDoH. It is important to appreciate that while not explicitly acknowledging SDoH, many well-being programs attempt to address specific social determinants, such as supporting individuals to modify nutrition and exercise-related lifestyle behaviors. For example, with a company-sponsored health promotion program, an individual living in an unsafe area may be given access to a fitness center in a more secure location. Farmers’ markets at work can help to improve access to healthier foods for individuals living in food deserts. Financial well-being programs help individuals to improve their socioeconomic status through better financial management and planning.
Yet, 2 important observations must be acknowledged. First, the workplace itself is an important and underacknowledged social determinant of health. 4,5 Employer policies and practices, including wages, attendance, leave policies, and performance-based compensation incentives, all contribute in some way to each employee’s health status. For example, consider the uncertainty and financial stress created by retail companies that implement variable work hour schedules for employees living paycheck-to-paycheck. As a result, any perceived misalignment of organizational health promotion or well-being programs with business practices may understandably generate negative employee reaction. For companies that strive to create a “culture of health,” it is essential that SDoH be included in organizational strategy.
Second, employers also need to understand both their role as a contributor to SDoH and their role in addressing identified priorities. 6 Some company leaders may feel that organizational responsibilities extend only as far as offering health promotion programs, while others who place a high value on investments in workforce human capital may want to think more broadly about how they are supporting their workforces and communities as part of their corporate social responsibility objectives.
Practically speaking, for health promotion and well-being programs to meaningfully address SDoH priorities, program structure should be able to incorporate the following processes: Have a clear understanding of the scope, capabilities, and limitations of existing benefits offerings to address SDoH concerns, including employee assistance programs. Be aware of resources that can help support unmet individual needs. Facilitate referral of individuals with unmet SDoH needs to available resource support, including community-based options such as Aunt Bertha (www.auntbertha.com), which is a free online social services search engine, and the 211 Helpline Center, which provides callers with information about and referral to available social services in their location. The 211 helpline is currently available in portions of all 50 states and Puerto Rico. Track referrals and ensure appropriate follow-up. Incorporate SDoH-related data in program participation and outcomes reporting.
Lastly, employers need to consider the impact of SDoH on their health promotion and well-being program incentives strategy. To our knowledge, few studies have evaluated incentives-driven program participation on the basis of employee wage status. Our experience has been that low-wage workers are significantly less likely to participate in the completion of health assessment and biometrics testing. 7 Further, our data indicate that low-wage workers participating in outcomes-based incentive programs earn less in incentive amounts than more highly paid workers (see Figure 1). This finding is in keeping with observations from the Robert Wood Johnson Foundation, which notes the risk of increasing disparities among disadvantaged individuals when implementing outcomes-based biometric testing. 8
Employee wage status is associated with earnings in an outcomes-based incentive program for biometric screening.
The Importance of Employers and Health Promotion Practitioners Addressing the Unique Needs of Low-Wage Earners
For health promotion practitioners to be effective, they must understand each individual’s personal priorities and motivation. Historically, wellness programs typically addressed lifestyle issues largely impacting physical health, with widespread recognition that those likely to engage already have health as a personal priority. What’s behind that observation is the fact that individuals who elect not to participate in wellness programs may have personal priorities that preclude their involvement. For example, an individual working 2 jobs may not have available time to engage in a health promotion program. Someone who is caregiving for an ailing parent may similarly be unavailable to participate in a wellness activity.
Low-wage workers often have personal priorities that take precedence over their own health. In a survey of individuals regarding the prevalence of personal stressors, financial stress topped the list, followed by work issues, health issues of family members—and then personal health. 9 It’s no wonder then, that engaging low-wage workers can be a challenge, particularly when they experience financial stress, are often in work settings that negatively impact their well-being, and have limited resources to respond to family member needs.
In order to meaningfully engage low-wage workers in health promotion activities, employers and health promotion practitioners must adopt a “whole-person” view of each individual. Well-being assessment domain scores can help to identify personal concerns, and surveys identifying sources of stress can also provide direction. However, a more pragmatic (and perhaps more holistic) approach might include adopting for use one of the available SDoH screening tools 10,11 to identify practical issues that require attention.
There is an important note of caution for employers. Our research suggests that low-wage workers may not be well represented among those completing well-being surveys, and as a result, program priorities may not be adequately represented by survey respondents alone.
Financial Well-Being Programs: A Case Study
How should employers take SDoH into consideration when planning a financial well-being program offering? The response to this question provides a representative example of the strategic and practical aspects of incorporating of SDoH into other benefits program activities. As previously noted, financial stress is one of the most prevalent concerns individuals face—among both low-wage workers and a number of middle-income earners.
Until recently, many employer financial well-being programs involved a focus on participation in and management of 401(k) investments. In light of the growing recognition of the relationship between financial well-being and employee performance, along with employee retention concerns in a tight labor market, employers have started implementing more broad-based financial well-being programs. These typically address more foundational concerns, including setting up a monthly budget, debt management, saving for retirement, and practical considerations, such as buying a home or car.
How should employers best incorporate SDoH into their financial well-being program offering? Representative considerations include the following:
1. Be relevant.
If the program goal is to alleviate financial stress within an identified population, ensure that the offering acknowledges specific employer attributes, including the approach to compensation, turnover rates, and supporting benefits programs (eg, student loan repayment services or educational scholarship fund availability).
2. Be genuine.
Ensure that messaging reflects a credible perspective that is sincere, candid, and direct—and consistent with organizational values and culture.
3. Align the reading level of program content with expected literacy and numeracy of the intended audience.
To be effective for specific population subgroups, financial well-being programs need to be understandable. For example, a financial well-being program called “frugality” may not attract much interest among low-wage workers because they may not understand the term.
4. Ensure financial well-being staff are effective communicators for employees at all levels of the organization.
A certified financial planner is probably not the best individual to counsel a low-wage employee about setting up a basic household budget. Individuals with less training may be better suited to address low-wage worker questions and concerns.
5. Offer financial well-being program design that accommodates low-wage worker lifestyles.
Low-wage workers may have multiple demands on their time, limiting their ability to take the time to complete an hour-long online educational curriculum. It may be best to provide “bite-sized” educational components that can be completed in shorter time increments.
6. Ensure that existing wage-related employer policies and practices are reasonably aligned with financial well-being programs.
Compensation level determinations aside, employer practices address a number of other attributes regarding employee wages, including, for example, just-in-time work scheduling that limits employees’ ability to have predictable weekly earnings. Similarly, the absence of employer subsidies for low-wage workers’ health benefits may serve to send an inconsistent message to employees about the extent to which employers care about employee well-being.
7. Give consideration to including offerings that address important subpopulation financial well-being needs.
If the employees are predominantly millennials with college degrees, student loan repayment support may be an attractive option for both current and prospective employees. Or if the company culture emphasizes personal growth, consider offering tuition benefit support.
8. Collect and use feedback from program participants and nonparticipants.
Ongoing performance improvement can help to optimize the success of any program. Feedback from program participants can provide meaningful insights to enhance program effectiveness and value. Importantly, input from individuals who choose not to participate can also provide learnings to foster broader participant engagement.
SDoH are vital considerations when planning health benefits programs for workers and their families. Employers will benefit from a thoughtful evaluation of their portfolio of current benefits offerings through the lens of SDoH. The resulting insights will undoubtedly contribute to more engaging and impactful program offerings.