Introduction

From its inception, the field of workplace health promotion has undergone periodic transformation like the evolutionary waves we’ve seen in public health [1]. New ideas, theoretical constructs, and clinical discoveries have expanded our understanding of personal and contextual factors influencing individuals’ health-related behaviors and health and wellbeing. Despite these advances and an increasingly technology-based approach, progress toward improved population-level health has been slow. Continued transformation may require attention to the alignment between personal and contextual factors to promote health in the workplace. The goal of this paper is to present a novel health promotion approach that targets intrinsic thought processes as a mediator of participation in employer sponsored programs and adoption of healthy lifestyle behaviors. We hypothesize that individuals’ thought processes are malleable, and that a structured understanding can inform targeted coaching to effect favorable change using principles of neuroplasticity.

To provide context for our hypothesis, it seems reasonable to revisit the history of modern-day health promotion in the United States. Expanding on occupational safety and health and employee assistance programs, the initiation of health promotion in the workplace was largely prompted by increasing health care costs. At the start, physical activity was the dominant component of workplace health promotion with a focus on limiting the rising prevalence of chronic conditions. Over time, programming scope expanded beyond a primary focus on physical activity to include nutrition, weight management, tobacco cessation, stress management and self-care. The business of health promotion began to grow, with new businesses, health plans, and healthcare systems all competing for the employer market share. As such, wellness as a corporate and public health strategy represented an early movement away from clinically dominated chronic condition management by addressing behavior-based and organizational contributors to health.
As part of the broadening array of health promotion offerings, progressive companies and researchers embraced the 1948 World Health Organization definition of health, “…as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” [2]. Adoption of a more holistic perspective led to development of expanded offerings that touched upon multiple domains of health, including physical, emotional, social, financial, spiritual, occupational, and purpose. As a new focus, well-being offerings supplanted more narrowly focused wellness benefits, expanding to a more holistic definition of health.

More recently, systems thinking about determinants of health has impacted workplace safety and health initiatives, leading to a reframing of organizational and other contextual factors contributing to workforce health. The Ottawa Charter for Health Promotion [3]. development of a socioecological model [4]. and creation of the National Institute for Occupational Safety and Health’s (NIOSH) Hierarchy of Controls framework [5]. have been important drivers of systems thinking for change in public health and the evolution and expansion of workplace health promotion efforts. As business leadership has broadened their perspective regarding the connection between workforce well-being and sources of business value, two additional contributors have gained attention: workplace culture and social determinants of health (SDoH). While the evolution of these two components began separately with origins in public health and organizational development, for employers, the two converged with recognition that the workplace itself is a determinant of health [6]. This awareness has commanded the attention of business leadership regarding the corporate role in employee health and well-being and recognition of the link between workforce health and the business bottom line [7]. With SDoH now more broadly accepted by employers as an important contributor to employee health status, businesses are beginning to explore and expand their stewardship to mitigate SDoH as systems-level barriers to workforce and family health [8]. Interest in evaluation and benchmarking the extent to which workplace culture and workplace-level factors support the health and well-being of employees has fostered the development of several survey instruments, among them the Worksite Health ScoreCard from the Centers for Disease Control and Prevention [9]. the Health Enhancement Research Organization’s Scorecard [10]. and the Wellness Council of America’s Well Workplace Checklist [11]. This broadening focus is also a consequence of an expanded value proposition – evolving from a narrow focus on return on investment (ROI) in healthcare costs to value on investment (VOI) that includes other business-related outcomes such as retention, job satisfaction, and employee well-being [12]. as well as stock market performance [13].

Even with this broader focus, challenges remain with respect to increasing employee participation and engagement in health and wellbeing programs offered by employers. Cultural misalignment between available programs and the needs, interests, and beliefs of the workforce may contribute to lower engagement rates. Employer-implemented programs with a more clinically-oriented focus may limit perceived value and participation especially among subpopulations such as low-wage workers who may be less receptive to engaging in health management programs due to personal or other competing priorities [14, 15, 16]. Further, organizational factors may inadvertently create participation barriers due to program schedules or out-of-pocket costs.

While changes at multiple levels of the social ecological model may be necessary to address these barriers and facilitate a culture of health in organizations, behavioral psychology emphasizes another critical component for health promotion – individual variations in choosing health as a personal priority [17]. A growing body of evidence suggests that an individual’s thought processes and sense of purpose may play a role in their engagement with health promotion initiatives and behaviors [18, 19]. Each individual’s psychological characteristics – personal values, belief systems, and cognitive and emotional competencies – influence their health and well-being status.

We postulate that individuals’ thought processes are important mediators of well-being and that those thought processes are malleable based on principles of neuroplasticity. Programs that strive to enhance well-being may not have value or impact for those whose thought processes are dominated by stress drivers such as self-defeating thoughts or need for reassurance. Objective assessment of individual thought processes may be a starting point for understanding individuals’ priorities and barriers to health promotion engagement. If our hypothesis is borne out, then addressing these intrinsic barriers with a coaching approach guided by principles of neuroplasticity can be expected to increase individual interest and willingness to engage in health-promoting programs and behaviors. Not replacing the need for organizations to engage in practices that facilitate a healthy and safe workplace culture, this approach may enhance alignment with employees’ interest and elicit motivation to engage in programs that support health promoting behaviors.

Theoretical foundations

When cognitive approaches to health promotion are considered, we are left with a sense that each individual has a unique way they respond to life’s circumstances. Charles Mann’s 1918 research at the Carnegie Foundation yields the basis for the commonly held belief that only 15% of work success comes from technical skills and knowledge, while 85% is a function of ‘soft’ skills [20]. A more recent interpretation of this belief is that life is 10% what happens to us, and 90% how we react to it [21]. With a clearer understanding of why individuals respond the way they do, only then does the opportunity exist to modify those underlying thought processes. It may then be possible to enhance the effectiveness and impact with which participation barriers are addressed.

Long-standing behavioral theories have been a cornerstone for planning interventions with a framework for hypothesizing individual engagement. Our understanding of the importance of cognition has provided insights about the value of tailored communications [22]. patient activation [23]. and healthcare consumerism engagement [24] to refine health promotion tactics. These areas of investigation have been complemented by the rapid expansion of number, scope, and quality of mental health and resilience offerings [25]. each providing additional insights regarding the importance of each individual’s thought processes.

Each individual’s thoughts and behaviors are mediated by internal mental processes, known in research as psychodynamic processes. By leveraging his experience as a psychotherapist and business leadership coach, Gary Morais termed “performance thinking” as a way to describe these thought processes that are mostly hidden from human consciousness but are integrated with both cognitive thought processes and behavioral choices [26]. Through his brain mapping efforts with thousands of clients, he identified 12 processes, or drivers of thinking, that provided a consistent and practical framework for individual and organizational coaching. These specific cognitive-behavioral processes, shown in Table 1, consist of five stress drivers, five success drivers, and two summative measures of thinking speed and overall anxiety. The cognitive and behavioral drivers continually reinforce each other over time, creating the reality each individual experiences.

                                                                   Table 1: Thought drivers

The stress drivers are supported by Carl Rogers’ self-development theory [27]. One's self-concept is a collection of beliefs about oneself. Generally, self-concept embodies the answer to "Who am I?". Self-concept is made up of one's self-schemas, and interacts with self-esteem, self-knowledge, the social self, and the idealized self. Rogers also hypothesized that psychologically healthy people actively move away from roles created by others' expectations, and instead look within themselves for validation. On the other hand, neurotic people have self-concepts that do not match their experiences. They are afraid to accept their own experiences as valid, so they distort them, either to protect themselves or to win approval from others.

The five success drivers are aligned with need achievement theory [28]. Success drivers are rooted in a need for achievement - a person’s orientation to strive for task success, persist in the face of failure, and experience pride in accomplishments. The need achievement theory model describes how five components interact to produce the resulting behavioral outcomes. Those five components include: personality factors, situational factors, resultant tendency, emotional reactions, and achievement behavior.

An assessment of these thought drivers provides a profile of a person’s overall thought process impacting their self-concept. The psychometrics used to measure the stress drivers are projective and cognitive in nature. The psychometrics used to measure the success drivers are predictive and behavioral in nature. Measurement of these stress drivers and success drivers provides insight into how they may help or hinder a person from experiencing a better quality of life and ability to live up to his or her full potential. When there is balance between them, the stress and success drivers foster clarity in thinking, more favorable life decision-making and greater levels of well-being. However, when not balanced, stress increases and cognitive dissonance begins to negatively impact individual behaviors. This cognitive-behavioral misalignment then limits quality of life and the ability to live up to one’s full potential. By measuring thought drivers, a targeted cognitive-behavioral coaching program can be initiated using individually-adapted tools and practices.

Not surprisingly, as foundational elements, these drivers represent the underpinnings for many of the focus areas for self-help offerings. By integrating theories of human psychology, coaches incorporate a ‘whole person’ perspective and can help individuals create alignment in their cognitive thinking and behavioral choices. Equipped with those insights, individuals will then be empowered to discover and more fully activate their potential and increase the overall quality of their lives.

Further argument for a focus on individual thought drivers is the understanding that neural pathways underlying thought processes are dynamic and can be modified through intentional effort. Neuroplasticity refers to the ability of our brain to ‘rewire’ thought processes through deliberate action, and has been characterized as playing a role in effecting behavior change through coaching for business [29]. or health goals [30]. In parallel, changes in brain anatomy have been demonstrated in relation to meditation [31]. physical activity [32]. and following self-affirmations [18]. Similar to the way that we have historically manifested a particular reaction to environmental or social triggers, we can learn new ways to respond by changing the workings of our foundational thought drivers.

We hypothesize that coaching for foundational thought drivers differs considerably in relation to more traditional lifestyle coaching. While both coaching approaches may result in neuroplasticity-induced changes, the former deals with foundational elements of thinking to create new neural pathways in the brain resulting in new outputs and behaviors. In contrast, the latter is more issue-driven (e.g. smoking cessation, healthy eating, increasing physical activity), often addressing specific symptoms or behaviors rather than underlying contributors such as thought processes. The difference between these two approaches may help to explain why some individuals engage and/or respond to well-being initiatives while others do not.

This proposed coaching approach is consistent with self-determination theory (SDT). SDT posits that both extrinsic and intrinsic motivation are influential determinants of behavior ( 33) and help to achieve the three SDT goals of autonomy, relatedness and competence. We believe that thought driver coaching has the potential to increase intrinsic motivation by improving self-efficacy and competence – central components of the Cognitive Evaluation Theory of SDT [34].

A look to the future

Thought process-focused assessment and coaching is well aligned with existing benefits and has the potential to enhance interest in workplace health promotion offerings to improve well-being, engagement, or even contributions to talent development. If neuroplasticity is indeed a means by which favorable changes in individual foundational thought drivers can be created, what consequences might result if this approach was offered to the workforce? We believe the results would manifest at an individual level as enhanced employee participation in employer and sponsored well-being programs or increased likelihood to change to healthier behaviors on their own. Likely benefits resulting from foundational thought process coaching include improved workforce health along with the potential for healthcare cost trend mitigation. Further research is needed, but current evidence points to greater adherence to medications [35]. and preventive services [19]. and reduced depression and anxiety [36]. as consequences of the described approach. In addition, worker job satisfaction and productivity may improve business performance at an aggregate level across the organization. While these findings are not de facto indicators of healthcare cost trend reduction, they offer significant promise.

The challenge is that the foundational thought driver coaching does not necessarily ‘fit’ within an existing human resources program offering category, and as a result, may be difficult for employer representatives to incorporate into the usual array of benefits and talent offerings. Importantly, this consideration should not pose a limitation on its application. Instead, objective assessment through implementation of pilot programs with thoughtful evaluation can provide evidence of business value for a novel approach to workforce development.

Conclusion

The proposed hypothesis aligns well with socioecological models used in public health professions, including epidemiology, and the NIOSH Hierarchy of Controls framework. These frameworks provide a means by which organizations can address workforce safety and health concerns from both organizational change and support of individual change. While the greatest impact is generated by systems-level interventions, these frameworks incorporate and recognize the value of individual-level components necessary for organizational changes to be impactful. In the context of organizational cultures of health, our proposed approach centers on the individual level as a complement to broader organizational policy and work environment changes to foster a sense of individual and collective engagement and wellbeing.

If we are to be effective at improving the health and well-being of the entire workforce – and not just those already willing to engage – it is time to explore a more foundational, holistic approach that has more instinctive and innate appeal. Insights combined from different research disciplines provide a compelling conceptual rationale and framework to address foundational thought processes as a means, in concert with organizational changes, to achieve desired health and well-being goals. As a business strategy and a complement to addressing SDoH and creating an organizational culture of health, this approach offers the promise of improved employee health, well-being, and productivity, along with a healthier and higher-performing organization.

Authorship: All authors have met all four criteria for authorship in accordance with the International Committee of Medical Journal Editors (ICMJE) authorship guidelines.
Concept and design: Sherman, Weaver, Bibeau
Acquisition, analysis, or interpretation of resource data: Sherman, Weaver, Bibeau
Drafting of the manuscript: Sherman, Weaver, Bibeau
Critical revision of the manuscript for important intellectual content: Sherman, Weaver, Bibeau
Administrative, technical, or material support: Sherman
Supervision: Sherman, Weaver, Bibeau
Potential conflict of interest: Dr. Sherman provides consultative data and analytics support for ThinkX.