Health Promotion: A Road to Stigmatization and Exclusion?
Karst Jaarsma (s1909983)
Health programs have seen a sharp increase in popularity. Companies try to influence employees’ behavior by rewarding them with items such as discount on health insurance and money prices. So far, little literature has focused on the negative aspects of these rewarding health programs. Next to the pure implementing issues, such initiatives have moral concerns as well. This paper focuses on the possible effect of these programs on the stigmatization and exclusion of overweight employees. It offers some support for rewarding health programs which are only benefitting a minority of employees increasing the level of stigmatization within a company. In particular, this turned out to be the case for overweight individuals. They were found to be more afraid of gaining weight after the implementation of a minority rewarding health program. Implications of this study will be discussed.
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Western societies more and more believe that obesity should be prevented from young age on. Dutch kids used to start their school lunch with singing ‘Enjoy food, enjoy drinks. Bite, bite, bite, sip, sip, sip. This will taste well, this will taste well. Eat it all!’ nowadays they get to sing songs like ‘Bite, bite, bite. Swallow, swallow, swallow. Do not eat too much, before you will end up being too fat’ (Volkskrant, 2014). It is a small example in a growing tendency to place overweight on the agenda.
Social views upon overweight and obesity tend to focus on the individual responsibility of overweight, by implying that individuals cause their own overweight (Brownell Et al., 2010). This trend is explicitly visible in the above shown children song. There are numerous examples for this tendency. The academic realm underlines the social-structural responsibility for overweight, by linking overweight to societal aspects. Research concluded that the main causes for overweight are to be found within the social realm (Schwartz, 2003) and can be traced back in the messages used by governments, civil society and the food industry (Mikkelsen, 2005). More specifically, the Australian academic realm argued that the main cause for overweight was a lack of services, programs and supportive social environment (Bastian, 2011).
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overweight. These researches highlight the individual rather than the societal responsibility for overweight. Such portrayals stand in sharp contrast with studies showing that obesity is just as much an individual responsibility as a societal responsibility (Mercer, 2010).
Obesity is not only a societal topic of concern; the business industry is looking for ways to fight obesity as well. One quarter of HRM professionals is already concerned about the high level of obesity within their organizations (Lavan, 2009). Unhealthy individuals will drive costs of companies. Health programs are, therefore, considered a good answer to the challenge and are implemented by more and more organizations. Jitendra et al. (2011) discovered that a primary benefit of reducing obesity in the workforce is the increased number of happy and healthy employees. This lowers the level of days taken off due to illness. Health programs and incentives to stay healthy have been positively appreciated by both employers and employees (Lavan, 2009).
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Konradt, 2014), rewarding employees for healthy behavior is likely to become a shared characteristic of health promotion initiatives within the business environment.
There is also a possible downside to such health promotion programs - those with a rewarding aspect. A rather limited amount of academic literature focuses on such negative effects. Various possible problems with the system have been shown. Hall (2008) suggested that health promotion with a rewarding aspect can lead to people fooling the system. Moreover, these rewarding health programs can encourage unhealthy behavior (e.g. people losing too much weight) and can have a positive short term outcome only (Hall, 2008). Next to that, little information is available about the right way of implementing proper incentive based health programs. There is, for example, no consensus on the thin line between healthy and unhealthy weights (Scalavitz, 2013). Such a measure has to form the key pillar of good health programs.
The rise of health programs raises ethical questions as well. Are you, as an employer, invading the privacy of employees when trying to control their behavior? (Lavan, 2009) Wells (2012), for example, points to the punitive function of health programs towards employees, who are not able to fully participate for legitimate reasons, or employees participating, but failing the health program. Hall (2008) argued that some reward based health programs might lead to exclusion of employees who do not participate in the program. Moreover, intrinsic motivation may be undermined by external pressures, such as financial rewards (Ryan & Deci, 2000). Replacing intrinsic motivation with external pressures leads to individuals enjoying tasks less and reduce their motivation (Vansteenkiste et al., 2008)
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have on the quality of their work. Have et al. (2011) slightly touches on the possible negative effects on individuals. From a philosophical and ethical perspective, the authors criticize health programs for their violations of individual’s well-being, their violations of privacy and violations of basic human rights (e.g. autonomy and freedom of choice).
Also, rewarding health programs could contribute to stigmatization of overweight employees. The responsibility of an individual’s weight is put upon the individual by rewarding its health. By rewarding healthy weight, the promoted message is that behavior is a key determinant for losing or gaining weight. This would imply that it is an individual’s own fault when he or she is overweight. This could lead to a situation, within an organizational context, where overweight individuals can be considered to not do their upmost for losing weight, or being the victim of their own irresponsible behavior. They will end up in what Paetzold et al. (2008) described, as a devalued out-group. In such a situation, overweight will be regarded as immoral rather than unhealthy (Mulder, 2013).
As a result of the above described process, rewarding health programs are expected to increase the stigmatizing discourse. Due to the strong focus on personal efforts towards losing weight, individual health becomes a complete personal responsibility (MacLean et al., 2009). Lynch et al. (2006) shows that in such circumstance, overweight people end up being stigmatized by their colleagues. Thirty-five per cent of employees felt stigmatized after the implementation of a health-related management program.
This leads to the following hypothesis:
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Weight related discrimination has been shown to have similar effects as racial discrimination. Prejudicial actions exclude the affected people from full participation in social life. This is, to a big extent, influenced by self-perceptions. The idea that one is being stigmatized already leads to a reduction in social life participation. (Schafer & Ferraro, 2011) Dovidio et al. (2010) showed that Latinos with a stronger foreign accent felt more excluded from American society than similar Latinos with a weaker accent. Similarly, overweight individuals might feel more excluded from their organization for not participating in health programs than normal weight individuals. As Barclay & Markel (2007) mentions, self-perception may place one as a marked individual between unmarked individuals (e.g. overweight and non-overweight individuals).
Weight stigmatization is, as a result of rewarding health programs, expected to occur in similar lines with the discrimination towards minority groups. Health programs are expected to create a great divide between marked and unmarked individuals. This research therefore expects that overweight individuals will be excluded from the majority. Something underlined by Giel et al. (2012) who stated that stigmatization is closely linked to experiences of social exclusion.
The research therefore assumes the following hypothesis:
H2: The implementation of rewarding health programs results in the exclusion of overweight employees.
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majority rewarding programs. In these programs, a majority of employees gets rewarded for their healthy behavior. Minority rewarding health programs will refer to health programs created in such a way that only a limited number of employees are rewarded for their healthy behavior. One can think, for example, of health programs where only one employee gets rewarded (e.g. a so-called health champion). This health champion can, for example, be rewarded with financial prizes.
Rewarding a majority may, in psychological terms, be regarded in similar terms as punishing the minority. After all, if everyone gets rewarded, except a small percentage of employees, this minority might experience the system as punitive. The reward, in such a situation, has become the standard. Within the punishment research field, Mulder (2007) showed that punishment increases moral concerns to a greater extent than rewards. Punishment oriented systems cause people to morally disapprove others engaging in undesired behavior. This is less the case when appropriate behavior is rewarded. Within this particular context, the overweight individuals can be considered as engaging in undesired behavior. Because a majority rewarding program can be considered punitive, the majority rewarding health programs are expected to lead to moral disapproval towards overweight individuals. This feeling is expected to lead to stigmatization and exclusion of the overweight employees.
The research therefore assumes the following two hypotheses:
H3: Majority rewarding health programs lead to higher stigmatization of overweight employees than minority rewarding programs.
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In addition, the report investigates whether the hypotheses are moderated by the weight of the individuals. It may be the case that reward programs increase stigmatization mainly among people who are not overweight, and increase perceptions of being excluded mainly among people who are overweight. Thus, for exploratory reasons, this is tested.
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Participants and design
Data has been collected via online surveys. People were approached via the investigator’s social network, via contacting companies interested in the topic, and promoting the survey via online fora. There was a total of 122 participants (48 males, 67 females, 7 unknown; Mage= 38,48 , SDage= 13,54). The majority of participants were working
within the public sector, pharmaceutical sector, education sector and social work sector, respectively. No participants were underweight, 75 participants had a healthy weight, 32 were overweight and 6 were obese1. The study was a scenario experiment where participants were randomly assigned to one of the three conditions: no reward condition, a minority rewarding condition and a majority rewarding conditions. A health program was introduced in all conditions.
Procedure
The survey started with a couple of demographic questions and a question about the participants’ weight and height. This was followed up with questions checking the well-being of the participant (Pontin et al., 2013) and questions asking about the participant’s self-image. Then, a scenario was presented in which the presence of a reward was manipulated.
The participant was asked to read about a company introducing a sport program. It was stated that the company wants to invest in the health of its employees. In the no-reward condition, this was the only information they read:
1
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“Imagine that you are working for a company. One day, this company introduces a sports program. The management states during the introduction that they want to invest in the health of their employees. A healthy weight is an important element of this.”
In the minority reward condition, the scenario description continued with the following paragraphs:
“The weight and fat percentage of the employees will be measured one year after the introduction. This will determine which employee has the healthiest weight and fat percentage.
The person with the most healthy weight and fat percentage will be announced ‘Health Champion’ and receive a suitable financial reward.”
In the majority reward condition, the final paragraph was changed into:
“All employees within the healthy realm of the weight and fat percentages will be rewarded with a discount on social welfare insurances.”
10 | P a g e Measures
Manipulation checks
The rewarding aspect of the manipulation was checked via the statements ‘healthy weight is rewarded in the above described situation’ and ‘there is a reward for possessing a healthy weight in the above described situation’. Participants responded to the statements on a seven-point answering scale (1= absolutely not, 7 = absolutely yes). The mean of the two statements has been combined in one scale (α = .95). The majority versus minority rewarding aspect was checked via the statements ‘in the above described situation, a majority of the individuals within the organization will be rewarded for possessing a healthy weight’ and ‘a small number of people will be rewarded for a healthy weight in the above described situation’. The second statement was reversed and both were combined in a second group (α = .54) that reflected the extent to which participants regarded the reward as majority rewarding.
Stigmatization 1
Respondents were asked to judge two pictures. One showed an overweight woman and one picture showed a non-overweight woman2. The two pictures were placed on the two ends of a 7-point scale. The non-overweight woman was placed on the right side and the overweight woman on the left side. Below this, 25 characteristics were presented (e.g. reliable, lazy, attractive, etc.) about which participants were asked to indicate on the 7-point scale whether these applied better to the left or the right woman. The scale was constructed
2 The pictures were found on the internet (Duramine Online, 2014). The pictures showed the same woman
before and after losing weight. A pilot experiment amongst twenty persons was conducted (11 males, 9 females; Mage = 29.5, SDage= 13.6). The pictures were perceived as similar in terms of attractiveness, clothes and
competence. The two pictures were considered significantly different in terms of weight and fat (Pfat & Pweight <
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as such that if participants found a characteristic to fit equally to both persons they chose “4”, if participants found a characteristic to fit the overweight woman perfectly they chose “1” and if participants found a characteristic to fit the thin woman perfectly they chose “7”. The negative characteristics were reversed during the analyses, thereby guaranteeing that the above description stayed in place. A high score indicated thereby that a participant regarded the overweight woman in more negative terms and less positive terms. In this way, the scale reflected people’s inclination to attribute positive characteristics to thin people and negative characteristics to overweight people. The measure thereby reflects the stigmatization of overweight.
The characteristics used were derived from the Fat Phobia scale as designed by Robinson et al. (1993). The characteristics consisted of two subscales. First, the Fat Phobia Undisciplined subscale consists of the following characteristics: “(1) Poor self-control”, “(2) No will power”, “ (3) Overeats”, “(4) Likes food”, “(5) Unattractive”, “(6) Shapeless”, “(7) Inactive”, “(8) Unambitious”, ”(9) Slow” (Alpha = .76). Second, the Fat Phobia Passive subscale consists of the following three characteristics: “(1) dependent”, “(2) Passive”, “(3) Weak” (α = .75).
Stigmatization 2
Another way in which weight stigmatization was measured is the Prejudice Against Fat People scale designed by Crandall (1994). The entire scale has been used. The scale consists of three subscales (e.g. Dislike, Fear of fat and Willpower). A seven-point response scale (1=completely disagree, 7 = completely agree) was used.
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who are overweight are a little untrustworthy”, “(4) Although some fat people are surely smart, in general, I think they tend not to be quite as bright as normal weight people”, “(5) I have a hard time taking fat people too seriously”, “(6) Fat people make me feel somewhat uncomfortable”, “(7) If I were an employer looking to hire, I might avoid hiring a fat person” (α = .84). The Fear of Fat subscale consists of the following statements: “(1) I feel disgusted with myself when I gain weight”, “(2) One of the worst things that could happen to me would be if I gained 25 pounds”, “(3) I worry about becoming fat” (α = .80). The Willpower subscale consists of the following statements: “(1) People who weigh too much could lose at least some part of their weight through a little exercise”, “(2) Some people are fat because they have no willpower”, “(3) Fat people tend to be fat pretty much through their own fault” (α = .75).
Exclusion
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holidays”, “(12) Colleagues will make an effort to get my attention”, “(13) Colleagues will invite me to go out and eat with them”, “(14) Colleagues will invite me to join them for weekend activities, hobbies or events”, “(15) Colleagues will invite me for lunches during breaks” (α = .92). Statements 8 up to 15 were reversely coded. A high score indicated thereby, that a participant regarded the overweight woman in more negative terms and less positive terms. In this way, the scale reflected people’s inclination to attribute positive characteristics to non-overweight people and negative characteristics to overweight people. Thereby, the measure reflects the level of exclusion of overweight colleagues.
Results
Manipulation
14 | P a g e Stigmatization 1
Based on their BMI, participants have been divided into two subgroups. Healthy weight participants (BMI smaller than 25) have been placed together in one group. Overweight and obese participants (BMI bigger than 25) have been placed together in another group. We hypothesized that the implementation of a rewarding program would increase the amount of stigmatization. We performed 3 (reward) x 2 (overweight) ANOVA’s on the various Fat Phobia subscales.
No significant main effect of reward was found for the Fat Phobia Undisciplined subscale, but a trend was found, F (2,100) = 2.31, p = .10. This showed that in the minority rewarding condition, participants judged the overweight woman as more undisciplined (M = 4.84, SD = 0.09) than in the non-rewarding condition (M = 4.58, SD = 0.09) (Tukey Post-hoc p’s < .05). No significant main effect of reward was found for the Fat Phobia Passive subscale.
Stigmatization 2
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A significant main effect of reward was found for the Crandall Fear of Fat subscale, F (2,94) = 3.48, p = .04. In the minority rewarding condition participants showed a higher fear of fat (M = 4.14, SD = 0.26) than in the non-rewarding condition (M = 3.20, SD = 0.25). The majority rewarding condition did not differ from the other two conditions (M = 3.68, SD = 0.27) (Tukey Post-hoc p’s < .05).
This main effect was qualified by a significant reward x overweight interaction, F (2, 94) = 3.35, p = .04 (see table 1). This showed that the effect of a reward on the fear of fat only occurred among people with overweight and not among people without overweight. Among people with overweight, there was a stronger fear of fat in the minority and majority reward condition, than in the no reward condition.
Table 1: 3 (reward) x 2 (overweight) ANOVA for Crandall Fear of Fat results
Overweight
No Yes
Manipulation No reward 3.52a 2.88a
Minority 3.72a 4.57b
Majority 3.14a 4.22b
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Crandall Willpower:
A marginally significant main effect of reward was found, F (2, 94) = 2.57, p < .01. Participants In the minority reward condition participants linked overweight to a greater extent to willpower (M = 4.56, SD = 0.22) than participants in the no reward condition (M = 3.97, SD = 0.21). The majority reward condition did not differ from the other two conditions (M =4.54, SD = 0.22) (Tukey Post-hoc p’s < .05).
Exclusion:
Based on their BMI, participants have been divided in two subgroups. Healthy weight participants (BMI smaller than 25) have been placed together in one group. Overweight and obese participants (BMI bigger than 25) have been placed together in another group. We hypothesized that the implementation of a rewarding program would increase the amount of exclusion measured in the statements related to the Ostracism scale. A 3 (manipulation) x 2 (overweight) ANOVA was performed on the participants’ response to the statements. This showed no significant effects.
General discussion
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rewarding health measures increased the perception that overweight people are undisciplined and have no willpower.
For overweight participants, the implementation of a rewarding health policy increased the fear of gaining weight. It is assumable that, due to the rewarding health program, the pressure of being thin is increased. This causes a higher fear of gaining weight. Moreover, individuals become more aware and might have an increased self-perception. This would place them as marked overweight individuals between unmarked thin individuals. Therefore they are likely to feel stigmatized (Markel, 2007).
It has been shown already that the question of overweight is as much a societal responsibility, as an individual responsibility (Mercer, 2010). This research questions the effectiveness of an approach focusing upon individual responsibility. It shows that by rewarding individual behavior, and thereby focusing upon the individual responsibility, a more stigmatized work climate might be created. It showed, in particular, that overweight individuals are likely to be influenced by the introduction of a minority rewarding health program.
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healthy weight individuals, after the implementation of a rewarding health policy, they might suddenly be facing their difference with colleagues. This increases their stigmatized position within an organization. The rewarding health program creates a discourse where difference is promoted, and this implicitly contains hierarchies of value (e.g. it is better to be thin than overweight) (Goldstein & Shuman, 2012). Barclay & Markel (2007) warned for the increased stigmatizing discourse due to the genetic testing. Companies measuring BMI of their employees shape the ground for marking individuals. This will probably result in stigmatization. Overweight individuals are therefore more likely to feel stigmatized after the implementation of a health program measuring their BMI.
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Lastly, the results could be explained by the kind of norms which are promoted. Literature distinguishes between descriptive and injunctive norms. Descriptive norms are based upon the prevalence or typicality of certain behavior. Injunctive norms are based upon the perceived degree of social approval of certain behavior (Jacobson et al., 2010). Promoting health via a minority rewarding system is a clear example of injunctive norms (e.g. the idea of a Health Champion creates a perceived feeling of glorification of healthy weight). Promoting health via a majority rewarding system is a clear example of descriptive norms (e.g. most people possess a healthy weight and receive an insurance discount). Jacobsen et al. (2010) linked injunctive norms to a greater interpersonal goal of social approval. It is argued that descriptive norms are more powerful in urging people to show the desired behavior (Smith et al., 2012).
No support has been found for the idea that rewarding health programs increase the exclusion of individuals. This can be explained by the below mentioned limitations of the research. A stronger based research is still expected to support the hypothesis. Next to that, the exclusion scale used was a very direct one. Due to social desirability it is imaginable that people did not fill in that they would exclude overweight persons. After a real implementation of such a program, a different reality might come into place.
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rewarding health program is therefore advisable. Next to that, various people commented that they considered the research too stigmatizing itself and they therefore left or did not participate. Few people angry contacted the researcher due to stigmatized feelings. They experienced the research as a personal attack (e.g. it would have been send to them especially because they are overweight). This underlines the sensitivity of the subject. It also implicates that a certain group of people might have been excluded from the research; the ones being more aware of the stigmatization and/or the ones feeling more easily stigmatized. Therefore, the results are less strong than they could have been.
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