Abstract
Although migration has been occurring since the origins of the human race, the recent era of expanding globalization has led to the increased movement of the global workforce across and within national boundaries. The social, political, and economic aspects of worker mobility have been the focus of numerous studies 1,2 and have led employers to pay closer attention to the impact that worker mobility may have on business continuity. As more multinational corporations (MNC) are starting to place workers in low- and middle-income countries (LMIC; eg, high-tech companies based in the US relocating assets to LMIC such as Bangalore, India), the health status of employees may be negatively affected by the new environment. Conversely, some countries might confer a protective effect as well. Better understanding of how subpopulations relocating to different countries might experience different health outcomes after deployment may provide further insight in the complexities that lead to health outcomes within migrant populations.
According to a recent report, international assignee levels have increased by 25% over the past decade, and a further growth of 50% is predicted in mobile employees by 2020. 3 A further study ranked the United Kingdom as having the highest rate of professionals leaving in 2016. 4 Those interviewed stated that their reason was the pursuit of a better quality of life (29.9%) and improved career progression (17.3%). The United States ranked fourth in terms of countries where national (US) employees are leaving (26%). According to the US Department of Commerce, investment and employment by MNCs have a 0.1% increase in hiring for jobs in the United States, while increasing their hiring abroad by 4.4%. 5
The Problem: Disparate Programs and Data From Multiple Systems
Years ago, Anne Marie Kirby, chief executive officer (CEO) of CoreHealth Technologies, was speaking with a very clever leader in a consulting organization and she shared her panacea for her “Jumbo” customers. These Jumbos, as she called them, are large global organizations with thousands of employees. She said that if the leaders could have visibility through a single unified view of health programs for all of their employees, it would be the Jumbos’ organizational Holy Grail. Unfortunately, not much has changed since then. Organizations are still struggling to synthesize and understand data from multiple systems, multiple vendors, and across multiple locales. The data definitions do not match. The benchmarks are different. And in fact, the programs and offerings are so diverse, there is no “apples to apples” comparison, even if the data are compatible. This lack of cohesive information is costing organizations money and lost opportunity.
Role of Private Sector in Global Health Promotion
Noncommunicable diseases (NCDs) kill 41 million people each year, accounting for 71% of all deaths globally. 6 Each year, 15 million people between the ages of 30 and 69 die from an NCD and over 85% of these “premature” deaths occur in LMIC. The World Health Organization has recognized the need to assemble a wide range of employer/workplace stakeholders in order to mitigate this growing NCD burden. Given the amount of time individuals spend at work, workplaces have been identified as an effective location to tackle the mounting NCD epidemic. Large multinational companies within the commodity, banking, retail, manufacturing, technology, and automotive industries, to name a few, have proven that when it comes to rapid mobilization and efficiency, their resources of human capital, intellectual capital, financial, and geographical footprint can contribute significantly to improving health outcomes in local and global populations. Whether it is providing free HIV antiretroviral medication or lending a hand in infectious disease outbreaks such as Ebola, a large number of case studies have shown the important role the private sector can play in global health promotion. 7,8
As CEO of a wellness technology company that works with global well-being service providers, Kirby has overseen the deployment of the CoreHealth platform in a number of countries around the world. CoreHealth has dealt with the same issues that all North American companies do when delivering programs to employees around the world. Kirby and her colleagues have experienced the first-hand technical issues of multiple languages and translations, cultural differences, and access to technology (computers, mobile, WIFI, etc). Most importantly, there are the unique regulatory rules for data privacy and security in every region or country. And in some cases, because they sell to foreign wellness providers, they have also dealt with business challenges such as taxation, company registration, and the local market.
Kirby also notes that the ideal scenario is when they work with organizations that have “boots on the ground” in every country where participants live. However, there are very few organizations in the world where: health is their primary focus; they understand the value of prevention; and they have health professionals in every locale.
International SOS 9 is one of the rare companies that has the first-hand experience on tailoring consultation, recommendations, programs, and approaches to meet the challenges of global deployment. Dr Rodriguez-Fernandez, the global medical director for International SOS, oversees the company’s operational aspects and strategic direction for workplace health promotion and NCDs. Having operational health teams on the ground in over 950 medical sites, and fluency in over 100 languages in all corners of the globe, has given the organization an “on the ground” understanding of the pain points that multinational companies face when expanding their workforce overseas. In addition, with fluctuating commodity prices and geopolitical uncertainty, large organizations are also faced with the demands of being able to maintain profitability for shareholders. Fortunately, International SOS has seen that industry leaders across the globe have begun to realize that workplace health promotion programs, if planned and executed correctly, are not only a successful platform for improving the health of their employee base but also impact the triple bottom line, leading to improved and sustainable business models.
A good example of this is leveraging worksite health promotion programs to prevent the world’s number 1 killer, cardiovascular disease (CVD). According to Dr Rodriguez-Fernandez, when it comes to CVD, tobacco cessation is one of the most cost-effective strategies for prevention. When assessing for tobacco use, there are many differences in how you assess what a population’s tobacco use habits might be. For instance, in Egypt, the use of hookahs for shishas might be important, where in India or Papua New Guinea oral use of tobacco might be relevant. Along a similar vein, some eastern Asian countries might avoid face-to-face counseling support in an attempt to “save face” while other Western cultures might prefer a one-to-one interaction instead of a telephone-based employee assistance program. This rich, country-specific insight has been built over the years thanks to International SOS’ “boots on the ground” running of these programs.
Moving From Rhetoric Toward Action
In 2016, 69% of multinational companies had a global strategy for health promotion, up from 34% in 2008, according to a Xerox-sponsored report. 10 This sounds like great progress, but results are lacking. The report points out the 2 significant barriers for global success: no global oversight and an inconsistent global strategy.
The best programs are the simplest ones. Ideally, they are designed to bring disparate groups together and to share new information. For example, it is a great opportunity for team building to share information about different aspects of the company and its projects in different areas that are not always visible to all staff. In one very successful program, a power utilities company asked participants to “walk their power grid.” At each location, they virtually met other employees through informative pictures of projects and people. A multifaceted, comprehensive communications strategy can help initially engage people in the program. Focusing on fun and a supportive culture then supports expansion of the program.
Another great example of a successful program was delivered by a Chief Medical Officer (CMO) Network, created by Bupa Healthcare. 11 They started out simply by creating a custom activity program and had 8 global organization members of their Network join. It was a very successful 4-week activity challenge that was designed to study the results of the same program in different company cultures. Dr Paul Zollinger-Read, the CMO at Bupa, credits the success of changing participants’ habits to the simplicity and inclusivity of the program. He also cited the team spirit and peer-to-peer support across all positions within the company that kept people motivated. He points out that only 10% of companies globally are doing this today. The CMO Network has now turned its focus to mental health for global populations. Interestingly, when Natural Language Processing was used to analyze the postprogram survey results of the most successful global programs, the word “fun” was found to be the most commonly used word in the postsurvey text.
Challenge of Complying With Privacy and Data Security Laws
One of the biggest challenges is ensuring your program is in compliance with privacy and data security rules around the world. The sheer quantity of rules is very challenging but so is the fact that the rules are constantly changing. Fortunately, there are lawyers who specialize in global health-care data privacy. To help get a clear understanding, CoreHealth worked with a data privacy lawyer to create a whitepaper about global privacy. 12 The biggest factor is to provide data storage in a country that is either in the European Union (EU)or is deemed to be equivalent to the EU, such as Canada. When the data are stored in an equivalent country, the majority of the laws focus on who has to give permission for the data to be stored out of country. Can the employer give permission, or does it reside with each employee?
Some countries have additional business, tax, and other laws that must be followed. A good example of a local law is Genetic Information Non-discrimination Act in the United States. 13 One avenue to ensure you have the best information is by accessing government resources. For example, in Canada, CoreHealth works with a trade commissioner who is part of a network of Canadian trade commissioners in over 140 countries. According to Kirby, their designated trade commissioner helps them access local resources to provide information regarding laws, general practices, and even culture. However, it is much simpler to work with a well-being provider that has their own people in each of the locales, such as was the case with International SOS.
When Cultural Beliefs, Lack of Technology, and Communications Differences Get in the Way
Cardiovascular disease is the world number 1 killer and cause of premature death in most countries around the world, including both high-income and LMIC. When it is too late for prevention, the first issue lies in being able to identify those with the disease. Once they have been clinically diagnosed and put on medication (not an easy task as, in some countries, over 70% of hypertension patients are walking around undiagnosed), then the issue becomes following the health-care providers’ advice on treatment. In Indonesia, a workplace health promotion program uncovered that adherence to NCD-related treatment was extremely low. 14,15 Conversations with health promotion staff revealed that even well-educated employees believed NCD medication for blood pressure issues or statins for cholesterol were addictive and, much like illegal narcotics, would create addiction. Such insights would be hard to find in any Cardiology or Internal Medicine book, so it is helpful to have local partners that can help you identify beliefs, challenges, and barriers that may require a unique approach.
Since CoreHealth provides no wellness services and focuses exclusively on wellness technology, they have gained experience through helping their customers deploy their software. Fortunately, their platform was built in Canada and had to support 2 languages and 2 metric systems natively. That has forced CoreHealth to adapt for unique cultures, which can only be determined by open conversation with a local representative. Supporting languages is key but even when it is the same language, there are nuances. For example, the United States uses the term “behavioral health” while in Canada they use “mental health.”
Interestingly, a lot of the world bypassed the “wired” stages of technology and went directly to cellular data. Therefore, mobile service is far more available than wired computers, so all programs must support a mobile platform. Not all countries have high-speed Internet service available, so allowing systems to adapt to lower bandwidths is ideal.
Communication, as with any North American program, is equally important globally. From CoreHealth’s experience, weekly communications bring the best success. In addition to providing adequate informational and instructional content, similar to North America, messages from organizational leaders make a significant difference. Kirby notes that some of the best program results they have seen have involved leaders providing video messages about the program.
Technology has become a double-edged sword in today’s globalized world. New levels of interconnectedness mean time zones can become blurred for employees communicating with worksites across the globe. The inability for employees to disconnect has been shown to impact psychological resilience not only in business travelers but within domestic employee populations. Worksite health promotion teams also face difficulties in communicating with entities across multiple time zones, despite today’s technological advances.
On the Road to Effective Worksite Health Promotion
Setting up and running a robust and sustainable worksite health promotion program comes with a unique set of demands. Planning, delivery, monitoring, and evaluation are no easy feat. These programs should be based on international best practices, and it takes time and effort to stay updated on evidence-based practices. Outsourcing health promotion programs to an experienced third-party partner allows the organization to focus on its core competency and transfers liability for issues like health data privacy. But until national systems are in place to respond to the global epidemic of NCDs, creating conducive political, social, and economic environments that enable happy and healthy individuals, worksite health promotion programs might be a first step in introducing preventive measures to a large portion of the global population.