Toward a Corporate Culture of Health: Results of a National Survey (2025)

Policy Points.

• The private sector has large potential influence over social determinants of health, but we have limited information about how businesses perceive or engage in actions to promote health and well‐being.

• We conducted a national survey of more than 1,000 businesses of varying sizes and industries to benchmark private sector engagement in employee, environmental, consumer, and community health, which we collectively refer to as a corporate culture of health.

• Overall, the private sector is taking steps to foster health and well‐being but still has substantial opportunity for growth.

Context

The private sector has a large potential role in advancing health and well‐being, but attention to corporate practices around health tends to focus on a narrow range of issues and on large businesses. Systematically describing private sector engagement in health and well‐being is a necessary step toward understanding the current state of the field and developing an agenda for businesses going forward.

Methods

We conducted a national survey of 1,017 private sector organizations to assess current levels of engagement in what we term a culture of health (CoH). We measured corporate CoH along four dimensions, which assess the extent to which businesses promote employee, environmental, consumer, and community health and well‐being. We also explored potential explanations for the number of health‐related actions taken in each dimension.

Findings

On average, businesses took 38% of health‐related actions included in our survey. For each dimension, we found variation among businesses in the number of actions taken (on average, there were almost fourfold differences between the bottom and top quartiles of businesses in terms of actions taken). Mentioning health and well‐being in the corporate mission, having a strategic plan for CoH, and perceiving a positive return on CoH investments were all associated with businesses’ actions taken. Fewer than half of businesses, however, perceived a positive return on their CoH investments.

Conclusions

Overall, the private sector is taking steps to foster health and well‐being. However, there remains substantial variation among businesses and opportunity for growth, even among those currently taking the most action. Strengthening the business case for a corporate CoH may increase private sector investments in health and well‐being. Actions taken by individual businesses, business groups, industries, and regulators have the potential to improve corporate engagement and impact.

Keywords: corporate health, social determinants of health, health policy, public health

Survey Development

To develop our survey, we consulted experts regarding leading‐edge actions and reviewed surveys and frameworks related to corporate involvement in aspects of health and well‐being, including employee benefits, sustainability practices, product safety, and community engagement.5, 16 We adapted selected questions and developed new ones through an iterative process of group discussion and feedback from experts in survey design and public polling. We organized the survey instrument around the four dimensions of a corporate CoH: employees, the environment, consumers, and communities. Our questions measured the depth of a business's CoH, inquiring about mission, strategic planning, health‐related activities, and the perceived financial returns to these actions. We designed survey items to be general enough to ensure relevance to businesses from a diversity of size categories, industries, and levels of knowledge about a corporate CoH (including no knowledge).

The final survey included 33 questions (see Online Appendix FigureA2). Response options for specific questions were structured as either a binary yes/no, Likert scales, or multiple choice. The survey was confidential and no identifying information was recorded with the exception of one multiple‐choice question to categorize the business industry. The polling firm did not store or transmit identifying information to the research team. The draft survey was piloted with 11 interviewees, after which the research team revised the survey instrument for clarity and flow.

Sample

The Dun & Bradstreet (D&B) database, which indexes more than 285 million commercial entities, was used to identify businesses that met the following inclusion criteria17: (1) the business had 50 or more employees; (2) the business was a single site or, for multisite businesses, the location surveyed was a headquarters or subheadquarters; and (3) the business was not a government entity. To capture an array of industries, businesses were sampled based on two‐digit Standard Industry Classification (SIC) codes, with the exception of public administration codes.18 The sample was stratified disproportionately to ensure 250 businesses with 50–99 employees, 250 businesses with 100–499 employees, and 500 businesses with 500 or more employees. We emphasized larger businesses, as we expected they would be engaged in a broader range of CoH activities, and because more than 70% of workers are employed at businesses with 50 or more employees.19 That said, half the sample was composed of small businesses having fewer than 500 employees, consistent with the Small Business Administration definition, which ranges from 250 to 1,500 employees, depending on industry.20 Within each business, the target interview subject was the individual in charge of human resources, someone familiar with general employment and health policies in the business, or the general manager. The Harvard T.H. Chan School of Public Health Committee on Use of Human Subjects approved all research methods.

Data Collection

SSRS, a professional polling firm, administered the survey using computer‐assisted telephone interviews, between October 9 and November 13, 2017. Interviews lasted on average 20 minutes. Interviewers were trained in the content of the interview, as well as in how to conduct outreach within organizations to optimize response rates. To increase response rates, SSRS made up to six follow‐up attempts for each interview target.

Survey Weighting

The survey was weighted to adjust for the fact that not all respondents were selected with equal probability (stratification by business size) and to account for systematic nonresponse along known parameters. Each business‐size subgroup was weighted to reflect the known makeup of businesses meeting the study qualifications using iterative proportional fitting.21 Parameters used for poststratification weighting were generated from the total D&B sample for each size subgroup and included census region, business size, and SIC code group (1‐39; 40‐49; 50‐59; 60‐69; 70 and higher). Proportional adjustment was used to account for deliberate oversampling of larger businesses. For the overall survey, the design effect was 1.7 and the margin of sampling error was plus or minus 4 percentage points.

Analysis

We produced descriptive statistics to analyze business characteristics (including business size and industry) and to assess responses for each survey question. We converted some responses, including all questions related to CoH‐oriented actions, into binary responses to facilitate analysis. We ran weighted linear regressions to examine the effect of business size and industry on CoH action. Finally, we examined response patterns across questions to consider associations between various business characteristics and CoH action.

Composite Measures of Action

We summed the binary responses to specific questions to create composite measures of the number of health‐oriented actions taken for each dimension. We also created an overall composite measure that summed the four dimension‐level composites for each organization. For each dimension, we asked two common questions: (1) the rank of the senior‐most person responsible for that domain of health in the business, coding a response of executive vice president (EVP) or higher as 1 and all others as 0; and (2) whether the business had assessed the impact of its programs in that dimension within the past five years. Other action questions varied according to activities relevant to each dimension of health. We counted seven action items related to employee health, five for environmental health, six for consumer health, and ten for community health. The overall action composite counted all 28 action items.

Respondents

Our final sample included 1,017 businesses (see Online Appendix Figure A3). Industries represented, based on SIC classifications, included manufacturing (141 businesses), agriculture (13), mining/oil/extraction (16), construction (61), transportation (49), retail (50), banking/finance (51), other services (198), food (48), media/communications (18), health care (196), education (131), and other, including a small number of nonprofit businesses (45). The survey response rate was 6.1%, calculated using the American Association for Public Opinion Research's response rate 3.0 formula, which divides the number of completed interviews in each sampling frame by the estimated number of eligible phone numbers in each frame.22 This response rate is consistent with current industry standards for telephone surveys, which are, on average, below 10%.23, 24

Business‐Level Prioritization of CoH

To understand the extent to which businesses explicitly prioritized CoH activities, we considered three factors: reference to CoH dimensions in a business's mission, inclusion of dimensions in a CoH strategic plan, and management's perceived return on investment (ROI) in CoH actions. With respect to the explicit inclusion of CoH dimensions in their corporate missions, 70% of businesses in our sample mentioned employee health, 49% mentioned each of consumer and community health, and 44% mentioned environmental health. Only 8% of businesses in our sample included all four dimensions of health and well‐being in a comprehensive CoH strategic plan, 8% of businesses addressed three dimensions, and 20% addressed at least two. Businesses perceived somewhat or very positive ROI on their actions to varying degrees across dimensions: 46%, 39%, 36%, and 30% for actions to promote employee, community, consumer, and environmental health, respectively.

Across each of the four dimensions, we asked about the rank of the senior‐most person responsible for efforts made by the business in that area. Almost 70% of businesses assign responsibility for environment, consumer, and community health to an EVP or someone more senior, compared to 61% for employee health. For each dimension, we asked whether the business had conducted an assessment of its work in that area within the prior five years. About half had done so regarding consumer health, but less than 30% had conducted a recent assessment in any of the three other areas.

Actions Businesses Take to Promote a CoH

On average, businesses took 10.6 (38%) of 28 total possible actions across the four CoH dimensions. They took 2.3 (33%), 1.8 (36%), 3.2 (53%), and 3.3 (33%) of the possible actions within the employee, environmental, consumer, and community dimensions, respectively.

The most common action taken to achieve employee health was to offer rewards or reimbursements for positive activities, such as obtaining fitness club memberships (42%). In contrast, only 14% of businesses imposed surcharges for unhealthy behaviors, 15% offered financial incentives for healthy behaviors, and 18% required their suppliers to offer health and wellness benefits to employees. For environmental health, almost 40% of businesses engaged in formal efforts to offset negative environmental impacts associated with production or consumption of their services, and about one‐third actively pursued opportunities to switch to renewable sources of energy. Just one‐quarter enforced measurable targets for business sustainability initiatives. In consumer health, more than half of businesses claimed to engage at least somewhat in each of the actions listed. Engagement in community health actions exhibited the widest range, with a high of 75% of businesses hosting social events in the community and a low of 10% of businesses investing in affordable housing development. As a follow‐up question, we asked businesses what role they played when participating in a community health program: 38% reported playing a leading role, 48% played a participating role, and 14% provided financial sponsorship only (Figure1).

Explanations for Variation in Action

Limitations

Our survey findings should be interpreted in light of several limitations. First, our data are cross‐sectional, so we cannot make inferences about the causality of certain relationships examined—for instance, whether the perception of a positive financial return from investing in health‐related actions is an antecedent or outcome of action is unknown. Additionally, survey respondents—in most cases, directors of human resources or equivalent—may be more knowledgeable about their organization's efforts within one dimension, likely employee health, than within others. Further, by opting to focus on larger businesses, our results do not apply to those with fewer than 50 employees.

To obtain national benchmarking data across a diverse range of businesses, our survey items were necessarily general. A limitation of this broad approach is that our results raise many important topics with which we cannot engage in detail.

Finally, our low response rate is a notable limitation, although it is typical of studies that involve telephone polling by prominent survey organizations.23 Studies have shown that selected measures (eg, partisan preference) are unbiased in surveys with probability samples but low response rates.23, 27 Studies have also shown that surveys with low response rates—if based on probability samples and weighted using US Census and other established parameters (in the case of this survey, D&B business size and SIC code groups)—yield accurate estimates in most cases when compared with both objective measures and surveys with higher response rates.23, 28, 29, 30 For instance, one recent study showed that the average difference on several measures, such as employment status and health insurance status, between government estimates from high‐response‐rate surveys and a Pew Research Center poll with a response rate similar to the poll used in this paper was three percentage points.23 Given that our survey data were drawn from a probability sample and used the best available sampling and weighting practices in polling methods (eg, making live phone calls rather than automated calls, and calling back nonrespondents up to six times at varying points in the day), we expect our results to be consistent with those that would be obtained from surveys with higher response rates. Most of the literature on response rates focuses on population polls and not employer surveys; however, comparability of our survey results with an employer survey that asked a similar question and achieved a higher response rate further validates our results.31

Public and Private Policy Recommendations

There are a variety of pathways by which businesses could improve their engagement and impact around health, including action within individual businesses, action across businesses, and industry‐level action and regulation.

• 1.Social determinants of health. Centers for Disease Control and Prevention website. https://www.cdc.gov/socialdeterminants/. Published February 15, 2018. Accessed April 16, 2018.
• 2.Brewster AL, Kunkel S, Straker J, Curry LA. Cross‐sectoral partnerships by area agencies on aging: associations with health care use and spending. Health Aff (Millwood). 2018;37(1):15‐21. 10.1377/hlthaff.2017.1346. [DOI] [PubMed] [Google Scholar]
• 3.McCullough JM, Leider JP.Government spending in health and nonhealth sectors associated with improvement in county health rankings. Health Aff (Millwood). 2016;35(11):2037‐2043. 10.1377/hlthaff.2016.0708. [DOI] [PubMed] [Google Scholar]
• 4.Carroll A.A History of Corporate Social Responsibility: Concepts and Practices. Oxford Handbooks Online; 2008. 10.1093/oxfordhb/9780199211593.003.0002. [DOI]
• 5.Deloitte volunteer impact research: Measuring impact (Deloitte Volunteer IMPACT Survey). Deloitte. https://www2.deloitte.com/us/en/pages/about-deloitte/articles/citizenship-deloitte-volunteer-impact-research.html. Accessed July 27, 2018.
• 6.DJSI family index. Dow Jones Sustainability Indices. http://www.sustainability-indices.com/index-family-overview/djsi-family-overview/index.jsp#tab-2. Accessed April 16, 2018.
• 7.Koh HK, Singer SJ, Edmondson AC. Health as a way of doing business. JAMA. 2019;321(1):33‐34. 10.1001/jama.2018.18935. [DOI] [PubMed] [Google Scholar]
• 8.Porter ME, Kramer MR. Creating shared value. Harvard Business Review. January–February 2011. https://hbr.org/2011/01/the-big-idea-creating-shared-value. Accessed April 23, 2019.
• 9.The Sustainability Imperative. New York: Nielsen; 2015. https://www.nielsen.com/wp-content/uploads/sites/3/2019/04/Global20Sustainability20Report20DIGITAL20FINAL.pdf Accessed August 16, 2019. [Google Scholar]
• 10.Fink's Larry2018. Letter to CEOs. BlackRock website. https://www.blackrock.com/hk/en/insights/larry-fink-ceo-letter. Accessed April 17, 2018.
• 11.page Home. Certified B Corporation website. https://bcorporation.net/?_ga=2.42220833.587142445.1536952631-329618127.1536952631. Accessed September 14, 2018.
• 12.Quelch JA, Boudreau EC.Building a Culture of Health: A New Imperative for Business. New York: Springer; 2016. http://www.springer.com/us/book/9783319437224. Accessed January 18, 2019. [Google Scholar]
• 13.Abraham J, White KM.Tracking the changing landscape of corporate wellness companies. Health Aff (Millwood). 2017;36(2):222‐228. 10.1377/hlthaff.2016.1138. [DOI] [PubMed] [Google Scholar]
• 14.Foundation Kaiser Family. 2017. Employer Health Benefits Survey: Section 10: Plan Funding. Washington, DC: Kaiser Family Foundation; 2017. https://www.kff.org/report-section/ehbs-2017-section-10-plan-funding/. Accessed April 16, 2018. [Google Scholar]
• 15.Winston A.U.S. business leaders want to stay in the Paris Climate Accord. Harvard Business Review website. https://hbr.org/2017/05/u-s-business-leaders-want-to-stay-in-the-paris-climate-accord. Published May 31, 2017. Accessed April 16, 2018.
• 16.HERO scorecard. Health Enrichment Research Organization website. https://hero-health.org/hero-scorecard/. Accessed July 27, 2018.
• 17.Learn more about our company. Dun & Bradstreet website. http://www.dnb.com/about-us.html. Accessed June 8, 2018.
• 18.SIC division structure. Occupational Safety and Health Administration website. https://www.osha.gov/pls/imis/sic_manual.html. Accessed January 18, 2019.
• 19.Firm size data. US Small Business Administration website. https://www.sba.gov/advocacy/firm-size-data. Accessed January 18, 2019.
• 20.Table of size standards. US Small Business Administration website. https://www.sba.gov/document/support-table-size-standards. Accessed January 18, 2019.
• 21.Deville J‐C, Särndal C‐E.Calibration estimators in survey sampling. J Am Stat Assoc. 1992;87(418):376‐382. 10.1080/01621459.1992.10475217. [DOI] [Google Scholar]
• 22.Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys. Lenexa, KS: American Association for Public Opinion Research; 2016. [Google Scholar]
• 23.Keeter S, Hatley N, Kennedy C, Arnold L. What low response rates mean for telephone surveys. Pew Research Center Methodshttp://www.pewresearch.org/methods/2017/05/15/what-low-response-rates-mean-for-telephone-surveys/. Published May 15, 2017. Accessed January 18, 2019.
• 24.AAPOR Task Force. The Future of U.S. General Population Telephone Survey Research. Lenexa, KS: American Association for Public Opinion Research; 2017. https://www.aapor.org/Education-Resources/Reports/The-Future-Of-U-S-General-Population-Telephone-Sur.aspx?utm_source=link_newsv9&utm_campaign=item_225143&utm_medium=copy. Accessed January 18, 2019. [Google Scholar]
• 25.Clark B.Anchor Institutions: The Economic Benefits of Putting Community First. Boston, MA: Federal Reserve Bank of Boston; 2017. https://www.bostonfed.org/publications/communities-and-banking/2017/spring/anchor-institutions-the-economic-benefits-of-putting-community-first.aspx. Accessed August 25, 2018. [Google Scholar]
• 26.Singer SJ, Vogus TJ. Reducing hospital errors: interventions that build safety culture. Annu Rev Public Health. 2013;34:373‐396. 10.1146/annurev-publhealth-031912-114439. [DOI] [PubMed] [Google Scholar]
• 27.Groves RM, Peytcheva E.The impact of nonresponse rates on nonresponse bias meta‐analysis. Public Opin Q. 2008;72(2):167‐189. 10.1093/poq/nfn011. [DOI] [Google Scholar]
• 28.Yeager DS, Krosnick JA, Chang L, etal. Comparing the accuracy of RDD telephone surveys and internet surveys conducted with probability and non‐probability samples. Public Opin Q. 2011;75(4):709‐747. 10.1093/poq/nfr020. [DOI] [Google Scholar]
• 29.Keeter S, Kennedy C, Dimock M, Best J, Craighill P. Gauging the impact of growing nonresponse on estimates from a national RDD telephone survey. Public Opin Q. 2006;70(5):759‐779. 10.1093/poq/nfl035. [DOI] [Google Scholar]
• 30.Kohut A, Keeter S, Doherty C, Dimock M, Christian L. Assessing the Representativeness of Public Opinion Surveys. Washington, DC: The Pew Research Center for The People and The Press; 2012. https://www.pewresearch.org/wp-content/uploads/sites/4/legacy-pdf/Assessing-the-Representativeness-of-Public-Opinion-Surveys.pdf. Accessed August 20, 2019. [Google Scholar]
• 31.2018 Employer Health Benefits Survey: Section 12: Health and Wellness Programs. Washington, DC: Kaiser Family Foundation; 2018. https://www.kff.org/report-section/2018-employer-health-benefits-survey-section-12-health-and-wellness-programs/. Accessed March 4, 2019. [Google Scholar]
• 32.Chandra A, Miller CE, Acosta JD, Weilant S, Trujillo M, Plough A. Drivers of health as a shared value: mindset, expectations, sense of community, and civic engagement. Health Aff (Millwood). 2016;35(11):1959‐1963. 10.1377/hlthaff.2016.0603. [DOI] [PubMed] [Google Scholar]
• 33.Rosen A.Deval Patrick revels in role developing Bain's social impact fund. Boston Globe. July 17, 2017. https://www.bostonglobe.com/business/2017/07/17/patrick-revels-role-developing-new-social-impact-bain-fund/hWtzrhYvIBPWVPL0UGKBqM/story.html. Accessed July 20, 2018.
• 34.James J. Health policy brief: nonprofit hospitals’ community benefit requirements. Health Affairs. February 25, 2016. https://www.healthaffairs.org/do/10.1377/hpb20160225.954803/full/. Accessed July 20, 2018.

Supplementary Materials