Executive Summary Correction

  

Please help me to Correction my Executive Summary Draft, Refer to the sample I provided!
Here are comments to guide my revision of the report:
1. Use a running header that consists of a shortened version of the report title; please see the example Executive Summary. 2. Include a blank line between paragraphs. 3. Delete findings and background material from the first paragraph. 4. Focus on presenting only major findings of strategies for increasing workplace mindfulness; delete other details that can be read in the report. The summary is a synopsis or abstract. 4. Explain how you located the report sources in the second paragraph. ( Professors provide two resources, and one is from the university online library)
using this exampel:
On January 27, 2020, Dr. XXXXXXXX, Professor of Management at XXXXXX University, Los Angeles, authorized a study to look at strategies for managing workplace stress and increasing wellbeing.
Secondary data for the study was gathered from online databases and the Internet.
Findings show that workplace stress can have a negative impact not only on work performance but also on overall health. The following shows what strategies can be implemented into daily life to lessen the effects of workplace stress:
1. Foster personal relationships by spending more time with family, friends, or significant others.
2. Participate in preferred physical activities often.
3. Participate in enjoyable leisure activities.
4. Establish boundaries by separating work life and home life.
5. Seek support from mental health professionals or contact a supervisor who can create a better work environment.
It is concluded that these are all viable options to consider when looking for ways to destress and improve mental and physical health. For greater overall wellbeing, it is recommended that these steps be taken to manage the challenges of workplace pressures.
.Three resources are:
1. Being Intentional About Workplace Mindfulness Programs(attached)
2. Promoting Sustainability: The Effects of Workplace Mindfulness Training (attached)
3. A Workplace Mindfulness Intervention May Be Associated With Improved Psychological Well-Being and Productivity. A Preliminary Field Study in a Company Setting ( https://www.frontiersin.org/articles/10.3389/fpsyg.2018.00195/full )
EXECUTIVE SUMMARY

Which Strategies are Most Effective

Don't use plagiarized sources. Get Your Custom Essay on
Executive Summary Correction
Just from $13/Page
Order Essay

for

Increasing Workplace Mindfulness?

Prepared for

Dr. XXXXXXXX
XXXXXXXXX University, Los Angeles

Prepared by

XXXXXXXX
In Partial Fulfillment of the Requirements

for BUS XXXXX
Section (30910)
XXXXXXX University, Los Angeles

March 18, 2022
To:

Dr. XXXXXXXXX
From:

XXXXXXXX
Date:

March,18,2022
Subject:
Completed Analytical Report Increasing Workplace Mindfulness Most Effective Strategies
Here is the report you requested on (January 30, 2022), Which Strategies are Most Effective or Increasing Workplace Mindfulness?
Data gathered from books, periodicals, and websites support the conclusion that present-moment awareness can be developed via both professional meditation and casual practice in daily life.
I am glad that this opportunity to write this report for you, Dr. XXXXXXXX. If I can answer any questions for you, please let me know.
Attachment

EXECUTIVE SUMMARY

The research problem in this article is the impact of workplace mindfulness training. Workplace mindfulness training is becoming increasingly popular, with the goal of increasing employees’ awareness of their state of mind and, as a result, their overall well-being. According to previous research, greater mindfulness is related to less stress and faster recovery after a stressful workday. Mindfulness is a state of non-judgmental, present-moment awareness that can be developed via both professional meditation and casual practice in daily life. Mindfulness encompasses a variety of components, including non-reaction, observation, conscious action, and articulating and non-judgmental experiences. Non-reaction, defined as the capacity to pull away from and be unaffected by stressful circumstances, is a critical component of employee welfare. The present study sought to investigate the impact of workplace mindfulness-based stress management training for manufacturing employees using quantitative and qualitative approaches.
The research study employed a quasi-experimental design and focus group interviews on data collection. In this quasi-experimental approach, pre-and post-measurements were taken between the Finnish forest industry workers. Before and following the instruction, participants filled out surveys (at Time 1 and Time 2). (Time 2). The 17 people who took the pre-and post-tests were included in the study. The study looked at the 17 people who took both the pre-and post-tests. These people are in the experimental group. Eleven of the people who worked in the industry were women, and they were all over the age of 43 and had worked there for about 16 years. SPPS 22 was used to do statistical analysis on the quantitative data. In order to assess the hypotheses, a two-way repeated test analysis of variance (ANOVA) was used. Focus group interviews were used to gather qualitative information about the training to capture the respondents’ perspectives, thoughts, and shared memories and gain a better comprehension of the training’s impacts.

The pre-post assessment results suggested that, compared to the control group, the mindfulness-based training team showed considerably more significant gains in mindfulness, positive feelings, and hope pathways following training. Additionally, the data from the interviews suggested that relaxation, innovation at work, the nature of social contacts, and sleep quality all had favorable benefits. Further, participants identified obstacles during the program, including inexperience, unusual and challenging mindfulness exercises, difficulty with house practices, low social support, as well as the demanding characteristics of the environment.
In conclusion, this study shows that mindfulness training can have a favorable impact on employee welfare, at least implicitly, by increasing employees’ awareness, pleasant emotions, a sense of hope, and their capacity to sleep and rest. These variables form a solid basis for employee well-being and productivity when taken together. According to research, positive emotions, such as joy and happiness, can moderate the influence of mindfulness on work engagement. Work engagement is defined as a good sense of well-being associated with one’s job characterized by vigor, devotion, and absorption. Moreover, optimistic and hopeful employees appear to be more capable of perceiving or experiencing workplace resources than work demands. When developing future workplace mindfulness workshops and solutions, the identified issues could be incorporated, for example, in selecting the training location and the mindfulness exercises to include in the initial and subsequent stages of training. Probably, stranger and more challenging practices ought to be added later, after participants have gained expertise and developed routines. EJBO Electronic Journal of Business Ethics and Organization Studies Vol. 23, No. 1 (2018)

20 http://ejbo.jyu.fi/

Promoting Sustainability: The Effects of
Workplace Mindfulness Training

Introduction

Mindfulness training is enjoying grow-
ing popularity in work life settings, with
the aim to increase employees mindful-
ness level and thereby their well-being.
Prior evidence suggests that higher
mindfulness is associated with reduced
stress (Ciesa and Serretti, 2009) and bet-
ter recovery from work (e.g. Hlsheger,
Land, Depenbrock, Fehrmann, Zijlstra
and Alberts, 2014). Mindfulness can be
defined as non-judgmental, moment-to-
moment awareness which can be culti-
vated through formal meditation and
informal practice in everyday life (e.g.
Kabat-Zinn, 2003). Trait mindfulness
refers to how mindful individual tend
to be and act in daily life. Mindfulness is
constituted of various facets, such as non-
reacting, observing, acting with aware-
ness, describing and non-judging experi-
ences. Of these, non-reacting, defined as
the ability to step back from and not be
overwhelmed by distressing experiences,
is an important contributor to employee
well-being (Malinowski and Lim, 2015).

Three broad streams of mindfulness
research exist. First, correlational and
cross-sectional research explores asso-
ciations between mindfulness levels and
other factors (e.g. Malinowski and Lim,
2015). Second, diverse intervention stud-
ies examine the effects of various types
of mindfulness training, while the third
stream consists of laboratory-based re-
search (c.f. Keng, Smoski and Robins,
2011). In this variety of methods used
to study the effects of mindfulness train-
ing, there seems to be a lack of studies
employing mixed methods. In addition,
participants in workplace mindfulness-
training interventions frequently have
been employees in the health care and
education sectors. Therefore, the aim of
the current study was to use quantitative
and qualitative methods to explore the
effects of workplace mindfulness-based
stress reduction (MBSR) training for
factory employees.

Mindfulness training

Previous research indicates that mind-
fulness training can lead to higher self-
reported mindfulness (e.g. Anderson,

Lau and Bishop, 2007), and a number of
studies have demonstrated that increases
in mindfulness levels mediate the effects
of mindfulness interventions on out-
comes, such as well-being (for a review,
see Keng, Smoski and Robins, 2011).
For instance, a structured, group-based
MBSR programme employed mindful-
ness meditation to develop enhanced
awareness of the moment-to-moment
experiences of perceptible mental pro-
cesses and thereby improve psychological
and physical well-being (e.g. Grossman,
Niemann, Schimidt and Walach, 2004).
In accordance of these findings, it was
proposed that:

Hypothesis 1: Compared with the par-
ticipants in the control group, the partic-
ipants in the mindfulness-based training
group will display increased mindfulness
after the training.

Mindfulness and emotions at work

In general, mindfulness seems to support
emotion regulation, for instance, reduc-
ing emotional reactivity (e.g. Arch and
Craske, 2010). Furthermore, mindful-
ness seems to stabilise attention in the
present and decrease mind wandering,
which has close links to negative affect
and negative mood. This link is espe-
cially strong when the mind wanders
to past topics which include negative
content (i.e. rumination). (Smallwood
and OConnor, 2011; Smallwood and
Schooler, 2015.) Therefore, if mind-
fulness training can increase focus on
the present moment and reduce mind
wandering, this training might decrease
negative emotions. In line with this spec-
ulation, a body of empirical evidence sug-
gests that MBSR training decreases the
emotions of fear, anger and worry (Rob-
ins, Keng, Ekblad and Brantley, 2012).
Mindfulness is associated not only with
diminished negativity but also enhanced
positive emotions. Overall, evidence from
correlational studies suggests that higher
mindfulness is associated with higher lev-
els of positive affect (Keng, Smoski and
Robins, 2011). For instance, Schutte and
Malouff (2011) reported an association
of mindfulness with higher positive affect
and lower negative affect, and in another
study, mindfulness training focused on

Jaana-Piia Mkiniemi
Kirsi Heikkil-Tammi

Abstract
Mindfulness training is enjoying
growing popularity in workplaces.
In the current study, the effects
of workplace mindfulness training
were evaluated using quantitative
and qualitative methods. The
studys novelty value arises from
the implementation of workplace
training among factory employees
and the mixed-methods approach to
evaluation. The quasi-experimental
design with training and control
groups included pre- and post-
measurements and four focus
group interviews. The results of
the pre-post-test indicated that,
compared with the participants in
the control group, the participants
in the mindfulness-based training
group displayed significantly greater
increases in mindfulness, positive
emotions and hope pathways
after training. The findings from
the focus group interviews also
indicated positive effects associated
with relaxation, creativity at work,
quality of social interactions and
quality of sleep. The participants
also perceived challenges in the
training, such as inexperience,
odd and difficult mindfulness
practices, difficulties with home
practice, a lack of social support
and the demanding features of the
environment. These results were
discussed in light of the added value
of the mixed-methods evaluation
approach.

Key Words: workplace mindfulness
training, mindfulness, positivity,
hope

EJBO Electronic Journal of Business Ethics and Organization Studies Vol. 23, No. 1 (2018)

21 http://ejbo.jyu.fi/

loving-kindness meditation was able to increase daily experi-
ences of positive emotions (Fredrickson, Cohn, Coffey, Pek and
Finkel, 2008). Based on these findings, it was hypothesised that:

Hypothesis 2: Compared with the participants in the control
group, the participants in the mindfulness-based training group
will show higher increases of positive affect (a) and greater de-
creases of negative affect (b).

Mindfulness and hope at work

Hope can be defined as the perceived capability to see path-
ways to desired goals and to motivate oneself through agency
thinking to use those pathways. The hope construct distin-
guishes between agency and pathway thinking, but hopeful-
ness requires both as they feed on each other (Snyder, 2002).
It has been proposed that, when individuals have mindfulness
and can step back from emotional reactivity, they experience
more hopeful attitudes (Malinowski and Lim, 2015). Accord-
ingly, an integrated mindfulness and hope-theory-based med-
itation-training intervention could increase participants hope
(Thorton, Cheavens, Heitzmann and Dorfman, 2014), and in
a mindfulness-based meditation-training intervention, the hope
of the training group increased significantly more than that of
the comparison group (Munoz, Hoppes, Hellman, Brunk,
Bragg and Cummins, 2016). In addition, higher trait mindful-
ness has been found to be associated with lower cynicism (Tay-
lor and Millear, 2016), which can be seen as a counterpoint to
hope. Basing on these findings, it was suggested that:

Hypothesis 3: Compared with the participants in the con-
trol group, the participants in the training group will display
increased hope in general (a) and increased agency (b) and path-
ways (c) in particular.

Mindfulness and social relations at work

Researchers have suggested that the participants in mindfulness
training relat[e] more mindfully to others and the ability to
be more present might result in better listening and focusing
on others needs (Bihari and Mullan, 2014),. Social interactions
at work can evoke many feelings, from irritation and anxiety
to joy. Mindfulness training suppresses automatic tendencies
to react to internal and external triggers, such as irritating per-
sons and uncomfortable topics of conservations. Consequently,
mindful people might be more able to respond to experiences
an intentional and skilful way, exhibiting less reactivity and
more tolerance in social interactions, for instance (c.f. Bihari
and Mullan, 2014). In a qualitative study of nurses experiences
of MBSR training, the participants explained that the training
helped them focus more on patients and listen more deeply at
work (Cohen-Katz, Wilev, Capuano, Baker, Deitrich and Sha-
piro, 2005). In another study, family therapist trainees reported
improved compassion and acceptance of others due to training
(McCollum and Gehart, 2010). Based on a review by Boelling-
haus, Jones and Hutton (2014), qualitative studies seem to give
more support than quantitative studies to the idea that mind-
fulness training improves other-focused concern. This differ-
ence suggests that different data collection methods can paint
divergent pictures of the benefits of mindfulness training in the
context of social relations. In addition, mindfulness also seems
to be linked to openness to new social relationships. For exam-
ple, one type of mindfulness meditation, loving-kindness medi-
tation, has been shown to increase feelings of social connection
and positivity towards novel individuals (Hutcherson, Seppl
and Gross, 2008). Together, these findings indicate that mind-

fulness training may affect the quality of social relations. Based
on these studies, it was hypothesised that:

Hypothesis 4: Compared with the participants in the control
group, the participants in the mindfulness-based training group
will show increased openness (a) and friendliness (b) to other
people at work.

Mindfulness and creativity at work

Mindfulness has been shown to be associated with creative
thinking. However, in a meta-analysis of 33 empirical corre-
lational and intervention studies, the effect sizes ranged from
small to medium. (Lebuda, Zabelina and Karwowski, 2016.)
The mindfulnesscreativity link likely exists as mindful atten-
tion to the present moment reduces the tendency to perform
habitual responses, and creative problem-solving often requires
openness to various new aspects which emerge in the present
situation. Similarly, empirical evidence suggests that even brief
mindfulness training can lead to better performance on insight
problems (a class of problems in which non-habitual respons-
es or intuition are key factors) (Ostafin and Kassman, 2012).
Mind wandering, which often decreases as mindfulness increas-
es, however, seems to be beneficial for creativity (Smallwood
and Schooler, 2015). Given that the general pattern of evidence
supports a positive link between mindfulness and creativity, it
was proposed that:

Hypothesis 5: Compared with the participants in the control
group, the participants in the mindfulness-based training group
will report higher increases of self-reported creativity at work.

Mindfulness and workability

Workability can be defined as employees ability to do their job
satisfactorily or how well and able they can do their job at pre-
sent and in the near future given their work demands, health
and mental resources. This concept can be divided into two di-
mensions: mental and physical workability (Ilmarinen, Tuomi
and Klockars, 1997). To the best of the authors knowledge, no
prior studies have measured the effects of mindfulness train-
ing on workability. However, one correlation study proposes
that mindfulness has an indirect effect on workability through
perceived quality of life (Vindholmen, Higaard, Spnes and
Seiler, 2014). Nevertheless, it can be assumed that constructs
such as burnout and work engagement are possible frames of
reference as they share features with the concept of workabil-
ity: all capture dimensions of employee well-being (c.f. Warr,
1990; Harju, Hakanen and Schaufeli, 2014). Generally, lower
self-reported mindfulness seems to be associated with ill-being
at work, such as higher burnout (e.g. Taylor and Millear, 2016),
whereas higher mindfulness seems to be related to well-being at
work, such as work engagement (e.g. Leroy, Anseel, Dimitrova
and Sels, 2013; Malinowski and Lim, 2015). For example, two
facets of mindfulness, non-judgmental attitudes and less reac-
tivity, have been shown to be associated with lower levels of
burnout, particularly lower emotional exhaustion and cynicism
(Taylor and Millear, 2016). In addition, mindfulness training
has been reported to be effective at reducing stress reduction
(Ciesa and Serretti, 2009) and supporting recovery from daily
work demands (e.g. Hlsheger et al., 2014), for instance, by im-
proving sleep quality and duration (e.g. Hlsheger, Feinholdt
and Nbold, 2015). Based on these findings, it was hypoth-
esised that:

Hypothesis 6: Compared with the participants in the control
group, the participants in the mindfulness-based training group

EJBO Electronic Journal of Business Ethics and Organization Studies Vol. 23, No. 1 (2018)

22 http://ejbo.jyu.fi/

will show increased physical (a) and mental (b) workability.

Methods

Intervention design
Before the training intervention, the researchers discussed
with management and other staff how to tailor the mindful-
ness training to meet the needs of the organisation and employ-
ees. In the discussion there was a concern that the scales and
measurements might be too difficult to complete as the topic
of the questionnaire was abstract and unfamiliar to many. Con-
sequently, there was we attempt to make the questionnaire as
easy to complete as possible. Some options on the scales were
harmonised, as described in detail in the measures section and
discussed in the limitation section. The management and com-
pany representative also made an input regarding the protocols
of the focus group; for instance, they helped to identify the most
suitable times for interviews and the most appropriate interview
duration for their employees.

The mindfulness training programme called InnoPresence
consisted of 10 sessions and an introductory session at which
information (e.g. procedure, risks) was given in oral and written
form to obtain informed consent following the principles of the
American Psychological Association (2010). The training was
held over approximately 10 months, with a break between the
spring and autumn sessions. Each training session lasted two
hours and took place in a large meeting room in the factory.
The first five sessions were intended to increase mindfulness
in general and were led by a certified MBSR teacher. These
sessions closely followed the principles and guidelines of the
MBSR programme, which aims to reduce stress and includes
specific exercises, such as mindfulness meditation, body scan
and gentle yoga (Kabat-Zinn, 1990; 2003). The participants
were also given a CD with recorded exercises to support mind-
fulness practice at home and were encouraged to informally
practice mindfulness at home or work (e.g. mindful lunch,
mindful conversation). The last five sessions were aimed at in-
creasing mindfulness at work and included short mindfulness
exercises and a variety of group exercisesalso art basedled
by an experienced facilitator. In these exercises, the participants
identified and shared moments in which they felt present and
mindful at work, as an example.

The training participants were blue- and white-collar work-
ers in a Finnish company in the forestry industry. Initially, 32
employees expressed willingness to participate, but only 25 ac-
tually started the training. The company representative selected
the participants and invited them to the introductory session
and training, but participation was voluntary. The average
number of participants at the training sessions was 17, ranging
from 11 to 25 per session.

Quantitative study

Participants
The quasi-experimental design consisted of pre- and post-
measurements among employees of a Finnish forest factory.
The participants completed a survey before (Time 1) and af-
ter the training intervention (Time 2). The analysis included
the 17 participants who completed both the pre- and post-test.
These participants form the experimental group. Eleven (64.7
per cent) were women, and they had an average age of 43 years
and had been at the company for approximately 16 years (SD =
8.2). None had previous mindfulness experience. About 65 per
cent had work which included some supervisory responsibilities

(e.g. factory foreman/woman).
A control group of 19 co-employees answered identical sur-

veys through an electronic answering system. The control group
(N =19) included fewer women and more managers: 52.6 per
cent were women (n=10), and about 84 per cent (n= 16) had
managerial duties. The participants in this group had an aver-
age age of 42 years (SD = 10.43) and had been with the com-
pany for 13.5 years (SD = 9.0). The training and control groups
had no significant differences in the initial mean values for the
main variables measured with independent samples t test.

Pre- and post-test measures
Mindfulness
Mindfulness was assessed with the one-dimensional, 14-item
Freiburg Mindfulness Scale (Walach, Buchheld, Buttenml-
ler, Kleinknecht and Schmidt, 2006). Its scale ranged from 1
(never) to 5 (always). Back translation was used to translate the
scale from English to Finnish.

Positive and negative emotions
Positive and negative emotions were measured with a slightly
modified version of the Short Form of the Positive and Nega-
tive Affect Schedule (PANAS; Thompson, 2007). The re-
spondents were asked to indicate how often they had experi-
enced certain feelings at work during the past week. The scale
ranged from 1 (never) to 5 (always) and included 10 feelings:
upset, hostile, alert, ashamed, inspired, nervous, determined, at-
tentive, afraid and active. Back translation was used.

Hope
The Trait Hope Scale (Sneider et al., 1991) was used to explore
the construct of hope. The scale used ranged from 1 (never) to 5
(always), and sub- and total scores were calculated. Back trans-
lation was used to translate the scale from English to Finnish.

Creativity
The Creativity at Work Scale was developed based on the em-
ployee creativity items (Tierney, Farmer and Graen, 1999).
The respondents were asked to indicate how often they acted in
certain ways at work. The scale included eight statements, such
as I demonstrate originality in my work, I like to produce new
ideas in doing my job and I generate novel but feasible work-
related ideas. The scale ranged from 1 (never) to 5 (always).

Social relations: connectivity and kindness at work
Connectivity was measured with the Connectivity at Work
Scale adapted from the longer High-Quality Relationship Scale
(Carmeli, Brueller and Dutton, 2009). The respondents were
asked to indicate how often they acted in certain ways at work.
The scale ranged from 1 (never) to 5 (always) and included four
items, such as I am open to listening to my co-workers new
ideas and I am open to diverse opinions, even if they come from
unconventional sources.

Friendliness in the workplace was measured with the modi-
fied Kindness at Work Scale developed by Perhoniemi and Ha-
kanen (2010). In practice, the respondents were asked to self-
evaluate, for instance, how often they were friendly to others
or tried to cheer up workmates. Four items were included on a
scale ranging from 1 (never) to 5 (always).

Workability
The Shortened Workability Index was used to measure the
respondents level of workability (Tuomi, Ilmarinen, Jahkola,
Katajarinne, and Tulkki 1998). The index had two questions:

EJBO Electronic Journal of Business Ethics and Organization Studies Vol. 23, No. 1 (2018)

23 http://ejbo.jyu.fi/

How do you rate your current workability regarding the physi-
cal demands of your work? How do you rate your current work-
ability regarding the mental demands of your work? The scale
ranged from 1 (very poor) to 5 (very good).

Quantitative analysis
The quantitative data were analysed with statistical methods
using SPPS 22. The hypotheses were tested with two-way
repeated measures analysis of variance (ANOVA) using time
(Time 1/pre-test vs. Time 2/post-test) by group (training
group vs. control group). Time was the within-subject factor,
while the group the between-subject factor. Finally, a paired
samples t-test was conducted to examine the within-group dif-
ferences between the two time points (see Table 1 p. 23).

Qualitative study

Focus group interviews
Qualitative data were collected through focus group interviews
to capture the participants views, opinions and shared experi-
ences of the training and to get a deeper understanding of the
effects of training. Four focus groups were organised. The first
author moderated all the interviews, and the research assistant
helped tape-record them. The interviews were organised in the
factorys meeting room and lasted approximately 50 minutes
each. All of the interviews were tape-recorded.

The key questions asked in the focus group interviews were:
1. Why did you decide to take this programme? 2. What moti-
vates you to continue with the programme? 3. What challenges
related to the training have you experienced? 4. Have you ob-
served any personal benefits from the programme? 5. How are
you practicing mindfulness outside the training? 6. What has
been your general experience of the training? In addition to
the key questions presented above, more specific questions were
asked in an attempt to elicit broader and more detailed answers.
The interview questions were devised on the basis of prior stud-
ies, for example, the study by Cohen-Katz et al. (2005), and on
observations during training. For instance, researchers noted
that some practices were more unpleasant than others, and this
presented an opportunity to obtain information about the chal-
lenges and possible negative experiences faced by employees.

Participants
The company representative invited potential participants to
the focus group interviews and helped with the practicalities
of the meetings. Also, anyone who had already dropped the
training was asked to participate. However, participation was
voluntary, and all of those who expressed willingness to par-
ticipate were admitted. Eighteen participants in the training
(experimental) group also took part in the four focus group
interviews. Two focus groups were held after the first five ses-
sions before the summer break, and the other two after all the
training was completed. The participants included 5 men and
13 women who worked in both office and factory settings. Two
participants dropped out during the first five training sessions.

Qualitative analysis
The interview data were transcribed verbatim and subjected to
inductive data-driven content analysis (Elo and Kyngs, 2008).
Two researchers independently read the interview transcripts
several times and coded the data. The two analyses were com-
pared, and any differences were discussed to reach mutual un-
derstanding. The analysis was carried out inductively so that
the themes emerged from the data. The same two researchers

analysed all four focus group interviews. Only the themes re-
lated to the perceived benefits and challenges of the training are
reported here.

Results

Quantitative study

Table 1 (p. 24) shows the alphas, means and standard devia-
tions for the training and control groups and the results of the
within-group t-tests.

Mindfulness
Two-way repeated measured ANOVA showed a significant
group x time interaction effect on self-reported mindfulness
(F(1,28) = 6.411, p = .02, n2 = .19). This result indicated that
the participants in the training group reported significantly
higher increases in mindfulness between the two time points
than the participants in the control group. Therefore, hypoth-
esis 1 was completely supported (Table 1).

Emotions
There was a significant group x time interaction effect on self-
reported positive emotions, (F(1,34) = 5.405, p = .03, n2 = .14),
indicating that the increase in positive emotions was significant-
ly higher in the training group than the control group. There
was no significant group x time interaction effect on negative
emotions (F(1,33) = .631, p = .43). Therefore, hypothesis 3a
was supported as positive emotions increased after the training,
as expected, and hypothesis 3b was rejected (Table 1).

Hope
There was a significant group x time interaction effect on self-
reported hope pathways (F (1, 32) = 5.347, p = .03, n2 = .14).
This indicated that, compared to the control group, the train-
ing group showed significant increases in hope pathway. There
was no significant group x time interaction effect on hope agen-
cy (F(1,34) = 3.601, p = .07) or on total hope (F(1,33) = 3.974,
p = .06). Therefore, hypothesis 2b was completely supported
(Table 1).

Social relations, creativity and workability
There was no significant group x time interaction effect on
the quality of social relations, namely, connectivity (F(1,34) =
1,154, p = .30) and friendliness (F(1,34) = .002, p = .97). There
was no significant group x time interaction effect on creativity
(F(1,34) = 2,501, p = .12), psychological workability (F(1,34) =
1.193, p = .28) or physical workability (F(1,34) = .035, p = .85).
Hypotheses 4a, 4b, 5 and 6 were rejected as the self-reported
quality of social relations, creativity and workability did not in-
crease significantly after the mindfulness training (Table 1).

Qualitative study

The key themes regarding the effects and benefits of the training
were the physical and emotional benefits, increased awareness,
quality of social interactions, creativity and increased accept-
ance. These themes are described in more detail in this section.

The physical and emotional changes were the most impor-
tant benefits described by all the participants. For instance, the
interviewees reported that their bodies felt more relaxed due to
the training. They were calmer, could keep their calm in dif-
ficult situations and could work with a good spirit. For the par-
ticipants who worked shifts, the practice gave them a tool to fall

EJBO Electronic Journal of Business Ethics and Organization Studies Vol. 23, No. 1 (2018)

24 http://ejbo.jyu.fi/

asleep. Several participants reported better sleeping in general,
and some blue-collar workers especially highlighted this bene-
fit. For instance, one participant stated: Well, in my opinion, it
is just therethat you know how to pay attention to relaxation.
It is that you are able to fall asleep when you can relax. Well,
yes, all in all, it has a big impact on overall well-being, that, in a
way, you know how to get yourself relaxed.

In the training, one of the main mindfulness practices was a
breathing exercise which taught how to stay present in breath-
ing. This practice seemed to help the participants stay present
and calm in difficult work situations. Also, the participants
felt that their stress tolerance increased. Factory-floor workers
did not panic in difficult and demanding situations. The par-
ticipants explained that, for example, when a machine broke
down, they had to deal with the situation quickly and remain
cool-headed. Some white-collar workers felt that their ability
to manage information load improved, as described in the fol-
lowing extract: Well, I have a bad habit of having lots of emails
open at the same time, and then I write a little bit on that and

on that. And then, I have tried to answer one of them, and then
that is done, and then next, so they are not all open at once.

The participants interviewed described increased awareness.
As the training progressed, the participants felt that they could
more easily notice when they were present in the moment.
They also described thinking more clearly and noticing some
things that they did not previously. At work, this meant, for
instance, that they noticed when they needed to take breaks
or calm down. Some changed their way of working. They de-
scribed working in a more focused way: I think, surely, I have
the samethat you can somehow pay attention to calming
down through breathing. That is the thing. It feels that, all to-
gether, everything goes at this point as hard as in the spring.
That is not the … the situation is what it is.

The training seems to have greatly varied effects on social
interactions. In general, the participants felt a growing com-
munality within the training group. They considered this to be
quite a remarkable change in the everyday work life in the fac-
tory. In the training groups, the blue- and white-collar workers,

Table 1. Mean scores, SDs, alphas for the study variables and results of within group t-tests

Training group Control group

M SD alpha t df p M SD alpha t df p
Mindfulness

Mindfulness pre 3.30 0.38 .88 3.34 0.55 .88
Mindfulness post 3.57 0.42 .90 -2.56 12 .025 3.30 0.51 .89 .53 16 .602

Emotions
Positive emotions pre 3.75 0.53 .84 3.77 0.55 .79
Positive emotions post 4.09 0.47 .79 -2.88 16 .011 3.74 0.54 .82 .29 18 .774
Negative emotions pre 2.08 0.40 .50 2.18 0.74 .78
Negative emotion post 1.98 0.48 .72 .89 16 .387 2.23 0.70 .77 -.34 17 .736

Social relations
Connectivity pre 4.12 0.57 .83 4.18 0.63 .89
Connectivity post 4.31 0.58 .89 -1.50 16 .154 4.20 0.57 .76 -.12 18 .904
Friendliness pre 4.32 0.48 .76 4.22 0.61 .78
Friendliness post 4.40 0.55 .89 -.70 16 .492 4.30 0.63 .81 -.92 18 .369

Hope
Hope agency pre 3.74 0.51 .54 3.53 0.64 .82
Hope agency post 3.90 0.41 .64 -1.32 16 .207 3.39 0.60 .82 1.37 18 .189
Hope pathway pre 3.35 0.39 .63 3.46 0.49 .60
Hope pathway post 3.51 0.53 .75 -1.40 16 .180 3.39 0.60 .82 1.00 17 .331
Hope total pre 3.54 0.38 .69 3.47 0.51 .84
Hope total post 3.71 0.42 .81 -1.49 .158 3.38 0.53 .85 1.35 17 .195

Creativity
Creativity pre 2.92 0.40 .84 2.95 0.61 .90
Creativity post 3.18 0.58 .90 -2.12 16 .050 2.95 0.59 .89 .06 18 .955

Workability
Physical workability pre 4.29 0.47 3.95 1.03
Physical workability post 4.35 0.49 -.44 16 .668 4.05 0.71 -.52 18 .607
Psychological workability pre 4.06 0.66 4.00 0.67
Psychological workability post 4.24 0.56 -1.00 16 .332 3.95 0.78 .44 18 .667

Table 1. Mean Scores, SDs, alphas for the study variables and results within the group t-tests

EJBO Electronic Journal of Business Ethics and Organization Studies Vol. 23, No. 1 (2018)

25 http://ejbo.jyu.fi/

even some supervisors, could talk to each other and exchange
ideas as equals. One participant stressed that it has brought,
kind of communality here, too, [that] is beneficial. When there
are different people like in the factory, like in this group, then
you get to know new people. Many participants also described
situations in which they used more mindful conversation styles.
They told that they had started to listen to each other and had
become more aware of their own ways of talking and listening.
One participant described this: I have paid attention to, lets
say, someone who says really something important. In a way,
you look at his/her facial expressions, and sometimes you wake
up, and you listen actively.

The participants also cited benefits related to creativity. They
reported that some new ideas emerged from group work dealing
with the innovation processes in the factory. For instance, one
participant explained how the training helped her think of ideas
and break habitual work routines: Of course, yes, [at work, this
could be useful for getting new ideas]. You are just there and
think about everything, and you are present in what you do. It
would take much more when you are somewhere else. You just
do your work routine and think of something else.

Increased acceptance meant that the participants could let go
of things more easily. In difficult situations, they could more
clearly see and understand what was happening and accept it
more easily, which seemed to help them move on. A female
participant, for instance, felt that, due to the training, she was
more able to accept and cope with a difficult situation in her
personal life, so it did not disturb her work as much: Well, lets
say, for me, it was kind of, of course … lets say, at the mental
level, this period in my private life was a heavy spring. In a
way, this I could let go a little bit in between. I have after-
wards thought that, if I had had this, it would have been much
heavier.

The analysis showed the different work groups in the first
(spring) and second (autumn) set of focus group discussions
had somewhat different emphases. In the first set of interviews,
the white-collar workers highlighted the importance of com-
munality in the training group. For blue-collar workers, the
most important changes were improved relaxation and sleep
habits, which aided in recovery from work. In autumn (the sec-
ond phase), the white-collar workers highlighted the change in
chaos management and handling information load, while the
blue-collar workers emphasised inventing new ideas and think-
ing clearly.

Challenges in training
In the focus group discussions, the participants also reported
challenges which can be assumed to have influenced how much
they benefited from the training, as briefly discussed here. The
challenges concerned difficulties with home practice, a lack of
social support, odd and difficult mindfulness practices, features
of the environment and a lack of experience in mindfulness
training.

Some participants found it difficult to practice at home be-
tween the training sessions. The primary reasons were difficul-
ties finding time and place at home amid their families. In ad-
dition, some participants confessed that they were too lazy to
practice at home: It is just that laziness. You cannot find that
place and time for it.

A lack of social support seemed to be a challenge for some
participants. Support from others in the factory would have in-
creased their commitment to the training, according to some
participants. Some interviewees reported that their co-workers,
mostly men, who did not belong to the training group called

the practices odd or even ridiculous. One male participant de-
scribed a specific instance in which social support was lacking:
What I heard in the smoking area was, Oh, you are part of
that mattress club, too. Several participants did not complete
the training, which affected negatively the climate of the train-
ing group.

Also, the participants considered some mindfulness practices
to be odd or difficult and were not motivated to do them. These
practices included compassion meditation, yoga, eating, and
talking about their experiences in the group, as the following
extract indicates: Everything was OK, but that walking medi-
tation and that kindness meditationthey were a bit that
walking meditation was really funny.

The environment also presented challenges. The physical
space where the sessions were held was considered to be un-
comfortable, especially at the beginning of training. The floor
was cold and drafty, and the noise of machines disturbed the
practice. A female participant, for example, stressed that con-
centrating in such a noisy environment was challenging: At
least, I couldnt cut out that noise there. However, later in the
autumn, these challenges no longer seemed to bother the partic-
ipants. The practice had become easiernot as challenging any
moreand the disturbances did not affect the participants in
the same way. Even lying on the floor was considered to be nice.
For instance, a female participant explained that a kind of train-
ing routine developed, and mindfulness training came more eas-
ily: Oh, yes, a certain kind of a routine. It was much easier when
you knew what you were doing with that pillow and blanket. It
was fun to lie down. You really looked forward to it.

Discussion

The present study was designed to investigate the effectiveness
of a tailored MBRS-based training intervention at a Finnish
forestry industry company. In addition to conventional pre-
post questionnaires, focus group interviews captured the expe-
riences of the perceived benefits. Thus, the novelty of this study
lies in the implementation of the workplace training among fac-
tory employees and the mixed-methods approach to evaluating
of the effectiveness of the training.

Based on existing empirical evidence, it was hypothesised
that, compared with the participants in the control group, the
participants in the mindfulness-based training group would
show higher increases in mindfulness (H1) and positive af-
fect (H2a) and greater decreases in negative affect (H2b). The
training group was also expected to display higher increases in
hope (H3a), hope agency (H3b) and hope pathways (H3c). Fi-
nally, it was proposed that the training group would experience
higher increases in openness (H4a) and friendliness (H4b) to-
wards co-workers and in self-reported creativity at work (H5)
and physical (H6a) and psychical (H6b) workability.

In general, the results revealed that the training intervention
was effective at increasing the mean scores for the all measured
variables in training group (Table 1.). Unexpectedly, not all the
changes in the mean scores were statistically significant, and
the results of the two-way repeated measures ANOVA sup-
ported only three hypotheses. As hypothesised, mindfulness
levels (H1), positive emotions (H2) and hope pathways (H3c)
increased significantly in the training group compared to the
control group. As expected, the control group reported no sig-
nificant changes. Overall, these findings are in line with existing
evidence suggesting that mindfulness-based training increases
mindfulness levels, positive emotions in general and hope spe-
cifically (e.g. Anderson et al., 2007; Robins et al., 2012; Keng et

EJBO Electronic Journal of Business Ethics and Organization Studies Vol. 23, No. 1 (2018)

26 http://ejbo.jyu.fi/

al., 2011; Munoz et al. 2016; Schutte and Malouff, 2001; Fre-
drickson et at., 2008).

Unexpectedly, based on the pre-post-test measures, the self-
reported quality of social relations, creativity at work and work-
ability did not increase significantly, so hypotheses 4a, 4b, 5 and
6 were rejected. The discrepancies between the current and pre-
vious findings likely arise from the use of non-identical scales in
studies. For instance, mindfulness and creativity are measured
with multiple scales. More specifically, the self-reported crea-
tivity scales used in the current study clearly differ from those
used to study the ability to resolve insight problems or to gener-
ate ideas as indicators of creativity (c.f. Ostafin and Kassman,
2012).

The reported challenges during the training also offer expla-
nations for the results and the absence of some expected effects.
Based on the focus group interviews, the key challenges were
difficulties with home practice, the perceived lack of social sup-
port, odd and difficult mindfulness practices, certain features of
the environment and lack of experience of mindfulness train-
ing. When planning future workplace mindfulness trainings
and interventions, these issues could be taken into account, for
instance, in the selection of the training space and which mind-
fulness practices to present in earlier and later in training. Most
likely, odder and more difficult practices should be introduced
later when the participants have more experience and estab-
lished routines.

However, it is worth noting that the qualitative focus group
interviews indicated benefits related to creativity, workability
and quality of social relations. For instance, the pre- and post-
measurements did not indicate significant increases in creativ-
ity levels, but the qualitative data suggested that the partici-
pants experienced heightened creativity. The participants, for
instance, reported that the training gave them new ideas and
enabled them to break habitual patterns of thought. These
findings support the notion that mindfulness can decrease ha-
bitual thinking, thereby increasing creativity (c.f. Ostafin and
Kassman, 2012). In addition, the pre-and post-tests did not
indicate statistically significant improvements in the quality
of social interactions, but the participants in the focus groups
spontaneously reported experiences related to improved qual-
ity of social interactions, such as a feeling of community and
increased ability to focus on and listen to others. These results
are in line with the claim of Boellinhaus et al. (2014) that quali-
tative studies offer stronger support than quantitative research
that mindfulness increases other-focused concern, which is a
necessary for constructive social interactions. Thus, the results
of the quantitative and qualitative analysis were not identical.
Possible explanations include that not all the participants who
answered the survey were interviewed, and qualitative measures
might simply be more sensitive than quantitative measures (c.f.
Boellinhaus et al., 2014).

However, some quantitative and qualitative results were also
well in line. For instance, based on the pre-post-test, levels of
mindfulness improved significantly due to the training, and
the participants in the qualitative interviews reported improve-
ments to their level of awareness and their ability to be present
in the present moment. In addition, the focus groups interviews
pointed to some benefits not measured in the pre-post-test. For
instance, the questionnaires included no questions about the
relaxation of the physical body or the quality of sleep, but the
interviewees considered these to be important benefits of the
training. These findings accord with existing evidence suggest-
ing that mindfulness is associated with sleep quality and recov-
ery from work (e.g. Hlsheger et al., 2014; 2015). Likely, the

discrepancies arose as the topics and options in the tests were
pre-selected and presented to the respondents, but in the focus
group discussions, the participants were free to raise any ben-
efits or other issues they felt were relevant. Similarly, a system-
atic review of the effects of mindfulness-based interventions on
nurses and nursing students found that qualitative and uncon-
trolled studies cited benefits, such as internal calmness, better
communication and clearer analysis of difficult situations, only
rarely taken into account in randomised controlled trials (Guil-
laumie, Boiral and Champagne, 2016).

Furthermore, based on the current results, a key strength of
a qualitative approach is that it can point to issues, such as ben-
efits and challenges, especially relevant for a particular group
of employees due to the type of work they do. For instance,
some participants did physical shift work, which likely explains
why they highlighted in the interviews that the training enabled
them to relax physically and sleep better. Those doing office
work, in contrast, emphasised benefits associated with better
managing intensive knowledge work and multitasking. There-
fore, it appears that qualitative research might be able to better
inform interventions about occupation- or work-specific factors
and relevant indicators (e.g. quality of sleep, ability to manage
knowledge work) and to take into account communities unique
characteristics in planning interventions. Overall, these results
support the view that qualitative data can complement quan-
titative data (c.f. Molina-Azorin, Bergh, Corley and Ketchen,
2017) and thus suggest that integrating or mixing methods can
create synergy and help better understand the benefits and chal-
lenges of mindfulness training in work life settings.

Although this study provides evidence suggesting that mind-
fulness training can increase mindfulness levels, positive emo-
tions and hope based on the pre-post-test and the participants
experiences of various benefits mentioned in the focus group
discussions, the conclusions must be tempered by the poten-
tial limitations of the study. First, the study design resulted in
small training and control groups. The factory where the train-
ing was held was also quite small, and more than 10 per cent
of all employees were included in either the training or control
group. During the design of the current study, the authors were
not aware of any mindfulness studies on factory employees, so
the training and intervention were designed and planned in
close co-operation with the factory management and human
resource staff to ensure the environmental fit of the procedures.
Doing so was considered to be important as it is well known
that organisational interventions often fail due not to the con-
tent of their design but to contextual and process factors (c.f.
Biron, Karanika-Murray and Cooper, 2012). Therefore, based
on management and staff feedback, some questionnaire scales
were homogenised to ensure the respondents ability to answer
fluently. Thus, the scales used are not totally identical with the
original ones, which should be taken into account when com-
paring results between studies.

As well, for practical reasons, follow-up-tests were not con-
ducted, so the current data do not provide information about
the long-term effects. Additionally, some scales used in the cur-
rent study could be applied differently in future studies. For
instance, creativity and the quality of social relations could be
measured through co-workers evaluations, instead of or in ad-
dition to self-reported. Further, although the atmosphere of the
focus group discussions was free and positive, that they were
organised at the workplace most likely influenced how they
proceeded. Experiences of mindfulness practices can be quite
personal and not appropriate for sharing at work. Therefore,
participants likely more discussed their experiences related to

EJBO Electronic Journal of Business Ethics and Organization Studies Vol. 23, No. 1 (2018)

27 http://ejbo.jyu.fi/

work than their personal experiences (c.f. Cohen-Katz et al.
2005). Also, social desirability bias might have appeared, espe-
cially during the focus group interviews. In practice, this means
that participants may have discussed matters and answered
questions intentionally in a manner that would be viewed fa-
vorably by other participants and/or by researchers.

At a more general level, it is important to note that mindful-
ness training in a workplace setting may have specific pitfalls
and limitations. First, some may experience unpleasant feelings
or discomfort during the formal training exercises, especially if
they have a past history of trauma (Creswell, 2017). Second, not
everyone is willing to express, deal with or discuss these feelings
in a workplace setting. Therefore, training may in some cases
threaten employees privacy, especially if they have no aware-
ness before the training of potential consequences that may
cause them discomfort. On the other hand, it is widely accepted
that employee well-being depends on multiple factors, such as
individual factors (e.g., level of mindfulness), work-related fac-
tors (e.g., workload), organisational factors (e.g., the organisa-
tions culture) and management (e.g., leadership styles). Thus,
in stressful work situations, demanding factors should be iden-
tified and modified accordingly. Mindfulness training should
not be used as the only way of coping with stress, especially in
cases where the stress is clearly a result of factors other than

individual ones, for example, an overly heavy workload, a low
level of autonomy or destructive leadership.

Overall, this study suggests that mindfulness training can
support, at least indirectly, employee well-being as employees
mindfulness, positive emotions and hopefulness increased sig-
nificantly, and they reported benefits related to the quality of
sleep and ability to relax. Together, these factors lay a strong
foundation for employee well-being. For instance, positive
emotions have been shown to mediate the effect of mindfulness
on work engagement, which is a positive work-related state of
well-being characterised by vigour, dedication and absorption
(Malinowski and Lim, 2015). Furthermore, positive, hopeful
employees seem to be more able to perceive or experience job re-
sources than job demands. Job resources are factors which help
employees to achieve work-related goals, reduce physiological
and psychological costs and stimulate personal growth and de-
velopment (Xanthopoulou, Bakker, Demerouti and Schaufeli,
2007). Finally, the abilities to relax and sleep well are important
contributors to recovery from work (c.f. Hlsheger et al., 2015).

Note: The authors would like to thank Business Finland (former The Finnish
Funding Agency for Technology and Innovation) for financial support
(Project name: HYVE 2020: Ty, yhteis ja kestv talous). We also
thank Anna-Liisa Liski, Laura Bordi and Jenni Heinonen for assistance.

References

American Psychological Association (2010). Informed Consent to
Research. Ethical Principles of Psychologists and Code of Conduct.
Available http://www.apa.org/ethics/code/.

Anderson, N.D., Lau, M.A., Segal, Z.V. and Bishop, S.R. (2007),
Mindfulness-Based Stress Reduction and Attentional Control,
Clinical Psychology and Psychotherapy, Vol. 14 No. 6, pp. 449-463.

Arch, J.J. and Craske, M.G. (2010), Laboratory Stressors in Clinically
Anxious and Non-Anxious Individuals: The Moderating Role of
Mindfulness, Behaviour Research and Therapy, Vol. 48 No. 6, pp.
495505.

Bihari, J.L. and Mullan, E.G. (2014), Relating Mindfully: A Qualitative
Exploration of Changes in Relationships through Mindfulness-
Based Cognitive Therapy, Mindfulness, Vol. 5 No. 1, pp. 4659.

Biron, C., Karanika-Murray, M. and Cooper, C.L. (2012),
Organizational Interventions for Stress and Well-BeingAn
Overview, In Improving Organizational Interventions for Stress
and Well-Being. Addressing Process and Context. Routledge,
Hove.

Boellinghaus, I., Jones, F.W. and Hutton, J. (2014), The Role of
Mindfulness and Loving-Kindness Meditation in Cultivating
Self-compassion and Other-Focused Concern in Health Care
Professionals, Mindfulness, Vol. 5 No. 2, pp. 129138.

Carmeli, A., Brueller, D. and Dutton, J.E. (2009), Learning Behaviours
in the Workplace: The Role of High-Quality Interpersonal
Relationships and Psychological Safety, Systems Research and
Behavioral Science, Vol. 26 No. 1, pp. 8198.

Chiesa, A. and Serretti, A. (2009), Mindfulness-based Stress
Reduction for Stress Management in Healthy People: A Review
and Meta-Analysis, Journal of Alternative and Complementary
Medicine, Vol. 15 No. 5, pp. 593600.

Cohen-Katz, J., Wiley, S.D., Capuano, T., Baker, D. M. and Shapiro,
S. (2005), The Effects of Mindfulness-Based Stress Reduction o
Nurse Stress and Burnout, Part II: A Quantitative and Qualitative
Study, Holistic Nursing Practice, Vol. 19 No. 1, pp. 2635.

Creswell, J. D. (2017),Mindfulness Interventions, Annual Review of
Psychology, Vol. 68 No. 1, pp. 491516.

Elo, S. and Kyngs, H. (2008), The Qualitative Content Analysis
Process, Journal of Advanced Nursing, Vol. 62 No. 1, pp. 107
115.

Fredrickson, B.L., Cohn, M.A., Coffey, K.A., Pek, J. and Finkel, S.M.
(2008), Open Hearts Build Lives: Positive Emotions, Induced
through Loving-Kindness Meditation, Build Consequential
Personal Resources, Journal of Personality and Social Psychology,
Vol. 95 No. 5, pp. 1045-1062.

Grossman, P., Niemann, L., Schmidt, S. and Walach, H. (2004),
Mindfulness-Based Stress Reduction and Health Benefits: A Meta-
Analysis, Journal of Psychosomatic Research, Vol. 57 No. 1, pp.
3543.

Harju, L., Hakanen, J. J. and Schaufeli, W.B. (2014), Job Boredom and
Its Correlates in 87 Finnish Organizations, Journal of Occupational
and Environmental Medicine, Vol. 56 No. 9, pp. 911918.

Hutcherson, C.A., Seppala, E.M. and Gross, J.J. (2008), Loving-
Kindness Meditation Increases Social Connectedness, Emotion,
Vol. 8 No. 5, pp. 720-724.

Hlsheger, U.R., Feinholdt, A. and Nbold, A. (2015), A LowDose
Mindfulness Intervention and Recovery from Work: Effects on
Psychological Detachment, Sleep Quality, and Sleep Duration,
Journal of Occupational and Organizational Psychology, Vol. 88
No. 3, pp. 464489.

Hlsheger, U.R., Lang, J.W., Depenbrock, F., Fehrmann, C., Zijlstra,
F.R. and Alberts, H.J. (2014), The Power of Presence: The Role of
Mindfulness at Work for Daily Levels and Change Trajectories of
Psychological Detachment and Sleep Quality, Journal of Applied
Psychology, Vol. 99 No. 6, pp. 1113-1128.

Ilmarinen, J., Tuomi, K. and Klockars, M. (1997), Changes in
the Workability of Active Employees over an 11-year Period,
Scandinavian Journal of Work, Environment and Health, Supple.
1, pp. 4957.

EJBO Electronic Journal of Business Ethics and Organization Studies Vol. 23, No. 1 (2018)

28 http://ejbo.jyu.fi/

Kabat-Zinn, J. (1990), Full Catastrophe Living: The Programme of the
Stress Reduction Clinic at the University of Massachusetts Medical
Center. Delacorte Press, New York, N.Y.

Kabat-Zinn, J. (2003), Mindfulness-Based Interventions in Context:
Past, Present, and Future, Clinical Psychology: Science and
Practice, Vol. 10 No. 2, pp. 144156.

Keng, S.L., Smoski, M.J. and Robins, C.J. (2011), Effects of
Mindfulness on Psychological Health: A Review of Empirical
Studies, Clinical Psychology Review, Vol. 31 No. 6, pp. 1041
1056.

Keng, S.L., Smoski, M.J., Robins, C.J., Ekblad, A.G. and Brantley,
J.G. (2012), Mechanisms of Change in Mindfulness-Based Stress
Reduction: Self-Compassion and Mindfulness as Mediators of
Intervention Outcomes, Journal of Cognitive Psychotherapy, Vol.
26 No. 3, pp. 270280.

Lebuda, I., Zabelina, D.L. and Karwowski, M. (2016), Mind Full
of Ideas: A Meta-Analysis of the MindfulnessCreativity Link,
Personality and Individual Differences, Vol. 93, pp. 2226.

Leroy, H., Anseel, F., Dimitrova, N.G. and Sels, L. (2013),
Mindfulness, Authentic Functioning, and Work Engagement: A
Growth Modeling Approach, Journal of Vocational Behavior, Vol.
82 No. 3, pp. 238247.

Malinowski, P. and Lim, H.J. (2015), Mindfulness at Work: Positive
Affect, Hope, and Optimism Mediate the Relationship between
Dispositional Mindfulness, Work Engagement, and Well-Being,
Mindfulness, Vol. 6 No. 6, pp. 12501262.

McCollum, E.E. and Gehart, D.R. (2010), Using Mindfulness
Meditation to Teach Beginning Therapists Therapeutic Presence:
A Qualitative Study, Journal of Marital and Family Therapy, Vol.
36 No. 3, pp. 347360.

Molina-Azorin, J.F., Bergh, D.D., Corley, K.G. and Ketchen Jr, D.J.
(2017), Mixed Methods in the Organizational Sciences: Taking
Stock and Moving Forward, Organizational Research Methods.
Vol. 20, No. 2, pp. 179192.

Munoz, R.T., Hoppes, S., Hellman, C.M., Brunk, K.L., Bragg, J.E.
and Cummins, C. (2016), The Effects of Mindfulness Meditation
on Hope and Stress, Research on Social Work Practice.
October-27-2016.

Ostafin, B.D. and Kassman, K.T. (2012), Stepping out of History:
Mindfulness Improves Insight Problem Solving, Consciousness
and Cognition, Vol. 21 No. 2, pp. 10311036.

Perhoniemi, R. and Hakanen, J. (2010), A New Measure of Kindness
at Work, 4th International Seminar of Positive Occupational
Health Psychology, Lisbon, 31 May 1 June 6 2010.

Schutte, N.S. and Malouff, J.M. (2011), Emotional Intelligence
Mediates the Relationship between Mindfulness and Subjective
Well-Being, Personality and Individual Differences, Vol. 50 No. 7,

pp. 11161119.
Smallwood, J. and OConnor, R.C. (2011), Imprisoned by the

Past: Unhappy Moods Lead to a Retrospective Bias to Mind
Wandering, Cognition and Emotion, Vol. 25 No. 8, pp. 1481
1490.

Smallwood, J. and Schooler, J.W. (2015), The Science of Mind
Wandering: Empirically Navigating the Stream of Consciousness,
Annual Review of Psychology, Vol. 66, pp. 487518.

Snyder, C.R. (2002), Hope Theory: Rainbows in the Mind,
Psychological Inquiry, Vol. 13 No. 4, pp. 249275.

Snyder, C.R., Harris, C., Anderson, J.R., Holleran, S.A., Irving, L.M.,
Sigmon, S.T..(1991), The Will and the Ways: Development and
Validation of an Individual-Differences Measure of Hope, Journal
of Personality and Social Psychology, Vol. 60, No. 4, pp. 570585.

Taylor, N.Z. and Millear, P.M.R. (2016), The Contribution of
Mindfulness to Predicting Burnout in the Workplace, Personality
and Individual Differences, Vol. 89, pp. 123128.

Thompson, E.R. (2007), Development and Validation of an
Internationally Reliable Short Form of the Positive and Negative
Affect Schedule (PANAS), Journal of Cross-cultural Psychology,
Vol. 38 No. 2, pp. 227242.

Thornton, L.M., Cheavens, J.S., Heitzmann, C.A., Dorfman, C.S.,
Wu, S.M. and Andersen, B.L. (2014), Test of Mindfulness and
Hope Components in a Psychological Intervention for Women
with Cancer Recurrence, Journal of Consulting and Clinical
Psychology, Vol. 82 No. 6, pp. 1087-1100.

Tierney, P., Farmer, S. M., and Graen, G. B. (1999), An examination
of leadership and employee creativity: The relevance of traits and
relationships. Personnel Psychology, Vol. 52 No. 3, pp. 591-620.

Tuomi, K., Ilmarinen, J., Jahkola, A., Katajarinne, L, and Tulkki, A.
(1998), Workability Index, 2nd revised edn, Finnish Institute of
Occupational Health, Helsinki.

Vindholmen, S., Higaard, R., Espnes, G. A., and Seiler, S. (2014),
Return to work after vocational rehabilitation: does mindfulness
matter?. Psychology Research and Behavior Management, Vol. 7,
77-78.

Walach, H., Buchheld, N., Buttenmller, V., Kleinknecht, N., and
Schmidt, S. (2006), Measuring mindfulnessthe Freiburg
mindfulness inventory (FMI). Personality and Individual
Differences, Vol. 40 No. 8, 1543-1555.

Warr, P. (1990), The measurement of well-being and other aspects of
mental health. Journal of Occupational Psychology, Vol. 63 No. 3,
193-210.

Xanthopoulou, D., Bakker, A. B., Demerouti, E., and Schaufeli, W. B.
(2007), The role of personal resources in the job demands-resources
model. International Journal of Stress Management, Vol. 14 No. 2,
121-141.

Authors
Jaana-Piia Mkiniemi Tampere University, FI-33014 University of Tampere, School of Management, Wellbeing at Work research group

Post-doctoral reseacher Jaana-Piia Mkiniemi holds a PhD in social psychology. She works with variety of topics related to employee well-
being, such as how to promote and lead well-being in digitalized work-life.
Email: [emailprotected]

Kirsi Heikkil-Tammi Tampere University, FI-33014 University of Tampere, School of Management, Wellbeing at Work research group

Research Director Kirsi Heikkil-Tammi holds a PhD in adult education and has a long history of working with the themes learning at work
and wellbeing at work. She leads Wellbeing at Work Research Group. She has several research and development projects in this area. She is
also responsible of the wellbeing at work-studies at the University of Tampere.
Email: [emailprotected] VOL. 27, ISSUE 1

‘-‘

. … ‘

BUSINESS FORUM Vol. 27, Issue 1 | 1

Business Forum is dedicated to improving the effectiveness of business in contemporary
society. We provide a forum for fresh ideas, impactful research, and possible solutions to business
challenges. We strive to close the gap between research and practice and enable evidence-based
business management.

Our peer-reviewed articles address specialized and interdisciplinary issues of interest to
business practitioners. We accept manuscripts from all domains of business, usually themed by
a particular journal issue. We also publish reviews of books and digital materials of interest to
our audiences as well as important insights shared by business and civic leaders.

Business Forum is published semiannually as an educational service of the College of Business
and Economics at California State University, Los Angeles. As such, papers addressing
economic development in our region, or useful to its business managers or for the public good
are especially welcome.

Editor-in-Chief
Marianne James, Ph.D., CPA, CMA, Cal State LA

Editorial Board Members
Andre S. Avramchuk, Ph.D., CGEIT, Cal State LA

Vickie Coleman Gallagher, Ph.D., Cleveland State University
Tyrone Jackson, Ph.D., Cal State LA

Xiaoquan Jiang, Ph.D., Florida International University
Michael R. Manning, Ph.D., Benedictine University

Robert Marley, Ph.D., CPA, University of Tampa

Managing Editor
Xiaohan Zhang, Ph.D.

Digital Works / Book Review Editor
Shirley Stretch-Stephenson, Ph.D.

Copy Editors
Rhonda Albey and Masood Khan

Issue Editor
Andre S. Avramchuk, Ph.D.

Cover design by Pablo Martinez

ISSN: 0733-2408
Publisher: College of Business and Economics, Cal State LA

5151 State University Drive, Los Angeles, CA 90032
Phone: 1-323-343-2942

Email: [emailprotected]
https://businessforum.scholasticahq.com

BUSINESS FORUM Vol 27, Issue 1 | 2

TABLE OF CONTENTS

Editorial ……………………………………………………………………………………………………………………………………………3
Andre S. Avramchuk

Adapting to an Evolving Healthcare Environment ……………………………………………………………………………..5
Cstulo de la Rocha

Cal State LAs Mind Matters Initiative: Making a Difference ……………………………………………………………..7
Jillian Beck

ARTICLES

Pixels and Patients: Using Technological Innovations to Reduce Healthcare Costs and
Improve Health Outcomes …………………………………………………………………………………………………………………8
David R. Weinstein
Lonnie S. Barish
Micah P. Frankel

Addressing Employee Burnout Through Mitigation of Workplace Stressors ………………………………………..17
Portia Jackson Preston

Fast Food, Supermarkets, and Obesity in the Inner City: A Study of Food Access and Health in South
Los Angeles ……………………………………………………………………………………………………………………………………….24
Tom Larson
Deborah Compel Larson

Who Did the Affordable Care Act Help and Who Did It Fail? ……………………………………………………………..33
Zhen Cui
Devika Hazra

Lessons from the Healthcare Funding Challenges at Konkola Copper Mines in Zambia? …………………….39
Mwadi Kakoma Chakulya
Francis Wambalaba
Barbara W. Son

Being Intentional About Workplace Mindfulness Programs ………………………………………………………………..48
Carol Blaszczynski

BOOK REVIEW

The Gene: An Intimate History by Siddhartha Mukherjee, M.D. ………………………………………………………..54
H. Rika Houston

Call for Paper Submissions and Reviewers …………………………………………………………………………………………57

Sponsors ……………………………………………………………………………………………………………………………………………58

BUSINESS FORUM Vol. 27, Issue 1 | 3

HEALTHCARE CURRENTS: A SPECIAL ISSUE FORUM

It is an exciting time at the Business Forum, a peer-reviewed,
scholar-practitioner journal published by the College of Business and
Economics at Cal State LA. The journal provided scholarly advice and
application to business practice since the mid-1970s and is now renewed
in a modern print-online format. Our articles have always aimed to
advance business practice through application of research or theoretical
synthesis of information relevant to business. This Healthcare Currents
issue is not an exception, as we highlight an array of interesting topics
from reviewing healthcare technology advancements that contribute to
reductions in costs of care to helping managers understand wellbeing
and mindful practices at work.

We open with two vignettes setting a practical context for the articles. The President of AltaMed
Health Services Corporation shares how his company handles healthcare industry changes and
leads the way into technological and service innovation in the underinsured Southern California
communities and beyond. The Mind Matters initiative in the second vignette showcases one
of the wellbeing programs that engender positive change in how work-and-study community
members empower themselves with knowledge about compassionate engagement and managing
stress. Echoing previous research on compassion and change (e.g., Avramchuk, Manning, &
Carpino, 2013; Worline & Dutton, 2017), both vignettes illustrate the need for leaders to take their
organizations further on a path toward social responsibility and human thriving.

The main Articles section begins with a review of technologies for monitoring and supporting
patient care remotely. David Weinstein, Lonnie Barish, and Micah Frankel lead us on a fascinating
journey into innovative market solutions targeting improvements in preventive care and therefore
increasing its quality while reducing overall care costs. The quality-versus-costs dilemma (Bradley
& Taylor, 2015) is central in the healthcare management field, and most articles chosen for this
special issue try to tackle it in some practical way.

Addressing healthcare costs from a workplace angle, for example, Portia A. Jackson Preston
synthesizes the literature on workplace stressors and shares evidence-based recommendations for
dealing with employee burnout. Tom Larson and Deborah Compel Larson then take us outside of
the workplace and into a South Los Angeles community to demonstrate through their research how
the food deserts in urbanized environments coexist with the obesity epidemic and other healthcare
cost drivers among our local population, including its working-age segment.

Among the key currents in our healthcare field is the set of monumental changes due to the
enactment and ongoing implementation challenges of the Patient Protection and Affordable Care
Act of 2010 (ACA). Zhen Cui and Devika Hazra have examined the associated positive and

EDITORIAL

BUSINESS FORUM Vol 27, Issue 1 | 4

negative impacts on healthcare cost coverage and provide interesting, original statistics on who the ACA
helped and who it failed in this regard. Their research gives insight into the issue of health insurance
for the self-employed and suggests policymaking implications for healthcare coverage of part-time
employees in the United States.

Mwadi Kakoma Chakulya, Francis Wambalaba, and Barbara W. Son bring into the spotlight an
increasingly important, global view on employee healthcare financing through a unique case of Zambian
copper miners. The authors survey research illuminates the nuances in employee attitudes toward
paying for healthcare costs, producing potentially useful lessons for the unionized miner workforces in
particular and labor-management partnerships in general.

We then close with the article by Carol Blaszczynski that harnesses and showcases the power of workplace
mindfulness through a synthesis of literature and current organizational practices. The author presents a
compelling business case for mindfulness programs in different work settings and across employee and
management job levels. The article furthers the encouragement from several authors of this special issue
to build organizational communities for a sustainable workplace and a healthy society.

Finally, H. Rika Houston reviews The Gene: An Intimate History, a book by Siddhartha Mukherjee, that
helps us to challenge and reimagine preconceived notions of health and wellness (Houston, 2018, p.
54). As we struggle to reconcile business imperatives with societal priorities (Rosenthal, 2018), there are
paradigm shifts emerging to affect the core of what we know about our struggles, passions, and nature.
The Business Forum journal aspires to bring our audiences fresh perspectives on how to work effectively
and organize efficiently yet continue to live with wonder about a better world filled with creativity,
innovation, and purpose. The Healthcare Currents issue attempts to deliver on this hefty promise.

Andre S. Avramchuk
Issue Editor

References

Avramchuk, A. S., Manning, M. R., & Carpino, R. A. (2013). Compassion for a change: A review
of research and theory. In A. B. (Rami) Shani, W. A. Pasmore, R. W. Woodman, & D. A. Noumair (Eds.),
Research in Organizational Change and Development, Vol. 21, pp. 201-232. Bingley, U.K.: Emerald.
Bradley, E. H., & Taylor, L. A. (2015). The American health care paradox: Why spending more
is getting us less. New York, NY: PublicAffairs.
Houston, H. R. (2018). The gene: An intimate history by Siddhartha Mukherjee, M.D., Business
Forum, 27(1), pp. 54-55.
Rosenthal, E. (2018). An American sickness: How healthcare became big business and how you
can take it back. New York, NY: Penguin.
Worline, M. C., & Dutton, J. E. (2017). Awakening compassion at work: The quiet power that
elevates people and organizations. Oakland, CA: Berrett-Koehler.

BUSINESS FORUM Vol. 27, Issue 1 | 5

If youve been
paying attention to
whats happening in
Washington, D.C., you
know that change is,
ironically, a constant in
health care. This includes
new policies from our
nations capital as well
as the medical needs of
our communities. Over
the last several years,
AltaMed Health Services
has adapted to these
changes and has forged

itself as a leader in ensuring access to health care and
preventive services. Whatever happens in Washington,
we are dedicated to continuing our nonprofit mission of
providing quality health care without exception to each
and every person we serve.

In more than four decades of operation, our key to success
remains our focus on serving our local communities,
particularly the underinsured. This has helped AltaMed
grow from one storefront neighborhood clinic, staffed by
volunteer physicians who treated 11,000 patients a year
on a five-figure budget, into a $600 million health care
provider with nearly 2,700 employees, delivering more
than one million patient visits annually.

One of the hurdles we faced in achieving this growth was
adapting to a state health care market that moved from a
fee-for-service model to a managed care system. To remain
competitive, we had to shift from operating as a grant-
driven organization to a market-driven one with the ability
to provide contracted Medi-Cal, Medicare and commercial
health care services to every HMO in the region.

The Affordable Care Act (ACA) proved to be both a
challenge and a growth opportunity. When the ACA was
enacted, it was a victory for health care advocates across

the nation. It also became a game changer for community
clinics. It enabled us to receive reimbursement for much
more of the care we provided, because more patients now
had private insurance or began to qualify for Medicaid
because of its expansion. Community clinics like ours
were able to use federal grants to expand facilities and
add services, such as dentistry, urgent care or mental
health care. Many clinics that once spent years in the
red, barely able to keep their doors open, are now finally
breaking even because of the ACA.

Patients who became insured as a result of the new
legislation were now able to visit the doctor without
the fear of unexpected medical costs. They have the
security of a known co-pay and deductible, and can plan
accordingly. In the case of Medicaid patients, they have
the security of knowing that lack of income will not get in
the way of their need for medical care.

At AltaMed, we have traditionally treated and prepared
ourselves to act as safety net to a largely low-income
demographic that would otherwise have very limited
options for receiving medical care. Close to 185,000 of
our patients approximately 70 percent currently rely
on Medicaid for coverage across Los Angeles and Orange
counties. Our ratio of Medicaid patients is significantly
higher than the Medicaid coverage rate across California,
as approximately one-third of California residents under
65 are on Medi-Cal.

We also have more than 50,000 patients who do not
qualify for traditional coverage. These are patients who
rely on our sliding fee scale and the fee-for-service
model.

The implementation of the ACA forced us to increase the
number of facilities we offer, to expand our capacity to
serve more patients, improve and manage our operational
costs, and ensure that we consistently deliver the best
possible outcomes for our patients. Adjusting to the
law was a difficult, two-year effort, but it helped move

Adapting to an Evolving Healthcare Environment
By Cstulo de la Rocha

Cstulo de la Rocha is President and Chief Executive Officer of AltaMed Health Services Corporation, the largest nonprofit Federally Qualified
Health Center in California in the nation. A social architect, Mr. de la Rocha has changed the faces of the communities AltaMed serves by
expanding a sustainable and innovative model of health care delivery to provide access to quality care for millions of underserved patients.
Accredited by the Joint Commission as a Patient Centered Medical Home, AltaMed is home to nearly 2,700 employees, provides care to
approximately 300,000 patients, and delivers more than one million patient visits annually across nearly 50 medical, dental, HIV and PACE sites in
Los Angeles and Orange counties.

BUSINESS FORUM Vol 27, Issue 1 | 6

AltaMed from the bottom quartile in performance to
being ranked among Kaiser Permanente, CareMore and
others as a top health care provider.

If Congress repeals the ACA, California could lose
$20 billion annually in federal funding for Medicaid
expansion and insurance subsidies, leaving 7.5 million
Californians without access to affordable insurance
coverage. It will be a dark, dark day in this countrys
history if we suddenly terminate coverage for the 22
million Americans who now receive some kind of benefit
through the ACA.

Although plans for a replacement continue to be
discussed in Congress, they just arent good enough.
Many of the previously proposed plans have included
potential cuts to Medicaid, which would largely affect the
working poor and elderly. Getting rid of the individual
mandate that all legal residents must be insured would
likely mean that young, healthy people would stop
buying plans, and insurers would once again be footing
the greater part of the bill to cover people with higher
medical expenses. That would lead to increased premiums
and out-of-pocket costs for those who do continue to
purchase insurance. By one estimate, 10 percent of those
living in Los Angeles, Fresno, Kern, San Bernardino,
San Joaquin and Tulare counties have received benefits
under ACA. Some of these regions are represented by
Republicans and have large numbers of Republican voters
whove taken advantage of the ACAs benefits. This is
also true of many of the key states Republicans carried in
the November election.

In 2015, U.S. health care costs reached an all-time high
of $3.2 trillion, partly due to millions of Americans
gaining coverage through the ACA. Employers, small
businesses and chambers of commerce have to take a
more active role in the debate over affordable health care.
In particular, we have a significant stake in serving the
Latino market where there are significant numbers of
unemployed and working poor. Washington has floated
many proposals, including health care spending accounts
and tax credits. We have to become actively engaged to
ensure that whatever policy Republicans and Democrats
pass will continue to provide access to affordable health
care for the maximum possible number of people. The
consequences of not instituting a policy solution that
keeps health care affordable would create an undue
burden for working-class Americans.

And though we have seen ideas floated around, like
expansion of tax-free health savings accounts or selling
insurance plans across state lines, the best way to increase
access to health care is yet to be determined. That said,

AltaMed will continue working closely with Covered
California to identify the greatest need for coverage that
remains in our state, and we will continue to offer one-on-
one assistance at our health centers to ensure that no one
who qualifies in our community is left without coverage.
We will continue to operate until changes are solidified,
and we will do our best to continue advocating for those
who are still seeking coverage assistance.

The effect that the ACA has had on operating budgets,
revenue and margins has forced some providers, like
Aetna and United Healthcare, to leave the program. On
a local level, weve seen Anthem Blue Cross exit the
Covered California market. However, since the ACA
became law, health care cost increases have been in the
single-digit range, compared to previous increases of 12
to 20 percent. To contain future health care costs, doctors,
hospitals, clinics and pharmacies will need to move away
from a fee-based system, reliant on volume, to a value-
based system with a capped monthly rate for services.

Across the spectrum, we all share responsibility for
managing health care costs. As employers, we need to
monitor and continually evaluate the care our employees
receive and work with insurers to better manage those
costs through wellness and other programs. Both
employers and individuals have a role to play in choosing
providers that deliver the best performance. Lastly,
employees need to become more informed consumers
and demand the information that will help them make
decisions about their health care.

Health care will soon resemble the consumer market
in that breakthrough innovations are being driven by
data and technology. Providers that leverage data and
technology to engage their patients will be the winners.
For AltaMed, it means we have to use more strategic
technology to deliver cost-effective, high-quality medical
care. Were already using electronic medical records in
our back offices, and electronic prescription management
and telemedicine in the clinical setting. Where technology
will be especially helpful is connecting bilingual
psychologists, cardiologists, dermatologists and other
specialists with our patients. Thats a major challenge for
providers, but advances like smartphone apps and remote
medicine will help us meet patients needs anywhere and
anytime. In order to stay relevant, we have to keep up
with the times and continue to listen and meet the ever-
changing needs of the communities we serve.

BUSINESS FORUM Vol. 27, Issue 1 | 7

Cal State LAs Mind Matters Initiative:
Making a Difference
By Jillian Beck | Cal State LA News Service

The goal of the Mind Matters initiative at
California State University, Los Angeles
is to integrate inner well-being into the
framework of University life as a means
of supporting student success.

Cal State LA President William A.
Covino and First Lady Dr. Debbie
Covino created the Mind Matters
initiative in 2013 to provide resources and
programs to help students navigate the
demands of academic excellence, family
responsibilities and jobs. The President
and First Lady realize that without inner
well-being, there is no academic success.

The Mind Matters initiative comes at a
time when college students nationwide are
experiencing high levels of stress, including
problems caused by sleep deprivation and
anxiety about adjusting to university life.

Now, perhaps more than ever, we need
to ensure that our students understand
the importance of caring for their inner
selves, President Covino said. And we
are providing them with ways to do so.

To help ensure student success, additional
counselors have been hired for the Student
Health Center, doubling the number
available to assist students. Space was
renovated in the center to accommodate
the additional counseling and workshops
and activities were added to promote
physical and mental well-being.

The number of peer health educators on
the Student Health Advisory Committee
(SHAC) has also expanded to more than
50 students. These volunteers help educate
students about health and wellness issues.

Mind Matters programs include Well-
Being Wednesdays, which promote
inner well-being by encouraging a
campus culture based on compassionate

engagement and mutual support. Mind
Matters and SHAC volunteers, Well-
Being Ambassadors and the new Mind
Matters eagle mascot, Welly, promote
inner well-being on the Main Walkway on
Wednesdays with materials that reinforce
the values of care and compassion.

More than 440 faculty, students and
staff, including the Presidents Leader-
ship Team, have been trained in Mental
Health First Aid, an eight-hour course
that teaches participants how to identify,
understand and respond to signs of mental
illnesses and substance use disorders. The
training provides skills needed to reach
out and provide initial help and support
to someone who may be developing a
mental health or substance use problem
or experiencing a crisis. On Well-Being
Wednesdays, those trained in Mental
Health First Aid wear green We Care, I
Care buttons.

The Mind Matters initiative also features a
speaker series, providing students, faculty
and staff with insights on compassion,
inner well-being and time management.

The engaging speakers have included Los
Angeles Times columnist Steve Lopez
and Rev. Gregory J. Boyle, S.J., founder
of Homeboy Industries.

The Mind Matters Town Halls have been
of great value to the campus commu-
nity, complementing the civic-learning
research Cal State LA students carry out
in their classes. During the gatherings,
students have created action plans for the
health and well-being of the University
community. Town halls are a proven
practice that can contribute to student
success and degree completion. More than
2,000 students have participated in Mind
Matters Town Halls, and another 2,500
are expected to participate in the 2017-18
academic year.

BUSINESS FORUM Vol 27, Issue 1 | 8

A R T I C L E S
_________________________________________________________

PIXELS AND PATIENTS: USING TECHNOLOGICAL
INNOVATIONS TO REDUCE HEALTHCARE COSTS AND

IMPROVE HEALTH OUTCOMES

David R. Weinstein
Extropy Health Solutions

Lonnie S. Barish

WellSpring Pharma Services

Micah P. Frankel
California State University, East Bay

SUMMARY: Advancements in remote monitoring technologies provide new opportunities to
mitigate the growth of healthcare costs while improving patient health outcomes. These
technologies have the promise to positively impact a patients health by producing and
contributing additional, valuable and timely health information pixels to the picture of a
patients clinical profile. In this article, we review how the use of remote monitoring and support
technologies to gather data, digitally connect patient data to healthcare teams, and generate
actionable messages may further contribute to addressing the key dilemma of improving
healthcare quality while reducing healthcare costs.

Introduction

The United States continues to grapple with significant challenges posed by the magnitude
of healthcare costs and their year-over-year rate of growth. For example, family deductibles under
the Affordable Care Act averaged over $12,000 for 2017 bronze plans, while average premiums
rose over 20% from the prior year (Mangan, 2016). Average healthcare spending in 2016 was over
$10,000 per capita in the United States. These numbers are projected to rise by another 50%
between now and 2025, so even just a 1% reduction in actual healthcare spending growth rates
will have a significant impact on absolute costs (Kamal & Sawyer, 2017). Advancements in remote
monitoring technologies provide new opportunities to mitigate the growth in healthcare costs while
improving patient health outcomes. These technologies have the promise to positively impact a
patients health by producing and contributing additional, valuable and timely health information
pixels to the picture of a patients clinical profile. In this article, we review how the use of remote
monitoring and support technologies to gather data, digitally connect patient data to healthcare

BUSINESS FORUM Vol. 27, Issue 1 | 9

teams, and generate actionable messages may further contribute to addressing the key dilemma of
improving healthcare quality while reducing healthcare costs.

Medication Adherence

One area targeted by these new technologies is poor medication adherence. The World

Health Organization defines medication adherence as the degree to which the persons behavior
corresponds with the agreed recommendations from a healthcare provider (Jose & Beena, 2011,
p. 155). Poor medication adherence is a growing concern for clinicians, healthcare systems, and
other stakeholders (e.g., payers) because of mounting evidence that it is prevalent and associated
with adverse outcomes and higher costs of care (Ho, 2009).

The statistics are staggering. Poor medication adherence costs the healthcare system nearly
$300 billion per year in additional doctor visits, emergency department visits, and hospitalizations
(Bresnick, 2015). Chronic diseases such as diabetes, hypertension, and hyperlipidemia (i.e., high
cholesterol) affect one out of every 10 American adults (Chronic Disease Overview, 2017) and
account for 86% of healthcare costs (At A Glance 2015, 2015). Poor medication adherence may
affect 50% of all patients and increases the likelihood of a hospitalization by up to 134% for
chronic diseases such as high blood pressure, diabetes, and high cholesterol (Chronic Disease
Overview, 2017). In 2003, the World Health Organization identified medication non-adherence as
a leading cause of preventable morbidity, mortality, and healthcare costs (World Health
Organization, 2003).

Data Pixelation

Past efforts at improving medication adherence have suffered from data pixelation, the
concept from computer graphics used to describe blurry digital images caused by a dearth of
pixelsthe information elements of these images. Data on daily medication dosing is rare.
Physicians typically rely upon monthly prescription insurance claims created when patients pick
up their medications at the pharmacy (Lam, 2015). Monthly data provide a fairly coarse view of
the patients adherence behavior and are usually actionable only weeks or months after the fact.
The metaphor of a low-resolution digital photo is striking; with their relatively few data points,
monthly prescription insurance-claims data present a pixelated, under-informed view of the
patients true medication adherence.

Consequently, physicians often make assumptions about medication dosing behavior
which may not comport with the facts (Goldberga, Cohena, & Rubinb, 1998; Hulka et al., 1976;
Rand & Wise, 1994). Generally, physicians tend to overestimate the level of their patients’
adherence to therapy (Philips, 1996). Non-adherence to medications reduces treatment benefits
and can confound the clinicians assessment of therapeutic effectiveness, and is thought to account
for 30% to 50% of cases where drugs fall short of their therapeutic goals (Wroth & Pathman,
2006, p. 478).

Let us consider a hypertensive patient who forgets to take prescribed blood pressure
medication every other day. This poor adherence behavior produces two health risks. First, by not
taking medication as prescribed, the patients blood pressure may remain above the clinical goal,
impacting long-term health through increased risk of cardiovascular events (Green, Kwok, &
Durrington, 2002). Second, in response to the patients continued high blood pressure, the
physician may raise the daily dose of blood pressure medication. Consequently, if the patient

BUSINESS FORUM Vol 27, Issue 1 | 10

adheres more to the medication regimen in the future, the increased dose may create a risk of an
undesired decrease in blood pressure resulting in lightheadedness or fainting (Victor, 2016).

Smart Medication Vial Caps

Among the patient-level factors underlying poor medication adherence, the leading cause
is forgetfulness (Bosworth, 2012). One recent technological development aimed at improving
medication adherence caused by forgetfulness as well as providing physicians with less pixelated
views of the patients medication adherence is the smart medication vial cap or smartcap.

Smartcaps have been introduced to the market by several companies in recent years and
may be purchased for under $50, making them accessible to many consumer budgets (Ulanoff,
2017). To use a smartcap to help support adherence, patients download an application (app) onto
their smartphones, set a medication dosing schedule (e.g., every day at 7:00 p.m.), and sync the
app with the smartcap. Smartcaps may be configured to fit on standard prescription medication
vials and may be reused on prescription refills. In an encouraging sign for the smartcap industry,
the Center for Connected Health, a division of Partners Health Care, reported a 27% increase in
medication adherence under a randomized controlled study it performed with hypertensive patients
using smartcaps (Brian, 2010).

How Smartcaps Work

Smartcaps employ a multi-modal approach to supporting good medication adherence. The
smartcap illuminates or glows when a medication dose is due, and the smartcap app produces a
dose alert on the patients phone. Dose reminders can also be configured to be sent to a patient by
SMS, email, or phone call. When a patient opens the smartcap to take a medication dose, the
smartcap sends data to the app recording the event. If a patient is late in taking a dose, the cap will
glow again, and the smartphone app will remind the patient accordingly by SMS, email, or phone
call. If the patient takes the medication dose at any time during this process, the reminders for that
dose will stop. Non-responsiveness is recorded as a missed dose (i.e., non-adherence). If the patient
is away from the medication vial, a taken dose can be logged directly via the smartphone app.

Through this process, reports on daily dosing are created on the smartphone and can be
shared with the patients physician at the next office visit. These data add greater pixels to the
picture of the patients medication adherence. By recording dose-level data, the resolution of the
patients adherence picture is increased from a single data point per monththe data produced by
prescription insurance claimsto 30 or more data points per month.

Sentinel Support

The smartcap also empowers a patients friends or relatives as a powerful medication
adherence support system. Not unlike a feature found in both Facebook and LinkedIn, a smartcap
user can send another individual a med friend invitation. The med friend receives alerts when
the patients medication doses are missed; patients can configure when those alerts are triggered
(e.g., one hour after a missed dose) and how those alerts are delivered to the med friend (e.g., SMS,
email, phone call). While the mechanics of a med-friend functionality seem simple, the impact of
having someone whom a patient trusts to support their appropriate medication dosing is powerful.
Economics dictate that physicians cannot be expected to fill the sentinel role for medication

BUSINESS FORUM Vol. 27, Issue 1 | 11

adherence. Now, through the use of technology, free support from friends and relatives can be
integrated into the patients care system.

In addition to the sentinel support provided by med friends, the power of smartcap is
enhanced by the Hawthorne Effect, a well-documented phenomenon from social sciences whereby
an individuals awareness of monitored behavior biases that behavior toward the desires of the
monitoring agent (The Hawthorne Effect, 2008). In this example, knowing that a med friend will
receive an alert if a dose is missed may contribute to reducing the likelihood of missing a dose in
the first place.

Additional Health Information Pixels

The challenges posed by data pixelation in health care are not limited to medication

adherence management. Let us continue considering a hypertensive patient, assuming medication
adherence can be under control with smartcap support. The patient visits a physician for a regular
monthly check-up where the blood pressure is measured as part of the encounter. The blood
pressure reading, however, is only a single data point and may not be representative of typical
blood pressure levels during the preceding 30 or more days. Wearable smart blood pressure cuffs
(smartcuffs) may provide a solution to this challenge by both reading daily blood pressure levels
as well as uploading the data to the patients smartphone to produce time-series reports for
physician review. Between the data provided by smartcap (medication adherence) and the
smartcuff (blood pressure time series), the physician would have a clearer, less pixelated picture
of the patients blood pressure and medication adherence.

Multiple Sclerosis Example

The challenges posed by data pixelation are not limited to behavioral or vital sign
interpretations. Data pixelation also impacts physicians abilities to manage diseases of motion
such as Multiple Sclerosis (MS), where patient progress is often measured subjectively. There are
over 20 different MS medications on the market (Medications for Multiple Sclerosis, 2017).
Today, medication selection and evaluation for MS patients involve considerable trial and error
(New Survey Finds Multiple Sclerosis Patients Struggle with Misdiagnosis and Invisible
Symptoms, 2017). It is not uncommon for the cost of MS medication therapy to exceed $5,000 per
month, so determining the proper medication and dose as soon as possible can significantly reduce
unnecessary costs (Hartung, 2015).

As part of the evaluation process of current medication therapy, a physician would typically
ask the MS patients to describe how they are feeling during face-to-face office visits. Perhaps a
particular patient just walked a long distance from the car to the office, generating a response of
not too well. Even if such a patients response was appropriately qualified, the physician is still
faced with assessing the patients condition based upon largely subjective data. An objective, time-
series report of how an MS patients physical pathway has presented over the past month or two
would be extremely informative to the physician. Because it is a disease manifesting in motion,
another technological innovation, the accelerometer, makes it possible to provide objective, time-
series data to physicians. An accelerometer is an electromechanical device that measures and
records acceleration-of-motion forces. Accelerometers are found in smartphones, smartwatches,
and automobiles. They can also be incorporated into bracelets or similar wearable devices that
patients can have on their bodies. Accelerometers are inexpensive; in 2013, the average price of
an accelerometer was less than a dollar (Carbone, 2013). A recent study showed that

BUSINESS FORUM Vol 27, Issue 1 | 12

accelerometers can be used to objectively quantify physical activity levels in individuals with MS
with different disability levels (Fjeldstad, 2015). By pairing two or more accelerometers worn by
an MS patient, perhaps one on the wrist and one on the ankle, a physician can gather time-series
information read by these devicespainting additional pixels into a more holistic picture of the
patients progress. Consequently, accelerometers have the promise to help reduce the time to reach
effective medication therapy in MS patients, improving outcomes and reducing healthcare costs.

Incentive Alignment

Ultimately, for this paradigm of remote monitoring, positive behavior reinforcement, and

more informative data production to become widely adopted, patients will need to find satisfaction,
ease of use, and value in using these supporting devices; and payers will need to find value in
sponsoring the costs of purchasing the devices and compensating physicians to monitor them. The
good news is that incentive alignment among these stakeholders has already begun.

Patients

Patient satisfaction is critical to facilitate widespread adoption of remote monitoring. One
study of asthma patients using a remote inhaler sensor found that over 90% of respondents reported
satisfaction using the device, and over 50% felt that their asthma was better controlled as a result
of using the device (Merchant, 2016). Similarly, a study at the Joslin Diabetes Center examined
patients via a survey tool about certain aspects of their diabetic care. The patients in the treatment
group used a remote glucose-monitoring device and shared data collected by the devices with care
management teams. The study found that these patients reported a significantly higher perception
of adherence to diabetes self-care recommendations, lower diabetes-related emotional distress and
an enhanced experience of health care delivery (Bose, 2016, p. 1).

Government Payers

In recent years, changes in payment structures have developed to motivate physicians to
embrace innovative solutions that reduce the growth in healthcare spending while improving
health outcomes. The Patient Protection and Affordable Care Act of 2010 (ACA) contains
elements that link compensation of healthcare providers to the quality of care they deliver. For
example, the ACA provides for the formation of Accountable Care Organizations (ACOs), loosely
defined affiliations that may include physicians, hospitals, and other healthcare providers to deliver
care to Medicare patients (Gold, 2015). An ACO may participate in a Shared Savings Program
(SSP) in which it can receive bonuses from the Centers for Medicare and Medicaid Services (CMS)
based upon cost savings if it also meets quality thresholds defined by CMS (Lazerow, 2014). With
SSPs, physicians in ACOs have a financial incentive to deliver cost-effective quality care.

In 2015, CMS initiated an incentive for physicians in the form of a reimbursement schedule
for Chronic Care Management Services (CCM) (CMS.gov, 2017). Using a new billing code for
CCM, CPT 99490, physicians now have an avenue for additional recurring revenue of between
$43 and $94 per month to remotely monitor patients with chronic diseases (Centers for Medicare
& Medicaid Services, 2016). This revenue is accretive to that received by physicians participating
in Shared Savings Programs or other quality driven incentives. By providing a cost effective type
of physician extender, remote monitoring technologies can play a meaningful role in helping
physicians realize these additional financial rewards.

BUSINESS FORUM Vol. 27, Issue 1 | 13

Commercial Payers

There are also signs that commercial payers are beginning to embrace payment for remote
monitoring and data collection. For example, a remote monitoring patch that can detect and
diagnose irregular heart rhythms is covered by Medicare and several commercial plans (irhythm,
2017). In 2016, Humana joined a program called Air Louisvillealbeit as an employerin which
asthma patients were given a commercially available sensor to use with their inhalers in order to
help drive better asthma-patient outcomes (Propeller Health, 2016). While the program is funded
by a third party (Robert Wood Foundation), positive results among Humana employees should
serve to encourage the insurer to cover the device in the future.

Positive Financial Returns

Widespread payer support of these technologies will require demonstrations that they can
produce financial returns. Since 2012, CMS has imposed severe penalties on hospitals for high
readmission rates (McKinney, 2012). Accordingly, reducing hospital readmissions is a common
metric of pilot programs that strive to prove the value of a new service or technology. In a study
with members of Capital Blue Cross diagnosed with heart failure, a remote monitoring system
found a 45% reduction in hospital readmission rates among the treatment group, translating into
an annual savings of over $8,000 per year in monitored heart-failure patients (Geneia LLC, 2016).
In a similar study focusing on hospital readmissions using a remote monitoring system that tracked
the blood pressure, heart rate, and weight of 31 recently discharged heart-failure patients, none of
the patients were readmitted within the first 30 dayswhile the expected number of readmissions
was eight. This reduction in readmissions translated into a $216,000 savings (iGetBetter, Inc.,
2015).

Conclusion

As healthcare spending, deductibles, and premiums grow at unsustainable rates,
technological innovations present pragmatic, cost-effective opportunities to drive down these
growth rates without undermining quality. Remote monitoring innovations such as smartcaps,
smartcuffs, and accelerometers can provide quantifiable, objective data to health providers, payers,
and patients. The examples reviewed in this article illustrate how such innovations allow patients
as well as their caregivers, including friends, relatives, and clinicians, to obtain a more informed,
less pixelated picture of patients health over time. The incentives of key stakeholderspatients,
healthcare providers, and payersappear to be aligning. As technologies become more effective,
easier to use and implement, and less costly, a future of widespread adoption appears achievable,
one that can contribute to a healthier society while mitigating the growth rate of healthcare costs.

Corresponding author: Dr. David R. Weinstein, [emailprotected]

BUSINESS FORUM Vol 27, Issue 1 | 14

References

Alonso-Zaldivar, R. (2016, July 13). $10,345 per person: U.S. health care spending reaches new
peak. Retrieved from PBS Newshour: http://www.pbs.org/newshour/rundown/new-peak-
us-health-care-spending-10345-per-person/

Amazon.com. (2017, October 27). Makerfire GY-521 MPU-6050 MPU6050 3 Axis
Accelerometer Gyroscope Module 6 DOF 6-axis Accelerometer Gyroscope Sensor
Module 16 Bit AD Converter Data Output IIC I2C. Retrieved from Amazon.com:
https://www.amazon.com/Makerfire-MPU-6050-Accelerometer-Gyroscope-
Converter/dp/B008BOPN40/

At A Glance 2015. (2015). Retrieved from CDC – National Center for Chronic Disease
Prevention:
https://www.cdc.gov/chronicdisease/resources/publications/aag/pdf/2015/nccdphp-
aag.pdf

Bose, T. (2016, June 24). 3 Key Learnings from ADA 2016. Retrieved from Glooko:
https://www.glooko.com/2016/06/3-key-learnings-from-ada-2016/

Bosworth, H. (2012). Enhancing Medication Adherence The Public Health Dilemma. Springer.
Bresnick, J. (2015, February 13). HealthIT Analytics. Retrieved from Medication Non-

Adherence Brings Millions in Avoidable Costs:
https://healthitanalytics.com/news/medication-non-adherence-brings-millions-in-
avoidable-costs

Brian, D. (2010, June 23). Study: GlowCaps up adherence to 98 percent. Retrieved from
mobihealth news: http://www.mobihealthnews.com/8069/study-glowcaps-up-adherence-
to-98-percent

Callaway, E. (2013, October 17). UK push to open up patients’ data: government faces obstacles
to mining medical records. Nature, 502.7471, p. 283.

Carbone, J. (2013, December 18). Expect Sensor Prices to Fall. Retrieved from Digi-Key
Electronics: https://www.digikey.com/en/articles/techzone/2013/dec/expect-sensor-
prices-to-fall

Centers for Medicare & Medicaid Services. (2016, December). Chronic Care Management
Services Changes for 2017.pdf. Retrieved from https://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-
MLN/MLNProducts/Downloads/ChronicCareManagementServicesChanges2017.pdf

Chronic Disease Overview. (2017, June 28). Retrieved from Center For Disease Control and
Prevention: https://www.cdc.gov/chronicdisease/overview/index.htm

CMS.gov. (2017). Retrieved from Centers for Medicare & Medicaid Services:
https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-
Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html

Daschle, T., & Frist, B. (2013, August 14). Technology And The Changing Business Of Health
Care. Health Affairs Blog .

Fjeldstad, C. (2015). Use of Accelerometers to Measure Real-Life Physical Activity in
Ambulatory Individuals with Multiple Sclerosis. International Journal of MS Care, 215-
220.

Geneia LLC. (2016, June 15). Geneia Study Finds Remote Patient Monitoring Could Save More
Than $8,000 Per Patient Annually. Retrieved from geneia.com:

BUSINESS FORUM Vol. 27, Issue 1 | 15

https://www.geneia.com/news-events/press-releases/2016/june/geneia-study-finds-
remote-patient-monitoring-could-save-more-than-8000-dollars-per-patient-annually

Gold, J. (2015, September 14). Accountable Care Organizations, Expalined. Retrieved from
Kaiser Health News: https://khn.org/news/aco-accountable-care-organization-faq/

Goldberga, A. I., Cohena, G., & Rubinb, A.-H. E. (1998). Physician assessments of patient
compliance with medical treatment. Social Science & Medicine, 47(11), 1873-1876.

Green, R., Kwok, S., & Durrington, P. (2002). Preventing cardiovascular disease in
hypertension: effects of lowering blood pressure and cholesterol. QJM: An International
Journal of Medicine, 95(12), 821826.

Hartung, D. M. (2015). The cost of multiple sclerosis drugs in the US and the pharmaceutical
industry. Neurology, 84(21), 21852192.

Ho, P. M. (2009, June 15). Medication Adherence. Retrieved from Circulation:
http://circ.ahajournals.org/content/119/23/3028

Hulka, B. S., Cassel, J. C., Kupper, L. L., & Burdette, J. A. (1976). Communication, compliance,
and concordance between physicians and patients with prescribed medications. American
Journal of Public Health, 66(9), 847-853.

iGetBetter, Inc. (2015). Congestive Heart Failure Study 2014. Retrieved from igetbetter.com:
http://www.igetbetter.com/case-studies

irhythm. (2017). Insurance and Billing. Retrieved from irhythm.com:
http://irhythmtech.com/patients/insurance-billing

Jose, J., & Beena, J. (2011). Patient Medication Adherence: Measures in Daily Practice. Oman
Medical Journal, 155-159.

Kamal, R., & Sawyer, B. (2017, May 22). How much is health spending expected to grow?
Retrieved from Peterson-Kaiser Health System Tracker:
https://www.healthsystemtracker.org/chart-collection/much-health-spending-expected-
grow/

Lam, W. Y. (2015). Medication Adherence Measures: An Overview. BioMed Research
International, 1-12.

Lazerow, R. (2014, November 18). What is the Medicare Shared Savings Program? Retrieved
from Advisory Board: https://www.advisory.com/research/health-care-advisory-
board/primers/shared-savings

Mangan, D. (2016). Obamacare deductibles are on the rise for 2017, along with monthly
premiums. Retrieved from CNBC: https://www.cnbc.com/2016/10/26/obamacare-
deductibles-are-on-the-rise-for-2017-along-with-monthly-premiums.html

McKinney, M. (2012). Preparing for Impact. Retrieved from Modern Healthcare:
http://www.modernhealthcare.com/article/20120929/MAGAZINE/309299996

Medications for Multiple Sclerosis. (2017). Retrieved from Drugs.com:
https://www.drugs.com/condition/multiple-sclerosis.html

Merchant, R. (2016, December 30). Patient Reported Value and Usability of a Digital Health
Intervention for Asthma. Retrieved from http://www.iproc.org/2016/1/e36/

Murph, D. (2007). Vitality’s GlowCaps remind you to pop those pills. Retrieved from
Engadget.com: https://www.engadget.com/2007/05/28/vitalitys-glowcaps-remind-you-to-
pop-those-pills/

New Online Reminder Service for Hospitals, Health Clinics, Pharmacies, and Insurance
Companies to Support Patient Medication Compliance. (2010, January 27). Retrieved
from PR Newswire: http://www.prnewswire.com/news-releases/new-online-reminder-

BUSINESS FORUM Vol 27, Issue 1 | 16

service-for-hospitals-health-clinics-pharmacies-and-insurance-companies-to-support-
patient-medication-compliance-82779967.html

New Survey Finds Multiple Sclerosis Patients Struggle with Misdiagnosis and Invisible
Symptoms. (2017, April 27). Retrieved from Health Union: https://health-
union.com/news/multiple-sclerosis-patients-struggle-with-misdiagnosis-and-invisible-
symptoms/

Osterberg, L., & Blaschke, T. (2005). Drug Therapy: Adherence to Medication. New England
Journal of Medicine, 353, 487-497.

Pai, A. (2016, March 01). UnitedHealthcare, Qualcomm launch mobile-enabled wellness
program, UnitedHealthcare Motion. Retrieved from mobihealth news:
http://www.mobihealthnews.com/content/unitedhealthcare-qualcomm-launch-mobile-
enabled-wellness-program-unitedhealthcare-motion

Philips, D. (1996). Medical professional dominance and client dissatisfaction. Social Science and
Medicine, 42(10), 1419-1425.

Propeller Health. (2016). Humana joins AIR Louisville, a Data-Driven Community
Collaboration Designed to Reduce the Burden of Asthma. Retrieved from Propeller
Health: https://www.propellerhealth.com/2016/02/04/humana-joins-air-louisville-a-data-
driven-community-collaboration-designed-to-reduce-the-burden-of-asthma/

Rand, C., & Wise, R. (1994). Measuring adherence to asthma medication regimens. American
Journal of Respiratory and Critical Care Medicine, 149, S69-S76.

Services, C. f. (2017, January). Frequently Asked Questions about Physician Billing for Chronic
Care Management Services. Retrieved from https://www.cms.gov/Medicare/Medicare-
Fee-for-Service-
Payment/PhysicianFeeSched/Downloads/Payment_for_CCM_Services_FAQ.pdf

Silvers, J. (2013). The Affordable Care Act: Objectives and Likely Results in an Imperfect
World. Annals of Family Medicine, 11(5), 402-405.

Team BioPlus Health. (2015, October 13). Making Assumptions. Retrieved from Bioplus
Speciality Pharmacy Service: https://bioplushealth.com/bph/making-assumptions/

The Hawthorne Effect. (2008, November 3). Retrieved from The Economist:
http://www.economist.com/node/12510632

Ulanoff, L. (2017). This Smart Cpp Won’t Let Your Forget to Take Your Medicine. Retrieved
from mashable.com: http://mashable.com/2017/05/02/pillsy-smart-medicine-cap-news

Victor, R. (2016). Arterial hypertension. In L. Goldman, & A. Schafer (Eds.), Goldman-Cecil
Medicine (25th ed.). Philadelphia, PA: Elsevier Saunders.

World Health Organization. (2003, January). Retrieved from Adherence to long-term therapies:
evidence for action.:
http://www.who.int/chp/knowledge/publications/adherence_report/en/index.html

Wroth, T., & Pathman, D. (2006). Primary medication adherence in a rural population: the role
of the patientphysician relationship and satisfaction with care. J Am Board Fam Med, 19,
478486.

BUSINESS FORUM Vol. 27, Issue 1 | 17

ADDRESSING EMPLOYEE BURNOUT THROUGH
MITIGATION OF WORKPLACE STRESSORS

Portia A. Jackson Preston
California State University, Los Angeles

SUMMARY: Workplace stressors are an increasing driver of healthcare costs in the United States.
Insufficient compensation, the way in which work is managed, as well as one’s sense of job control
may compromise employee health and productivity, and ultimately lead to increased job turnover.
The reduction of burnout within organizations is best maintained through a combination of
interventions at the individual and organizational levels. Future research should examine how
work and non-work stressors can influence job-related stress.

Introduction

The World Health Organizations global strategy on occupational health emphasizes that

the way in which work is managed and ones sense of job control can affect employee stress and
health, which in turn, impacts worker engagement and productivity (WHO, 1994). Kronos
Incorporated and Future Workplace (2017) surveyed human resource professionals in leadership
positions and found that nearly half cited burnout as the driving factor in 20-50% of employee
turnover. Contributing factors were cited as insufficient compensation, excessive responsibilities,
and substantial work outside of business hours.

Investment banking, for instance, is notorious for long work hours in exchange for a
rewarding salary and the prospect of future success. A nine-year ethnography of two investment
banks revealed that because work-life balance was hailed as an institutional value, individuals
believed that they were in control of their choice to work up to 120 hours per week (Michel, 2011).
While overwork led to increased performance in the short term, employee health and productivity
declined in the end.

According to Maslach, Shaufeli, and Leiter (2001), prolonged exposure to emotional and
interpersonal stress at work can produce job-related burnout, characterized by emotional
exhaustion, depersonalization or cynicism, and a lack of personal sense of accomplishment.
Physicians are more likely than other workers in the U.S. to report burnout and dissatisfaction with
work-life balance (Shanafelt et al., 2016), and suicide attempts among healthcare practitioners are
of increasing concern (Braquehais et al., 2016). The impact that burnout can have on productivity,
for example, an increase in medical errors, has significant implications for patient safety (Hall,
Johnson, Watt, Tsipa, & OConnor, 2016).

A desire to remain competitive has led to an increase in job stress across various sectors,
as employees work longer hours and take on additional responsibilities. In the gaming industry,
developers work in excess of 20 hours per day for weeks or months on end, called crunch, to
finish developing a game (Schreier, 2017). These long stints can have disastrous consequences for
employee health and organizational productivity.

BUSINESS FORUM Vol 27, Issue 1 | 18

This paper reviews the relationship between work-related stressors and employee burnout.
Interventions at the organization and individual level designed to help promote sustainable
performance are also explored. While external stressors and individual characteristics undoubtedly
influence burnout, and there is a wide range of consequences of burnout to the employee and
organization, such a discussion is beyond the scope of this paper.

What are workplace stressors?

It is estimated that 5-8% of total health care costs in the United States, estimated at $125-

190 billion, are attributable to workplace stress (Goh, Pfeffer, & Zenios 2016). One of the greatest
drivers of these health care costs is work demands that exceed ones capacity and resources. The
National Institution of Occupational Safety and Health (NIOSH) (1999) describes job stress as the
harmful physical and emotional responses that occur when the requirements of the job are not
aligned with the workers capabilities, resources, or needs. A survey of 2,200 chief financial
officers and 1,000 US-based office workers conducted by Accountemps (2017) cited top
contributors to job stress as overwhelming responsibilities, deadlines, trying to strike a balance
between personal and professional lives, and fulfilling the expectations of those in supervisory
roles. A meta-analysis of cohort studies conducted with employees in the US, Asia, and Europe
found that the risk of cardiovascular disease among workers who experienced job stress was 50%
greater than those who did not experience job stress (Kivimaki, Virtanen, Elovainio, & Kouvonen,
2006).

What makes job stress so harmful to ones health? McEwen (1998) describes the health
impact of chronic stress over time by differentiating between the human bodys response to acute
versus chronic stress. If one is startled by a loud, unexpected noise, a fight or flight may be
triggered in response to this one-time stressor. Afterwards, hormones are released that ultimately
help the body return to homeostasis (or balance) through a process called allostasis. However,
chronic stressors that are experienced repeatedly can have a lasting effect on the body as a result
of constantly activating the stress response system. Over time, this system may cease to work
properly, producing a strain on the body. This wear and tear, also known as allostatic load, results
in behavioral and physiological changes, increasing the risk of disease.

In management practice, there is a prevailing belief that a moderate amount of stress can
help motivate employees to achieve peak levels of engagement and performance (Gino, 2016;
Benson, & Allen, 1980). This is an application of the Yerkes-Dodson law, which states that
exposure to external stimuli can improve task performance to an extent, but exposure beyond a
certain point can negatively impact performance (Yerkes & Dodson, 1908). It is believed that an
optimal amount of stress should be encouraged in the work environment to stimulate peak
performance, while excessive stress should be avoided. Person-environment theory, developed by
Edwards, Caplan, and Van Harrison (1998), argues that stress results from a lack of fit between the
individual and their environment, or in this context, the employee and their work. This theory relies
on the assumption that all stress is negative. However, LeFevre, Matheny, and Kolt (2003) contend
that whether stress is experienced as positive or negativewith the latter leading to strainis
ultimately determined by the individual, and whether they have the capacity to meet the demands
placed upon them (LeFevre, 2003). Because the experience of stress is subjective, it is not possible
to gauge (or manage) optimal levels of stress for all employees across an organization.

BUSINESS FORUM Vol. 27, Issue 1 | 19

What is burnout?

As mentioned in the introduction, ongoing exposure to job-related stress can result in

burnout. Freudenberger (1974) coined the term of burnout based on his work with volunteers at a
free clinic who exhibited signs of emotional exhaustion over time. As a result, burnout initially
referred to those in the helping professions, with high levels of client interaction, who were
increasingly unable to cope with pervasive stress and excessive job demands. Thus, a large volume
of studies on burnout focuses on doctors, nurses, and educators. However, over time, burnout has
increasingly been applied across professions.

While there are a multitude of scales that assess burnout, this paper focuses on the Maslach
Burnout Inventory (MBI), which measures burnout by assessing three dimensions: emotional
exhaustion, depersonalization, and a lack of personal accomplishment (Maslach & Jackson, 1981).
Emotional exhaustion occurs at the individual level when work demands exceed ones physical or
emotional capacity to fulfill them. A systematic review of studies examining burnout symptoms
and factors in the workplace environment found substantial evidence to support the association
between sense of control over ones job and emotional exhaustion, as well as the link between
support in the workplace and emotional exhaustion (Aronnson et al., 2017). Depersonalization
operates at the interpersonal level, in which there is a sense of cynicism, negativity or disdain
towards components of ones work, including the clients they serve. Lastly, personal
accomplishment entails how an individual assesses his or her own work. It captures feelings of
incompetence or a lack of fulfillment from ones role.

Burnout is a cyclical process in which efforts to cope with negative stress lead to emotional
exhaustion. This, in turn, activates depersonalization and a subsequent decrease in ones sense of
personal accomplishment, which leads to further emotional exhaustion (Maslach, Schaufeli, &
Leiter, 2001). The Maslach Burnout Inventory General Survey (MBI-General Survey) is a
validated measure of burnout in professions with less focus on personal interaction, and measures
the three main dimensions as exhaustion, cynicism (a distant attitude towards the job), and
reduced professional efficacy (Maslach, Schaufeli, & Leiter, 2001). When employees experience
burnout, it takes a toll on their physical and emotional health. For example, burnout has been
identified as a risk factor for coronary heart disease (Toker, Melamed, Berliner, Zeltser, & Shapira,
2015) and depression (Aronnson, 2017). Having established the negative impact of burnout, the
next section will discuss how organizations can address or prevent it.

How interventions can promote sustainable performance

Interventions to address burnout typically occur at the organization leveladdressing

policy and the way in which work is organized or deliveredor the individual levelfocusing on
stress management and communication. Organization level interventions might focus on
modifications to job roles, performance assessment, and timing of shifts, while individual level
interventions might include cognitive behavior based therapy or counseling, enhancing social
support, and addressing skills that enhance ones ability to adapt and communicate (Awa,
Plaumman, & Walter, 2010).

Several meta-analyses of burnout interventions have found that a combination of
organization and individual-level interventions are most effective in sustaining reductions in
burnout scores over the long term (Ahola, Toppinen-Tanner, & Seppanen, 2017; Awa, Plaumman,
& Walter, 2010). It is not possible to eliminate all workplace stressors, thus underscoring the

BUSINESS FORUM Vol 27, Issue 1 | 20

importance of combining both levels. Refresher sessions are recommended in order to maintain
intervention effects. Le Fevre, Kolt, and Matheny (2006) recommend the introduction of
individual-level interventions prior to employing organization-level interventions, to provide a
strong foundation and supportive resources for individuals in preparation for organizational change.

Practical Tips for Managers

Managers who are interested in addressing burnout in their organizations should consider

the following in developing their approach:

1. Identify workplace stressors and implement strategies to reduce them
According to Sauter, Muphy, and Hurrell (1990), there are a wide range of strategies that

can be employed at the organization level to address workplace stress:
Assess job demands to determine whether they are aligned with employee capabilities, and

ensure employees have adequate resources to fulfill their responsibilities
Define roles clearly and in a way that engages employees, imbuing them with a sense of

meaning and the opportunity to use their skills
Assess the extent to which employees have a sense of control over their jobs. Ensure that

they are consulted on decisions that impact them directly
Engage in clear conversation with employees about their career development and future

options for advancement
Provide opportunities for social interaction at work, as interpersonal relationships can help

to build collegiality and provide social support
Consider responsibilities employees have outside of the work environment when

developing work schedules, to minimize work-family conflict

2. Promote opportunities for employees to engage in positive stress coping behaviors
Evidence-based wellness programs that promote healthy stress coping behaviors such as

physical activity, getting adequate rest, proper nutrition, and relaxation practices should also be
considered for adoption. In the Accountemps survey (2017), individuals reported dealing with
stress positively through engagement in physical activity or hobbies, taking vacation, and spending
time with others outside of work. Protecting time during the work day to take a break for exercise
or rest can help individuals recharge and manage work-related stress. The Health and Retirement
study found that those who reported high stress in their job were more likely to smoke (Ayyagari
& Sindelar, 2010). Addressing job stress through workplace policies and interventions may
ultimately reduce engagement in unhealthy coping behaviors.

3. Make sustained performance a priority for your organization

Set the pace for your organization by clearly communicating expectations from the top.
Some gaming developers are addressing crunch by signing a pledge to decrease unnecessary
overtime (Schreier, 2017). Investment banks are communicating to analysts that they should take
one weekend day off, while others are setting a maximum number of average work hours per week
(Surowiecki, 2014).

Managers should be careful in leveraging tools such as email to enhance productivity
without producing overwhelm. As technology continues to develop, the potential for overload will
only increase (McMurtry, 2014). For example, the ability to check work email from ones watch

BUSINESS FORUM Vol. 27, Issue 1 | 21

or other wearable device may lead to checking email more frequently. In the end, it is not what an
organization says regarding work-life balance, but rather what managers do that communicates
expectations to employees. If managers regularly send email outside of work hours or do not take
vacations, employees may believe that such behavior is required for success.

4. Make these changes a part of your organizational culture.

Building approaches to promote well-being into the organizational policy, such mandatory
vacation, flexible work hours, remote working opportunities, or expectations regarding
communication is essential to sustainable performance over the long-term. This may require
frequent reminders of benefits to the organization. A study of middle-age men at high risk for
coronary heart disease found that those who reported a higher frequency of annual vacations had
a lower risk for mortality due to coronary heart disease than those who did not (Gump & Matthews,
2000). Meanwhile, two-thirds of employees surveyed by MetLife (2016) stated that flexibility in
work site (remote work) would increase their loyalty to an organization, while 74% of employees
believed flexibility in work hours would do so.

Conclusion and Future Directions

In summary, workplace stressors, such as job demands that exceed ones capacity or

resources, management style, and job control, can lead to burnout in employees. This should be of
concern to managers because burnout is increasingly cited as a driving factor in employee turnover.
It is also a risk factor for coronary heart disease and other conditions. Interventions to address
burnout should focus on a combination of organization level interventions that address workplace
stressors, as well as individual interventions that focus on stress management. Managers looking
to address burnout in their organizations should take a top-down approach and ensure that efforts
to reduce workplace stressors, promote positive coping behavior, and prioritize sustained
performance are embedded within the organizational culture.

Future research should examine the influence of personal stressors and characteristics on
how employees experience stress in the workplace. Hakanen and Bakker (2016) encourage the
examination of demands and resources outside of the workplace, as well as major life events (e.g.,
marriage, birth of a child, divorce) that undoubtedly impact individuals. There also is a need to
explore how felt strain from workplace stress drives engagement in negative coping behaviors,
such as substance abuse, overwork, and sedentary behavior. An understanding of this relationship
can lead to more effective interventions to prevent burnout.

Corresponding author: Dr. Portia A. Jackson Preston, [emailprotected]

References

Aronsson, G., Theorell, T., Grape, T., Hammarstrm, A., Hogstedt, C., Marteinsdottir, I.,

Hall, C. (2017). A systematic review including meta-analysis of work environment and
burnout symptoms. BMC Public Health, 17, 264-277.

BUSINESS FORUM Vol 27, Issue 1 | 22

Awa, W.L., Plaumann, M., & Walter, U. (2010). Burnout prevention: A review of intervention
programs. Patient Education and Counseling, 78(2), 184-190.

Ayyagari, P., & Sindelar, J. L. (2010). The Impact of Job Stress on Smoking and Quitting:
Evidence from the HRS. The B.E. Journal of Economic Analysis & Policy, 10(1), art27.

Braquehais, M. D., Eiroa-Orosa, F. J., Holmes, K. M., Lusilla, P., Bravo, M., Mozo, X., Sher,
L. (2016). Differences in Physicians and Nurses Recent Suicide Attempts: An
Exploratory Study. Archives of Suicide Research, 20(2), 273279.

Benson, H., & Allen, R.L. (1980). How much stress is too much? Harvard Business Review,
58(5): 86-92.

Edwards, J.R., Caplan, R.D., & Van Harrison, R. (1998), Person-environment fit theory:
conceptual foundations, empirical evidence, and directions for future research,
in Cooper, C.L. (Ed.), Theories of Organizational Stress, Oxford University Press, New
York, NY, pp. 28-67.

Future Workplace, LLC & Kronos Incorporated (2016). Employee Engagement Lifecycle Series.
Retrieved from: https://www.kronos.com/ about-us/newsroom/employee-burnout-crisis-
study-reveals-big-workplace-challenge-2017.

Gino, F (2016). Are you too stressed to be productive? Or not stressed enough? Harvard
Business Review, April 2016. Retrived from: https://hbr.org/2016/04/are-you-too-stressed-

to-be-productive-or-not-stressed-
enough?referral=03758&cm_vc=rr_item_page.top_right.

Goh, J., Pfeffer, J., & Zenios, S. A. (2016). The Relationship Between Workplace Stressors and
Mortality and Health Costs in the United States. Management Science, 62(2): 608-628.

Gump, B., & Matthews, K. (2000). Are Vacations Good for Your Health? The 9-Year Mortality
Experience After the Multiple Risk Factor Intervention Trial. Psychosomatic Medicine,
62(5), 608612.

Hakanen, J., & Bakker, A.B. (2017). Born and Bred to burn out: A life-course view and
reflections on job burnout. Journal of Occupational Health Psychology, 22(3), 354-364.

Hall, L. H., Johnson, J., Watt, I., Tsipa, A., & OConnor, D. B. (2016). Healthcare Staff
Wellbeing, Burnout, and Patient Safety: A Systematic Review. PLoS ONE, 11(7),
e0159015.

Kivimaki, M., Virtanen, M., Elovainio, M., & Kouvonen, A. (2006). Work stress in the etiology
of coronary heart disease a meta-analysis. Scandinavian Journal of Work,
Environment & Health, 32(6), 431442.

Kronos Incorporated and Future Workplace (2017). The Employee Engagement Study. (2017,
January 9). Retrieved from: https://workplacetrends.com/the-employee-burnout-crisis-
study/.

Le Fevre, M., Matheny, J., & Kolt, G.S. (2003). Eustress, distress, and interpretation in
occupational stress. Journal of Managerial Psychology, 18(7): 726-744.

Le Fevre, M., Kolt, G.S., & Matheny, J. (2006) Eustress, distress and their interpretation in
primary and secondary occupational stress management interventions: which way
first? Journal of Managerial Psychology, 21(6): 547-565.

Maslach C. & Jackson, S.E (1981). The measurement of experienced burnout. Journal of
Organizational Behavior, 2(2), 99-113.

Maslach, C., Schaufeli, W.B., & Leiter, P.M. (2001). Job burnout. Annual review of
Psychology, 52(1): 397-422.

BUSINESS FORUM Vol. 27, Issue 1 | 23

McMurtry, K. (2014). Managing Email Overload in the Workplace. Performance Improvement,
53(7), 3137.

MetLife (2016). Work redefined: A new age of benefits. 2016 Annual U.S. Employee Benefit
Trends Survey. Retrieved from: https://benefittrends.metlife.com/media/1382/2017-ebts-
report_0320_exp0518_v2.pdf.
McEwen, B.S. (1998). Stress, adaptation, and disease. Allostasis and allostatic load. Annals of

the NY Academy of Sciences. 840, 33-44.
Michel, A. (2011). Transcending Socialization: A Nine-Year Ethnography of the Bodys Role in

Organizational Control and Knowledge Workers Transformation. Administrative Science
Quarterly, 56(3), 325368.

Shanafelt, T., Boone, S., Tan, L., & Al, E. (2012). Burnout and satisfaction with work-life
balance among US physicians relative to the general US population. Archives of Internal
Medicine, 172(18), 13771385.

Schreier, J. (2017, October 25). New York Times. Video games are destroying the people who
make them. Retrieved from: https://www.nytimes.com/2017/10/25/opinion/work-culture-
video-games-crunch.html.

Surowiecki, (2014, January 27). The New Yorker. The Cult of Overwork. Retrieved from:
https://www.newyorker.com/magazine/2014/01/27/the-cult-of-overwork.

Toker, S., Melamed, S., Berliner, S., Zeltser, D., & Shapira, I. (2012). Burnout and Risk of
Coronary Heart Disease: A Prospective Study of 8838 Employees. Psychosomatic
Medicine, 74(8), 840-847.

World Health Organization (1994). Global strategy on occupational health for all: The way
to health at work. Recommendation of the second meeting of the WHO Collaborating
Centres in Occupational Health, 11-14 October 1994, Beijing, China. Retrieved from:
http://www.who.int/occupational_health/globstrategy/en/index6.html.

Yerkes R.M., & Dodson J.D. (1908). The relation of strength of stimulus to rapidity of habit-
formation. Journal of Comparative Neurology and Psychology, 18, 459-482.

BUSINESS FORUM Vol 27, Issue 1 | 24

FAST FOOD, SUPERMARKETS, AND OBESITY IN THE INNER
CITY: A STUDY OF FOOD ACCESS AND HEALTH IN SOUTH

LOS ANGELES

Tom Larson
California State University, Los Angeles

Deborah Compel Larson

Los Angeles Harbor College

SUMMARY: The U.S. is experiencing an obesity epidemic. Obesity rates are especially high in
low-income, inner-city areas. Many inner-city neighborhoods have been labeled food deserts,
where affordable, nutritious food is scarce. South Los Angeles has been labeled a food desert as
it is reported to lack full-service supermarkets but has a growing number of fast-food restaurants.
This paper examines some of the claims about food access and health, provides new data on the
availability of supermarkets and fast-food restaurants in South Los Angeles, and reviews solutions
for improving the health of South Los Angeles residents through changes in food access.

Introduction

Obesity rates in the United States have increased for several decades, with a dramatic rise
after 1980. Obesity is defined as a Body Mass Index (BMI) of 30 or more. Adult obesity rates rose
from 15% in 1980 to 31.3% in 2001 and to 38.1% in 2014 (Fryar, Carroll, & Ogden, 2016; see
Figure 1 below). The U.S. is among the most obese nations on earth and is the most obese
developed nation (OECD, 2017). In California, obesity rates are lower than in most states, but have
also grown, for example, for adults, from 19.3% in 2001 to 24.8% in 2012 (Wolstein, 2015). This
is leading to new challenges for grocers and restaurants, as government interventions are pursued
in order to combat obesity.

Obesity rates in Los Angeles County have also increased for adults from 13.6% in 1997 to
22.2% in 2008. Obesity rates are much higher in low-income neighborhoods. South Los Angeles
City Council Districts 8 and 9 have adult obesity rates of 35.1% and 36.7%, respectively. Child
obesity rates are also linked to geographic locations, with a low rate of 3.4% in the affluent
community of Manhattan Beach to a high rate of 38.7% in low-income Walnut Park (County of
Los Angeles Public Health, 2011).

Obesity is considered a disease by the World Health Organization (Wang & Beydoun,
2007). It is also linked to two of the highest causes of death in the United States: heart disease (#1)
and diabetes (#7) (Centers for Disease Control, 2016). Obesity is reported in medical journal
articles as a public health epidemic (Wang & Beydoun, 2007). The health costs associated with
current levels of obesity may be larger than those associated with smoking tobacco or excessive
drinking (Strum, 2002). Health experts at the global and national level are advocating government
interventions (Kleinert, 2015; OECD, 2017; World Health Organization, 2016).

BUSINESS FORUM Vol. 27, Issue 1 | 25

Source: https://www.cdc.gov/nchs/data/hestat/obesity_adult_13_14/obesity_adult_13_14.pdf

Figure 1. United States obesity rates

The rise in obesity is linked to changes in both diet and exercise. Here, the impact of

changes in the food environment is examined. A major problem in South Los Angeles is seen as a
shortage of affordable nutritious food. This is a common problem in low-income, inner-city
neighborhoods across the nation. South Los Angeles has had high poverty rates for more than 25
years. Across South LA, the poverty rate was 34 % in 2013 (Pastor et al., 2016). Many low-income
neighborhoods have been labeled food deserts because of a lack of affordable nutritious food.
Part of the problem has been a shortage of full-service supermarkets. Below, it is shown that a
shortage of supermarkets in South Los Angeles has persisted over the last 25 years. What has
changed is the availability of chain fast-food restaurants.

Across the United States, full-service supermarkets that are part of major chain stores have
been leaving low-income, inner-city neighborhoods. Full-service supermarkets are larger stores
that have a wide variety of foodsfrom canned foods to dairy to fresh meat to fresh fruits and
vegetables. They are likely to have healthy choices as well as high-fat-high-calorie foods. The
chain stores have been moving to the suburbs, and the suburbs have expanded. This trend has been
going on for decades and has been called supermarket redlining by Eisenhauer (2001). This
exodus does not reflect a lack of demand for food in our inner cities. In South Los Angeles,
residents often must leave their neighborhood to shop at a supermarket. This inner-city shortage
reflects the attraction to major chain supermarkets of higher mark-ups that more prosperous
neighborhoods will tolerate (Larson, 2003).

15%

23%

31%
34%38%

10%
15%
20%
25%
30%
35%
40%

1980 1990 2000 2010

United States Obesity Rates,
1980 to 2014

BUSINESS FORUM Vol 27, Issue 1 | 26

A consequence of this supermarket shortage is the reduced availability of fruits, vegetables,
and quality meat in low-income neighborhoods. This shortage of nutritious food is seen as an
important contribution to the rise in obesity in inner-city neighborhoods (Chen et al., 2010).

Chain Supermarkets in South Los Angeles

This study identifies the supermarkets today and in 1995 in an area that was studied by

Rebuild LA (RLA) after the 1992 Los Angeles riots. The area examined is shown on the maps in
Figures 2 and 3. This is the RLA Retail Focus Area and represents the neighborhoods that had the
greatest property damage due to the 1992 riots. RLA reported in 1996 that there were 32 major
chain supermarkets in the RLA Retail Focus Area (RLA, 1996). This area included South Central
LA plus neighborhoods north of the I-10 freewaylargely Koreatown and Pico-Union. This area
was later examined by Amanda Shaffer (2002), who found only 30 major chain supermarkets.
Today, there are 24 major chain stores. There were 23 independent supermarkets reported in 1996,
with a total of 55 full-service supermarkets in 1996 (shown in Map1), serving a population of over
700,000 (U.S. Census, American Community Survey). The total number of supermarkets is 56
today (shown in Map 2), but is 60 if we add in stores near the RLA Focus Area that are in
Inglewood. The majority of supermarkets today are independent.

Los Angeles had a long history of development of local chains and independent stores,
which was followed by a wave of mergers in the 1980s and 1990s that greatly concentrated
ownership of supermarkets. In 1992, there were mostly independent and small chain, full-service
supermarkets in South Central. The merger waves created the major chains we see today in Los
Angeles. The dominant grocery chain today is owned by Kroger Corporation, which operates as
Ralphs and Food 4 Less. The other major chain stores, Vons and Albertsons, are owned by a private
investment company Cerberus Capital (Peltz, 2015). The wave of mergers brought major chains
into South Central as they bought out local chains with some stores in South Central (Larson,
2003). After taking over stores located in South Central, Ralphs divested of some of the stores and
stayed with mostly warehouse stores under the Food 4 Less brand. Independents have taken over
some of the Ralphs stores and have added some new supermarkets.

The stores that serve South Central have been viewed collectively as inadequate for the
needs of the population. An RLA survey done in 1995 of the retail needs of residents of the RLA
Focus Area revealed that a lack of supermarkets was the number one problem facing residents.
Residents were traveling up to five miles to get to a full-service supermarket. Of the residents
surveyed, 25% had to use public transportation to get to a supermarket (RLA, 1996). Much grocery
shopping occurred outside South Central due to the shortage of supermarkets. The RLA study of
the demand and supply conditions for food in South Central estimated that 40% of the food
purchased by residents had to be bought outside South Central. RLA estimated that South Central
needed thirty more full-service supermarkets to satisfy resident demand in 1995. A more recent
study by Community Health Councils compared travel access to grocers in South LA and West
LA and found access was much easier in West LA (Bassford et al., 2010).

For access to nutritional food, that food has to be affordable. It is often assumed that major
chain supermarkets offer food at prices lower than at independent supermarkets. The chains do
have a history of offering lower prices than small grocery stores and mom-and-pop stores. The
major chains often have an advantage in paying lower prices for their inputs. For years, it has been
argued that the poor pay more when living in ghettoes and barrios. This may be true for many
purchases, but may not be true for food in independent supermarkets.

BUSINESS FORUM Vol. 27, Issue 1 | 27

Sources: GIS map by Mario Garcia, UCLA Center for Neighborhood Knowledge. Data are from
RLA (1996).

Figure 2. Map 1: Supermarkets in South Los Angeles, RLA (1996)

BUSINESS FORUM Vol 27, Issue 1 | 28

Sources: GIS map by Mario Garcia, UCLA Center for Neighborhood Knowledge. Data are
available from authors.

Figure 3. Map 2: Supermarkets in South Los Angeles in 2017

BUSINESS FORUM Vol. 27, Issue 1 | 29

Survey results from different cities have different conclusions. Chung and Meyers (1999)
found higher food prices in inner-city grocery stores in Minneapolis and St. Paul. Ambrose (1979)
found no difference between inner-city stores and suburban stores in Omaha. Hayes (2000) found
that prices in inner-city neighborhoods in New York City were not higher. In studies where the
poor have been found paying higher prices, small grocery stores in inner cities are often being
compared to larger suburban, full-service supermarkets. Larson (2003) compared full-service
supermarkets that were independent to similar-size, major chain supermarkets and found that the
independent markets had much lower prices on fresh fruits, vegetables, bread, and eggs and similar
prices on milk and sodas. This price study was repeated by the author in the Fall of 2016 with
similar results. The independent supermarkets in South Los Angeles do have a reputation for low
prices compared to the major chain stores.

The Rise of Fast-Food Chain Restaurants in South Los Angeles

Supermarkets compete with restaurants as well as with small markets, farmers markets,

street vendors, and even with liquor stores, in providing food. Since 1995, as some chain
supermarkets left South Central, fast-food restaurants were coming in. While supermarkets remain
the major source of food, chain restaurants are getting a growing share of food sales.

Before 1992, national chain fast-food restaurants were very rare in South Central. Around
1994, McDonalds opened its first restaurant in South Central. Since 1992, a number of other
national and regional fast-food chains have built stores in South Los Angeles. This has increased
the variety of foods available and has aided full-time workers in saving time from household food
preparation. This has also benefited those without access to a kitchen. EBT cards can be used in
many fast food restaurants in low-income neighborhoods. These cards are used for food stamps
and cash welfare benefits. People with no kitchen can spend food-stamp money at participating
McDonalds. There are also more jobs for low-skilled workers.

In 2008, the City of Los Angeles enacted a partial and temporary ban on new stand-alone,
chain fast-food restaurants in South Los Angeles. The ban reflected the view that chain fast-food
restaurants were themselves serious public health problems (Office of the City Clerk, 2008). The
ban also reflected a concern that the presence of fast-food restaurants was denser than in more
affluent neighborhoods. The ban was made permanent in 2010. The ban was limited to stand-alone
restaurants. Restaurants connected to other buildings (as in malls) were still allowed. Sturm and
Hattori (2015) report that 17 more fast-food restaurants were built in South Los Angeles after the
ban. The ban may provide the community with a signal that fast food represents a health hazard,
but seems ineffective in halting the growth of fast-food outlets. Community Health Councils has
recommended further restrictions on chain fast-food restaurants (Bassford et al., 2011).

We used Los Angeles County Public Health data to identify and count the number of chain
fast-food restaurants in South Los Angeles and in Los Angeles County overall (Los Angeles
County, 2017). The number of chain fast-food restaurants in South Central today is higher per
capita than across Los Angeles County. There are almost 19 fast-food restaurants per 100,000
residents in Los Angeles County. For South Los Angeles, there are almost 27 fast-food restaurants
per 100,000 residents.

BUSINESS FORUM Vol 27, Issue 1 | 30

Discussion

This study has shown that just as there was a shortage of full-service supermarkets in South
Central (the RLA Focus Area) in 1996, there is still a shortage. Meanwhile, South Central and
South Los Angeles have gone from hardly any chain fast-food restaurants to having a higher per
capita number of chain restaurants than Los Angeles County overall. The shortage of supermarkets
and the abundance of fast-food restaurants are both identified as contributing to an obesity
epidemic.

The shortage of supermarkets may not represent a lack of opportunity for profit. In South
Los Angeles, there is a major chain, Ralphs, that has stayed with most of the supermarkets acquired
through mergers and has even built new discount supermarkets (Food for Less). There are also
small independent chains that have expanded their supermarkets in South Los Angeles while
offering competitive prices. The shortage of supermarkets may reflect a mis-assessment of profit
opportunities by other major chains and a difficulty with financing for the small independent
supermarkets. There are also other barriers that have been identified and solutions proposed in a
report to the City of Los Angeles (Jordan, 2009). Urban planners need to think of supermarkets as
important neighborhood institutions and look for ways to help bring more supermarkets into inner-
city neighborhoods like South LA. A principle problem is simply finding sites large enough to be
developed for a standard size supermarket. This can be done. The Juanita Tate Marketplace is an
example of successful development in one of the poorest parts of South LA. The Marketplace has
an independent grocer, Northgate, plus the kind of stores that are found in more affluent
neighborhoods: CVS Pharmacy, Starbucks, Panda Express, Fatburger, and others. But, it took
seventeen years to create the Marketplace.

South LA has long lacked investment by major chain stores of all types. Community
organizations have expressed frustration over the inability to get major corporations to invest in
low-income neighborhoods. McDonalds, Burger King, and other fast-food chains are bringing new
businesses. This may not be good for diets, but does bring some pride to neighborhoods that lack
brand name retailers and shows that there are opportunities for investment in South LA.

Sturm and Hattori (2015) found no impact of the City of Los Angeles ban on new chain
fast-food restaurants. Plus, small mom-and-pop restaurants (mostly serving fast food) that number
in the hundreds in South Los Angeles are not subject to the ban. There are alternatives to the ban
on chain restaurants that could be more effective. Sturm and Cohen (2009) state that a primary
cause of empty calories is drinking sugar-sweetened beverages (SSBs). The World Health
Organization (WHO) advocates taxing SSBs globally. The WHO also recommends a number of
other government interventions aimed at combatting obesity epidemics in many nations (World
Health Organization, 2015). A different approach than a ban was taken by the City of Berkeley
when it placed a tax on SSBs in 2015. The SSB tax targeted beverages that are linked to obesity.
Falbe (2016) states that SSB consumption has become a public health priority. In a study of
Berkeley after the SSB tax was imposed, Falbe found that SSB consumption has been reduced
significantly in low-income neighborhoods while water consumption increased. The tax is one
cent per ounce and is associated with reduced SSB consumption of 21% and with increased water
consumption of 63% in Berkeley.

The obesity epidemic has costs to society that exceed private costs (known in economics
as negative externalities). When individuals make choices that are harmful not just to themselves,
but to others as well, economists accept that government action may be justified on the grounds of
improvements in efficiency. Taxes on cigarettes and alcohol are seen as beneficial to society by

BUSINESS FORUM Vol. 27, Issue 1 | 31

curbing harmful behavior that is costly to society and not just to individuals. It is not clear what
intervention would be efficient in combating obesity. The Berkeley experiment shows that a SBB
tax can be effective and may represent an alternative to trying to limit the number of fast-food
restaurants. Another alternative may be an increase in education regarding the links between diet
and health. States, such as California, with successful anti-smoking campaigns have used bans,
health education, and taxes to discourage smoking (Pierce, White, & Emory, 2011). The obesity
epidemic is forcing businesses and government to work on solutions. Here, a tax may be better
than a ban, but other interventions have to be expected.

Corresponding author: Dr. Tom Larson, [emailprotected]

References

Ambrose, D. (1979). Retail grocery pricing: Inner-city, suburban and rural comparisons. Journal
of Business, 52, 95-102.

Bassford, N., Galloway-Gilliam, L., & Flynn, G. (2010). Food Desert to Food Oasis: Promoting
Grocery Store Development in South Los Angeles. Community health councils.

Bassford, N., Galloway-Gilliam, L., Flynn, G., & Morrison, B. N. (2011). Fast Food Restaurant
Report. Community health councils.

Chen, S., Florax, R., Snyder, S., & Miller, C. C. (2010). Obesity and Access to Chain Grocers,
Economic Geography, 86(4), 431-452.

Centers for Disease Control and Prevention, Leading Causes of Death,
www.cdc.gov/nchs/fastats/leading-causes-of-death.htm, 2016.

Chung, C., & Meyers, S. (1999). Do the Poor Pay More for Food: an Analysis of Grocery Store
Availability and Food Price Disparities. The Journal of Consumer Affairs, 33(2).

County of Los Angeles Public Health (2011). County of Los Angeles Public Health, Obesity and
Related Mortality in Los Angeles County, Sep. 2011.

Eisenhauer, E. (2001). In poor health: Supermarket redlining and urban nutrition, GeoJournal
53, 125133.

Falbe, J., Thompson, H.R., Becker, C.N., Rojas, N., McCulloch, C.E., & Madsen, K.A. (2016).
Impact of the Berkeley Excise Tax on Sugar-Sweetened Beverage Consumption, American
Journal of Public Health, 106(10),1865-71. doi: 10.2105/AJPH.2016.303362.

Fryar, C. D., Ervin, R. B. (2013). Caloric intake from fast food among adults: United States,
20072010. NCHS data brief, no 114. Hyattsville, MD: National Center for Health
Statistics.

Fryar, C. D., Carroll, M. D., & Ogden, C. L. (2016). Prevalence of Overweight, Obesity, and
Extreme Obesity Among Adults: United States, 19601962 Through 20132014, Centers
for Disease Control and Prevention, Division of Health and Nutrition Examination
Surveys, July, 2016.

Hayes, L. R. (2000). Are prices higher for the poor in New York City?, Journal of Consumer
Policy; Jun 2000; 23, 2.

Jordan, J. (2009). Stimulating Supermarket Development in South Los Angeles, UCLA.

BUSINESS FORUM Vol 27, Issue 1 | 32

Kleinert, S., & Horton, R. (2015) Rethinking and Reframing Obesity. The Lancet, 385(9985),
2326-2328, June 13, 2015.

Larson, T. (2003). Why There Will be No Chain Supermarkets in Poor Inner-City
Neighborhoods, Journal of California Politics and Policy, Edmund G. “Pat” Brown
Institute of Public Affairs, 7(1), June, 2003.

Los Angeles County Department of Public Health, Obesity and Related Mortality in Los Angeles
County, September, 2011.

Los Angeles County Department of Public Health Environmental Health,
https://ehservices.publichealth.lacounty.gov/ezsearch, 2017.

Los Angeles Food Policy Council, Los Angeles Food System Snapshot, 2016.
Morland, K., Diez Roux, A. V., & Wing, S. (2006). Supermarkets, Other Food Stores, and

Obesity, The Atherosclerosis Risk in Communities Study, American Journal of
Preventive Medicine, 30(4).

Office of the City Clerk, City of Los Angeles, 2010. Council File No.10-1843.
Pierce, J. P., White, V. M., & Emery, S. L. (2017). What public health strategies are needed to

reduce smoking initiation? Retrieved from http://tobaccocontrol.bmj.com/ on June 6.
OECD, Obesity Update 2017, www.oecd.org/health/obesity-update.htm, OECD 2017.
Pastor, M., Hondagneu-Sotelo, P., Sanchez-Lopez, A., Stephens, P., Carter, V., & Thompson-

Hernandez, W. (2016). USC Center for the Study of Immigrant Integration, Oct. 2016.
Peltz, J. F. (2015). Grocer Albertsons Cos., Parent of Vons, Plans Public Stock Offering, Los

Angeles Times, July 8.
RLA, RLA Final Report, Michael Milken Foundation, Santa Monica, 1996.
Shaffer, A. (2002). The Persistence of LAs Grocery Gap: The Need for a New Food Policy and

Approach to Market Development. Los Angeles, CA: Center for Food and Justice, Urban
and Environmental Policy Institute, Occidental College.

Stikes, A. S., & and Preston, S. H. (2017). Deaths Attributable to Diabetes in the United States:
Comparison of Data Sources and Estimation Approaches, PLOS ONE
DOI:10.1371/journal.pone.0170219 January 25, 2017 1 / 12.

Sturm, R. (2002). The effects of obesity, smoking, and drinking on medical problems and costs,
Health Affairs 21(2), 245-253. doi: 10.1377/hlthaff.21.2.245.

Sturm, R., & Cohen, D. A. (2009). Zoning For Health? The Year-Old Ban on New Fast-Food
Restaurants in South LA, Health Affairs 28(6), w1088-w1097, doi:
10.1377/hlthaff.28.6.w1088. Originally published online October 6, 2009.

Sturm, R., & Hattori, A. (2015) Diet and obesity in Los Angeles County 2007-2012: Is there a
measurable effect of the 2008 Fast-Food Ban? Social Science and Medicine, 133, 2015.

Tavernise, S. (2016, Oct. 11). WHO Urges Tax on Sugary Drinks to Fight Obesity, New York
Times.

U.S. Census, American Community Survey, https://www.census.gov/programs-surveys/acs.
Wang, Y., & Beydoun, M. A. (2007). The Obesity Epidemic in the United StatesGender,

Age, Socioeconomic, Racial/Ethnic, and Geographic Characteristics: A Systematic
Review and Meta-Regression Analysis, Epidemiologic Reviews, Johns Hopkins
Bloomberg School of Public Health, Vol. 29.

World Health Organization (2015). Fiscal Policies for Diet and Prevention of Noncommunicable
Diseases, Technical Meeting Report, 56 May 2015, Geneva, Switzerland.

Wolstein J., Babey, S. H., & Diamant, A. L. (2015). Obesity in California. Los Angeles, CA:
UCLA Center for Health Policy Research.

BUSINESS FORUM Vol. 27, Issue 1 | 33

WHO DID THE AFFORDABLE CARE ACT HELP AND WHO
DID IT FAIL?

Zhen Cui
&

Devika Hazra
California State University, Los Angeles

SUMMARY: This study uses the 2007 and 2013 Annual Social and Economic Supplement of the
Current Population Survey to examine the effect of the Affordable Care Act (ACA) on health
insurance coverage among adults in the U.S. It finds that the ACA has improved coverage for men,
youth, minorities, and low-income and less-educated individuals. However, those who are self-
employed or do not work full-time have been negatively impacted. We analyze these results and
discuss business and policy implications.

Introduction

The Patient Protection and Affordable Care Act of 2010 (ACA) has been a contention for
policymakers since its inception. While evidence on actual health outcomes is still sparse, a few
studies have shown a decrease in the number of the uninsured. A study done by Sommers,
Buchmueller, Decker, Carey, and Kronick (2013) found sizable coverage gains for adults aged 19
25. The gains continued to grow throughout 2011, with the largest gains seen in unmarried adults,
non-students, and men. According to Sommers, Gunja, and Finegold (2015), low-income adults
within the states that expanded Medicaid reported significant gains in insurance coverage and
access compared with adults within the states that did not expand Medicaid. Moreover, Sommers,
Maylone, Blendon, Orav, and Epstein (2017) assessed changes in health care use and self-reported
health after three years of the ACAs coverage expansion, using survey data collected from low-
income adults through the end of 2016 in two states (Arkansas and Kentucky) that expanded
coverage, and Texas that did not expand coverage. By the end of 2016, the uninsurance rate in the
two expansion states had dropped by more than 20 percentage points relative to the non-expansion
state. Finally, Figure 1 shows the percentage of adults aged 1864 who were uninsured or had
private or public coverage at the time of interview in the U.S. between 19972016.

After the main ACA provisions went into effect in 2014, racial disparities in coverage
declined slightly as the percentage of adults who were uninsured decreased by 7.1 percentage
points for Hispanics, 5.1 percentage points for Blacks, and 3 percentage points for Whites
(Buchmueller et al., 2016). McMorrow, Long, Kenny, and Anderson (2015) found significant
improvements in insurance coverage for all racial and ethnic groups between the second and third
quarters of 2013 as well as 2014, which translated into reductions in absolute disparities in the
uninsurance rates for Blacks and Hispanics in both expansion and non-expansion states.
Furthermore, Chen, Vargas-Bustamante, Mortensen, and Ortega (2016) demonstrated that racial
and ethnic disparities in access had been reduced significantly during the initial years of the ACA
implementation.

BUSINESS FORUM Vol 27, Issue 1 | 34

Figure 1. Percentages of adults aged 1864 who were uninsured or had private or public coverage
at the time of interview: United States, 19972016

Despite coverage improvement for men, single adults, and minorities, the ACA had a

negative effect on other subpopulations. For example, Blumberg, Corlette, and Lucia (2014)
roughly estimated that the number of uninsured self-employed individuals and entrepreneurs
would relatively increase by more than 11% following the ACA.

Against the above background, the present study applies a probit regression separately to
the 2007 and 2013 Annual Social and Economic Supplement of the Current Population Survey
(ASEC CPS). It then compares the effects of main demographic traits and socioeconomic factors
on health insurance coverage in the U.S. for adults across all ages before and after the signing of
the ACA. We find that the coverage has improved for men, youth, minorities, and low-income and
less-educated individuals, while adversely impacting those who are self-employed or do not work
full-time. These findings are largely consistent with the existing studies. Thus, this study makes
two major contributions to the literature. First, it adds more empirical evidence regarding the
impact of the ACA on health insurance coverage for the adult population in the U.S. Second, it
provides practical policy and business insights by identifying specific groups which policymakers
and practicing managers should focus on extending the insurance coverage to in the post-ACA era.

The rest of the paper proceeds as follows. We describe the data and the econometric model,
explain the regression results, and then present the concluding remarks as well as policy and
business recommendations.

BUSINESS FORUM Vol. 27, Issue 1 | 35

Empirical Strategy

The ASEC CPS is a rich dataset that has detailed information on employment,
demographics, and health insurance. The data used in this study are extracted from its 2007 and
2013 series, marking the three years before and after the signing of the ACA. After removing
missing values and restricting respondents to civilians aged 1879, the number of individual
observations in our final sample is 247,943 (125,851 for 2007 and 122,092 for 2013).

The dataset has a constructed variable that indicates whether a respondent had any health
insurance coverage (private or public) in the previous year. This study considers a respondent
covered by health insurance if the answer is yes, and not covered by health insurance if the answer
is no. Per this definition, about 82% of our sample had health insurance (83% for 2007 and 82%
for 2013). Clearly, not everyone was covered even three years after the ACA was signed into law.
This highlights the relevance and importance of studying the determinants of health insurance
coverage in the post-ACA era. All statistics reported in this study are appropriately weighted.

Existing studies on the determinants of health insurance coverage typically employ a binary
response model (i.e., logit or probit regression). For example, Gius (2010) used the 2008 National
Health Interview Survey and adopted a logit regression to examine the determinants of health
insurance coverage for young adults. Cantiello, Fottler, Oetjen, and Zhang (2015) used the 2005
and 2008 Medical Expenditure Panel Survey to investigate the factors that influence young adults
decisions to have private health insurance. They incorporated structural equation modeling into a
standard logit regression.

Following those studies, we apply the probit regression below to the 2007 and 2013 data
separately. A comparison of results from these two years would enable us to examine the effect of
the ACA on adult health insurance coverage in the U.S.
coveredi = + 1 agei + 2 malei + 3 log_incomei + 4 fulltimei + 5 self_empi

+ 6 highschooli + 7 collegei + 8 graduatei + 9 whitei + ui,
where coveredi is a dummy variable that takes 1 if individual i has health insurance coverage and
0 otherwise, agei denotes the individuals age, malei is a dummy variable that takes 1 if the
individual is male and 0 otherwise, log_incomei denotes the individuals logged annual pre-tax
wage and salary income,1 fulltimei is a dummy variable that takes 1 if the individual has a full-time
job and 0 otherwise, self_empi is a dummy variable that takes 1 if the individual is self-employed
and 0 otherwise, highschooli is a dummy variable that takes 1 if the individual has completed 12
years of schooling or received a high school diploma and 0 otherwise, collegei is a dummy variable
that takes 1 if the individual has some college education or received an Associates or a Bachelors
degree and 0 otherwise, graduatei is a dummy variable that takes 1 if the individual has a Masters
degree or above and 0 otherwise, whitei is a dummy variable that takes 1 if the individual is White
and 0 otherwise, and ui denotes the standard classical error term. Therefore, our analysis takes into
account both basic demographic traits (i.e., age, gender, and race) and various socioeconomic
factors (i.e., income, employment, and educational attainment). Table 1 describes the summary
statistics of all the variables.

1 The income amounts have been adjusted for inflation using the Consumer Price Index (1999 =
100). Also, striving for the maximum number of observations, we use log (inflation-adjusted income + 0.1)
to account for income value of zero.

BUSINESS FORUM Vol 27, Issue 1 | 36

Table 1
Summary Statistics

2007 2013
VARIABLE MEAN SD MIN MAX MEAN SD MIN MAX
covered 0.83 0.38 0 1 0.82 0.39 0 1
age 44.14 16.03 18 79 45.05 16.40 18 79
male 0.49 0.50 0 1 0.49 0.50 0 1
log_income 5.99 5.80 -2.30 13.16 5.55 5.91 -2.30 13.80
fulltime 0.57 0.50 0 1 0.51 0.50 0 1
self_emp 0.08 0.26 0 1 0.07 0.25 0 1
highschool 0.33 0.47 0 1 0.31 0.46 0 1
college 0.46 0.50 0 1 0.49 0.50 0 1
graduate 0.09 0.29 0 1 0.10 0.31 0 1
white 0.81 0.39 0 1 0.79 0.41 0 1

Notes. SD = standard deviation.

Results

Table 2 shows the average marginal effects estimated using the probit regression model for
the 2007 and 2013 data, respectively. The estimates suggest that all marginal effects are highly
statistically significant. The age and gender gap in health insurance coverage has shrunk. A one
year decrease in age reduced the average probability of having health insurance by 0.54 percentage
point in 2007, but by 0.50 percentage point in 2013. The probability of adult males having health
insurance was 3.32 percentage points lower than that of adult females in 2007; this number dropped
to 2.99 in 2013.

Table 2
Average Marginal Effects of Probit Model, 2007 vs. 2013

2007
(N = 125,851)

2013
(N = 122,092)

VARIABLE MARGINAL
EFFECTS

STANDARD
ERRORS

MARGINAL
EFFECTS

STANDARD
ERRORS

age 0.0054*** 7.30e-05 0.0050*** 7.28e-05
male -0.0332*** 0.0025 -0.0299*** 0.0025
log_income 0.0031*** 0.0003 0.0007** 0.0003
fulltime 0.0040 0.0034 0.0330*** 0.0034
self_emp -0.0859*** 0.0044 -0.1130*** 0.0047
highschool 0.0884*** 0.0033 0.0801*** 0.0037
college 0.1850*** 0.0033 0.1780*** 0.0036
graduate 0.2890*** 0.0069 0.2740*** 0.0064
white 0.0391*** 0.0029 0.0368*** 0.0029

Notes. * p < 0.1. ** p < 0.05. *** p < 0.01. The race and income gap in health insurance coverage has also shrunk. For example, Whites were 3.91 percentage points more likely to have health insurance than non-Whites in 2007, but were 3.68 percentage points more likely in 2013. A 10% decrease in income reduced the BUSINESS FORUM Vol. 27, Issue 1 | 37 average probability of having health insurance by 0.031 percentage point in 2007, but by 0.007 percentage point in 2013. In addition, the education gap in health insurance coverage has shrunk. High school graduates were 8.84 percentage points more likely to have health insurance than those with below high school education in 2007; this number fell to 8.01 in 2013. For college-educated individuals, the probability of having health insurance was 18.5 percentage points higher than those who did not go to college in 2007, but were 17.8 percentage points higher in 2013. Individuals with graduate degrees or higher were 28.9 percentage points more likely to have health insurance than those who did not have graduate degrees in 2007; this number fell by 1.5 in 2013. Unfortunately, health insurance coverage has deteriorated for individuals who are self- employed or do not have full-time jobs. The self-employed were 8.59 percentage points less likely to have health insurance than their non-self-employed counterparts in 2007, but were 11.3 percentage points less likely in 2013. For people without full-time jobs, they were 0.4 percentage point less likely to have health insurance than full-time job holders in 2007, but were 3.3 percentage points less likely in 2013. These two marginal effect changes are the biggest among all the factors examined. Lastly, despite the changes observed between 2007 and 2013, the magnitudes of most changes are fairly small. Also, men, minorities, and young people are still less likely to have health insurance, so are low-income and less-educated individuals as well as those who are self-employed or do not have full-time jobs. Discussion of Implications This study examines the determinants of adult health insurance coverage in the U.S. between 2007 (pre-ACA) and 2013 (post-ACA). We find that after the signing of the ACA, health insurance coverage has improved among males, youth, minorities, and low-income and less- educated individuals, but deteriorated for people who are self-employed or do not work full-time. While the first set of findings is encouraging, the observed changes are still rather small. Moreover, the ACA did not expand health insurance coverage as fast and drastically as expected. Perhaps more public outreach and education are needed to magnify the positive impact. Also, future research should re-examine this topic when more recent data become available. The second set of findings is troubling. In light of these findings, we make the following recommendations to policymakers and practicing managers. For policymakers, we suggest that future policies offer companies more incentives to provide their part-time employees with health insurance. Also, policymakers should pay more attention to people who are self-employed by encouraging them to obtain coverage and making health insurance more affordable to them. This group of people will grow rapidly in size in the near future as technology advancement makes freelancing and entrepreneurship more accessible to the general public. For practicing managers, as internet-based technology progresses further, freelancing will become the future of work either by workers choice or due to business contingency. Currently, freelancers are considered as self-employed and are responsible for their medical and dental insurance entirely on their own. While this group of people is largely neglected by policymakers, one wonders if there is a solution in the private sector. For example, businesses could offer to partially contribute to a freelancers health insurance, if the freelancer agrees to pay into the companys account reserved for covering the benefits of their regular employees. Given our BUSINESS FORUM Vol 27, Issue 1 | 38 findings, this approach would not only demonstrate a companys commitment to social responsibility, but would potentially make itself more attractive to certain freelancers. Corresponding author: Dr. Zhen Cui, [emailprotected] References Blumberg, L.J., Corlette, S., and Lucia, K. 2014. The Affordable Care Act: Improving incentives for entrepreneurship and self-employment. Public Policy & Aging Report, 24(4), 162-7. Buchmueller, T. C., Levinson, Z. M., Levy, H. G., and Wolfe, B. L. 2016. Effect of the Affordable Care Act on racial and ethnic disparities in health insurance coverage. American Journal of Public Health, 106, 1416-21. Cantiello, J., Fottler, M. D., Oetjen, D., and Zhang, N. J. 2015. The impact of demographic and perceptual variables on a young adults decision to be covered by private health insurance. BMC Health Services Research, 15, 1-15. Chen, J., Vargas-Bustamante, A., Mortensen, K., and Ortega, A. N. 2016. Racial and ethnic disparities in health care access and utilization under the Affordable Care Act. Medical Care, 54(2), 140-6. Gius, P. M. 2010. An analysis of the health insurance coverage of young adults. International Journal of Applied Economics, 7(1), 1-17. McMorrow, S., Long, S. K., Kenney, G.M., and Anderson, N. 2015. Uninsurance disparities have narrowed for Black and Hispanic adults under the Affordable Care Act. Health Affairs, 34(10), 1774-8. Sommers, B. D., Buchmueller, T., Decker, S. L., Carey, C., and Kronick, K. 2013. The Affordable Care Act has led to significant gains in health insurance and access to care for young adults. Health Affairs, 32(1), 165-74. Sommers, B. D., Gunja, M. Z., Finegold, K., and Musco, T. 2015. Changes in self-reported insurance coverage, access to care, and health under the Affordable Care Act. Journal of the American Medical Association, 314(4), 366-74. Sommers, B. D., Maylone, B., Blendon, R. J., Orav, E. J., and Epstein, A. M. 2017. Three-year impacts of the Affordable Care Act: Improved medical care and health among low- income adults. Health Affairs, 36, 1119-28. BUSINESS FORUM Vol. 27, Issue 1 | 39 LESSONS FROM THE HEALTHCARE FUNDING CHALLENGES AT KONKOLA COPPER MINES IN ZAMBIA Mwadi Kakoma Chakulya Konkola Copper Mines Medical, Zambia Francis Wambalaba United States International University, Kenya Barbara W. Son Anaheim University, USA, and Medical Tactile Imaging, Inc. SUMMARY: The global challenge of healthcare financing due to rising healthcare costs requires innovative solutions. This challenge is present not only at the U.S. national level and employer- based financing, but also internationally in organizations such as Konkola Copper Mines (KCM) in Zambia. This study sought to determine effective healthcare funding options for KCMs employee medical services to be more self-sustaining and reduce its reliance on a single source of funding. We surveyed 285 KCM employees and nine management staff from June to July 2016. The employees showed a willingness to contribute towards prepayment medical schemes and earmarked employee contributions to support funding for specific areas of medical services. However, they did not favor employee contributions directly towards general medical services. This research offers suggestions for addressing inefficiencies with the current resources and implementing prepayment employee medical schemes as a funding option. Introduction Located in the middle of Southern Africa, Zambia was one of the worlds fastest growing economies with a real GDP growth averaging roughly 6.7% per year during 2004-2014. The countrys dependency on copper as its sole major export made it vulnerable to global price fluctuations (World Factbook, 2017). According to the Center for Disease Control (CDC, 2015), Zambias population was about 15 million, per capita income was $3,860, life expectancy at birth was 56 for women and 51 for men, and the top three diseases were HIV/AIDS, tuberculosis, and diarrheal and cardiovascular diseases. Therefore, timely access to healthcare services and their availability and affordability that are dependent on well-functioning healthcare models are critical for Zambias development. According to the WHO Regional Office for Africa (2013), some of Zambias healthcare-funding models include sources such as donor countries that fund specific healthcare programs. Another model involves private organizations and facilities that also provide healthcare in Zambia. For example, the mining industry historically had developed a network of health facilities, particularly across the Copperbelt Province of Zambia, to provide healthcare to miners. Unlike in the United States, where the health insurance system has been well established, the insurance system in Zambia has not been well developed. However, in both Zambia and the BUSINESS FORUM Vol 27, Issue 1 | 40 U.S., labor unions have been very instrumental in pushing the miners health agenda. For example, even after threats of coal-mining companies bankruptcies, the United Mine Workers Association (UMWA) has been instrumental in working with U.S. legislators to continue providing financial support, as evidenced in the 2017 Miners Protection Act (Volcovici, 2017). Mwale (2014) posits that, in terms of representation, the Mine Workers Union of Zambia (MUZ) was one of the most vital bargaining agents for most major mining companies in Zambia. Among the key goals of MUZ was providing members relief in sickness, accidents, disability, distress, unemployment, victimization trade disputes, and funeral expenses for deceased members. This study examines the health challenges for Zambian miners with implications for the mining industry in the US and elsewhere. Although the benefits of promoting employee health are extensively covered in the healthcare management literature, there is a lack of in-depth research that considers employee health promotion from the employee perspective in the Zambian mining industry. Furthermore, limited information is available to address the Zambian mining industry and how organizations such as Konkola Copper Mines (KCM) can develop strategies for funding employee medical services. Due to lack of resources and conflicting priorities between copper production and funding employee health services, KCMs medical services were faced with the inability to become more financially self sufficient. Accordingly, this study examines how employees could have a role in helping the medical services department become financially sustainable. To address this issue, this study analyzes hypotheses regarding KCM employees potential contributions towards medical services with respect to union membership, gender, marital status, and location based on a 2016 survey. The study also discusses implications of the empirical results on employer-based healthcare financing in the Zambian mining industry in general. Furthermore, this study sheds light on the growing challenges in the US mining industry and on the union problems regarding health coverage and financing. These issues are further examined in the discussion. Background KCM, one of Africa's largest integrated copper producers, is situated in the Copperbelt Province of Zambia. The organization is a subsidiary of Vedanta Resources, which was founded in India in 1976 (Vedanta, 2017). KCM was previously under a mining conglomerate called Zambia Consolidated Copper Mines (ZCCM). ZCCM had established water and electricity utility facilities, recreational facilities, educational facilities, and health services. The privatization process in the late 1990s and early 2000s required the mining companies to take up most of the social services. Therefore, at the time of privatization, KCM inherited two mine hospitals, eight community clinics, and six plant site clinics (Kumar, 2016). The company has been offering free medical services to employees and their dependents for the past fifteen years since privatization. Despite opening up services to the public and contractors, the income generated by the services is only 11% of the total annual operating costs. Income earned from services rendered to fee-paying contractor companies began to dwindle as the decline of contractor jobs around the mine resulted in a reduced number of contractor clients accessing the services (Carrin, Doetinchem, Kirigia, Mathauer, & Musango, 2008). The organization therefore needed to seek other options in order for medical services to become self- sustaining. The increasing operational costs of running medical services with the ever-increasing costs of running the mining operations created internal competitive financial pressure on how the organization prioritizes and utilizes its resources. The low copper prices on the international BUSINESS FORUM Vol. 27, Issue 1 | 41 markets also meant that the organization could not make significant revenues and profits needed to cover costs for the medical department (Chuma, Mulupi, & McIntyre, 2013). This is unlike the US coal mining industry, in which some mines had been abandoned and, hence, their retired workers had faced health benefit cuts (Samuels, 2017). Therefore, the purpose of this study was to examine the potential of employee contributions for enhancing sustainability of employee medical services. Given the potential for decreased availability of company-sponsored health services for employees, it was anticipated that employee contributions would reduce the risk of losing such services. Hovlid, Bukve, Haug, Aslak, and Von Plessen (2012) used the learning theory to assess the sustainability of healthcare improvements. They argued that theoretical frameworks can guide further research on the sustainability of quality improvements and that theories of organizational learning have contributed to a better understanding of organizational change in other contexts. Similarly, the moral hazard theory has been referenced in this context, arguing that when people pay a higher share of total health spending, they become more careful consumers of healthcare and forgo unneeded care (Gould, 2013). For example, in their study of the UMWA Health Plan in the US, Roddy, Wallen, and Meyers (1986) noted that in 1977, UMWA members were given a 40% coinsurance requirement with $250 deductible for hospital care. However, Nyman (2007) refuted the application of the moral hazard theory in this context, arguing that most of the theory represented healthcare that patients would not access without insurance. Considering ecological models, health promotion can be most effective when all the interwoven social, institutional, and environmental factors are targeted together (Golden & Earp, 2012). Employers, too, have realized that by not investing in employee healthcare, they will incur high indirect health costs such as absenteeism, sick leaves, and loss of highly qualified labor (Porter, Teisberg, & Wallace, 2008). Employer-sponsored healthcare also ensures that employee welfare in the workplace is maintained by ensuring that employees are safeguarded from poor and unsafe working conditions through adherence to occupational health regulations, particularly in large industries such as mining, oil, and steel. This research assessed KCM employee preferences for healthcare cost share based on union membership, gender, marital status, and site location. Methodology This study used a descriptive research design that measures behavior, prevalence, or outcomes of a population under certain conditions (Bless, Smith, & Kagee, 2006). Employee healthcare benefits studies have previously utilized this form of study design to describe the various factors or phenomena associated with employer-sponsored healthcare (HRET, 2015). In this study, the population constituted 7,000 KCM employees, and the sampling frame was the list of all KCM employees in the human resources database in the information management system (SAP). Clustered and stratified random sampling techniques were used to obtain a representative sample of KCM employees. The clustering units were based on integrated business units (IBUs) or work locations, and each IBU was partitioned into several subpopulations, called strata, according to the KCM grade system. Samples were drawn independently across each stratum (Ahmed, 2009). Employees were then further randomly sampled according to their KCM grade, salary scale, or department. Hence, two hundred and eighty-five KCM employees and nine management staffs constituted the sample and were surveyed during the period from June to July 2016. The nine management staffs were identified as key informants with a good understanding of the medical services program. BUSINESS FORUM Vol 27, Issue 1 | 42 Two pre-tested structured questionnaires were employed to obtain data from KCM employees and management staff, respectively. A proposal was presented to the senior KCM Human Capital Management and KCM Medical Ethics Committee for approval to conduct the study among KCM employees. Meetings were also held with union officials in the presence of human resource officials to explain the study and to address any concerns. Research assistants were recruited and trained to ensure data accuracy. Employees could consent to participate in the study, were assured of confidentiality, and were allowed to opt out if they were not willing to participate. Data were coded, entered, and analyzed to compute descriptive statistics using the SPSS, STATA, and Minitab. Data Analysis Overall, the study found that most employees were not in favor of healthcare cost sharing. Agree and strongly agree had the highest combined rating, as shown in Table 1, with almost 89% of employee respondents preferring that KCM continued funding and providing free employee medical services. They were not keen on a monthly employee contribution for medical services or for the medical services to be handed over to the government. Table 1 Healthcare Funding Options for KCM Medical Services Employee Responses RESPONSE (%) Strongly Agree Agree Neither Agree or Disagree Disagree Strongly Disagree KCM should continue funding and providing free employee medical services 67.1 21.8 3.2 5.7 2.1 Employee willingness to make monthly contributions towards KCM medical services 4.3 20.1 9.3 30.1 35.8 Handing over KCM medical services to the government 4.3 11.1 9.3 27.6 47.7 Partnerships with other private organizations to run the medical services as a commercial unit 13.2 28.3 14.3 21.9 22.2 To further examine the negligible willingness by employees to contribute financially toward medical services, the study compared the proportions of union and non-union employees by testing the hypotheses: null hypothesis is Ho: p1 - p2 = 0 and alternative hypothesis is Ha: p1 BUSINESS FORUM Vol. 27, Issue 1 | 43 - p2 0, where groups 1 and 2 are union and non-union, respectively. Table 2 shows the output from the hypothesis testing using Minitab software. The z-value in the output is 4.14, and the p- value is 0.000, which is less than the significance level of value = 0.05. Thus, the p-value is highly significant and the null hypothesis is rejected in favor of the alternative. From the sample proportions, 75.2% of union employees opposed financial contribution to medical services versus 50.5% of non-union employees who opposed. The difference was statistically significant. Table 2 Employee Willingness to Contribute to Medical Services SUBSAMPLE N OPPOSE % OPPOSE Union 169 127 0.751 Non-Union 101 51 0.505 Female 74 47 0.635 Male 204 137 0.672 Single 52 33 0.635 Married 212 142 0.670 Nchanga 113 67 0.593 Konkola 109 80 0.734 Regarding gender influence on employee contributions towards medical services, the study compared the sample proportions for males and females where the null hypothesis was Ho: p1 - p2 = 0 and the alternative hypothesis was Ha: p1 - p2 0, where groups 1 and 2 were females and males, respectively. The z-value in the output was -0.57, while the p-value was not significant, hence the null hypothesis was not rejected. Therefore, the gender influence on employee contributions to medical services was not statistically significant, although from the sample proportions, males were more opposed to cost-share than were females (67.2% for males versus 63.5% for females). With respect to marital status, the study assessed the statistical significance of the difference in marital status on the willingness to contribute toward medical services and compared the proportion of single and married employees by testing the hypotheses: null hypothesis is Ho: p1 - p2 = 0 and alternative hypothesis is Ha: p1 - p2 0, where groups 1 and 2 were single and married employees, respectively. Since the p-value was greater than the significance level of value = 0.05, the null hypothesis was not rejected in favor of the alternative. Hence, the study concluded that the effect of marital status on the willingness to financially contribute toward medical services was not statistically significant, even though the sample proportions showed married employees were more opposed to the cost-share compared to single employees (67% for married employees versus 63.5% for single employees). Finally, to examine site locations influence on employee contributions to medical services, the study compared the sample proportions for employees at the Nchanga and Konkola sites. The null hypothesis was Ho: p1 - p2 = 0 and alternative hypothesis was Ha: p1 - p2 0, where groups 1 and 2 were employees in Nchanga and Konkola, respectively. The z-value in the output was - BUSINESS FORUM Vol 27, Issue 1 | 44 2.22, and the p-value =0.026 was less than the significance level of value = 0.05. Thus, the p- value was highly significant and the null hypothesis was rejected in favor of the alternative. From the sample proportions, 73.4% of employees in Konkola opposed financial contribution to medical services versus 59.3% of employees in Nchanga who opposed contributions. The difference was statistically significant. Discussion This study tested hypotheses regarding the willingness to contribute to medical services with respect to union membership, gender, marital status, and work sites of employees. As revealed in the analysis, the results demonstrated significant differences between union and non-union employees. Union employees strongly opposed more employee contributions to medical services, compared to non-union employees. It appears that union employees were more inclined to actively seek employee benefits including healthcare benefits than were low-paid non-union employees who were on short-term contracts. KCM had almost 50% contract employees (6,000) compared to 6,500 direct employees (Koyi, 2017). Most mining firms in Zambia increasingly preferred independent contractors for cost saving. Contractors typically earn 50-80% of what permanent employees earn (Danish Trade Union Council, 2014). For the gender hypothesis, the results showed that gender has insignificant influence on employee contributions to medical services, although males seemed to oppose more financial cost- share contributions towards medical services than did females. Male miners in Zambia have been vulnerable to labor abuses and have been exposed to unsafe working conditions for a longer period. Consequently, they have been continuously facing injuries and poor health, as the Zambian Ministry of Mines, Energy, and Water Development has been loosely enforcing the national labor law and safety regulations (Zambia: Safety Gaps, 2013). The study further revealed that marital status exerts weak impacts on employee contributions to medical services. Nonetheless, the sample proportions showed that married employees were more likely than single employees to oppose employee contributions to medical services. This could be explained by the fact that married employees have responsibilities toward their dependent children. They are estimated to have at least 10 dependents and must pay for school, food, and medical expenses (KCM workers, 2014). Finally, work locations seemed to have a significant impact on the willingness to financially contribute toward medical services as demonstrated. Employees in Konkola strongly opposed more employee contributions to medical services as compared to employees in Nchanga. In addition, permanent employees in Konkola seemed to be more determined to maintain current healthcare benefits in contrast with contract employees in Nchanga. KCM laid off 2,500 contract employees at its loss-making Nchanga site in 2015 (Hill, 2015). Furthermore, in 2016, the company notified MUZ about their continuous outsourcing plan to lure enormous investments. Consequently, over 4,000 workers were handed over to private contractors despite the opposition of Zambian government and mining unions (KCM handover, 2017). This could explain their willingness to contribute to avoid further layoffs. According to management respondents, the major challenge in financing KCM medical services was the dependence on copper revenues as the only source of financing. Additionally, allocation of healthcare funding is competing with priorities associated with copper production and the current liquidity challenges on the global market. Despite these challenges, management faces employees who prefer that KCM continue to provide free medical services to employees and BUSINESS FORUM Vol. 27, Issue 1 | 45 who are not keen on making financial contributions towards their medical services or benefits. In contrast, management respondents were more inclined towards employee contributions and fostering strategic partnerships with other organizations. Like the Zambian mining industry, rising healthcare costs are unsustainable in the US mining industry. To cope with the upward-spiraling healthcare costs, some US coal companies are seeking telemedicine and wellness programs, while reducing employer contributions to health savings accounts (Giardina, 2014). Meanwhile, mining unions are lobbying the government to protect their members benefits (Thornton, 2017). UMWA has been actively lobbying for the Black Lung Benefits Improvement Act, but it has been facing strong opposition from mining employers and their political allies (UMWA, 2017). Furthermore, oversight lapses in safety laws whether in Zambia or in the U.S put miners at higher health risks. Non-union miners in Zambia and the US are especially vulnerable to unsafe work conditions. Rising outsourcing and non-union jobs are fueled by foreign investors in the Zambian mining industry, while UMWA faces tough huddles due to the shrinking mining industry and falling memberships (Peterson & Jones, 2015). Conclusions and Recommendations Like the Zambian mining industry, the US mining industry has faced labor unions that have sought to protect miners health. In both cases, the industry has not only been financially hit by falling prices but has also been facing rising healthcare costs (Thornton, 2017). Despite these rising challenges, miners continue to demand permanent health benefits and safe work protections. Major challenges in the Zambian copper mining industry have been the reliance on limited sources of funding, particularly copper revenues. Other major challenges have been inefficiencies in areas such as procurement processes and underutilization of information technology. In the US, mining companies bankruptcies have been a major challenge. Nonetheless, funding of employee medical services is important for several reasons as ascertained by this study. Providing financial protection, improving employee satisfaction and morale, and ensuring dependents remain healthy are important factors at the employee level. It was evident that KCM would not perform better financially or operationally without serious consideration of employee medical services. While legislative intervention has been one of the approaches in the US, cost-share in company-operated medical facilities has been an option in Zambia. Given there were some employees in the Zambian case who saw the need for cost-share, there is a need for strategic deliberations between management and workers towards buy-in for a dedicated fund that could be jointly managed. KCM should promote wellness programs and partner with other healthcare providers who are able to provide better services that KCM is not able to undertake alone. Enhancing services through partnership and providing better services could also lead to more clients who would be able to pay and thereby increase the critical mass and the base of income for the fund. It is noteworthy that 50% of employees were influenced by the presence of employee health services and benefits when selecting KCM as an employer. Employee health can be closely tied to organizational effectiveness. Accordingly, cost-benefits of worksite interventions should consider these interrelated criteria (Stokols, Pelletier, & Fielding, 1996). This studys findings will also allow the medical management team in KCM and other similar organizations in Zambia or the US and elsewhere to evaluate which multi-level strategies can be considered for miners health promotion. Apart from providing employee health services, mining industry employers all over need to ensure that value is obtained from health services. BUSINESS FORUM Vol 27, Issue 1 | 46 Management needs to consider alternative approaches for better healthcare and quality service provision to strike a balance between employee satisfaction with healthcare benefits and sufficient value for money invested in healthcare that can support future healthcare investment (Fronstin, 2012). Corresponding author: Dr. Barbara W. Son, [emailprotected] References Ahmed, S. (2009). Methods in Sample Surveys. Baltimore: Johns Hopkins School of Public Health. Bless, C. Higson-Smith, C. Kagee, A. (2006). Fundamentals of Social Research Methods: An African Perspective, Cape Town: Juta. Carrin, G. (2008). Social health insurance: how feasible is its expansion in the African region? Development Issues, 10, 7-9. Center for Disease Control and Prevention, (2017). Population Reference Bureau Fact Sheet, 2015. Center for Disease Control and Prevention Global Health Zambia. Chuma, J. Mulupi, S. & McIntyre, D. (2013). Providing Financial Protection and Funding Health Service Benefits for the informal sector: Evidence from Sub-Saharan Africa. Cape Town. Danish Trade Union Council. (2014). Zambia Labor Market Profile. Fronstin, P. (2012). Employment Based Health Benefits: Recent Trends and Future Outlook. The Journal of Health Care Organization, Provision, and Financing, 49(2), 101- 115. Giardina, M. (2014, October 10). Coal mining company tackles health care spending with telehealth, nurse practitioners. EBN. Golden, S. Earp, J. (2012). Social ecological approaches to individuals and their contexts: Twenty years of health education & behavior health promotion interventions, Health Education & Behavior, 39(3), 364-372. Gould, E. (2013), Increased Health Care Cost Sharing Works as Intended: It Burdens Patients who Need Care the Most. Economic Policy Institute. Briefing Paper #358. Hill, M. (2015). Vedanta Zambia unit to cut 2,500 jobs as it shutters copper mine. LiveMint. Hovlid, E. Bukve, O. Haug, K. Aslaksen, A. B. Von Plessen, C. (2012), Sustainability of Healthcare Improvement: What can we Learn from Learning Theory?, BMC Health Services Research, 12 (235). HRET (Kaiser Family Foundation and Health Research & Educational Trust). (2015). Employer Health Benefits 2015 Summary Findings. Kaiser Family Foundation. KCM handover 4,000 miners to JHX. (2017). ZNBC. KCM workers fight back. (2014). Foil Vedanta. Koyi, G. (2017). Working and Living Conditions of Workers in the Mining Sector in Zambia. Kumar, R. (2016). Corporate Social Responsibility in Copper Belt of Zambia. International Journal of Science Technology and Management, 5(1), 142-149. Mwale, H. (2014). An Evaluation of Trade Union Effectiveness in the Zambian Mining Sector: A Case for the Mine Workers Union of Zambia (MUZ). University of Greenwich, Masters Thesis. BUSINESS FORUM Vol. 27, Issue 1 | 47 Nkombo, G., & Abubakar, B. (2002). To privatise or not? The case of Zambia, Africa Insight, 32(4), 12-20. Nyman, J. (2007). American Health Policy: Cracks in the Foundation. Journal of Health Politics, Policy and Law, 32, 759783. Peterson, E. & Jones, W. (2015, February 26). Kentucky Doesnt Have Any More Working Union Coal Miners. WFPL. Porter, M., Teisberg, E. & Wallace, S. (2008). What Should Employers Do About Healthcare, Harvard Business School Working Knowledge, Harvard Business School. Roddy, P., Wallen, J., & Meyers S. (1986). Cost Sharing and Use of Health Services; The United Mine Workers of America Health Plan, Medical Care, 24, 873. Samuels, A. (2017, April 22), Why Would Congress Bail Out Miners Pensions?, The Atlantic Daily. Stokols, D., Pelletier, K., & Fielding, J. (1996). The ecology of work and health: Research and policy directions for the promotion of employee health. Health Education Quarterly, 23(2), 137-158. Swartz, K. (2010). Cost Sharing: Effects on Spending and Outcomes. The Robert Wood Johnson Foundation Synthesis Project, Research Synthesis Report No. 20. Thornton, N. (2017, May 1). Miners get permanent funding for health care, but fate of pensions is dubious. BenefitsPro Magazine. UMWA. (2017). Black Lung Benefits Improvement Act. United Mine Workers Of America. Vedanta. (2017). Our Journey. Retrieved from http://www.vedantaresources.com/about-us/our- journey.aspx Volcovici, V. (2017), Coal Miner Health Benefits Deal Reached, Thomson Reuters, Editing by Chizu Nomiyama. WHO Regional Office for Africa. (2013). State of Health financing in the African Region. World Factbook. (2017). Central Intelligence Agency, Zambia. Zambia: Safety Gaps Threaten Copper Miners. (2013, Feb 20). Human Rights Watch.org. Retrieved from https://www.hrw.org/news/2013/02/20/zambia-safety-gaps-threaten- copper-miners BUSINESS FORUM Vol 27, Issue 1 | 48 BEING INTENTIONAL ABOUT WORKPLACE MINDFULNESS PROGRAMS Carol Blaszczynski California State University, Los Angeles SUMMARY: In the past decade mindfulness practices, one component of employee and organizational wellbeing, have become more prevalent in workplaces. How can organizations design and implement workplace mindfulness programs? To answer that question, a short history of mindfulness programs is presented. Further, types of workplace mindfulness programs and their corresponding emphases and benefits are discussed. The pros and cons of mindfulness practices are identified as well as cautions when designing workplace mindfulness programs. The business case for supporting mindfulness as a dimension of employee wellness and healthcare is presented. Introduction As a dimension of employee wellbeing and healthcare, mindfulness has become a buzzword in healthcare during the past few years. Simply put, mindfulness has been defined by Kabat-Zinn, the creator of Mindfulness Based Stress Reduction (MBSR) programs, as awareness, cultivated by paying attention in a sustained and particular way: on purpose, in the present moment and non-judgmentally (2012/2016, p. 1). In essence, mindfulness describes a comprehensive, integrated approach toward improving health and productivity in work environments (Solon & Kratz, 2016, p. 31). Organizations such as Apple and Google have embraced mindfulness and have implemented programs to foster employee wellness, resulting in better performance, heightened creativity, deeper self-awareness, and increased charismanot to mention greater peace of mind (Harvard Business Review Press, 2017, p. back cover), all of which contribute to an enhanced business bottom line. In addition to Apple and Google, other notable organizations that provide mindfulness programs for their employees include Accenture, American Express, General Electric, Ikea, KLM, Microsoft, Nike, Ogilvy, Roche, Royal Bank of Canada, and Sony (Hougaard, Carter, & Coutts, 2015). Smolkin (2016) reported that 22% of organizations currently have mindfulness programs. This article presents information about the history of mindfulness, the types of workplace mindfulness programs, the pros and cons of organizational mindfulness programs, and the business case for supporting mindfulness as a dimension of employee wellness and healthcare. Short History of Mindfulness Mindfulness practices have a long history stemming from Eastern traditions such as Buddhism and Taoism (Brendel, 2017). In 1979 mindfulness-based stress reduction programs were launched at the University of Massachusetts by Kabat-Zinn. Langer wrote the classic book Mindfulness in 1989. In 1996 the first empirical research project about mindfulness in the workplace was conducted. The mobile mindfulness app Headspace was made available in 2012. In 2013 the number of articles about mindfulness totaled 549. Mindful, a new magazine, was launched in 2013 to promote mindfulness. Time magazine featured The Mindful Revolution on its cover in 2014. A mindfulness segment featuring Anderson Cooper was aired on the television show 60 Minutes in 2014 (Frey & Totten, 2015). The coverage of mindfulness has grown dramatically in recent years. BUSINESS FORUM Vol. 27, Issue 1 | 49 Types of Workplace Mindfulness Program Generally speaking, mindfulness programs can be classified as contemplative or non- contemplative. Contemplative-based mindfulness programs are those that emphasize shortened versions of contemplative practices such as meditation (Yeganeh & Good, 2016, p. 26). Non- contemplative based programs introduce practices that focus on analyzing automatic routines, shifting attention to the five senses, and mindful thinking (Yeganeh & Good, 2016, p. 26). In addition to seated meditation, contemplative-based mindfulness programs can include practices such as walking meditation, focused breathing activities (pranayama), yoga in its many forms, chanting, and tai chi and its variant forms. These longstanding contemplative Oriental practices are widely perceived by healthcare professionals as means for reducing stress and increasing employee wellbeing (e.g., Dwivedi, Kumari, & Nagendra, 2015). All of these practices require a moderate amount of intentionality, which is conscious awareness of what you are doing and why you are doing it, and engagement, which is full and active participation. Practitioners find that many traditional but difficult-to-master exotic contemplative practices appeal to only some employees. For example, employees who have xenophobic tendencies and strong cultural attachment to the American way of life may shy away from foreign- originated contemplative-type health and wellness activities such as meditation and chanting. For those who have experienced trauma or post-traumatic stress disorder (PTSD), the closing of eyes during meditation activities may cause anxiety. Others may perceive the names of certain common yoga poses such as savasana (corpse pose, which is traditionally the last pose practiced in a yoga class because it is relaxing) as revolting and culturally unacceptable. Atheists oftentimes object to engaging in the anjali mudra (prayer pose with the palms of the hands together by the heart center), another common yoga pose, because of their beliefs. The Sanskrit yoga vocabulary used by most teachers puzzles and alienates some neophyte yoga learners. Chanting may be perceived as having a mystical or spiritual connotation that can be objectionable or unacceptable to some employees. Others may frown upon these contemplative practices and embrace easier-to-master less traditional but more practically oriented non-contemplative techniques such as journaling and mindful eating. Non-contemplative mindfulness programs consist of three basic approaches: modifying automatic responses, focusing on the five senses, and thinking mindfully. Modifying automatic responses involves moving from subconscious autopilot reactions to consciously aware ways when necessary. Such automatic behaviors are helpful when they are appropriate; in other words, these behaviors enable us to save energy for new situations by reducing energy spent on the things we do every day (Yeganeh & Good, 2016, p. 27). In new situations, automatic responses should be set aside to avoid catastrophic thinking and related calamities. Focusing on the five senses of seeing, hearing, touching, smelling, and tasting allows employees to disrupt their automatic response patterns and to obtain a more accurate multiple- sensory perspective of reality. Noticing the details of the workplace environment shifts the observers mind to the senses. For example, seeing a colleagues facial expressions while speaking shifts the observers attention by engaging in the present moment (Yeganeh & Good, 2016). While some may perceive engaging the senses as a passive or useless activity, intentionally engaging the senses is a powerful way to shape how we pay attention to the present moment (Yeganeh & Good, 2016, p. 29). Mindful thinking focuses around accepting the moment rather than rejecting it. The practice of acceptance allows employees to switch from the unhealthful, stress-inducing worrying mode to the healthful, stress-reducing caring mode (Yeganeh & Good, 2016). For example, rather than responding to a colleague who is unprepared for a meeting by thinking I cant believe this person is not fully prepared; what a waste of everyones time when we all have lots of work to do, a mindful thinker might depersonalize the situation and think I am very annoyed by this; its all right for me to be angry with unprepared colleagues occasionally. This acceptance of the emotion allows the person to move on to address the situation constructively. BUSINESS FORUM Vol 27, Issue 1 | 50 Pros and Cons of Organizational Mindfulness The pros and cons of selected organizational mindfulness practices are presented in Table 1. Most of the listed mindfulness practices are contemplative with journaling and mindful eating standing out as non-contemplative practices. Primary benefits and drawbacks are presented. Table 1 Primary Intended Benefits and Primary Potential Drawbacks of Selected Mindfulness Practices _____________________________________________________________________________________ Mindfulness practice Intended benefits Potential drawbacks _____________________________________________________________________________________ Meditation Reduces stress levels Misguided beliefs that meditation requires long periods of time Pranayama* Increased level of energy Perceived by some as difficult to (breathing practices) Experience calmness practice Can promote sleep Yoga Reduces stress levels Perceived confusion about which Fosters mind-body yoga style(s) to practice connection Viewed as costly at yoga studios (except for community classes) Chanting Clears the mind Requires a separate room Inhibited participant responses Journaling Allows processing of Can be done virtually anywhere, any emotions time May reduce stress levels Considered difficult by some Mindful eating Allows focus on food Requires self-discipline consumed Identifies emotional eaters Reduces tendency to eat on autopilot _____________________________________________________________________________________ *Note. Benefit varies depending on the type of breath practiced. Most of Fidelitys 2016 survey of Employer-Sponsored Health and Wellbeing revealed that the level of employee engagement in wellness programs ranged from 10% for consulting a life coach to 53% when employees completed a basic health survey (Fry, 2017). Lewis (as cited by Fry, 2017, p. 99) distinguishes wellness programs and benefits that are done for employees from wellness done to employees, which includes compulsory weight-loss programs among other initiatives. The language used during a wellbeing program can influence the acceptance of the mindfulness program. Reitz (2016/2017) suggests using the words performance and attention in addition to the word mindfulness during presentations and workshops since the word mindfulness has a negative connotation for some people and its use may discourage employee participation. Silcox (2016) recommends using the following strategies when introducing and building a wellbeing program: (a) involve employees in policy development, (b) use multiple media to communicate about the wellbeing program, (c) use company data (e.g., about absences) and data gleaned from employee surveys when designing a wellness program, (d) determine how to hook BUSINESS FORUM Vol. 27, Issue 1 | 51 employees who typically do not participate in wellness programs (men often participate at a lower rate than do women), (e) follow and evaluate wellness program participation rates, (f) consider holding workplace competitions and giving recognition, (g) schedule health seminars and fairs featuring speakers from outside the firm, (h) consider using interactive activities since they have been found to sustain interest, (i) schedule a launch for each new wellbeing activity, (j) provide staff with adequate notice about events to encourage participation, and (k) give employees time off from work responsibilities to engage in wellbeing activities. One potential practice is to have employees complete a mindfulness questionnaire twice: once as a pretest before training begins and again following the training as a posttest measure. While there are several instruments from which to choose, a commonly used public domain measure is the Five Facet Mindfulness Questionnaire (FFMQ). The FFMQ focuses on the five mindfulness components of observing, describing, detaching, acting mindfully, and loving yourself (being self-compassionate) (Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006; Strosahl & Robinson, 2015). Forty workplace mindfulness intervention programs disseminated in the literature were analyzed by Jamieson and Tuckey (2017, p. 189). Of these intervention programs, 22 investigated the effect of mindfulness interventions on at least one aspect of employee health or well-being. Results from three of the less robust studies did not support the use of mindfulness intervention programs in the workplace; nevertheless, most of the studies produced results that corroborate the efficacy of mindfulness programs. Duarte and Pinto-Gouveia (2016) introduced a six-week mindfulness-based intervention program to oncology nurses. This intervention involved exposure to mindful eating, mindful communication, pranayama (breathing exercises), and various types of meditation and appeared to reduce burnout and helped to decrease compassion fatigue. Workplace mindfulness programs should be voluntary, not imposed on employees (Brendel, 2017). The voluntary nature of workplace mindfulness programs encourages employee participation. Business Case for Supporting Mindfulness The current business environment has been dubbed the attention economy in which the ability to maintain focus and concentration is every bit as important as technical or management skills (Hougaard & Carter, 2017, p. 40). Langer (2017), who has conducted mindfulness research for over 40 years, identifies better performance, greater innovation, enhanced charisma, a lower level of procrastination, and being less judgmental about other people as mindfulness practice benefits. Congleton, Holzel, and Lazar (2017) assert that mindfulness research results have revealed that mindfulness is now a necessity for executives. Two areas of the brain that are positively affected by mindfulness practice are the anterior cingulate cortex, important in self-regulation, and the hippocampus, which is central to resilience (Congleton et al., 2017). Chakravorty (2017, p. 29) reported that a mindfulness program introduced in a critical care unit (CCU) resulted in a significant increase in throughput, (e.g., number of patients admitted in CCU per year), a decrease in work-in-process (e.g., average number of hours in CCU per patient), and an increase in quality (e.g., live discharge) with a slight decrease in cost. Staff were encouraged to engage in meditation for five to ten minutes every few hours. Prior to treating a patient, staff were asked to clear their mind[s] for one to two minutes and taught to communicate often with other caregivers about patient condition. Although research has indicated that mindfulness training provides several benefits, practicing mindfulness is not a panacea for all ills. While mindfulness practice is a valuable endeavor, the practice is only one of several potential offerings that can be beneficial for employees. As Connolly, Stuhlmacher, and Cellar (2016) so elegantly stated, Given the variety of objectives, techniques, and outcomes, it is imperative that mindfulness training receives mindful scrutiny (p. 682). Above all, it is important to acknowledge that results from workplace mindfulness programs take time to become apparent (Adams, 2016). BUSINESS FORUM Vol 27, Issue 1 | 52 Conclusion Workplace mindfulness programs have become widespreadperhaps even trendyover the last decade. While several research studies have demonstrated various wellbeing benefits stemming from corporate mindfulness programs including decreased costs, diminished compassion fatigue, and reduction of stress levels, care should be taken in the design and implementation of workplace mindfulness programs with experts. Involving employees during the program design, implementation, and follow-up stages is critical to the success and sustainability of mindfulness program participation. Evaluation of program results should be conducted on an ongoing basis to determine the efficacy of the program and to identify aspects that should be added, changed, or omitted. Follow-up training offerings would be a mindful practice to encourage employee and program sustainability. Corresponding author: Dr. Carol Blaszczynski, [emailprotected] References Adams, J. (2016). Building the business case for mindfulness. Occupational Health, 68(5), 15. Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment, 13(1), 27-45. Brendel, D. (2017). There are risks to mindfulness at work. In Mindfulness: HBR emotional intelligence series (pp. 107-116). Boston, MA: Harvard Business Review Press. Chakravorty, S. S. (2017). Mindfulness boosts process performance. ISE Magazine, 49(9), 28- 33. Congleton, C., Holzel, B. K., & Lazar, S. W. (2017). Mindfulness can literally change your brain. In Mindfulness: HBR emotional intelligence series (pp. 27-35). Boston, MA: Harvard Business Review Press. Connolly, D., Stuhlmacher, A. F., & Cellar, D. F. (2016). Be mindful of motives for mindfulness training. Industrial & Organizational Psychology, 8(4), 679-682. Duarte, J., & Pinto-Gouveia, J. (2016). Effectiveness of a mindfulness-based intervention on oncology nurses burnout and compassion fatigue symptoms: A non-randomized study. International Journal of Nursing Studies, 64, 98-107. Dwivedi, U. C., Kumari, S., & Nagendra, H. R. (2015). Model of yoga intervention in industrial psychology for counterproductive work behavior. Industrial Psychiatry Journal, 24(2), 119-124. doi:10.4103/0972-6748.181730 Frey, A., & Totten, A. (2015). I am here now: A creative mindfulness guide and journal. New York, NY: Tarcher Press. Fry, E. (2017). Corporate wellness programs: Healthy . . . or hokey! Fortune, 175(4), 99-100. Harvard Business Review Press. (2017). Mindfulness: HBR emotional intelligence series. Boston, MA: Harvard Business Review Press. Hougaard, R., & Carter, J. (2017). How to practice mindfulness throughout your workday. In Mindfulness: HBR emotional intelligence series (pp. 37-45). Boston, MA: Harvard Business Review Press. Hougaard, R., Carter, J., & Coutts, G. (2015). One second ahead: Enhance your performance at work with mindfulness. New York, NY: Springer. Jamieson, S. E., & Tuckey, M. R. (2017). Mindfulness interventions in the workplace: A critique of the current state of the literature. Journal of Occupational Health Psychology, 22(2),180-193. doi:10.1037/ocp0000048 Kabat-Zinn, J. (2012/2016). Mindfulness for beginners: Reclaiming the present momentand your life. Boulder, CO: Sounds True, Inc. Langer, E. (2017). Mindfulness in the age of complexity. In Mindfulness: HBR emotional intelligence series (pp. 1-25). Boston, MA: Harvard Business Review Press. BUSINESS FORUM Vol. 27, Issue 1 | 53 Reitz, M. (December 2016/January 2017). How to introduce mindfulness at work. People Management, p. 48. Silcox, S. (2016). Encouraging employee participation in wellbeing activities. Occupational Health & Wellbeing, 68(5), 16-17. Smolkin, S. (2016). Corporate mindfulness programs grow in popularity. Retrieved from Ebn.benefitsnews.com. 7/14/2016, 1. Solon, R., & Kratz, R. (2016). How mindfulness and situational awareness training help workers. Benefits Magazine, 53(3), 30-33. Strosahl, K. D., & Robinson, P. J. (2015). In this moment: Five minutes to transcending stress using mindfulness and neuroscience. Oakland, CA: New Harbinger Publications. Yeganeh, B., & Good, D. (2016). Mindfulness as a disruptive approach to leader development. OD Practitioner, 48(1), 26-31. BUSINESS FORUM Vol 27, Issue 1 | 54 B O O K R E V I E W __________________________________________________________ The Gene: An Intimate History by Siddhartha Mukherjee, M.D. H. Rika Houston California State University, Los Angeles Health care in the United States of America is a complex topic fraught with the historical and emotional trappings of most political minefields. With so many health care companies and organizations focusing upon the endless minutiae of how to deliver, manage, and reimburse health care; embracing a big picture perspective is a path followed only by those rare innovators who are willing and discerning enough to embrace the unknown. In this review, I will focus upon a book that calls out to the latter group and speaks to the larger and more hopeful perspective of twenty-first century innovation in health care. Through my lifelong fascination with the history of science and technology, I have navigated and explored the never-ending landscape of biomedical innovations as diverse as assisted reproductive technologies, cutting-edge human prosthetics, and other technological promises of a post-human vision. Many authors have intrigued me but Siddhartha Mukherjee, M.D., the author of The Gene: An Intimate History (2016), is one author who eloquently amplifies the potential of such a future world. In his most recent book, he reveals not only an amazing grasp of the history of (biological) science, but also a preternatural understanding of how health in general and our DNA specifically can impact, devastate, and even enlighten our everyday lives. Through his eyes, we can challenge and reimagine preconceived notions of health and wellness. And, through his powerful and historically informed gaze, we can recognize that we have entered a new eraone that will hopefully change the means and machinations of health, health care delivery, and anything related to it for decades to come. Organized in a thought-provoking combination of chronological, historical events and thematic groupings; Mukherjees book leads us through the convoluted and sometimes serendipitous discovery of the human genome. In an approach like his earlier book on the history of cancer; Mukherjee draws us into the story by weaving his personal stories, those of his patients, and the history of science into a powerful chronicle about how all these perspectives are so deeply connected (Mukherjee, 2010). Genetics, a relatively new science whose origins can be traced historically back to Gregor Johann Mendels 1866 study of pea plants, is based upon a surprisingly simple conceptthe forty-six chromosomes in the human genetic code (Mendel, 1866; Mukherjee 2010, 2016). These chromosomes, twenty-three received from one biological parent and twenty- three received from the other, contain thousands of genes that provide the master instructions to build, repair, and maintain a unique human being (Mukherjee, 2016). Clearly, as Mukherjee (2016) points out, this scientific discovery is fraught with the same paradox of simplicity and complexity inherent in the discovery of two other transformational scientific discoveriesthe atom and the byte. On one hand, the human genome offers the promise of unlocking the mystery of human existence. By doing so, the field of medicine and our understanding of health and wellness can be revolutionized beyond our collective imaginations. On the other hand, it offers BUSINESS FORUM Vol. 27, Issue 1 | 55 the danger of man-made manipulation as evidenced by the gruesome application of human eugenics in 1940s Nazi Germany; an idea launched originally, by the way, by English and American reformers in search of a way to engineer human evolution. Mukherjee (2016) adeptly travels through a historical chain of post-World War II discoveries that reach their crescendo in the Human Genome Project, a global project to map and sequence the entire human genome. And, unlike the measured and objective image of the academic and scientific worlds that is typically portrayed to the public eye; Mukherjee (2016) exposes us to the backstage rivalry, politics, and maneuverings involved in the prolonged race to claim the genomic victory. Backstage politics aside, the draft sequence of the human genome was finally published in 2001 through a joint effort of the publicly funded Human Genome Project and the privately funded effort of Celera Genomics. To date, the modern science of genetics continues to uncover the mysteries of both the normal and abnormal behavior of genes. And, this transformational knowledge gives us a deeper understanding of diseases and how to prevent them. While the backstage politics is no doubt here to stay, the competition could possibly lead to new discoveries to help eradicate genetic disorders such as Huntingtons disease or cystic fibrosis. For those in search of a historical understanding of the human genome and its fascinating evolution over time; Mukherjees book offers us a thrilling journey and helps us to contemplate the possible implications for the practice of medicine and health care delivery, the notion of health and wellness, and how much we can or cannot control about our unique genetic codes in the end. For the healthcare industry specifically, the implications are endless. And, according to Robinson (2016), as genomic medicine becomes more mainstream; it is even more important that health care professionals and companies stay informed of the dynamic changes in this field. Jimenez-Sanchez (2015) discusses some of the health care industry innovations that have emerged from the genomic revolution. For example, he contemplates its valuable contributions to the identification of genes associated with common diseases such as diabetes, obesity, cardiovascular disease, and cancers and how genomics will be merged with other technologies such as gene therapy and personalized drugs to eradicate such diseases. While these new technologies are no doubt changing the way such diseases are diagnosed and treated; they also offer the opportunity for astute, informed innovators to create companies that utilize these very technologies. For example, the emerging genomics and pharmagenomics industries exemplify this global market trend (http://medicalfuturist.com/top-companies-genomics/). While many social and ethical questions remain, successful innovators such as the personal genomics company 23andMe (https://www.23andme.com) the pharmagenomics company MyDNA (https://www.mydna.life), and the diagnostic genomics company Rosetta Genomics (https://rosettagx.com) are at the forefront of transforming the business and practice of health care. As the price of genome sequencing continues to fall drastically, the start-up potential will continue to grow exponentially. And so, Mukherjees The Gene: An Intimate History is a book that arrived just in time for those who understand the critical need for a big picture perspective. It provides a powerful and insightful gaze into the history and journey of the human genomea must read for anyone even remotely connected to or interested in its implications for the health care industry, health care delivery, and the transformation of health and wellness as we know it. Book review authors information: Dr. H. Rika Houston, [emailprotected] BUSINESS FORUM Vol 27, Issue 1 | 56 References Jimenez-Sanchez, Gerardo (2015). Genomics Innovation: Transforming Healthcare, Business, and the Global Economy, Genome, 58, 511-517. Mukherjee, Siddhartha (2010). The Emperor of All Maladies. Scribner Publishers: New York, New York. Mukherjee, Siddhartha (2016). The Gene: An Intimate History. Scribner Publishers: New York, New York. Mendel, Gregor Johann (1866). Versuche ber Pflanzen-Hybriden [Experiments Concerning Plant Hybrids] [1866]. In Verhandlungen des naturforschenden Vereines in Brnn [Proceedings of the Natural History Society of Brnn] IV (1865): 347. Reprinted in Fundamenta Genetica, ed. Jaroslav Keneck, 1556. Prague: Czech Academy of Sciences, 1966. http://www.mendelweb.org/Mendel.html Robinson, Ann (2016). Genomics-The Future of Healthcare and Medicine. Prescriber, April 2016, 51-55. BUSINESS FORUM Vol. 27, Issue 1 | 57 The Business Forum, a scholar-practitioner, peer-reviewed journal published by the College of Business and Economics at Cal State LA, invites submissions and reviewers for its Fall 2018 Startups Issue. Target timeline: June 15, 2018: All submissions are due electronically via the link below: https://submissions.scholasticahq.com/login Spring and Summer 2018: Double-blind review and revision processes Fall 2018: Issue is published in print and online The Business Forum has provided scholarly advice with application to business practices since 1975 and it is now revitalized in a modern print-online format. This is not a traditional academic journal. Our articles aim to advance business practice through application of research or theoretical synthesis of information relevant to business. We adhere to The American Psychological Association (APA) style and our target article length is from 2000 to 3000 words, inclusive of all artifacts such as tables, figures, and references. The Startups issue welcomes original manuscripts on a wide range of topics related to startups from a business perspective. Startups operate in the entrepreneurial landscape and are interdisciplinary by nature. As such, we welcome and encourage articles from various disciplines with a focus on specific concerns related to startups and their managers. Examples of issues that can be addressed include: How to increase the presence of women and minorities executives in VCs? How can a startup attract VCs? What are the best ways to fund startups? How successful is crowdfunding? Does Trumps Tax Plan help or hinder startups? Do incubators help startups? Where are the new startups? What is the structure of a successful startup? What are the drivers and inhibitors of startup growth? How to predict if a new business idea will lead to startup success? What role does sustainability have in startups? Is the culture of startups different from established companies? Whether your paper is about synthesizing theory and practice, applying interesting research to contemporary business issues related to startups, or illustrating both in a rigorous and vivid case, all submissions must curb academic jargon in favor of incorporating research findings in accessible language for non-specialist busi- ness audiences. Each submission should include practical insights and recommendations for managers. We look forward to receiving your papers! Marianne James, Ph.D., Editor-in-Chief Xiaohan Zhang, Ph.D., Managing Editor Tye W. Jackson Ph.D., Issue Editor Call for Paper Submissions and Reviewers BUSINESS FORUM Vol 27, Issue 1 | 58 5151 State University Drive, Los Angeles CA 90032 8120 | 323.343.2942 [emailprotected] 2018 All Rights Reserved College of Business and Economics California State University, Los Angeles cover front Business Forum cover back

  

Leave a Reply

Your email address will not be published.

Related Post

Open chat
💬 Need help?
Hello 👋
Can we help you?