Report 3 - Exploring the Link Between Work-Life Conflict and Demands on Canada's Health Care System

Chapter 8 - Conclusions and Recommendations

The following research questions were addressed in this study:

• How do Canadian employees view their physical health?
• To what extent are Canadian employees making use of the various facets of Canada's health care system?
• How much do Canadian employees spend on prescription medicine?
• What is the impact of gender, job type, sector of employment and dependent care status on each of the above issues?
• How does work-life conflict (operationalized to include role overload, work to family interference, family to work interference and caregiver strain) affect each of the above issues?
• What impact does high work-life conflict have on health care costs in Canada?

These research questions were used to structure the main body of the report. Chapter Four looked at how Canadians employed in firms with more than 500 people view their health. Chapter Five provided benchmark data illustrating how often Canadian employees use various facets of Canada's health care system. An attempt to quantify the costs of work-life conflict on Canada's health care system and prescription drug use was made in Chapter Six. Data on prescription drug use by Canadian employees were given in Chapter Seven. Material on the effect of the various contextual variables (i.e. gender, job type, dependent care status, sector of employment) and work-life conflict on perceived health and use of the health care system was incorporated into Chapters 4, 5 and 7.

In an effort to clarify the material for readers, this final chapter of the report takes a different tack and uses the various forms of work-life conflict (rather than the research questions) as the organizing framework. The chapter is organized into seven sections beginning with a summary of relevant benchmark data from this study with respect to perceived health, prescription drug use and use of Canada's health care system (Section 8.1) and recapping key findings with respect to the impact of gender, job type, sector of employment and dependent care status on these constructs (Section 8.2). The next four sections look at the link between work-life conflict, perceived health, use of Canada's health care system and prescription drug use. Material on role overload is covered first (Section 8.3), followed by details associated with work to family interference (Section 8.4), family to work interference (Section 8.5) and caregiver strain (Section 8.6). Conclusions and key recommendations are offered in the final section of the chapter (Section 8.7).

8.1 Benchmarking the Current State of Affairs

How do Canadian employees view their physical health? While just under half of the respondents to this survey (48.4%) indicated that their health was very good or excellent, almost one in five (16.7% ) perceived personal health to be fair or poor. This is a significantly lower proportion of respondents perceiving that they were in very good to excellent health (and not surprisingly a higher proportion reporting that they were in fair to poor health) than reported by Statistics Canada for Canadians aged 12 or older. While some of this difference might be explained by the age differences in the two samples (younger Canadians can be expected to enjoy better health than older Canadians), it is also likely that working conditions and job-related stress are taking their toll on Canadian employees' health status. These numbers are also a wake-up call for employers as they provide a conservative estimate of the proportion of the Canadian workforce that may be negatively impacting Canadian productivity through ill health, higher absenteeism and higher benefit costs.

To what extent are Canadian employees making use of the various facets of Canada's health care system? Employed Canadians routinely seek medical care from their physician and other health care professionals. In the six months prior to this study being done:

• Just over half (54%) of the respondents sought care from their physician for reasons other than a routine check-up or maternity follow-up. These employees made an average of 5.7 physician visits per year.²⁹
• One in three (29.3%) visited a hospital or clinic on an outpatient or day-use basis for medical tests or procedures. These employees made an average of 3.8 outpatient visits per year.
• One in three (31.8%) of the respondents sought medical care from a medical/health professional other than a physician. These employees made an average of 10 visits per year to other health care professionals.
• Just over one in ten of the employees in the sample (13.1%) sought medical care at a hospital emergency department for a personal health problem. These employees made an average of 3.2 visits per year to an emergency department.
• Just over one in ten (10.6%) of the respondents sought help from a mental health professional. These individuals made an average of 8.2 visits per year to a mental health professional.
• Almost 6% of the respondents required inpatient hospital care (i.e. stayed overnight in the hospital). These employees stayed in hospital for an average of 4.6 nights per year.

How much do Canadian employees spend on prescription medicine? The typical Canadian who works for the country's larger employers spent approximately $164 per year on prescription medicine for personal use. While 44% of employees did not purchase any prescription drugs, one in five (19%) spent more than $300 per year.³⁰ In 80% of these cases, these prescription drug costs are borne by the employer. The high degree of correspondence between the data on prescription drug expenditures and perceived health (i.e. respondents who spent $300 or more on prescription medication also rated their health as fair or poor) increases our confidence in these findings.

8.2 Impact of Gender, Job Type, Sector of Employment and Dependent Care

This research initiative has culminated in the collection of a large, rich, comprehensive data set with which to examine perceived health and the use of Canada's health care system by employed Canadians. One of the strengths of this research is the capacity this large data set provides to examine how key factors, such as the gender of the employee, the type of job held, the sector worked in, and the dependent care responsibilities assumed, affect an individual's perceived health, spending on prescription medication and use of various facets of the health care system. Key differences associated with these variables are summarized in Table 2 and discussed in the main body of the report.

Table 2 Summary of Between-Group Differnces in Health Outcomes

8.3 Role Overload

Role overload is defined as the perceptual aspect of feeling overwhelmed, overloaded or stressed by the pressures of multiple roles. High levels of role overload have become systemic within the population of employees working for Canada's largest employers. Data from this research study indicate that the majority of Canadians who work for firms employing 500 or more people (58% of the sample) are currently experiencing high levels of role overload-an increase of 11 percentage points over the past decade.³¹

What is the impact of high levels of role overload on perceived health and the use of Canada's health care system?

What implications do high role overload have on the health of Canada's employees and the burdens placed on Canada's health care system? The findings from these data are unequivocal: employees with high levels of role overload are in poorer physical and mental health and made greater use of Canada's health care system than those with low levels of role overload. Compared to their counterparts with low levels of role overload, employees with high role overload are:

• 2.9 times more likely to say their health is fair/poor,
• 2.6 times more likely to have sought care from a mental health professional,
• 2.4 times more likely to have received care on an outpatient basis,
• 1.9 times more likely to have spent $300 or more on prescription medicine in the past year,
• 1.8 times more likely to have made 6 or more visits per year to a physician,
• 1.6 times more likely to have made 8 or more visits per year to another health care professional,
• 1.5 times more likely to have required inpatient hospital care, and
• 1.4 times more likely to have visited a hospital emergency room.

What do these data mean in terms of the health care system? Higher work-life conflict is associated with increased health care costs. For example, we calculated the direct cost of:

• physician visits due to high role overload to be approximately $1.8 billion per year,
• inpatient hospital stays due to high role overload to be almost $4 billion per year, and
• visits to the hospital emergency department due to high role overload to be approximately one quarter of a billion dollars per year.

What is the link between high work-life conflict and demands on the health care system? Could we reduce system demands if we could reduce role overload? The data reviewed in this study indicate a resounding yes! By implementing workplace and population health strategies targeted at reducing role overload, Canada would likely reduce the problems many hospitals have with respect to available beds, and substantially reduce wait times at hospitals and demands on health care personnel.

These data also indicate that employers who overwork their employees (i.e. place a high reliance on unpaid overtime) will pay a price-increased benefit expenditures. Companies that focus on reducing role overload would reap a number of benefits to their bottom line, including reduced absenteeism (see Duxbury & Higgins [2003]) and lower benefit costs.

8.4 Work to Family Interference

This form of work-life conflict arises because employees cannot be in two different places doing two quite different things at exactly the same time. People who experience this type of work-life conflict meet work demands at the expense of their family. A plurality of the working Canadians in our sample (38%) report moderate levels of work to family interference; just over one in four of the respondents (28%) report high work to family interference.

What is the impact of high levels of work to family interference on perceived health and the use of Canada's health care system?

From the analysis presented in this report, we conclude that employees with high levels of work to family interference are in poorer physical and mental health and make greater use of Canada's health care system than those with low levels of work to family interference. Compared to their counterparts with low levels of work to family interference, employees with high levels of interference are:

• 2.4 times more likely to say their health is fair/poor,
• 1.7 times more likely to have sought care from a mental health professional,
• 1.7 times more likely to have received care on an outpatient basis,
• 1.6 times more likely to have made 6 or more visits per year to a physician,
• 1.5 times more likely to have visited a hospital emergency room,
• 1.4 times more likely to have required inpatient hospital care, and
• 1.3 times more likely to have spent $300 or more on prescription medicine in the past year .

Not surprisingly, given the above data, higher levels of this form of work-life conflict are also associated with increased health care costs. For example, we calculated the direct health costs of high levels of work to family interference to be approximately $2.8 billion per year (two thirds of a billion dollars per year in physician visits, $2 billion per year in inpatient hospital stays and just over $100 million per year in visits to a hospital emergency department).

8.5 Family to Work Interference

This form of work-life conflict also arises because employees cannot be in two different places doing two quite different things at exactly the same time. This type of conflict reflects a different set of priorities, however, as employees who experience this form of interference allow their family demands to interfere with the fulfillment of responsibilities at work. The study indicates that only a small number of working Canadians experience this form of work-life conflict (approximately 10% of the sample). It should be noted, however, that the percentage of the sample with high family to work interference has doubled over the past decade. Analysis of the data (Duxbury & Higgins, 2003) suggests that much of this increase can be attributed to an increased need to care for elderly dependents.

What is the impact of high levels of family to work interference on perceived health and the use of Canada's health care system?

This form of work-life conflict is not as strongly associated with perceived health and use of the health care system as the other forms of work-life conflict examined in this study. While family to work interference is negatively associated with perceived health (employees with high family to work interference are almost twice as likely to say their health is fair/poor than employees with low family to work interference), and positively associated with use of Canada's health care system and prescription drug use, the magnitude of these relationships are (with one exception) lower than observed for the other three forms of work-life conflict. The extent to which this form of work-life conflict increases health care costs and demands is also lower than observed with respect to role overload and caregiver strain. These data would suggest that Canadian society will benefit (though employers may not) if more Canadians place a higher priority on family than work.

That being said, the data do indicate that there are health consequences associated with giving family roles a higher priority than work roles-poorer mental health. Employees with high family to work interference are almost twice as likely to seek care from mental health professionals than their counterparts with low levels of this form of interference. The cause of the increased incidence of mental health problems in this group (e.g. increased stress and depression) is hard to determine from the cross-sectional data collected for this analysis. Future research should seek to determine the direction of causality with respect to these findings (i.e. does putting family first cause increased stress or does an individual who is suffering from poorer mental health place an increased importance on family?).

8.6 Caregiver Strain

Caregiver strain is defined as feeling overwhelmed, overloaded or stressed by the pressures associated with being employed and being responsible for the care of an elderly or disabled dependent. Approximately one in four working Canadians experiences what can be considered to be high levels of caregiver strain. We can expect that this form of work-life conflict will increase dramatically over the next several decades as more employees become "at risk" (the aging of the Canadian population means that more employees will take on elder care responsibilities).

As such, it is important for us to understand how this form of work-life conflict affects perceived health and use of the health care system.

What is the impact of high levels of caregiver strain on perceived health and the use of Canada's health care system?

This form of strain appears to be more closely linked to physical health problems and less strongly associated with mental health concerns than the other three forms of work-life conflict. Employees with high levels of caregiver strain make the greatest use of physician services and are the most likely to have spent time in hospital on both an inpatient and an outpatient basis. They also make the highest use of the emergency room and spend the greatest amount on prescription medication. Compared to their counterparts with low levels of caregiver strain, employees with high levels of caregiver strain are:

• 1.8 times more likely to have received care on an outpatient basis,
• 1.7 times more likely to say their health is fair/poor,
• 1.6 times more likely to have spent $300 or more on prescription medicine in the last year,
• 1.5 times more likely to have sought care from a mental health professional,
• 1.5 times more likely to have required inpatient hospital care,
• 1.5 times more likely to have visited a hospital emergency room, and
• 1.4 times more likely to have made 6 or more visits per year to a physician.

It would appear from these data that caregiver strain is associated with an increased incidence of illness that requires treatment and prescription drugs.

Data on caregiver strain provide further support for our conclusion that work-life conflict is associated with increased health care demands and costs. For example, we calculated the direct costs of inpatient hospital stays due to high caregiver strain to be approximately $4 billion per year, of physician visits due to high caregiver strain to be over half a billion dollars per year and of visits to a hospital emergency department due to high caregiver strain to be over $100 million per year.

8.7 Conclusions and Recommendations

In this report, we have established that:

• work-life conflict in its various forms is a problem for many Canadian employees;
• high work-life conflict is associated with lower levels of perceived health for working Canadians, regardless of how we conceptualize work-life conflict;
• high levels of work-life conflict have a negative impact on the employers' bottom line and increase demands on Canada's health care system;
• the health care-related costs of high work-life conflict are staggering-approximately $6 billion a year attributable to high role overload, $5 billion a year to high caregiver strain, $2.8 billion to high work to family interference and half a billion dollars to high family to work interference,³² and
• two forms of work-life conflict are particularly costly (both in terms of increased demands on the health care system, and increased health care and benefits costs): role overload and caregiver strain.

How can governments afford not to address the issue of work-life conflict?

After examining the data in this chapter, the relevant question changes from "how much will it cost us to reduce work-life conflict" to "how can governments afford not to address this issue?" Why should employers and governments promote and practise healthy workplaces that allow employees to balance work and life? Simply put, Canada's ability to be globally competitive in the future depends on our ability to address this issue. The data presented in this report paint a frightening picture of how inattention to workplace health is impacting our health care system. Health issues that arise due to heavy workloads at home and at work and an inability to balance conflicting demands not only cost the employer in increased absenteeism and health benefit costs but sick employees also have a negative impact on the health care system. As CCIH (2002, p. 22) notes:

"The boundaries of the workplace are permeable and costs are easily transferred to other facets of society. It is for these reasons that workplace health must become a priority for governments and not just for employees, employers and unions."

The first priority for both employers and governments is to reduce the demands on working Canadians

The data suggest that employers and governments who wish to improve the health of their workforce, reduce the tax burdens on their citizens, and positively influence the health care system need to pay attention to role overload. This form of work-life conflict is strongly associated with heavy work demands, longer hours at work, higher amounts of unpaid overtime, greater amounts of work-related travel and a culture of face time (i.e. emphasis is on "presenteeism" as opposed to outputs and deliverables). It also represents the highest levels of relative and absolute risk with respect to poorer physical and mental health and all measures of use of Canada's health care system included in this study.

The main predictor of high role overload is time spent in paid employment. As we noted in Report One of this series (Higgins and Duxbury [2002]), time in work has increased dramatically during the past decade. Whereas one in ten respondents in 1991 worked 50 or more hours per week, one in four do so now; during this same time period, the proportion of employees working between 35 and 39 hours per week declined from 48% of the sample to 27%. This increase in time in work was observed for all job types and all sectors. Further work is needed to determine exactly why work demands have increased over the decade. Possible explanations drawn from the data include:

• organizational anorexia (downsizing-especially of the middle manager cadre-has meant that there are not enough employees to do the work and managers to strategize and plan);
• corporate culture (if you don't work long hours and take work home, you will not advance in your career, not keep your job during downsizing);
• increased use of technology (data collected elsewhere in the survey provide partial support for this supposition);
• global competition (work hours have been extended to allow work across time zones; increased competition and a desire to keep costs down have limited the number of employees it is deemed feasible to hire);
• the speed of change has increased to the point where many organizations have lost their ability to plan and prioritize-workloads increase when organizations practise crisis management (partial support for this hypothesis comes from data collected elsewhere in the survey); and
• employees are worried about the consequences of "not being seen to be a contributor"
• non-professionals may fear that they will lose their jobs if they do not work overtime, and
• professionals may worry that their career will stagnate if they do not work overtime.

The link between hours in work and role overload, burnout and physical and mental health problems (see Duxbury & Higgins, 2003) suggest that these workloads are not sustainable over the long term. The data from this study reinforce this conclusion. Canadians are subsidizing, through their tax dollars and financial support of the health care system, organizational practices such as "doing more with less," downsizing, basing promotions on hours at work, setting unrealistic work expectations, managing by crisis, etc. Organizations which employ such strategies should bear the financial costs of such strategies-not Canadian taxpayers. Duxbury and Higgins (2003) included several specific recommendations regarding the reduction of role overload. Other recommendations that may also address this issue are given below.

The second priority for both employers and governments is to reduce caregiver strain

As noted above, this form of work-life conflict appears to be closely linked to physical health problems and higher use of medical care services and prescription medications. The proportion of the workforce experiencing high levels of caregiver strain is also expected to increase dramatically in the next decade as, first the parents of the baby boomers, and then the baby boomers themselves, require care. If steps are not taken now to put policies, procedures and institutions into place to help employees care for their aging parents, the health care demands and costs associated with this kind of strain can be expected to increase dramatically in the near future.

The issue of caregiver strain was also covered in depth in Duxbury and Higgins (2003) and a number of recommendations on how such strain could be reduced were offered. Again, the interested reader is directed to this report for ideas and suggestions with respect to reducing caregiver strain. These suggestions can be augmented by implementing several of the additional recommendations given below.

Looking at the issue through a workplace health lens

This study has established the need for organizations to take more responsibility for workplace health issues such as work-life conflict-to look at these issues through a population health lens. How can this best be done? The recommendations given below offer concrete suggestions on how the two major stakeholders, governments and employers, can work toward this goal. It should be noted, when reading this list of recommendations, that many of them are not unique to this study. As was noted at the beginning of this report, the last several years have seen a flurry of activity with respect to scrutinizing the health care system. The resulting studies have offered some excellent recommendations and suggestions on what should be changed and how this change can be accomplished. The recommendations and strategies suggested by CCIH (2002) were particularly useful in the formulation of advice offered in this document.

8.7.1 Recommendations to governments

Governments at all levels have a critical role to play with respect to this issue. Accordingly, we offer recommendations in five broad areas: structural changes at the governmental level; financial incentives for change; health promotion activities; elder care; and support of relevant research and data collection.

The health care system, as it is currently structured, does not support change

In the health care system, leadership is constantly in flux (since 1990 there have been 85 deputy ministers of health and 79 ministers of health at the federal, provincial and territorial levels) and the number of players at the government level makes it difficult to implement a coherent, focused, national strategy. Accordingly, we recommend that:

1. Governments focus on ensuring consistent leadership with respect to this issue. To do this, they need to investigate how to best reduce the amount of turnover at the top of government departments with responsibility for workplace health issues.
2. The federal government create one agency that takes the lead role in support of nationwide workplace health promotion and monitoring. This agency would coordinate and integrate the efforts of various government departments³³ with responsibility for health care delivery and health promotion. This agency would allow government to consolidate both knowledge and budgets, thereby increasing both efficiency and effectiveness.

Governments need to make the idea of change in this area attractive to employers

At this point in time, governments pay the lion's share of the costs associated with poor workplace health practices through their support of the country's health care system. To motivate employers to focus more attention on this issue, governments need to increase the tangible costs to employers of inaction in this area. They need to consider financial incentives to support employers that do their part to promote workplace health and penalties for those who do not. We recommend that they consider the following activities in this regard:

3. Offer employers financial incentives to encourage investment in workplace health promotion and disease prevention. Included within this umbrella should be activities targeted to reduce role overload, role interference and caregiver strain. These incentives could take the form of a tax rebate, changes to income tax, or come through the Workers' Compensation Program.
4. Remove the financial disincentives for employers to expand their health care funding activities. This could be done by allowing employers to write off the cost of health promotion and work-life programs.
5. Publish report cards on organizations which link employment practices to health care systems costs. These report cards would allow taxpayers to determine the extent to which they are subsidizing different organizational actions.

Governments need to create a public push for change in this area

Governments also have a critical role to play with respect to communicating the need for change in this area to the public at large and brokering partnerships with key stakeholder groups which have an interest in addressing these issues. Such a strategy will create further incentives for change at the organizational level. To this end, we recommend the following:

6. The costs (to the bottom line as well as opportunity costs) of ignoring workplace health and work-life issues should become the focus of government social marketing campaigns. These campaigns should be similar to those done for drinking and driving, and cigarette smoking and should
7. Canada needs to use a population health model to re-frame the business case for workplace health promotion. Instead of discussing the achievement of individual return on investment (ROI) goals, the focus should be broader social objectives linked to health, wellness, balance and use of the health care system.
8. Governments need to create a website that serves as an electronic distribution centre for knowledge and best practices in this area. This website should also link these practices with organizations' bottom lines and illustrate the social benefits of these practices.

This issue has multiple stakeholders and it is unrealistic to think that governments alone can make the changes that are necessary. Accordingly, we recommend that:

9. Governments partner with communities and employers to find solutions to these issues.

Issues associated with elder care need to be given higher priority

The demands on family caregivers are likely to increase as Canada's population continues to age and the provision of services shifts from institutions to home and the community. Adequate and appropriate supports for caregivers are required to support them in their role. The data examined in this report identify the short-term costs of caregiving (e.g. poorer health, increased physician visits and prescription drug use). Recent research by Fast et al. (2000), however, indicates that this may be "the tip of the iceberg"-that there may also be long-term public expenditure implications if informal caregivers are not supported (i.e. they estimated that it would cost between $4.9 and $6.3 billion to replace voluntary family members with paid caregivers). Accordingly, we recommend the following:

10. Governments and employers increase the range of supports for employed Canadians with elder care responsibilities. Specifically:
    •  Employees should consider implementation of the following types of supports: flexible work arrangements; compressed work weeks; family leave with pay; long-term leave of absence with pro-rated benefits.
    • Governments should consider the following types of support: making "out-of-pocket" elder care expenses tax deductible; sponsoring flexible, professionally staffed in-home and community-based respite care; extension of the compassionate care leave benefit³⁴

Governments need to provide financial support for empirically sound research in the area

There is still a need to "prove" the business value of workplace health programs and develop the business case for change. There is a need for timely, accurate and reliable data on the health of Canadians and the health care system as "we cannot improve what we cannot measure" (CIHI, 2002). More research needs to be directed toward studies that specify the link between performance and productivity, and workplace health practices (CCIH, 2002). Accordingly, we recommend that governments:

11. Support research and pilot projects that establish best practice in workplace health management and support the development of sound public policy in this area.
12. Ensure that measurement systems are put in place to collect the data that are needed to track costs and change in this area. The following groups need to be involved in the collection of relevant data: hospitals, health care professionals and employers.

Finally, as one of the largest employers in the country, we recommend that:

13. Governments at all levels lead by example (e.g. promote workplace health and work-life balance initiatives).

8.7.2 Recommendations to employers

In Duxbury and Higgins (2003), we suggested a number of steps that could be taken by employers who were interested in improving workplace health and work-life balance. Suggestions included increasing employees' control over their workday (e.g. give them more flexibility) and their work (e.g. participation in decision making, empowerment), making work demands more realistic, and providing supportive work cultures and managers. Additional recommendations specific to the issues addressed in this report include:

14. Employers need to analyze their benefit costs and understand who is using what facet of their benefit plan: employee assistance programs, short- and long-term disability claims (incidence and duration), workers' compensation benefits, workplace accidents, absenteeism, prescription drugs. Such assessment would allow the organization to put a dollar figure on the costs associated with workplace health and work-life conflict and help interested parties make a compelling case for change. As CCIH (2002) notes:

"Such a case is necessary before organizations will make the financial/ cultural commitment to put together the changes necessary to move their organization towards healthier workplace practices and policies."

15. Human resource and occupational health and safety groups should work together to address these issues. Both groups have a key role to play in this area and have much to gain by working together (e.g. can broaden their constituencies and gain a better understanding of the big picture). A siloed approach to change in this area is likely to fail.
16. Employers should focus on the implementation of proactive workplace health measures (i.e. child care and elder care referral services, cafeteria benefit plans, flexible work arrangements, screening programs for disease or depression) rather than just reactive measures (e.g. employee assistance programs).
17. Employees should strategically link workplace health and work-life balance initiatives to broader organizational goals, such as recruitment, retention and succession planning. This strategy would reduce the need to prove the benefit of each work-life balance or workplace health initiative.
18. Employers should measure the impact of their work-life balance and workplace health programs on key outcomes and critical success factors.
19. Organizations should place accountability for work-life balance and workplace health initiatives with senior management (not human resources). Senior management has a critical role to play in creating a healthy work environment as they make most of the decisions with respect to how, when, where and under what conditions work gets done.

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