Download - The Health and Cost Benefits of Work Site Health-Promotion Programs

ANRV337-PU29-19 ARI 14 February 2008 16:7

The Health and CostBenefits of Work SiteHealth-PromotionProgramsRon Z. Goetzel1 and Ronald J. Ozminkowski21Department of Health and Productivity Research, Thomson Healthcare,Washington, DC 20008; email: [email protected] Arbor, Michigan 48108; email: [email protected]

Annu. Rev. Public Health 2008. 29:303–23

First published online as a Review in Advance onJanuary 3, 2008

The Annual Review of Public Health is online athttp://publhealth.annualreviews.org

This article’s doi:10.1146/annurev.publhealth.29.020907.090930

Copyright c© 2008 by Annual Reviews.All rights reserved

0163-7525/08/0421-0303$20.00

Key Words

work site health promotion, work site wellness, return oninvestment, economic benefits, work site programs

AbstractWe review the state of the art in work site health promotion (WHP),focusing on factors that influence the health and productivity ofworkers. We begin by defining WHP, then review the literaturethat addresses the business rationale for it, as well as the objectionsand barriers that may prevent sufficient investment in WHP. De-spite methodological limitations in many available studies, the re-sults in the literature suggest that, when properly designed, WHPcan increase employees’ health and productivity. We describe thecharacteristics of effective programs including their ability to assessthe need for services, attract participants, use behavioral theory asa foundation, incorporate multiple ways to reach people, and makeefforts to measure program impact. Promising practices are notedincluding senior management support for and participation in theseprograms. A very important challenge is widespread disseminationof information regarding success factors because only ∼7% of em-ployers use all the program components required for successful in-terventions. The need for more and better science when evaluatingprogram outcomes is highlighted. Federal initiatives that supportcost-benefit or cost-effectiveness analyses are stressed, as is the needto invest in healthy work environments, to complement individualbased interventions.

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WHP: work sitehealth promotion

INTRODUCTION

In a 1993 report prepared by the Office ofDisease Prevention and Health Promotion,McGinnis, former Deputy Assistant Secretaryof Health, wrote, “Worksite health promo-tion has taken on increasing importance asa contributor to improved health for manyAmericans.” He continued, “With the ex-panded activity comes an interest and obliga-tion to assess the results of such programs toensure that we have a clearer notion of whatworks best in various settings” (83).

The report, written a decade and a half ago,spotlighted the experience of 61 employers,large and small, public and private, that wereproviding work site health promotion (WHP)programs aimed at improving the health andwell-being of their employees and reducinghealth care, workers’ compensation, and dis-ability costs. Since that report was released,researchers and program evaluators, largelyuniversity based, have increased the knowl-edge base related to health promotion effortsin the workplace. However, that experienceand the insights garnered from the researchhave not been well communicated and appliedto the audience that would benefit the most:employers.

Here, we critically examine WHP anddiscuss how knowledge from this field hasadvanced since the early 1990s. We reviewthe literature supporting the hypotheses thatWHP programs positively influence workers’health, medical service use, and productivity,and we evaluate the quality of the evidence.We discuss ways in which evidence-basedWHP practices can and should be dissemi-nated more broadly so that the positive healthand economic outcomes from such initiativescan be realized.

DEFINING WORK SITEHEALTH PROMOTION

WHP programs are employer initiatives di-rected at improving the health and well-beingof workers and, in some cases, their depen-dents. They include programs designed to

avert the occurrence of disease or the pro-gression of disease from its early unrecog-nized stage to one that’s more severe (27).At their core, WHP programs support pri-mary, secondary, and tertiary prevention ef-forts. Primary prevention efforts in the work-place are directed at employed populationsthat are generally healthy. They also offer op-portunities for workers who do not maintaingood health and who may fall prey to diseasesand disorders that can be prevented or de-layed if certain actions are taken. Examplesof primary prevention include programs thatencourage exercise and fitness, healthy eat-ing, weight management, stress management,use of safety belts in cars, moderate alcoholconsumption, recommended adult immuniza-tions, and safe sex (53).

Health promotion also incorporates sec-ondary prevention directed at individuals al-ready at high risk because of certain lifestylepractices (e.g., smoking, being sedentary, hav-ing poor nutrition, practicing unsafe sex, con-suming excessive amounts of alcohol, andexperiencing high stress) or abnormal bio-metric values (e.g., high blood pressure,high cholesterol, high blood glucose, over-weight). Examples of secondary preventioninclude hypertension screenings and manage-ment programs, smoking cessation telephonequit lines, weight loss classes, and reduction orelimination of financial barriers to obtainingprescribed lipid-lowering medications.

Health promotion sometimes also includeselements of tertiary prevention, often referredto as disease management, directed at individ-uals with existing ailments such as asthma, di-abetes, cardiovascular disease, cancers, mus-culoskeletal disorders, and depression, withthe aim of ameliorating the disease or re-tarding its progression. Such programs pro-mote better compliance with medications andadherence to evidence-based clinical prac-tice guidelines for outpatient treatment. Be-cause patient self-management is stressed,health-promotion practices related to behav-ior change and risk reduction are often partof disease management protocols. Full-service

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disease management programs also encour-age collaboration among patients, their fam-ilies, physicians, other health care providers,and the staff of the disease management pro-gram, and routine feedback loops are estab-lished among these groups (33).

ESTABLISHING A BUSINESSCASE FOR WORK SITEHEALTH PROMOTION

The Centers for Disease Control and Preven-tion (CDC), in conjunction with its HealthyPeople in Healthy Places initiative, has observedthat workplaces are to adults what schools areto children, because most working-age adultsspend a substantial portion of their wakinghours in their workplaces (113). Historically,WHP programs have been referred to as well-ness, health management, health promotion,health enhancement, and health and produc-tivity management (HPM) programs. For thesake of simplicity, we use the term WHP anddefine it as a set of workforce-based initiativesthat focus primarily on providing traditionalhealth-promotion services (e.g., health man-agement or wellness programs) and may alsoinclude disease management (e.g., screening,care management, or case management pro-grams), demand management (e.g., self-care,nurse call line programs), and related efforts tooptimize employee productivity by improvingemployee health (54).

Today, many employers associate poorhealth with reduced employee performance,safety, and morale. The organizational costs ofworkers in poor health, and those with behav-ioral risk factors, include high medical, dis-ability, and workers’ compensation expenses;elevated absenteeism and employee turnover;and decreased productivity at work (often re-ferred to as presenteeism) (44, 48, 51). In addi-tion, one worker’s poor health may negativelyaffect the performance of others who workwith him or her (44, 48, 80).

The question for employers is whetherwell-conceived WHP programs can improveemployees’ health, reduce their risks for dis-

ease, control unnecessary health care utiliza-tion, limit illness-related absenteeism, and de-crease health-related productivity losses (1,26, 43, 92, 93). If effective, WHP programscould reach large segments of the populationthat would not normally be exposed to and en-gaged in organized health improvement ini-tiatives. Still, many employers are reluctantto offer sufficiently intensive and comprehen-sive work site programs because they are notconvinced that these programs deliver on thepromise that they can reduce risk factors fortheir employees and achieve a positive finan-cial return on investment (ROI) (8, 42, 73, 90).

BARRIERS TO IMPLEMENTINGWORK SITE PROGRAMS

A 1999 survey of WHP fielded by the U.S. Of-fice of Disease Prevention and Health Promo-tion reported that 90% of work sites offeredworkers at least one type of health-promotionactivity (68). The key word in that report was“activity.” Almost all employers reported hav-ing one or a string of activities loosely con-nected to WHP, but most had no organiz-ing framework for these programs. The mostrecent National Worksite Health PromotionSurvey (68) reports that only 6.9% of employ-ers provide all five elements considered keycomponents of a comprehensive program: (a)health education, (b) links to related employeeservices, (c) supportive physical and social en-vironments for health improvement, (d ) inte-gration of health promotion into the organi-zation’s culture, and (e) employee screeningswith adequate treatment and follow up.

Some employers do not opt to invest inWHP, and some even cut funding to existingprograms, sometimes in spite of compellingdata showing that these programs achievegood results. Their reasons for not support-ing new or existing work site initiatives aremultifaceted.

A subset of employers are philosophicallyopposed to interfering with their workers’private lives, health habits, and medicaldecision-making, considering such actions as

www.annualreviews.org • Benefits of Work Site Health Promotion 305

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akin to playing the role of big brother. Someemployers consider WHP programs as luxu-ries and not central to the organization’s mainbusiness purpose. Still others may be con-cerned that programs promoted during workhours may distract workers from their day-to-day duties and consequently negatively impactworker productivity. Some employers arguethat there is no grassroots support for WHP,as evidenced by poor attendance in health ed-ucation sessions, or that labor unions mayobject, claiming that company cash outlaysfor such programs reduce workers’ take-homepay (16, 97).

Other employers’ objections to health pro-motion may be less defined, and in fact, theymay believe that these programs exert a posi-tive effect. However, they may find it difficultand expensive to prove positive outcomes tosenior managers seeking hard evidence of pro-gram impacts. Furthermore, it may also be dif-ficult to isolate specific program elements thatare more effective than others—those that de-liver the “biggest bang for the buck.”

Furthermore, some employers may be re-luctant to institute programs that achieve apositive ROI only after many years of invest-ment, and the promises of quick returns nevermatch reality. Also, they contend, even if theywished to start such programs, there are toofew best practices to emulate. Finally, smallbusinesses complain they lack the resourcesnecessary to implement initiatives similar tothose of large companies because they lackthe advantages of scalability and infrastruc-ture possessed by larger employers (112).

RATIONALE FOR INVESTINGIN WORK SITE HEALTHPROMOTION

Despite these objections to WHP, our recentinformal discussions with health-promotionvendors report a heightened interest in anddemand for their services. Vendors report thatthey are besieged with requests for proposals(RFPs) from employers wishing to provide totheir employees health risk appraisals (HRAs),

health education programs, health decisionsupport tools, health improvement coaching,and other preventive care services, within thecontext of a more holistic way to manageemployee health and costs (R. Goetzel, per-sonal communication, October 2, 2007). Ben-efit consultant surveys that usually target largeemployers report that almost two thirds ofthose responding to their surveys now offerwellness programs, and 15% more plan to doso (73).

There are several reasons offered by em-ployers for investing in WHP.

Workplaces Offer a Practical Settingfor Health Promotion

The workplace presents a useful setting for in-troducing and maintaining health-promotionprograms for working-age adults. It containsa concentrated group of people, usually sit-uated in a small number of geographic sites,who share a common purpose and commonculture. Communication and information ex-change with workers are relatively straight-forward. Individual goals and organizationalgoals, including those related to increasingprofitability, generally are aligned with oneanother.

Because good worker health has the poten-tial to enhance company profitability and helpachieve other organizational goals, the objec-tives of health promotion can be aligned withthe organization’s mission. Social and organi-zational support is likely to be available whenbehavior change efforts are attempted. Orga-nizational policies and social norms can helpguide certain behaviors and discourage oth-ers, and financial or other incentives can beintroduced to encourage participation in pro-grams. Finally, measurement of program im-pact is often practical, using available admin-istrative data collection and analysis systems.

Health Care and Health-PromotionExpenditures

The main driving force behind employers’growing interest in providing WHP services


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to their workers is undoubtedly rapidly risinghealth care costs (74, 78).

Employers’ health care costs, primarily fo-cused on sickness care, are increasing expo-nentially with no immediate attenuation insight. In 2006, U.S. health care spending to-taled $2.1 trillion—about 16.0% of the grossdomestic product (95). Employers pay morethan one third of the total annual medicalbill, and the balance is funded by Medicare,Medicaid, other government programs, indi-vidual insurance coverage, and patient out-of-pocket expenditures (64). In 2006, employerpremiums for medical care averaged $3615 ayear for single coverage and $8508 for familycoverage (61).

At the same time, the prevalence of ill-nesses that are at least partly caused by mod-ifiable health risk factors and poor lifestylehabits also continues to rise. For example, theUnited States has been witnessing alarmingincreases in obesity, contributing to height-ened rates of diabetes and related disorders(84). These strain the health care system’s re-sources because individuals who are burdenedby them generate significantly higher healthcare costs (36).

A large body of medical and epidemio-logical research confirms the links betweenchronic illnesses and common modifiable riskfactors, such as smoking, obesity, physical in-activity, excessive alcohol consumption, poordiet, high stress, and social isolation (3, 18,72, 75). Preventable or postponable illnessesmake up ∼70% of the total burden of disease(as measured in terms of premature deaths andpotential years of life lost and their associ-ated costs) (113). The World Health Organi-zation (77) has observed that smoking, alco-hol misuse, physical inactivity, and poor dietare among the top five contributors to diseaseand injury worldwide. McGinnis & Foege andMokdad et al. showed that about half of alldeaths in the United States may be prematurebecause they are caused by behavioral risk fac-tors and behavior patterns that are modifiable(71, 72, 75).

MODIFIABLE HEALTH RISKSAND EMPLOYER COSTS

Studies by Goetzel et al. (45) and Andersonet al. (7) examined the relationships betweenten modifiable health risk factors and medicalclaims for more than 46,000 employees fromprivate and public sector employers over a 6-year period. The risk factors studied includedobesity, high serum cholesterol, high bloodpressure, stress, depression, smoking, diet, ex-cessive alcohol consumption, physical fitnessand exercise, and high blood glucose. The au-thors found that these risk factors accountedfor ∼25% of total employer health care ex-penditures for the employees included in thestudy. Moreover, employees with seven of therisk factors (tobacco use, hypertension, hy-percholesterolemia, overweight/obesity, highblood glucose, high stress, and lack of physicalactivity) cost employers 228% more in healthcare costs compared with those lacking anyof these risk factors (45). Other reports haveshown that workers with these modifiable riskfactors are also more likely to be absent, havehigher rates of disability, and be less produc-tive (2, 9, 11, 13, 17, 24, 29, 30, 58–60, 62, 63,66, 103, 105, 110, 111, 118).

Synthesizing the health-promotion litera-ture spanning 15 years, Aldana (1) concludedthat there is consistent evidence of a relation-ship between obesity, stress, multiple risk fac-tors, and subsequent health care expendituresas well as subsequent worker absenteeism.Thus, the health risk profile of an employer’sworkforce is likely to have a significant impacton total labor costs.

Work Site Health-PromotionPrograms’ Effects on Behaviorsand Health Risks

Work site programs have been associatedwith changes in the health habits of work-ers. A systematic review of the literature per-taining to workplace-based health-promotionand disease-prevention programs was com-missioned by the CDC in 1995 (117), and


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a more recent review was concluded by theCommunity Preventive Services Task Forcein 2007 (109).

One specific focus of the earlier review wasmulticomponent WHP programs and theirimpact on employee health and productivity.In that review, Heaney & Goetzel examined47 peer-reviewed studies over a 20-year pe-riod (57) and found that WHP programs var-ied widely in terms of their comprehensive-ness, intensity, and duration. Consequently,the measurable impact of these programswas shown to be uneven because differentintervention and evaluation methods wereemployed.

Despite the variability in programs andstudy designs, the authors concluded thatthere was “indicative to acceptable” evi-dence supporting the effectiveness of mul-ticomponent WHP in achieving long-termbehavior change and risk reduction amongworkers. The most effective programs of-fered individualized risk-reduction counsel-ing to the highest risk employees, but theydid so within the context of broader healthawareness programs and a “healthy company”culture. On the basis of the evidence, thereviewers noted that changing the behav-ior patterns of employees and reducing theirhealth risks were achievable objectives in awork site setting, assuming favorable condi-tions exist, including proper program designand execution (26, 57, 117). Unfortunately,this review did not report on the average effectsizes of the interventions, but instead only onwhether the program achieved “significant”reductions in the health and productivity out-comes examined.

Findings from the CommunityGuide Review of Work SiteHealth Promotion

In February 2007, the Community GuideTask Force released the findings of a compre-hensive and systematic literature review fo-cused on the health and economic impactsof WHP (109). Using established and rig-

orous guidelines for their review (119), theTask Force examined the literature for worksite programs that include an assessment ofhealth risks with feedback, delivered verballyor in writing, followed by health education orother health-improvement interventions. Ad-ditional health-promotion interventions in-cluded counseling and coaching of at-risk em-ployees, invitations to group health educationclasses, and support sessions aimed at encour-aging or assisting employees in their effortsto adopt healthy behaviors. Interventions withan environmental or ecological focus includedenhancing access to physical activity programs(exercise facilities or time off for exercise),providing healthy food choices in cafeterias,and enacting policies that support a healthierwork site environment (such as a smoke-freeworkplace). In most cases, WHP interven-tions provided at the work site were offeredfree of charge to encourage participation.

Health and productivity outcomes fromthese interventions were reported from 50studies qualifying for inclusion in the review.The outcomes included a range of healthbehaviors, physiologic measurements, andproductivity indicators linked to changes inhealth status. Although many of the changes inthese outcomes were small when measured atan individual level, such changes at the popu-lation level were considered substantial (109).

Specifically, the Task Force found strongevidence of WHP program effectiveness inreducing tobacco use among participants(with a median reduction in prevalence ratesof 1.5 percentage points), dietary fat con-sumption as measured by self-report (medianreduction in risk prevalence of 5.4 percentagepoints), high blood pressure (median preva-lence risk reduction of 4.5 percentage points),total serum cholesterol levels (median preva-lence reduction of 6.6 percentage points), thenumber of days absent from work becauseof illness or disability (median reduction of1.2 days per year), and improvements in othergeneral measures of worker productivity.

However, insufficient evidence of effec-tiveness was found for some desired program


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outcomes, such as increasing dietary intakeof fruits and vegetables, reducing overweightand obesity, and improving physical fitness.Also, in a parallel review, the Task Force con-cluded that evidence was insufficient to deter-mine the effectiveness of HRAs with feedbackwhen implemented alone, without follow-upprograms (109). Thus, employers that admin-istered an HRA but provided no meaningfulfollow-up interventions would likely not real-ize changes in employees’ health and relatedoutcomes. These findings confirmed an ear-lier review that reached similar conclusions(6).

Aside from changes in health risks, theTask Force noted that there may be addi-tional benefits associated with work site pro-grams, including increasing worker awarenessof health issues; increasing detection of cer-tain diseases, or risk for disease at an earlieror presymptomatic stage; referral to medicalprofessionals for employees at high risk fordisease; and creation of need-specific health-promotion programs based on the analysis ofaggregate results. The Task Force also identi-fied some possible negative consequences as-sociated with these programs, including work-ers’ fear of breaches in confidentiality and thepossibility that those who think or know theyhave significant health risks may be unwillingto participate in programs that expose thoserisks.

Several threats to internal and externalvalidity inherent in work site studies werealso highlighted in the Task Force review.These included using biased samples com-prised of volunteers willing or even anxious toparticipate in health improvement-initiatives(the so-called worried well, who actively seekout medical information on their own); highattrition rates; the possibility that the so-cial desirability of responses to HRA ques-tions will yield invalid answers to surveyquestions; maturation effects; unaccounted-for secular changes (e.g., introduction of newlaws or company policies); and publicationbias (whereby studies that report positive re-sults are more likely to be reported, leading to

an overly optimistic view of health-promotionimpacts).

Return on Investment from WorkSite Health-Promotion Programs

If WHP programs can influence employees’health habits and behaviors, can they also re-duce health care costs? Over the past 20 years,several studies have addressed that question,and there is growing evidence that work siteprograms can yield acceptable financial re-turns to employers that invest in them. Sev-eral literature reviews that weigh the evidencefrom experimental and quasi-experimentalstudies suggest that programs grounded in be-havior change theory and that utilize tailoredcommunications and individualized counsel-ing for high-risk individuals are likely to pro-duce a positive return on the dollars investedin those programs (1, 26, 50, 93, 114).

The ROI research is largely based on eval-uations of employer-sponsored health pro-grams. One important caveat in assessingthose evaluations is that they are most oftenfunded by employers implementing the pro-grams, and these employers may desire a posi-tive assessment to justify their investment de-cisions. Studies often cited with the strongestresearch designs and large numbers of sub-jects include those performed at Johnson andJohnson (15, 19), Citibank (86), Dupont (12),Bank of America (38, 67), Tenneco (10), DukeUniversity (63), the California Public RetireesSystem (39), Procter and Gamble (49), andChevron Corporation (46). Even accountingfor inconsistencies in design and results, mostof these work site studies produced positivefinancial results.

A 1998 review of early WHP studies,mostly conducted in the 1980s and early 1990s(50), estimated ROI savings ranging from$1.40 to $3.14 per dollar spent, with a me-dian ROI of ∼$3.00 saved per dollar spent onthe program. The review acknowledged thatnegative results were not likely to be reportedin the literature and that the quality of manyof the studies was less than optimal.


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In 2001, Aldana (1) performed a compre-hensive literature review of the financial im-pact of health-promotion programming onhealth care costs in which he rated the rigorof the evaluations. In his analysis, only 4 of32 studies reviewed reported no effects ofhealth promotion on health care costs. How-ever, these four studies did not employ a ran-domized design, whereas several of the otherstudies that reported positive results appliedexperimental or rigorous quasi-experimentalmethods. The average ROI for seven studiesreporting costs and benefits was $3.48 for ev-ery dollar expended.

In the same review, Aldana (1) also re-ported the impact of work site programs onabsenteeism. All 14 absenteeism studies re-viewed by Aldana found reductions in em-ployee absenteeism, regardless of the researchdesign used, but only three reported ROI ra-tios, from $2.50 to $10.10 saved for every dol-lar invested.

In a more recent review of economic out-comes, summarizing results from 56 qualify-ing financial impact studies conducted overthe past two decades, Chapman in 2005 con-cluded that participants in work site programshave 25%–30% lower medical and absen-teeism costs compared with nonparticipants,over an average study period of 3.6 years (26).However, Chapman’s review included a mix ofcross-sectional and prospective research stud-ies and did not adjust for study design as rig-orously as did Aldana, so his higher estimatesof cost savings may be inflated.

Some researchers point to selection biasas the likely reason for finding cost savingsand high ROI estimates in work site studies.In many studies, it is unclear whether pro-gram participants are healthier or more highlymotivated than nonparticipants to begin with.Such a priori differences in health or motiva-tion may explain why participants use fewermedical care or other services and may con-tinue to do so even if a program was not avail-able. Under this scenario, changes in medi-cal expenditures or absenteeism may be dueto underlying health and motivational factors

that are independent of the program beingevaluated, and these should not be countedin the program’s favor. This type of selectionbias can be minimized, however, if researchersare able to obtain data explaining why thedecision to participate was made. Recent fi-nancial impact studies of work site programshave attempted to control for such inherentdifferences between participants and nonpar-ticipants at baseline, referred to as selectionbias, using methods suggested by Heckman,such as propensity matching and weighting,to yield more accurate estimates of programsavings and ROI (87).

ELEMENTS OF PROMISINGPRACTICES

As illustrated above, when WHP programsare grounded in behavior theory, imple-mented effectively using evidence-based prin-ciples, and measured accurately, they are morelikely to improve workers’ health and perfor-mance. These results can contribute to the or-ganization’s competitiveness and potentiallyenhance the organization’s standing in thecommunity. However, we need to learn moreabout the mechanisms and processes that fa-cilitate behavior change among workers, aswell as those that are ineffective.

Research is also needed to investigatethe relationships between program designand implementation and the amount of timeneeded to develop new participant healthhabits initiated by such programs. An oft-cited example pertains to weight-reductionprograms that help participants lose weightwithin a relatively short period, only to havethem regain much of that weight after the pro-gram ends. Investigators must seek to under-stand more fully whether such behavior is dueto poor program design, poor follow-up, oroverriding influences of the environment thatcannot easily be corrected.

Recent benchmarking and best-practicestudies suggest that the effectiveness of worksite programs is influenced greatly by such fac-tors as having senior management support, a


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champion at the work site promoting the pro-gram, alignment between the program andbroader organizational objectives, data docu-menting program achievements, and the abil-ity to create a healthy company culture (31,40–42, 47, 81, 82, 116; D. Anderson, unpub-lished information).

In addition, several other key componentsfrequently found in successful WHP pro-grams are described below.

Needs Assessment

As highlighted in the Community Guide review,using an HRA to assess employees’ healthrisks is a necessary but insufficient componentof successful WHP programs (109). Nonethe-less, most effective programs begin with theadministration of an HRA in which employeesanswer questions about their health behaviors,biometric measures may be collected, and a se-ries of estimates of health risks are provided tothe individual. These HRAs also include ques-tions designed to shape interventions mostlikely to improve employees’ health risk pro-files. For example, HRAs often assess partici-pants’ readiness to change, perceived level ofself-efficacy, or other psychosocial factors af-fecting their willingness or ability to changebehaviors. Without an HRA, it is difficult totailor interventions that fit well with individu-als’ states of readiness to change behavior andlearning style.

The HRA is usually a fairly low-cost tool,ranging in price from a few pennies to ∼$50per respondent depending on whether it isadministered electronically or through themail, and whether biometric measures are alsotaken (102). Thus, the HRA can be an efficientmethod of providing a gateway to follow-upinterventions that are more costly and thatshould be recommended for those who aremost in need.

One illustration of the value HRAs wasprovided in a study of retirees conducted byOzminkowski et al. (88). In their financialanalysis of Medicare claims data, the inves-tigators found that the HRA was the cor-

nerstone of successful programs for the el-derly and that its administration, along withother health-promotion programs, was as-sociated with significant cost savings. Theyused growth-curve analyses to account forpreexisting trends in utilization for programparticipants and nonparticipants, along withpropensity score weighting and other multipleregression analyses to control for differencesin baseline health status, prior to estimatingthe impact of program participation.

The researchers found that cost trendswere lowest (and savings were therefore high-est) for HRA participants who also engaged inone or more follow-up interventions. Theseinterventions included on-site biometricscreenings, telephone lifestyle managementcounseling for high-risk individuals, nurse-support telephone lines, and wellness classes.In general, the more programs in which se-niors participated, the lower were their sub-sequent health care costs. Cost savings werenot observed for beneficiaries who engagedin follow-up programs without also complet-ing an HRA; in some analyses, these bene-ficiaries even cost more. The authors there-fore surmised that the HRA was an effectivetool to triage and direct beneficiaries to otherprograms in an appropriate manner. Indeed,combining HRA results with other data, suchas medical and pharmacy claims, may offer ad-ditional triage and targeting opportunities.

Achieving High Participation Rates

A high participation rate is a key elementof any successful risk-reduction program. AsAnderson opines, “Nothing happens until[people] participate” (101; D. Anderson, un-published information). As described below,many methods can be used to achieve highparticipation rates, including the shrewd useof incentives. Participation is defined in manyways including taking HRAs, enrolling in pro-grams, completing programs, and participat-ing in self-care and self-management activitiesthat are difficult to monitor. In a survey ofKoop Award winners, Goetzel et al. (52) found


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that the majority of former winners consid-ered high participation rates “very impor-tant,” especially among employees who arehard to reach, and that the average participa-tion rate among exemplary WHP programswas 60%.

Providing Tailored BehaviorChange Messages

A number of studies have demonstrated theincreased efficacy of tailored messages rela-tive to generic ones. For example, Kreuterand Strecher (65) compared the effects oftailored HRA feedback with generic feed-back and found that individuals receiving thetailored feedback were 18% more likely tochange at least one risk factor (usually choles-terol screening, dietary fat consumption, orphysical activity).

This finding was confirmed in studies ad-dressing single risk behaviors as well. Forexample, Rimer et al. (96), in a smokingcessation study, found that participants whoreceived tailored print material were signifi-cantly more likely to reread the material andbelieve that the ideas were new, that the ma-terial was helpful, and that it was easy touse. In a randomized study of exercise be-havior, Peterson & Aldana (94) found that in-dividuals who received written messages tai-lored to their stage of change (as defined byProchaska) demonstrated a 13% increase inphysical activity, compared with 1% for thosewho received generic messages, and an 8% de-crease for the control group over a six-weekperiod.

Supporting Self-Careand Self-Management

Self-care or self-management refers to the no-tion that the individual is an active participantin his or her medical treatment or in ensur-ing health maintenance (69). For the chroni-cally ill, effective self-management increasespatients’ ability to manage their prescribedmedical treatment, by teaching or otherwise

helping them adhere to medication or dietregimens, teaching them to use medical careservices appropriately, and helping to addressthe emotional sequelae of health conditions.

Thus, self-management education is de-signed to teach skills and increase the par-ticipant’s confidence in his or her ability todefine and solve problems, make decisions,find resources, and form partnerships withhealth care providers. Such an approach canreduce symptoms and distress caused by manychronic diseases and improve psychologicalwell-being as measured by standardized in-struments (69). For example, in a review ofself-management programs, Lorig & Holman(69) found that goal setting and action plan-ning were critical to perceived health im-provements.

As shown above, a key component of self-care and self-management is goal setting,which enhances treatment compliance andmotivates behavior change. Lovato & Green(70) found that goal setting was the most ef-fective method to maintain employee partici-pation in WHP programs. They further notedthat goal setting was most effective when goalsare realistic, short-term, flexible, and set bythe participant rather than imposed by pro-gram staff (70).

Guided self-help strategies are also key el-ements of self-management. These come inthe form of printed materials or conversa-tions with trained counselors that help par-ticipants define their goals (e.g., manage theirsymptoms or reduce their morbidity or mor-tality risks) and develop action plans (e.g.,find better ways to adhere to pharmacother-apy or other treatments) (69). Orleans et al.(85) presented evidence that self-help smok-ing cessation guides are a promising additionto clinical treatments such as nicotine patchesand that complementing pharmacotherapywith self-help guides and frequent interac-tions with trained counselors can help achievehigh smoking-cessation rates.

In short, individualized and tailoredbehavioral interventions that use goal-setting techniques, reflective counseling, and


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motivational interviewing, provided in apersonalized and consistent manner, are moreeffective than general awareness building andinformation and education sharing programs(35, 55, 57, 91, 104).

Addressing Multiple Risk Factors

Addressing multiple risk factors simultane-ously can increase the impact of the in-tervention because it facilitates individuals’involvement in the program through manyentry channels. However, a strategic approachto addressing a participant’s multiple risks isimportant. Several studies cited by Strecheret al. (108) suggest a need to break bad habitsone at a time. People with multiple risk factorsmay be overwhelmed with the sheer numberof health risks they have and may find it dif-ficult to sort out the major from the minor.Thus a program should avoid recommendingtoo much too quickly.

Risks can be prioritized on the basis oftheir near-term likelihood of morbidity ormortality and the participant’s readiness tochange any given risk factor. This approachis based on the presumption that an individ-ual’s high intrinsic motivation to change oneeven relatively benign behavior is more likelyto achieve success, thus generating a senseof self-efficacy and continued motivation tochange more behaviors. Thus, once one be-havior or risk is successfully mitigated, the in-dividual may feel greater confidence in his orher ability to address other health issues. Of-fering a comprehensive program that allowsparticipants to move from one risk categoryto another is therefore desirable.

Offering a Variety of EngagementModalities

With the understanding that some individu-als prefer to work on behavior change on theirown while others prefer to utilize social sup-port, most work site programs offer a menuof interventions, including printed health ed-ucation materials, individualized counseling,

group classes, and work site–wide health-promotion activities. Although classes appealto some, Erfurt et al. (34) found that offeringa menu, including guided self-help, one-to-one, mini group, and full-group interventions,is more successful than offering only didac-tic sessions. Fries analyzed two programs forretirees delivered entirely through the mailand found that tailored print materials had asignificant behavioral impact (38, 39). How-ever, he did not test whether impacts wouldhave been greater with additional engagementmodalities. Several studies support the ideathat with tailored interventions, on-site, face-to-face encounters between health educatorsand participants may not be necessary (35).However, this area requires further researchbecause it is not clear what might be the rela-tive effects of different engagement modalities(109).

Providing Easy Access to Programsand Effective Follow-Up

In WHP programs, easy access to programsis key to recruiting and maintaining partici-pation. Erfurt et al. (34) found that, althoughhalf of employees indicated interest in smok-ing and weight-loss classes, fewer than 1%enrolled in the classes when offered off-site,compared with 8%–12% when offered onsite.Lovato & Green (70) cite several studies basedon surveys of employees who dropped out ofhealth-promotion programs; that the surveysidentified logistical barriers (time and loca-tion) as the most often cited reasons for drop-ping out of the program.

For employees who participated in bloodpressure treatment, work site weight-loss,or smoking-cessation programs, gains madeare best maintained when the program in-cludes ongoing routine and persistent follow-up counseling (34). Several studies reviewedby Pelletier (91) in these three areas found thatone-time screening and counseling can haveshort-term impacts (up to three months), butwithout additional follow-up, the effect dis-appears within a year.


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Social Support

Lovato & Green (70) cited social supportand reinforcement as important factors in in-fluencing participation in exercise programs,especially the support of a spouse, family,or significant others. Feedback from pro-gram staff can also be a source of social sup-port. In a review of smoking-cessation studies,Orleans (85) noted that successful quitters re-ported more positive support from signifi-cant others than did relapsers or continuedsmokers.

Use of Incentives

In WHP programs, incentives have been of-fered for participation, compliance with be-havior change recommendations, or achieve-ment of certain health goals. Researchers haveobserved that an incentive valued at ∼$100(in 2006 dollars) is necessary to encourage themajority of employees to complete an HRA(101). However, others have argued that in-centives should be used sparingly or inter-mittently to avoid situations in which pos-itive health improvements are tied directlyto incentives and then healthy actions stopwhen incentives are removed (25). Ander-son (5) presented preliminary data at a recentconference showing that increasing incen-tives (typically through reductions in medicalpremiums) at $100 intervals (from a base of$100 in 2007 dollars) will result in incremen-tal 10% improvements in HRA and programparticipation.

Culture of Health

Workplace programs embedded within ahealthy company culture are more likely tosucceed. A healthy company culture allowsfor the use of company equipment, facil-ities, and other forms of infrastructure tosupport health behaviors. In larger compa-nies, physical plants are used to house fit-ness centers, on-site health education classes,and cafeterias featuring healthy food choices.

Employers embodying a healthy culture canestablish policies to reinforce desired behav-iors and brand health improvement programsin ways that mirror other organizationalinitiatives (54).

Assuring Sufficient Durationof Programs

Evaluation studies have followed WHP par-ticipants from as short a period as six monthsto as long as 10 years (91). Heaney & Goet-zel (57) suggest that a program must be inoperation for at least one year to bring aboutrisk reductions among employees, and Gomel(55) and Moore (76) state that it may be mis-leading to evaluate the program in less thana year because changes that occur in the firstfew months of a program may not be main-tained over time. Aldana (1) calculated an av-erage study duration of 3.25 years. Consen-sus opinion is that WHP programs need tobe in place for at least three years to measurehealth and financial outcomes but that annualassessments of those outcomes are necessaryto track progress and fine-tune the interven-tions (1, 26, 50, 93).

SUMMARY FINDINGS FROMBENCHMARK STUDIES

This review has touched on several in-dividual components of WHP. Large-scalebenchmarking and promising practice stud-ies, conducted over the past decade, havelooked at broad and general themes emanat-ing from successful WHP programs. A re-view of benchmarking and best-practice stud-ies was recently published by Goetzel et al.(54), and their observations mirror many ofthe individual success factors already noted.On the basis of findings from previous stud-ies, coupled with discussions with subject mat-ter experts and observations from site visits toseveral exemplary programs, the authors iden-tified the following as effective WHP prac-tices: a) integrating WHP programs into the


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organization’s central operations; b) address-ing individual, environmental, policy, andcultural factors affecting health and produc-tivity; c) targeting several health issues simul-taneously; d ) tailoring programs to addressspecific needs of the population; e) attaininghigh participation rates; f ) rigorously evalu-ating outcomes; and g) effectively communi-cating these outcomes to key stakeholders.

REPRODUCIBILITY OFPROMISING PRACTICEPROGRAMS

Although insights about effective WHP pro-grams are available in the scientific literature,many employers, especially small businesses,lack the knowledge and experience to design,implement, and evaluate effective programslikely to achieve desired outcomes (42). Nolarge-scale education, communication, anddissemination efforts have been launched inthis area, and consequently, we need bet-ter marketing and real-world application ofcurrent and emerging knowledge related toWHP—knowledge about what works, whatdoes not work, and where significant gaps inknowledge exist.

More consistent evaluation of these in-terventions, their impact, and their potentialfor translation into public health practiceis needed. Careful evaluation can improvethe information relevant to translation issues(e.g., critical success factors, impediments)and thus provide needed data to public healthpractitioners, employers, local communities,organizations, and individual consumers tomake informed health-promotion practicedecisions.

Moreover, well-structured and large-scaleexperiments examining the application ofcommercially developed health-promotionprograms are still in their infancy. Althoughseveral key process components leading tosuccessful program outcomes have been doc-umented and applied by leading employers,there is insufficient evaluation of programoutcomes, especially financial outcomes, us-

ing rigorous study methods. Thus more re-search is needed before early successful WHPapplications can be generalized to the broaderemployer community.

CONCLUSIONS

Recently, interest in WHP has increaseddramatically. Examples of increased activityin this area include the work of Partnershipfor Prevention in promoting the Leadingby Example Initiative (89), the Score CardProject from the Health EnhancementResearch Organization (HERO) (56), theNational Committee for Quality Assurance(NCQA) interest in accrediting and certi-fying health-promotion vendors (79), theCDC Foundation Worksite Initiative (22),The Conference Board Health PromotionConsortium (28), the NIOSH/CDC Work-Life Symposium (23), and several researchstudies funded by the CDC (21) and NationalInstitutes of Health (115) focused on worksite health promotion and disease preventionprograms.

To maintain their momentum and achievethe status of a must-have company benefit,WHP programs will need to document en-during health improvements for their targetedpopulation and related cost impacts. This in-volves periodically measuring the health risksof their workers and evaluating changes inhealth behaviors, biometric measures, and uti-lization of health care services. Furthermore,for WHP programs to be deemed successful,they will need to engage large segments of thepopulation, especially those with the greatestneed for such programs.

In addition, to remain viable and sustain-able as a business investment, WHP pro-grams will need to produce data supportingtheir cost-effectiveness and cost-benefit. Toachieve a positive ROI, programs will need tobe funded at an optimal investment level sothat program savings can be deemed accept-able or, ideally, equal to or greater than pro-gram expenses. Knowing the tipping point—how much to spend to improve health and save


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money—is currently an unanswered questionfor most employers. Hence, more researchis needed on the optimal design and cost ofinterventions, and this research must reachemployers for these programs to be appliedmore broadly.

The notion of delivering health improve-ment at a reasonable cost through WHP isthe key to achieving greater support from pri-vate and public employers. Very few newlyapproved medical interventions actually savemoney, but they can improve health at a rea-sonable expense. However, this notion hasrarely been used when considering the valueof health-improvement programs. Instead,the more difficult-to-achieve objective of re-alizing net savings has been required in WHPprogram evaluations (16).

As employers and other payers acknowl-edge that investments in WHP are long-termin nature, and that there may be a significantlag between improvements in health and sav-ings in medical expenditures or improvementsin productivity, the importance of document-ing cost-effectiveness may become a higherpriority.

Today, many employers (especially largeones) provide WHP programs because theybelieve that good health care programs in-crease worker productivity and organizationaleffectiveness. Their view is that paying forquality health care and WHP programs isnot just the cost of doing business, but ratheris an investment in their human capital. Asevaluations of WHP programs become moresophisticated, program impact estimates arelikely to expand to include productivity mea-sures and their effects on ROI. This will re-quire the ability to link multiple sources ofdata to fully investigate the impact of WHPprograms.

Sophisticated employers are also becom-ing increasingly aware that to improve thehealth and well-being of workers, they alsoneed to address the organizational, environ-mental, and ecological elements of the work-place. Preliminary evidence suggests that the

physical environment affects workers’ physi-cal activity levels and dietary habits (4, 14, 20,37, 98, 99).

An organization is supportive of individualhealth-improvement efforts when it providesenvironmental and ecological supports forhealth improvement such as offering healthyfood choices in cafeterias, stocking vend-ing machines with nutritious snacks, requir-ing company-sponsored meals to be healthy,providing opportunities for physical activ-ity, having a campus-wide no-smoking pol-icy, making staircases attractive, and providingbenefit coverage for recommended preventivescreenings. Although many of these environ-mental and policy innovations have alreadybeen introduced at work sites, there is stillsparse research on their individual and com-bined effects on such outcomes as improvingthe health of workers, reducing utilization ofhealth care services, and improving workerproductivity.

Consistent with this notion is a small butgrowing movement to integrate occupationalsafety initiatives with work site health promo-tion (32, 44, 100, 106, 107). Evidence showsthat poor health increases the likelihood ofindustrial accidents or injuries (32, 100, 106).

If that is the case, successfully integratedWHP and safety initiatives can also helpensure the safety of work environments,leading to healthier and more productiveemployees.

Finally, as noted above, several large fed-erally funded studies are currently under-way to test alternative WHP models. Armedwith better and more practical data on pro-gram effects, federal, state, and local govern-ments can play a larger role in disseminatinginformation about evidence-based programs,with the expectation that such disseminationwill prompt more employers to adopt theseprograms. Through legislative or other ini-tiatives, government agencies may also sup-port financial incentives (e.g., tax credits) toencourage employers to implement effectiveprograms.


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DISCLOSURE STATEMENT

The authors have been engaged in work site health promotion evaluation research for over adecade. Support for such research has been provided by organizations implementing programs,federal, state and local governments. They have also functioned as paid consultants to businesseswishing to design, implement, and evaluate their work site programs.

ACKNOWLEDGMENTS

No external funding was provided for the preparation of this paper. The authors would liketo thank Jennie Bowen for her help in providing background research and editing the finalmanuscript. The opinions expressed in this paper are the authors’ and do not necessarily repre-sent the opinions of Thomson Healthcare or Cornell University. This article was written whileR.G. was Director of the Institute for Health and Productivity Studies at Cornell University.R.G. is now a Professor in the Department of Health Policy and Management, Rollins Schoolof Public Health, at Emory University.

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51. Goetzel RZ, Long SR, Ozminkowski RJ, Hawkins K, Wang S, Lynch W. 2004. Health,absence, disability, and presenteeism cost estimates of certain physical and mental healthconditions affecting U.S. employers. J. Occup. Environ. Med. 46:398–412

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AR337-FM ARI 22 February 2008 17:45

Annual Review ofPublic Health

Volume 29, 2008Contents

Commentary

Public Health Accreditation: Progress on National AccountabilityHugh H. Tilson � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �xv

Symposium: Climate Change and Health

Mitigating, Adapting, and Suffering: How Much of Each?Kirk R. Smith � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �xxiii

Ancillary Benefits for Climate Change Mitigation and Air PollutionControl in the World’s Motor Vehicle FleetsMichael P. Walsh � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �1

Co-Benefits of Climate Mitigation and Health Protection in EnergySystems: Scoping MethodsKirk R. Smith and Evan Haigler � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 11

Health Impact Assessment of Global Climate Change: Expandingon Comparative Risk Assessment Approaches for Policy MakingJonathan Patz, Diarmid Campbell-Lendrum, Holly Gibbs,

and Rosalie Woodruff � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 27

Heat Stress and Public Health: A Critical ReviewR. Sari Kovats and Shakoor Hajat � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 41

Preparing the U.S. Health Community for Climate ChangeRichard Jackson and Kyra Naumoff Shields � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 57

Epidemiology and Biostatistics

Ecologic Studies RevisitedJonathan Wakefield � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 75

Recent Declines in Chronic Disability in the Elderly U.S. Population:Risk Factors and Future DynamicsKenneth G. Manton � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 91

vii

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The Descriptive Epidemiology of Commonly Occurring MentalDisorders in the United StatesRonald C. Kessler and Philip S. Wang � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �115

The Women’s Health Initiative: Lessons LearnedRoss L. Prentice and Garnet L. Anderson � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �131

U.S. Disparities in Health: Descriptions, Causes, and MechanismsNancy E. Adler and David H. Rehkopf � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �235

Environmental and Occupational Health

Industrial Food Animal Production, Antimicrobial Resistance,and Human HealthEllen K. Silbergeld, Jay Graham, and Lance B. Price � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �151

The Diffusion and Impact of Clean Indoor Air LawsMichael P. Eriksen and Rebecca L. Cerak � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �171

Ancillary Benefits for Climate Change Mitigation and Air PollutionControl in the World’s Motor Vehicle FleetsMichael P. Walsh � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �1

Co-Benefits of Climate Mitigation and Health Protection in EnergySystems: Scoping MethodsKirk R. Smith and Evan Haigler � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 11

Health Impact Assessment of Global Climate Change: Expanding onComparative Risk Assessment Approaches for Policy MakingJonathan Patz, Diarmid Campbell-Lendrum, Holly Gibbs, and

Rosalie Woodruff � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 27

Heat Stress and Public Health: A Critical ReviewR. Sari Kovats and Shakoor Hajat � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 41

Preparing the U.S. Health Community for Climate ChangeRichard Jackson and Kyra Naumoff Shields � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 57

Protective Interventions to Prevent Aflatoxin-Induced Carcinogenesisin Developing CountriesJohn D. Groopman, Thomas W. Kensler, and Christopher P. Wild � � � � � � � � � � � � � � � � � � �187

Public Health Practice

Protective Interventions to Prevent Aflatoxin-Induced Carcinogenesisin Developing CountriesJohn D. Groopman, Thomas W. Kensler, and Christopher P. Wild � � � � � � � � � � � � � � � � � � �187

Regionalization of Local Public Health Systems in the Era ofPreparednessHoward K. Koh, Loris J. Elqura, Christine M. Judge, and Michael A. Stoto � � � � � � � �205

viii Contents

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The Effectiveness of Mass Communication to Change Public BehaviorLorien C. Abroms and Edward W. Maibach � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �219


The Diffusion and Impact of Clean Indoor Air LawsMichael P. Eriksen and Rebecca L. Cerak � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �171

Public Health Services and Cost-Effectiveness AnalysisH. David Banta and G. Ardine de Wit � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �383

Social Environment and Behavior

Creating Healthy Food and Eating Environments: Policyand Environmental ApproachesMary Story, Karen M. Kaphingst, Ramona Robinson-O’Brien,

and Karen Glanz � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �253

Why Is the Developed World Obese?Sara Bleich, David Cutler, Christopher Murray, and Alyce Adams � � � � � � � � � � � � � � � � � � �273

Global Calorie Counting: A Fitting Exercise for Obese SocietiesShiriki K. Kumanyika � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �297

The Health and Cost Benefits of Work Site Health-PromotionProgramsRon Z. Goetzel and Ronald J. Ozminkowski � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �303

The Value and Challenges of Participatory Research: StrengtheningIts PracticeMargaret Cargo and Shawna L. Mercer � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �325

A Critical Review of Theory in Breast Cancer Screening Promotionacross CulturesRena J. Pasick and Nancy J. Burke � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �351

The Effectiveness of Mass Communication to Change Public BehaviorLorien C. Abroms and Edward W. Maibach � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �219


Health Services

A Critical Review of Theory in Breast Cancer Screening Promotionacross CulturesRena J. Pasick and Nancy J. Burke � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �351

Nursing Home Safety: Current Issues and Barriers to ImprovementAndrea Gruneir and Vincent Mor � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �369

Contents ix

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Public Health Services and Cost-Effectiveness AnalysisH. David Banta and G. Ardine de Wit � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �383

The Impact of Health Insurance on HealthHelen Levy and David Meltzer � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �399

The Role of Health Care Systems in Increased Tobacco CessationSusan J. Curry, Paula A. Keller, C. Tracy Orleans, and Michael C. Fiore � � � � � � � � � � �411

Indexes

Cumulative Index of Contributing Authors, Volumes 20–29 � � � � � � � � � � � � � � � � � � � � � � � �429

Cumulative Index of Chapter Titles, Volumes 20–29 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �434

Errata

An online log of corrections to Annual Review of Public Health articles may be foundat http://publhealth.annualreviews.org/

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AnnuAl Reviewsit’s about time. Your time. it’s time well spent.

AnnuAl Reviews | Connect with Our expertsTel: 800.523.8635 (us/can) | Tel: 650.493.4400 | Fax: 650.424.0910 | Email: [email protected]

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Annual Review of Statistics and Its ApplicationVolume 1 • Online January 2014 • http://statistics.annualreviews.org

Editor: Stephen E. Fienberg, Carnegie Mellon UniversityAssociate Editors: Nancy Reid, University of Toronto

Stephen M. Stigler, University of ChicagoThe Annual Review of Statistics and Its Application aims to inform statisticians and quantitative methodologists, as well as all scientists and users of statistics about major methodological advances and the computational tools that allow for their implementation. It will include developments in the field of statistics, including theoretical statistical underpinnings of new methodology, as well as developments in specific application domains such as biostatistics and bioinformatics, economics, machine learning, psychology, sociology, and aspects of the physical sciences.

Complimentary online access to the first volume will be available until January 2015. table of contents:•What Is Statistics? Stephen E. Fienberg•A Systematic Statistical Approach to Evaluating Evidence

from Observational Studies, David Madigan, Paul E. Stang, Jesse A. Berlin, Martijn Schuemie, J. Marc Overhage, Marc A. Suchard, Bill Dumouchel, Abraham G. Hartzema, Patrick B. Ryan

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•High-Dimensional Statistics with a View Toward Applications in Biology, Peter Bühlmann, Markus Kalisch, Lukas Meier

•Next-Generation Statistical Genetics: Modeling, Penalization, and Optimization in High-Dimensional Data, Kenneth Lange, Jeanette C. Papp, Janet S. Sinsheimer, Eric M. Sobel

•Breaking Bad: Two Decades of Life-Course Data Analysis in Criminology, Developmental Psychology, and Beyond, Elena A. Erosheva, Ross L. Matsueda, Donatello Telesca

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Susan A. Murphy•Statistics and Related Topics in Single-Molecule Biophysics,

Hong Qian, S.C. Kou•Statistics and Quantitative Risk Management for Banking

and Insurance, Paul Embrechts, Marius Hofert

Access this and all other Annual Reviews journals via your institution at www.annualreviews.org.

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