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

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  • 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: Ron.Goetzel@Thomson.com2Ann Arbor, Michigan 48108; email: ronoz@verizon.net

    Annu. Rev. Public Health 2008. 29:30323

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

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

    This articles 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 workershealth, 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 thats 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 workers 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 wasactivity. Almost all employers reported hav-ing one or a string of activities l

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