Workplace wellness is any workplace health promotion activity or organizational policy designed to support healthy behavior in the workplace and to improve health outcomes. Known as 'corporate wellbeing' outside the US, workplace wellness often comprises activities such as health education, medical screenings, weight management programs, on-site fitness programs or facilities. These programs can be classified as primary, secondary, or tertiary health programs, depending on the goal of the specific program. Primary prevention programs usually target a fairly healthy employee population, and encourage them to more frequently engage in health behaviors that will encourage ongoing good health. Example of primary prevention programs include stress management, and exercise and healthy eating promotion. Secondary prevention programs are targeted at reducing behavior that is considered a risk factor for poor health. Examples of such programs include smoking cessation programs and screenings for high blood pressure or other disease related risk factors. Tertiary health programs address existing health problems, and aim to help control or reduce symptoms, or to help slow the progression of a disease or condition. Such programs might encourage employees to better adhere to specific medication or self-managed care guidelines. Workplace wellness programs can be categorized as primary, secondary, or tertiary prevention efforts, or an employer can implement programs that have elements of multiple types of prevention.
The lifestyles of people in the workforce are important both for the sake of their own health and for the sake of their employer's productivity. Companies often subsidize these programs in the hope that they will save companies money in the long run by improving health, morale and productivity, although there is some controversy about evidence for the levels of return on investment.
Other examples of workplace wellness organizational policies include allowing flex-time for exercise, providing on-site kitchen and eating areas, offering healthy food options in vending machines, holding “walk and talk” meetings, and offering financial and other incentives for participation. In recent years, workplace wellness has been expanded from single health promotion interventions to create a more overall healthy environment including, for example standards of building and interior design to promote physical activity.
In 2013, the Kaiser Family Foundation estimated that approximately 77% of U.S. firms offered employee wellness programs (99% of large firms, and 76% of small firms. The survey also found that only 10% of firms offered incentives to participate, and that large firms were much more likely to do so (36% versus 8% of small firms). Federal regulations govern the use of financial and non-monetary incentives to participate in these programs, in order to protect employees from potential discrimination. These include three laws that directly affect wellness initiatives:
- the Employee Retirement Income Security Act (ERISA)
- the Americans with Disabilities Act (ADA)
- and the Genetic Information Nondiscrimination Act (GINA).
As health care costs rise in the U.S., emmployers are also seeing increased spending associated with health care for employees. Costs can be incurred by paying for care, and in lost productivity due to employee illness or absence. Reducing costs associated with preventable illness is in the financial interests of both employers and employees, and researchers cite two specific reasons, in addition to financial incentives, for why workplace intervention might be an effective and efficient delivery location for wellness programs to improve health outcomes. The workplace is a setting where many U.S. adults spend the bulk of their time, and the workplace offers a "common purpose and culture" that may increase the odds of participation in, and successful completion of, a wellness program.
Concern about the economic burden associated with obesity is also growing. Obesity is associated with increased absenteeism, disability, injury and healthcare claims, which alongside the affects on those affected, also drive up costs for employers. Furthermore, when compared to other industrialized countries, the US has the highest per capita costs for health care and also as a percentage of gross domestic product, yet ranks in the bottom quartile for life expectancy and infant mortality.
While the stated goal of workplace wellness programs is to improve employee health, many US employers have turned to them to help alleviate the impact of enormous increases in health insurance premiums experienced over the last decade. Some employers have also begun varying the amount paid by their employees for health insurance based on participation in these programs. Cost-shifting strategies alone, through high copayments or coinsurance may create barriers to participation in preventive health screenings or lower medication adherence.hypertension.
One of the reasons for the growth of healthcare costs to employers is the rise in obesity-related illnesses brought about by lack of physical activity, another is the effect of an ageing workforce and the associated increase in chronic health conditions driving higher health care utilization. In 2000 the health costs of overweight and obesity in the US were estimated at $117 billion. Each year obesity contributes to an estimated 112,000 preventable deaths. An East Carolina University study of individuals aged 15 and older without physical limitations found that the average annual direct medical costs were $1,019 for those who are regularly physically active and $1,349 for those who reported being inactive. Being overweight increases yearly per person health care costs by $125, while obesity increases costs by $395. A survey of North Carolina Department of Health and Human Services employees found that approximately 70 cents of every healthcare dollar was spent to treat employees who had one or more chronic conditions, two thirds of which can be attributed to three major lifestyle risk factors: physical inactivity, poor diet, and tobacco use. Obese employees spend 77 percent more on medications than non-obese employees and 72 percent of those medical claims are for conditions that are preventable.
According to Healthy Workforce 2010 and Beyond, a joint effort of the US Partnership for Prevention and the US Chamber of Commerce, organizations need to view employee health in terms of productivity rather than as an exercise in health care cost management. The emerging discipline of Health and Productivity Management (HPM) has shown that health and productivity are “inextricably linked” and that a healthy workforce leads to a healthy bottom line. There is now strong evidence that health status can impair day-to-day work performance (e.g., presenteeism) and have a negative effect on job output and quality. Current recommendations for employers are not only to help its unhealthy population become healthy but also to keep its healthy population from becoming sick. Employers are encouraged to implement population-based programs including health risk appraisals and health screenings in conjunction with targeted interventions.
Wellness programs are being implemented across the country in large and small companies, and the results are positively impacting the bottom line. “Research is showing that it’s more cost-effective to invest in preventive health practices, such as screenings, immunizations, health risk appraisals, behavioral coaching, and health awareness/education, rather than spending resources exclusively on the small minority of employees/dependents who are responsible for high-cost health claims.” A U.S. Department of Health and Human Services report revealed that at worksites with exercise programs as components of their wellness programs, healthcare costs decreased from 20 to 55%, short-term sick leave was lowered from 38 to 32%, and productivity increased from 50 to 52%. A 2010 meta-analysis of 36 peer-reviewed workplace wellness program studies estimated that investing in these programs can create a return on investment (ROI) for employers. Researchers estimated an average decline in medical costs of $3.27 per every dollar spent on these programs within the sample studies, and a drop in "absenteeism" costs of up to $2.73 per dollar spent on these programs.
Researchers from the Centers for Disease Control and Prevention studied strategies to prevent cardiovascular disease and found that over a two- to five-year period, companies with comprehensive workplace wellness programs and appropriate health plans in place can yield $3USD to $6USD for each dollar invested and reduced the likelihood of employee heart attacks and strokes. Also, a 2011 report by Health Fairs Direct which analyzed over 50 studies related to corporate and employee wellness, showed that the ROI on specific wellness related programs ranged between $1.17 to $6.04. In general, it is estimated that worksite health promotion programs result in a benefit-to-cost ratio of $3.48 in reduced health care costs and $5.82 in lower absenteeism costs per dollar invested, according to the Missouri Department of Health & Senior Services. Additionally, worksite health programs can improve productivity, increase employee satisfaction, demonstrate concern for employees, and improve morale in the workplace.
The Affordable Care Act increases the cap on incentives which can be granted to employees for participating in health-contingent wellness programs from 20% of the total cost of employee-only healthcare to the 30% of the total cost, while smoking cessation must reach 50% of the total cost. Employers can incentivize employees with significant rewards for participation in biometrics screenings and health risk assessments and/or hitting their targets in a manner which theoretically saves both the employer and the employee money, especially when these programs are implemented at a large scale. Rewarding employees based on meeting goals is known as a "results-based wellness program." Incentives, however, have increased from 2011 to 2012 by 13%. Generally, incentives take the form of "Pay or Play".
Worksite wellness programs including nutrition and physical activity components may occur separately or as part of a comprehensive worksite health promotion program addressing a broader range of objectives such as smoking cessation, stress management, and weight loss. A conceptual model has been developed by the Task Force for Community Preventive Services and serves as an analytic framework for workplace wellness and depicts the components of such comprehensive programs. These components include worksite interventions including 1) environmental changes and policy, 2) informational messages, and 3) behavioral and social skills or approaches.
Worksite environmental change and policy strategies are designed to make healthy choices easier. They target the whole workforce rather than individuals by modifying physical or organizational structures. Examples of environmental changes may include enabling access to healthy foods (e.g., through modification of cafeteria offerings or vending machine content) or enhancing opportunities to engage in physical activity (e.g., by providing onsite facilities for exercise). Policy strategies may involve changing rules and procedures for employees, such as offering health insurance benefits, reimbursement for health club memberships, or allowing time for breaks or meals at the worksite.
Informational and educational strategies attempt to build the knowledge base necessary to inform optimal health practices. Information and learning experiences facilitate voluntary adaptations of behavior conducive to health. Examples include health-related information provided on the company intranet, posters or pamphlets, nutrition education software, and information about the benefits of healthy diet and exercise. Behavioral and social strategies attempt to influence behaviors indirectly by targeting individual cognition (awareness, self-efficacy, perceived support, intentions) believed to mediate behavior changes. These strategies can include structuring the social environment to provide support for people trying to initiate or maintain weight change. Such interventions may involve individual or group behavioral counseling, skill-building activities such as cue control, use of rewards or reinforcement, and inclusion of coworker or family members for support.
Healthy People 2010 is a blueprint for a 10-year national initiative to improve the health of all Americans. Employers can use Healthy People 2010 objectives to focus business-sponsored health promotion/disease prevention efforts and measure worksite and community-wide outcomes against national benchmarks. As defined by Healthy People 2010, a comprehensive worksite health promotion program contains five program elements:
- Health education, which focuses on skill development and lifestyle behavior change along with information dissemination and awareness building, preferably tailored to employees’ interests and needs.
- Supportive social and physical environments. These include an organization’s expectations regarding healthy behaviors, and implementation of policies that promote health and reduce risk of disease.
- Integration of the worksite program into your organization’s structure.
- Linkage to related programs like Employee Assistance Programs (EAPs) and programs to help employees balance work and family.
- Worksite screening programs, ideally linked to medical care to ensure follow-up and appropriate treatment as necessary.
In addition, Partnership for Prevention includes two additional components:
- Support for individual behavior change with follow-up interventions.
- Evaluation and improvement processes to help enhance the program’s effectiveness and efficiency.
The Centers for Disease Control and Prevention's National Institute for Occupational Safety and Health (NIOSH), through its Total Worker Health program, offers an extensive list of resources to assist employers, employees, and practitioners with their efforts to implement and develop programs in their organizations that integrate employee health activities. Most of the publicly available reputable sources provides tips and tools, but are not "off-the-shelf" or "turn-key solutions." Organizations wishing to obtain more assistance will find there are numerous private companies offering fee-based services.
The Partnership for Prevention offers extensive background and program-specific information in its Healthy People 2010 and Beyond report which is available to anyone at no charge on the internet.
Most employers have yet to embrace the worksite wellness strategy according to the findings of the 2004 National Worksite Health Promotion Survey. Only 6.9 percent of surveyed organizations met the criteria for a comprehensive health promotion program. This is far short of the 75 percent target included in the Healthy People 2010 goal which shows that there are still significant barriers to the large-scale adoption of worksite health promotion practices by organizations, both large and small.
The encouraging news is that since the 2004 report was published, there appears to be more momentum toward implementation of comprehensive work site health promotion. This is evident by pending federal legislation and the growth of employer-based health coalitions such as the National Business Group on Health, Institute for Health and Productivity Management, Center for Health Value Innovation, and the National Business Coalition on Health. Peer-based executive advocacy through the Leading by Example initiative of Partnership for Prevention is another example of this trend towards comprehensive workplace health promotion.
Low participation rates by employees could significantly limit the potential benefits of participating in workplace wellness programs, as could systematic differences between participants and non-participants. Little is known or reported about the determinants of participation, but some clues are emerging. A 2008 study from the University of Minnesota provided insight into the likelihood of employee participation in an exercise promotion program. Their findings illustrate barriers to program participation that may be applicable to other types of programs and workplace settings. Employees were offered a financial incentive to attend a designated set of fitness facilities at least 8 times per month during the study period, and researchers administered a survey to over 3,000 program participants and non-participants to better understand their decision to participate. The research team included survey questions to assess each employee's attitudes and practices related to fitness prior to the program being offered, their marginal utility related to the financial incentive offered, the marginal cost of exercising (based on the cost of time and the financial cost of fitness center membership), prior history of chronic disease, and demographic characteristics related to age, gender, race and ethnicity, income, and employment type within the university system. Based on these survey responses, researchers reported the marginal effects related to the probability of 1) signing up for the program and 2) meeting program participation criteria by exercising 8 times per month to receive the financial incentive.
Employees with a higher time cost of exercise, calculated by the campus where the employee worked and by the number of participating fitness sites in the employee's home zip code, had a lower probability of signing up for and completing the program. Younger workers (ages 18–34)were more likely to sign up for the program relative to older employees, and women were more likely to sign up for the program than men. Researchers also found that employees with diabetes or low back pain were less likely to participate.
Program participation reflects a different trend. When researchers investigated the likelihood that an individual would be a regular program exerciser, defined as a participant in the program who checked in at a participating facility at least 8 times per month, for at least 50% of the time period for which the financial incentive was offered. Program participation in this sense means that an employee both signed up and completed the criteria to receive the reward. Regular exercise were more likely to be older (ages 55+), male, and to be classified as regular exercisers before the program was offered. These findings suggest that there may be differences between employees who would like to, or intend to, participate in certain workplace programs, and those who are likely to be able to participate and benefit. While this study focuses specifically on exercise and participation, lessons regarding the time cost of participation, location barriers to participation, and age and gender differences in participation rates are all important considerations for a firm interested in designing an effective workplace wellness program, especially if the goal is to promote a new behavior.
Ongoing management support and accountability are critical to successful worksite health promotion programs. Men and women participate in different types of activities, and white-collar employees engage in activities at a greater rate than blue-color employees. There are legal and ethical issues to consider as well including obtaining participant release forms, and maintaining employee confidentiality, especially concerning health risk appraisals and other information protected under federal law. One reason for low participation rates may have to do with the messaging associated with the policy or program. In order to motivate or persuade employees to participate and change behavior, messages should be individually targeted which results in more significant positive attitude change.
Workplace wellness programs should also be culturally sensitive and appropriate to economically challenged minority and other underserved populations. One of the strongest predictors of health status is socioeconomic status (SES), and the gap between SES groups is widening (Thompson). Research is being conducted to better understand the challenges and come up with solutions. One idea involves soliciting the assistance of member of the community and giving ownership of the program to the employees. This approach is based on Bracht’s 5-stage community organizational model for health promotion with adaptations for the worksite. Restrictive participation policies (e.g., off-the-clock scheduling) for onsite health promotion activities such as health screenings, health risk appraisals, and workshops may act as a barrier to participation and therefore have a negative impact on health outcomes and effectiveness.
The Centers for Disease Control and Prevention conducted a case study of a workplace wellness program at Austin, TX's Capital Metro, Austin’s local transit authority.
Capital Metro employs 1,282 people. In 2003, Health & Lifestyles was hired to help promote healthier lifestyles, increase employee morale, and combat rising health care costs and absenteeism rates.
Health & Lifestyles provided consultations with wellness coaches and personal trainers, a 24-hour company fitness center, personalized health assessments, and preventive screenings. The program expanded to include healthier food options, cash incentives, health newsletters, workshops, dietary counseling, smoking cessation programs, and a second fitness center. As of lately companies have begun adopting technological trends in efforts to increase participation in work site wellness programs. Companies have been embracing technology from corporate wellness companies to provide their workforce with wellness website portals, mobile applications, and health coaching.
Participants in the wellness program reported improvements in physical activity, healthy food consumption, weight loss, and blood pressure. Capital Metro’s total health care costs increased by progressively smaller rates from 2003 to 2006 and then decreased from 2006 to 2007. Absenteeism has decreased by approximately 25% since the implementation of the program, and the overall return on the investment was calculated to be 2.43.
Since its beginning in 2003, the wellness program at Capital Metro has shown promising results in improving employee health and reducing costs associated with health care and absenteeism, and the financial benefits outweigh the annual investment (2.43 ROI). Employees engage in more physical activity, have better knowledge of disease management (diabetes and asthma), have better eating habits, and smoke less than they did before the program was implemented. Health care and absenteeism costs have been reduced and are continuing to decline, most likely as a result of the program. Managerial staff have reported that employee morale has increased since the program was implemented. Most importantly, however, we believe that the wellness program has the potential to reduce the prevalence and severity of chronic diseases, allowing Capital Metro employees to lead longer, healthier lives.
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