A review of health-related outcomes of multi-component worksite health promotion programs

Checklist of Health Promotion Environments at Worksites (CHEW): development and measurement characteristics

PURPOSE

Health promotion policy frameworks, recent theorizing, and research all emphasize understanding and mobilizing environmental influences to change particular health-related behaviors in specific settings. The workplace is a key environmental setting. The Checklist of Health Promotion Environments at Worksites (CHEW) was designed as a direct observation instrument to assess characteristics of worksite environments that are known to influence health-related behaviors.

METHODS

The CHEW is a 112-item checklist of workplace environmental features hypothesized to be associated, both positively and negatively, with physical activity, healthy eating, alcohol consumption, and smoking. The three environmental domains assessed are (1) physical characteristics of the worksite, (2) features of the information environment, and (3) characteristics of the immediate neighborhood around the workplace. The conceptual rationale and development studies for the CHEW are described, and data from observational studies of 20 worksites are reported.

RESULTS

The data on CHEW-derived environmental attributes showed generally good reliability and identified meaningful sets of variables that plausibly may influence health-related behaviors. With the exception of one information environment attribute, intraclass correlation coefficients ranged from 0.80 to 1.00. Descriptive statistics on selected physical and information environment characteristics indicated that vending machines, showers, bulletin boards, and signs prohibiting smoking were common across worksites. Bicycle racks, visible stairways, and signs related to alcohol consumption, nutrition, and health promotion were relatively uncommon.

CONCLUSIONS

These findings illustrate the types of data on environmental attributes that can be derived, their relevance for program planning, and how they can characterize variability across worksites. The CHEW is a promising observational measure that has the potential to assess environmental influences on health behaviors and to evaluate workplace health promotion programs.

The long-term impact of Johnson & Johnson's Health & Wellness Program on employee health risks

To be viewed as successful, corporate health promotion and disease prevention programs must demonstrate that they can improve the risk profile of employees as a whole, and, in particular, those employees at highest risk. This study reports the effectiveness of Johnson & Johnson's newly configured Health & Wellness Program in reducing the health risks of 4586 employees who participated in two serial health screening programs, with a minimum of 1 year between screenings. The study also examines the impact of participation in a high-risk intervention program called Pathways to Change on health risk factors. McNemar chi-squared and z-test statistics were used to evaluate changes in health risks over time. Results indicate significant risk reduction in 8 of 13 risk categories examined for all employees who participated in two health risk assessments over an average of 2 3/4 years. When comparing Pathways to Change participants with non-participants, participants outperformed their non-participant counterparts in six categories but performed worse in five other categories that were not specifically targeted by the high-risk program. In two categories, no differences were found. The study underscores the ability of large-scale, well-attended, and comprehensive corporate health and productivity management programs to positively impact the health and well-being of workers.

Effect of the Heart At Work program on awareness of risk factors, self-efficacy, and health behaviors

This study evaluates the effects of the American Heart Association's Heart At Work program on cardiovascular disease risk factor awareness, self-efficacy, and health behaviors. A prospective, quasi-experimental research design was used to assess the impact of the program at two factory sites (one intervention and one control). A total of 633 employees participated. Intervention site respondents significantly improved their knowledge of blood pressure management, the relationship between nutrition and cardiovascular disease, and heart attack risk factors. They also were more likely to begin treatment for hypertension, to report fewer sick days, and to have plans to improve their diet and lose weight. These findings suggest that the Heart At Work program had a favorable overall impact.

Long-term impact of Johnson & Johnson's Health & Wellness Program on health care utilization and expenditures

The long-term impact of corporate health and wellness programs is largely unknown, because most evaluations focus on impact in just 1 or 2 years after program initiation. This project estimated the longer-term impact of the Johnson & Johnson Health & Wellness Program on medical care utilization and expenditures. Employees were followed for up to 5 years before and 4 years after Program implementation. Fixed-effects regression models were used to control for measurable and unmeasurable factors that may influence utilization and expenditures. Results indicated a large reduction in medical care expenditures (approximately $224.66 per employee per year) over the 4-year Program period. These benefits came from reduced inpatient use, fewer mental health visits, and fewer outpatient visits compared with the baseline period. Most benefits occurred in years 3 and 4 after Program initiation. We conclude that programs designed to better integrate occupational health, disability, wellness, and medical benefits may have substantial health and economic benefits in later years.

Evaluation of a multicomponent workplace health promotion program conducted in Japan for improving employees' cardiovascular disease risk factors

BACKGROUND

The long-term effectiveness of multicomponent worksite health promotion programs targeting cardiovascular disease risk factors remains unclear in Japan. This study was conducted to evaluate the effectiveness of such a health promotion program consisting of a main program provided over 4 days and a follow-up program provided over 1 year.

METHODS

The subjects of this randomized controlled trial were male employees working for a building maintenance company in Japan. The intervention group (n = 152) and the control group (n = 150) consisted of employees having abnormal findings in at least one of the following items at baseline health examination: body mass index (BMI), systolic (SBP) or diastolic blood pressure, total cholesterol, HDL cholesterol, triglycerides, and fasting blood glucose. Evaluation was conducted at 18 months after the main program.

RESULTS

BMI, SBP, total cholesterol, and triglycerides improved significantly in the intervention group compared with the control group (P < 0.05). When comparisons were limited to those who showed abnormality at baseline, BMI, total cholesterol, and triglycerides improved significantly in the intervention group (P < 0.05).

CONCLUSIONS

The multicomponent health promotion program provided to employees was shown to be effective in improving obesity, high blood pressure, and hyperlipidemia when evaluated 18 months after the main intervention program.

A review and analysis of the clinical- and cost-effectiveness studies of comprehensive health promotion and disease management programs at the worksite: 1998-2000 update

PURPOSE

This article is the fifth in a series of critical reviews of the clinical effectiveness and cost-effectiveness studies of comprehensive, multifactorial health promotion and disease management programs conducted in worksites. As with the previous reviews, the purpose of this article is to review and assess the randomized control trials that have focused on both clinical and cost outcomes of worksite health promotion and disease management programs. For this current review, a new category of quasi-experimental studies has been added because this represents a major new trend in such interventions over the last 2 years. Comprehensive worksite programs are those that provide an ongoing, integrated program of health promotion and disease prevention that integrates specific components into a coherent, ongoing program that is consistent with corporate objectives and includes program evaluations of both clinical and cost outcomes.

DATA SOURCES

A comprehensive search was conducted using a multistage process that included MEDLINE, ERIC, ADI, EDGAR, CARL, Inform, and Lexis-Nexis databases and direct inquiries to worksite researchers.

INCLUSION AND EXCLUSION CRITERIA

The search identified 27 new studies to which the following inclusion criteria were applied: research conducted in the United States; results published in English; methodological quality of nonexperimental (pre- and postmeasures but no comparison group); quasi-experimental to randomized control trials; and both clinical and cost outcomes. Exclusion criteria were studies outside of the United States; non-English publications; and clinical or cost outcomes only. Fifteen studies remained for this review. FINDINGS EXTRACTION METHODS: Findings extraction and analysis of the 15 studies was done by extracting the relevant population, intervention design, clinical results, and cost outcomes from the published article. As in previous reviews, findings are summarized in a table format that extracts and describes each study by the following: (1) study author(s); (2) corporate site; (3) purpose of the evaluation; (4) employee population; (5) percentage of program participants; (6) number of employees included in the evaluation; (7) brief description of the intervention; (8) evaluation design; (9) evaluation period; (10) outcomes; (11) research rating; and (12) findings. FINDINGS SYNTHESIS: Based on these 15 studies, a methodological critique was conducted with brief reference to appropriate prior studies. Conclusions regarding study quality and new trends over the time period of 1998 to 2000 are discussed.

MAJOR CONCLUSIONS

Results from randomized clinical trials and quasi-experimental designs suggest that providing individualized risk reduction for high risk employees within the context of comprehensive programming is the critical element of worksite interventions. Despite the many limitations of the current methodologies of the 15 new studies, the vast majority of the research to date indicates positive clinical and cost outcomes.

Using theory to understand the multiple determinants of low participation in worksite health promotion programs

Low participation at the employee or worksite level limits the potential public health impact of worksite-based interventions. Ecological models suggest that multiple levels of influence operate to determine participation patterns in worksite health promotion programs. Most investigations into the determinants of low participation study the intrapersonal, interpersonal, and institutional influences on employee participation. Community- and policy-level influences have not received attention, nor has consideration been given to worksite-level participation issues. The purpose of this article is to discuss one macrosocial theoretical perspective--political economy of health--that may guide practitioners and researchers interested in addressing the community- and policy-level determinants of participation in worksite health promotion programs. The authors argue that using theory to investigate the full spectrum of determinants offers a more complete range of intervention and research options for maximizing employee and worksite levels of participation.

Worksite tobacco control programs: the role of occupational health

Worksite tobacco control initiatives face a crucial challenge: the growing occupational disparity in smoking prevalence. Blue-collar workers are more likely to be smokers than workers are in white-collar jobs. Blue-collar workers also experience a high prevalence of hazardous exposures on the job. Given these multiple risks, it is imperative that successful comprehensive programs be developed to promote and protect the health of blue-collar workers. Although evidence is still accruing about the efficacy of workplace interventions integrating tobacco control and occupational health, it is possible to identify promising intervention strategies by drawing on the preliminary evidence on effective worksite interventions. The effectiveness of worksite tobacco control interventions will be enhanced when coordinated interventions aim to promote cessation among individual smokers, build social support for quitting and social norms that support non-smoking, engage management in assuring a healthy work environment, involve workers' families in non-smoking initiatives, and provide links to community and public policy initiatives that support tobacco control as well as a broader effort promoting worker health.

Changes in health risks among the participants in the United Auto Workers--General Motors LifeSteps Health Promotion Program

PURPOSE

To examine health risk changes among participants of a multicomponent worksite health promotion program.

DESIGN

A study using health risk changes among health risk appraisal (HRA) participants linked to program participation records. Baseline risk and participation in multiple programs were examined in relation to risk change in multivariate models.

SETTING

Worksite health promotion programming sponsored by the United Auto Workers (UAW) and General Motors (GM).

SUBJECTS

Active employees (12,984) who voluntarily participated in an HRA in each of two program years.

INTERVENTION

The nationwide program was a mailed HRA and a 1-800 nurse line. A pilot program (implemented in two cities) added screening, wellness programs, a materials resource, and, for high risk participants, health coaching and vouchers for medical office visits.

MEASURES

Using 13 selected health risk factors from the HRA, changes in overall health risks were measured as program outcomes in three ways: one-directional, net, and risk status change.

RESULTS

A greater decrease in the number of health risks was observed with increased program participation. The decrease was significantly related to the number of baseline risk factors and eligibility for high risk programs. Associated with program participation, the number of people at low risk status increased from 70.1% to 71.3% at year 2 among nationwide participants and from 52.4% to 58.9% among pilot participants.

CONCLUSIONS

Participation was associated with a significant impact on health risk. Baseline risk of participants and eligibility for high risk programs were necessary factors to control when measuring program effects on health risk changes.

Creating safer and healthier workplaces: role of organizational factors and job characteristics

BACKGROUND

A comprehensive understanding of workplace organizational risk factors for illness and injury and interventions to alleviate these factors is important for workplace prevention efforts.

METHODS

We summarize the evidence for the role of workplace organizational factors and work factors in occupational health and safety (OHS). To the extent possible, we concentrate on factors at the level of the workplace, rather than the level of the individual.

RESULTS

Three types of outcomes are considered: injuries, ill-health, and musculoskeletal problems; and we note the evidence for their relationship to work. We review workplace interventions intended to alleviate each type of outcome and note methodological limitations of previous research.

CONCLUSIONS

Despite the methodological limitations, the balance of the literature supports the work-relatedness of the three types of outcomes, although questions remain about exact mechanisms and the effectiveness of specific interventions. We discuss barriers to and incentives for creating safer and healthier workplaces.

Evaluation of a Wellness-Based Mindfulness Stress Reduction intervention: a controlled trial

PURPOSE

To determine if participation in a Wellness-Based Mindfulness Stress Reduction intervention decreases the effect of daily hassles, psychological distress, and medical symptoms.

DESIGN

A randomized controlled trial of a stress reduction intervention with a 3-month follow-up.

SETTING

A university setting in West Virginia.

SUBJECTS

A total of 103 adults, with 59 in the intervention group and 44 in the control group. Eight-five percent of subjects completed the intervention. Fifty-nine percent and 61% of the intervention and control subjects completed the study, respectively.

INTERVENTION

The intervention consisted of an 8-week group stress reduction program in which subjects learned, practiced, and applied "mindfulness meditation" to daily life situations. The control group received educational materials and were encouraged to use community resources for stress management.

MEASURES

The Daily Stress Inventory assessed the effect of daily hassles, the Revised Hopkins Symptom Checklist measured psychological distress, the Medical Symptom Checklist measured number of medical symptoms, and a Follow-up Questionnaire measured program adherence.

RESULTS

Intervention subjects reported significant decreases from baseline in effect of daily hassles (24%), psychological distress, (44%), and medical symptoms (46%) that were maintained at the 3-month follow-up compared to control subjects (repeated measures analysis of variance [ANOVA]; p < .05).

CONCLUSIONS

Self-selected community residents can improve their mental and physical health by participating in a stress reduction intervention offered by a university wellness program.

Effects of worksite physical exercise intervention on physical fitness, perceived health status, and work ability among home care workers: five-year follow-up

OBJECTIVE

The effects and constancy of a worksite physical exercise intervention were examined in relation to the physical fitness, perceived health status, and work ability of female service workers during periods of 1 and 5 years.

METHODS

The subjects comprised female home care workers divided into an intervention group (n = 50, mean age 41.8 (SD 10.4) years) and a control group (n = 37, mean age 43.3 (SD 8.8) years). The intervention group participated in 9 months of supervised exercise intervention twice a week during the workday. Functional capacity, perceived health, and work ability were assessed at the beginning of the study and after a 1- and a 5-year period of follow-up.

RESULTS

In the 1-year follow-up measurements, body fat had decreased (4%) and dynamic muscle performance and maximal oxygen consumption in relation to body mass (30-38 and 7%, respectively) had increased in the intervention group. The differences in outcome variables between the intervention and the control groups were significant (from P = 0.014 to P < 0.001). These positive effects of worksite exercise were observed despite the age of the subjects, and the changes were consistent during a 5-year period. In the control group the decline of the work ability index (L smean) was about three times faster than in the intervention group during the 5-year period.

CONCLUSIONS

Physical exercise executed in work units can be used to improve the physical capacity of female home care aides and prevent the early decline of their work ability. In jobs that are physically demanding, such as home care work, early prevention must start before the age-related deterioration of health and physical capacity.

Conceptual framework, critical questions, and practical challenges in conducting research on the financial impact of worksite health promotion

A conceptual framework to guide research on the financial impact of health promotion programs is described. Important questions that must be answered within this framework are discussed and brief summaries of the research addressing these questions are summarized. Key issues and challenges that are encountered in designing and implementing financial outcome research are reviewed.

Getting closer to the truth: overcoming research challenges when estimating the financial impact of worksite health promotion programs

The authors describe the most important methodological challenges often encountered in conducting research and evaluation on the financial impact of health promotion. These include selection bias, skewed data, small sample size, metrics. They discuss when these problems can and cannot be overcome and suggest how some of these problems can be overcome through a creating an appropriate framework for the study, and using state of the art statistical methods.

Promoting breast and cervical cancer screening at the workplace: results from the Woman to Woman Study

OBJECTIVES

This article reports findings from a peer-delivered intervention designed to increase use of breast and cervical cancer screening.

METHODS

Twenty-six worksites were randomly assigned to the intervention or comparison group. The 16-month intervention consisted of group discussions, outreach, and educational campaigns. Data were collected from a random sample of women employees stratified by age (baseline n = 2943; final n = 2747). Cross-sectional analyses were conducted to evaluate the impact of the intervention on screening behaviors.

RESULTS

Relative to comparison worksites, the intervention group experienced greater increases in the percentage of women who reported a recent mammogram (7.2% vs 5.6%), clinical breast examination (5.8% vs 2.1%), and Papanicolaou (Pap) test (4.7% vs 1.9%). After worksite cluster and age strata were controlled for, the observed increase in Pap tests was significantly greater in the intervention group (odds ratio [OR] = 1.28; 95% confidence interval [CI] = 1.01, 1.62); however, differences in mammography screening rates (OR = 1.14; 95% CI = 0.90, 1.44) and clinical breast examination (OR = 1.19; 95% CI = 0.96, 1.49) were not statistically significant.

CONCLUSIONS

Intervention activities produced a modest increase in cervical cancer screening, but they did not accelerate breast cancer screening rates above the observed secular trend.

Relationships of physical activity with dietary behaviors among adults

BACKGROUND

Physical activity and diet are important influences on health, but few data are available about the relationship between these two factors. The purpose of this study was to examine relationships between physical activity and dietary quality and to identify determinants of the combination of sedentary behavior and suboptimal diet.

METHODS

The design of this study was cross-sectional. The setting was a large managed-care organization and the participants were 1,322 racially diverse men and women ages 25-91 years. We categorized subjects' physical activity into vigorous, moderate, and sedentary based on answers to two validated interviewer-administered questions about intensity and duration of specified activities. Dietary assessment was by means of a validated short food frequency questionnaire. We defined suboptimal diet as consuming unhealthful quantities of at least two of the following five food groups: fruits, vegetables, whole grain foods, whole-fat dairy foods, and red and processed meats.

RESULTS

Seven hundred fifty-four (57%) subjects were sedentary and 617 (47%) consumed a suboptimal diet. Using multiple linear regression, we found that sedentary individuals consumed smaller amounts of foods and nutrients considered to be healthful, such as fruits and vegetables, fiber, calcium, folate, and vitamins A, C, and E, than more active participants. For nutrients considered to be harmful, such as saturated fat, trans fat, and dietary cholesterol, the association with physical activity was inverse. In multiple logistic regression analyses, the strongest sociodemographic correlates of the joint presence of inactivity and poor diet were less education [odds ratio for 1-year decrease 1.14 (95% confidence interval 1.06, 1.22)], nonwhite race [1.48 (1.05, 2.07)], and nonmarried status [1.49 (1.06, 2.10)].

CONCLUSIONS

Physical activity and diet quality are correlated behaviors. Suboptimal diet and sedentary behavior tend to cluster in individuals who are less educated, not married, and of nonwhite race. Programs that target diet and activity together, informed by their joint determinants, may attain enhanced outcomes.

Financial incentives, participation in employer-sponsored health promotion, and changes in employee health and productivity: HealthPlus Health Quotient Program

Employer-sponsored health promotion can improve employee health and morale and reduce medical claims and absenteeism. Effectiveness depends on the participation of those employees who are at increased risk of ill health. HealthPlus Health Quotient is an incentive/disincentive approach to health promotion. The employer's contribution to the employee cafeteria-plan benefit package is adjusted on the basis of an annual health risk appraisal. We evaluated whether this financial incentive/disincentive predicted participation in health promotion activities, and whether participation improved future health risk and productivity. In the first year, participation was proportional to overall health risk (P < 0.01). Participation in targeted programs was proportional to levels of body fat, cholesterol, and blood pressure. Participation in activity-related health promotion was proportional to prior-year activity or fitness scores. Health promotion participants improved their subsequent-year health risk more than did non-participants. Participation was associated with reduced illness-related absenteeism and (although inconsistently) with medical claims paid and short-term disability.

Impact of a telephone-based intervention on the reduction of health risks

PURPOSE

Evaluate the long-term impact of telephone-based interventions that target high risk, ready-to-change individuals.

DESIGN

Quasi-experimental design with pre/post comparisons of lifestyle-related health risks between participants and nonparticipants.

SETTING

Six organizations from the private and public sectors.

SUBJECTS

Subjects were 607 intervention participants who were compared with a control group of 1134 eligible nonparticipants.

MEASURES

Health risk assessment at baseline and at an average of 2 years later measured risk in 13 lifestyle areas.

INTERVENTION

Programs were offered in seven areas: back care, cholesterol control, eating habits, exercise and activities, stress management, tobacco use, and weight control. Each program was conducted by a trained health educator who provided information and counseling to facilitate change in the area selected by the participant. All counseling was done by telephone and included three to five contacts over a 1-year period.

RESULTS

Binary logistic regression models controlling for gender and age revealed both specific and general effects. Participants were 1.8 to 3.5 times as likely as nonparticipants to reduce the targeted risk in six of seven risk areas. In addition, participants were 1.7 to 3.5 times as likely as nonparticipants to reduce their risks in nine of 13 areas not targeted by the intervention (i.e., general effect). Overall, participants significantly reduced their number of risks, whereas nonparticipants significantly increased their risk (difference of .85 risks).

CONCLUSIONS

Results show that at-risk participants make long-term improvements in health risks directly related to the intervention in which they participate. Results also suggest that this intervention may help individuals develop behavior-change skills they can apply to other lifestyle issues.

Projecting future medical care costs using four scenarios of lifestyle risk rates

PURPOSE

This study predicts medical care expenditures over 10 years for Union Pacific Railroad (UPRR) under alternative health risk factor scenarios for the UPRR workforce.

DESIGN

This paper describes the development of an economic forecasting model to predict medical care expenditures assuming four different scenarios of population risk. The variables used to predict medical care expenditures are employee demographics and health risk profiles.

SETTING

UPRR is a transportation company with more than 56,000 employees in 25 states west and south of the Mississippi River.

SUBJECTS

Employees of UPRR.

MEASURES

Intermediate outcomes included health risk measures related to exercise patterns, body weight, eating habits, smoking, alcohol consumption, total cholesterol, blood glucose, blood pressure, stress, and depression. Major outcome measures included projected total annual payments by UPRR for medical care services for the decade following 1998.

RESULTS

The UPRR work force is projected to grow by 500 employees per year over the 10-year study period. The average age is expected to increase from 44 to 48 years. Without further health promotion intervention, 7 of the 11 risk factors assessed would likely worsen among UPRR's workforce. Medical care cost increases are projected to range from $22.2 million to $99.6 million in constant 1998 dollars over the next decade, depending on the effectiveness of risk factor modification programs. With an expected health promotion budget averaging $1.9 million annually over 10 years, health risks must decline at least 0.09% per year for the program to pay for itself.

CONCLUSIONS

Estimating various risk and cost scenarios can facilitate program planning and produce an economic justification for worksite health programs.

The Australian National Workplace Health Project: design and baseline findings

BACKGROUND

This paper describes the study design, recruitment, measurement, and initial recruitment outcomes of Australia's largest workplace intervention trial, the National Workplace Health Project.

METHODS

This was a cluster-randomized trial of socio-behavioral and environmental interventions focusing on key behaviors of physical activity, healthy food choices, cigarette smoking, and alcohol consumption, as well as motivational readiness for change. Twenty worksites were randomized separately for each intervention using a two-by-two factorial design. All participants underwent a health risk appraisal and measurements were made at baseline and at 1 and 2 years.

RESULTS

The overall response rate for the baseline survey was 73% with 61% attending the health risk appraisal. The sample was predominantly male, English-speaking, married, blue-collar workers. Overall, 12% reported unsafe alcohol consumption, 26% were current smokers, 44% were physically inactive, 74% ate at most one piece of fruit per day, and 26% ate at most one serving of vegetables per day. Intervention and control conditions were similar at baseline for the primary outcomes, except that a higher proportion of the sociobehavioral intervention condition was more physically active (59%) than the corresponding control condition (53%).

CONCLUSIONS

This study will permit the rigorous evaluation of the efficacy of sociobehavioral and environ mental intervention approaches to workplace health promotion. Although participants were randomized by worksite, intervention and control conditions were similar at baseline; any differences in the primary out come variables will be controlled for in the analysis.

The limitations and promise of health education in managed care

Managed care has become the predominant form of health insurance in the United States. With its features of capitation, provider monetary risk, and population perspective, managed care represents a huge growth opportunity for advocates of disease prevention and health promotion, including those in the field of health education. In reality, however, health education's role has fallen far short of expectations. This article is presented to initiate a dialogue on the role of health education and its subset, worksite health promotion, within managed care. The worksite is emphasized because of its attractiveness as a site in delivering population-based medicine. Furthermore, employers exercise considerable influence in shaping the health care marketplace. A list of recommendations is presented, offering suggestions on what health education needs to do to increase its impact in the managed care movement. These arguments are posed to better position this profession in a changing health care environment.

Substance abuse intervention for health care workers: a preliminary report

The Workplace Managed Care Cooperative Agreement project targets 3,300 health care professionals in hospital, specialty clinic, and primary care settings located in metropolitan New Mexico communities. This project will evaluate whether enhancements to existing substance abuse prevention/early intervention programs can prevent the onset of risky drinking, reduce prevalence of risky drinking, better identify employees who abuse alcohol and drugs, and improve employee wellness. This article describes one such enhancement (Project WISE [Workplace Initiative in Substance Education]), implemented at Lovelace Health Systems. Project WISE includes relatively low-cost elements such as substance abuse awareness training, information on how to reduce drinking, and brief motivational counseling. Evaluation will consist of baseline comparisons of the intervention and comparison sites, a process evaluation, a qualitative analysis using focus groups, and an outcome evaluation using health and work records. Methodological challenges, solutions, and implications for researchers undertaking similar projects are presented.

Physical activity initiatives for male factory workers: gatekeepers' perceptions of potential motivators and barriers

OBJECTIVE

Worksites have been argued to be a key setting for physical activity promotion, particularly for lower-paid, less-skilled workers. These occupational groups are at increased risk of cardiovascular disease. There is no strong evidence in support of the efficacy of worksite fitness and physical activity interventions. This study assessed potential motivators and barriers to worksite physical activity initiatives for less-skilled workers.

METHOD

We conducted telephone interviews with 13 Victorian WorkCover insurance providers and 30 manufacturing industry worksite managers. The manufacturing industry was selected as it contains a substantial portion of workers from this high-risk occupational group.

RESULTS

Most insurers incorporated physical activity elements into injury-prevention programs. Few worksite managers reported programs to encourage workers to be more active; they identified reduced premiums and lower-cost programs through insurers as possible motivators. Both groups identified workers' reluctance to participate in physical activity, lack of awareness of potential benefits and program cost as major barriers for worksite physical activity. Other barriers included potential adverse effects on productivity and increased injury risk.

CONCLUSIONS

Broader occupational health and safety policies and joint initiatives between insurers and worksite managers may have the potential to provide more opportunities for workers to be more active. However, the barriers identified outweighed the perceived benefits.

IMPLICATIONS

Without structural and regulatory changes or new incentives, the adoption of physical activity initiatives in Australian manufacturing-industry workplaces is unlikely.

A return on investment evaluation of the Citibank, N.A., health management program

OBJECTIVES

Citibank, N.A., initiated a comprehensive health, demand, and disease management program in 1994, using program services offered by Healthtrac, Inc., of Menlo Park, California. Program components included an initial screening of employees, computerized triage of subjects into higher and lower risk intervention programs, extensive follow-up with the higher risk subjects, and general health education and awareness building. The objective of this study was to estimate the financial impact of this program on medical expenditures.

METHODS

A quasiexperimental design was applied comparing medical expenditures before vs. after the intervention for program participants and nonparticipants. The 22,838 subjects (11,194 program participants and 11,644 nonparticipants) were followed for an average of 38 months before and after administration of a Healthtrac health risk appraisal (HRA) instrument that triggered the start of the program. To adjust for selection bias to the extent possible with these data, multiple regression models were used to estimate the savings in medical expenditures associated with program participation. The resulting dollar savings were compared to program costs to estimate the economic return on the company's investment in the program.

RESULTS

The return on investment (ROI) was estimated to be between $4.56 and $4.73 saved per dollar spent on the program, depending on the discount rate applied. These results are similar to published evaluations of Healthtrac programs implemented with other populations.

CONCLUSIONS

Despite limitations inherent in any retrospective observational study, the strong, positive ROI shown here suggests that a well-designed health management program (HMP), which focuses interventions on high risk populations, can result in monetary savings to an organization.

The Working Healthy Project: a worksite health-promotion trial targeting physical activity, diet, and smoking

Worksites are a key channel for delivery of interventions designed to reduce chronic disease among adult populations. Although some evaluations of worksite physical-activity interventions have been conducted, to date very few randomized trials of worksite health promotion have included the goal of increasing physical-activity levels as part of a comprehensive multiple risk factor approach to worksite health promotion. This article presents the results regarding behavior change found among the cohort of 2055 individuals who completed three health-behavior assessments as part of their worksites' participation in The Working Healthy Project (WHP), a multiple risk factor intervention implemented in 26 manufacturing worksites. In this study, a randomized matched-pair design was used. Fifty-one percent (n = 2,761) of the employees who completed the baseline assessment also completed the interim survey. Eighty-three percent of those who completed the interim assessment also completed the final survey. The WHP intervention targeted smoking, nutrition, and physical activity. At baseline, 38% of the sample reported engaging in regular exercise, and subjects reported consuming an average of 2.7 servings of fruits and vegetables per day, 7.9 grams of fiber per 1000 kilocalories, and 35.4% calories from fat per day; 28% of the sample were smokers. By the time of both the interim (intervention midpoint) and final (end of intervention) assessments, participants in the intervention condition had significantly increased their exercise behavior, compared with the control condition. There was also increased consumption of fruits and vegetables and fiber in the intervention condition by the time of the final assessment, compared with the control condition. No differences by condition were found with regard to percentage of calories from fat consumed or smoking cessation. These results suggest that among a cohort of participants in a worksite health promotion study, there were significant health behavior changes across two risk factors over time. These data suggest that further investigation of multiple risk factor worksite health promotion is warranted, particularly with a focus on ways to increase participation in these programs and to diffuse intervention effects throughout the entire workforce.

A review and analysis of the clinical and cost-effectiveness studies of comprehensive health promotion and disease management programs at the worksite: 1995-1998 update (IV)

The fourth in a series of critical reviews, this study examines the clinical and cost outcome evaluations of 10 worksite health promotion programs that were comprehensive, multifactorial, and directed at risk management. The studies, conducted between 1994 and 1998, indicate favorable clinical and cost outcomes and suggest characteristics of worksite interventions that may be critical for effectiveness.

Health promotion programs in small worksites: results of a national survey

PURPOSE

This study documents the prevalence of workplace health promotion activities at small worksites with 15 to 99 employees.

DESIGN

A random sample of U.S. worksites stratified by size and industry (n = 3628) was drawn using American Business Lists.

MEASURES

Each worksite was surveyed using a computer-assisted telephone interview system to document activities related to health promotion and related programs, worksite policies regarding health and safety, health insurance, and philanthropic activities.

SUBJECTS

Participation varied by industry and size, with an overall response rate for eligible worksites of 78% for a total sample of 2680 worksites.

DATA ANALYSIS

Data were analyzed using SUDAAN statistical software.

RESULTS

Approximately 25% of worksites with 15 to 99 employees offered health promotion programs to their employees, compared with 44% of worksites with 100+ employees. As with the larger worksites, the most common programs for worksites with 15 to 99 employees were those related to occupational safety and health, back injury prevention, and CPR. The majority of worksites in both size categories had alcohol, illegal drug, smoking, and occupant protection policies. The majority of both small and large worksites also offered group health insurance to their employees (92% and 98%, respectively), with many of the worksites also extending benefits to family members and dependents (approximately 80% for both business sizes).

CONCLUSIONS

The results indicated that small worksites are providing programs to their employees, with a primary focus on job-related hazards. Small worksites also have formal policies regarding alcohol, drug use, smoking, and seatbelt use and offer health insurance to their employees at a rate only slightly lower than that of large worksites.

Carrots and sticks: impact of an incentive/disincentive employee flexible credit benefit plan on health status and medical costs

PURPOSE

Employee wellness programs aim to assist in controlling employer costs by improving the health status and fitness of employees, potentially increasing productivity, decreasing absenteeism, and reducing medical claims. Most such programs offer no disincentive for nonparticipation. We evaluated an incentive/disincentive program initiated by a large teaching hospital in western Michigan.

METHODS

The HealthPlus Health Quotient program is an incentive/disincentive approach to health promotion. The employer's contribution to the cafeteria plan benefit package is adjusted based on results of an annual appraisal of serum cholesterol, blood pressure, tobacco use, body fat, physical fitness, motor vehicle safety, nutrition, and alcohol consumption. The adjustment (health quotient [HQ]) can range from -$25 to +$25 per pay period. We examined whether appraised health improved between 1993 and 1996 and whether the HQ predicted medical claims.

RESULTS

Mean HQ increased slightly (+$0.47 per pay period in 1993 to +$0.89 per pay period in 1996). Individuals with HQs of less than -$10 per pay period incurred approximately twice the medical claims of the other groups (test for linear trend, p = .003). After adjustment, medical claims of employees in the worst category (HQ < -$10 per pay period) were $1078 (95% confidence interval $429-$1728) greater than those for the neutral (HQ between -$2 and +$2 per pay period) category. A decrease in HQ of at least $6 per pay period from 1993 to 1995 was associated with $956 (95% confidence interval $264-$1647) greater costs in 1996 than was a stable HQ.

CONCLUSIONS

The HealthPlus Health Quotient program is starting to yield benefits. Most employees are impacted minimally, but savings are accruing to the employer from reductions in medical claims paid and in days lost to illness and disability.

A review of the health impact of smoking control at the workplace

PURPOSE

To summarize and provide a critical review of worksite health promotion program evaluations published between 1968 and 1994 that addressed the health impact of worksite smoking cessation programs and smoking policies.

METHODS

A comprehensive literature search conducted under the auspices of the Centers for Disease Control and Prevention identified 53 smoking cessation program evaluation reports, of which 41 covered worksite single-topic cessation programs. Nine additional reports were located through manual search of citations from published reports and reviews. These 50 reports covered 52 original data-based studies of cessation programs. The search produced 19 reports for tobacco policy evaluations, of which 12 addressed health impact. An additional 17 reports were located by the authors. These 29 reports covered 29 studies of policy impact.

SUMMARY OF IMPORTANT FINDINGS

Smoking cessation group programs were found to be more effective than minimal treatment programs, although less intensive treatment, when combined with high participation rates, can influence the total population. Tobacco policies were found to reduce cigarette consumption at work and worksite environmental tobacco smoke (ETS) exposure.

CONCLUSIONS

The literature is rated suggestive for group and incentive interventions; indicative for minimal interventions, competitions, and medical interventions; and acceptable for the testing of incremental effects. Because of the lack of experimental control, the smoking policy literature is rated as weak, although there is strong consistency in results for reduced cigarette consumption and decreased exposure to ETS at work.

Worksite physical activity interventions

BACKGROUND

National objectives for public health have targeted worksite as important settings for interventions to increase physical activity. However, expert reviews reveal no scientific consensus about the effectiveness of worksite interventions for increasing physical activity or fitness.

METHODS

We judged the quantity and quality of existing evidence against scientific standards for the internal and external validity of the research design and the validity of measurements. Meta-analytic methods were used to quantify the size of effects expressed as Pearson correlation coefficients (r). Variation in effect was examined in relation to several features of the studies deemed important for implementing successful worksite interventions. Pre-experimental cohort studies were excluded because they are sensitive to secular trends in physical activity.

RESULTS

Twenty-six studies involving nearly 9,000 subjects yielded 45 effects. The mean effect was heterogeneous and small, r = 0.11 (95% CI, -0.20 to 0.40), approximating 1/4 S.D., or an increase in binomial success rate from 50% to 56%. Although effects varied slightly according to some of the study features we examined, effects were heterogeneous within levels of these features. Hence, the moderating variables examined did not explain variation in the effects (P > 0.05). The exception was that effects were smaller in randomized studies compared with studies using quasi-experimental designs (P < 0.05).

CONCLUSIONS

Our results indicate that the typical worksite intervention has yet to demonstrate a statistically significant increase in physical activity or fitness. The few studies that have used an exemplary sample, research design, and outcome measure have also yielded small or no effects. The generally poor scientific quality of the literature on this topic precludes the judgment that interventions at worksites cannot increase physical activity or fitness, but such an increase remains to be demonstrated by studies using valid research designs and measures.

The relationship between modifiable health risks and health care expenditures. An analysis of the multi-employer HERO health risk and cost database

This investigation estimates the impact of ten modifiable health risk behaviors and measures and their impact on health care expenditures, controlling for other measured risk and demographic factors. Retrospective two-stage multivariate analyses, including logistic and linear regression models, were used to follow up 46,026 employees from six large health care purchasers for up to 3 years after they completed an initial health risk appraisal. These participants contributed 113,963 person-years of experience. Results show that employees at high risk for poor health outcomes had significantly higher expenditures than did subjects at lower risk in seven of ten risk categories: those who reported themselves as depressed (70% higher expenditures), at high stress (46%), with high blood glucose levels (35%), at extremely high or low body weight (21%), former (20%) and current (14%) tobacco users, with high blood pressure (12%), and with sedentary lifestyle (10%). These same risk factors were found to be associated with a higher likelihood of having extremely high (outlier) expenditures. Employees with multiple risk profiles for specific disease outcomes had higher expenditures than did those without these profiles for the following diseases: heart disease (228% higher expenditures), psychosocial problems (147%), and stroke (85%). Compared with prior studies, the results provide more precise estimates of the incremental medical expenditures associated with common modifiable risk factors after we controlled for multiple risk conditions and demographic confounders. The authors conclude that common modifiable health risks are associated with short-term increases in the likelihood of incurring health expenditures and in the magnitude of those expenditures.

Worksite health promotion programs in the U.S.: factors associated with availability and participation

PURPOSE

To examine how the availability of and participation in worksite health promotion programs varies as a function of individual (e.g., age), organizational (e.g., occupation), and health (e.g., high blood pressure) characteristics. Availability of worksite programs was also compared to that reported in two previous national surveys of private companies.

DESIGN

Data analyzed were from the 1994 National Health Interview Survey (NHIS), a national cross-sectional probability sample of the U.S. civilian population.

SUBJECTS

Five thousand two hundred nineteen NHIS respondents met the inclusion criteria of (1) being currently employed in a company of at least 50 employees, and (2) completing the NHIS section on worksite health promotion.

MEASURES

Employees indicated the availability of, and their participation in, 33 different types of worksite programs. National Health Interview Survey data were also available regarding general health, blood pressure, body mass index, and medical conditions.

RESULTS

Smoking cessation programs had the highest mean availability (43%), followed by health education programs (31%) and screening tests (31%). Overall, availability of worksite programs appeared comparable to that reported in a recent national survey. Participation ranged from 32% for health education programs to 5% for smoking cessation programs. Compared to availability, participation depended less on individual and organizational characteristics. Healthy employees were not consistently more likely to participate in worksite health promotion programs than nonhealthy employees.

CONCLUSIONS

Although availability of worksite health promotion programs remains high, participation by employees in specific types of programs can vary widely. Attempts to increase participation should look beyond individual, health, and organizational variables, to specific features of the work environment that encourage involvement in health promotion activities.

Differences between descriptive and multivariate estimates of the impact of Chevron Corporation's Health Quest Program on medical expenditures

This investigation focused on alternative methods for evaluating the impact of Chevron Corporation's Health Quest Fitness Center program on medical expenditures, comparing descriptive and multivariate research designs. Many uncontrolled studies of corporate health management programs base estimates of program effectiveness on descriptive analyses such as Student's tests. Unlike more sophisticated multivariate analyses, descriptive analyses often produce biased estimates of program cost savings. To test alternative research design methods, the investigators compared inpatient and pharmacy expenditures for program participants and non-participants over a 2.5-year period, using descriptive and multivariate regression analyses. Results showed that compared with non-participants, expenditures for participants were significantly lower for subjects who used a Health Quest fitness center at least twice weekly. Previous descriptive studies suggested a much broader impact. The results underscore the need to use multivariate analyses when evaluating the financial impact of corporate health management programs, especially when randomization cannot be used to assign participation status.

Clinical and cost outcomes of multifactorial, cardiovascular risk management interventions in worksites: a comprehensive review and analysis

This paper is a critical review of the clinical and cost outcome evaluation studies of multifactorial, comprehensive, cardiovascular risk management programs in worksites. A comprehensive international literature search conducted under the auspices of the National Heart, Lung and Blood Institute identified 17 articles based on 12 studies that examined the clinical outcomes of multifactorial, comprehensive programs. These articles were identified through MEDLINE, manual searches of recent journals, and through direct inquiries to worksite health promotion researchers. All studies were conducted between 1978 and 1995, with 1978 being the date of the first citation of a methodologically rigorous evaluation. Of the 12 research studies, only 8 utilized the worksite as both the unit of assignment and as the unit of analysis. None of the studies analyzed adequately for cost effectiveness. Given this limitation, this review briefly considers the relevant worksite research that has demonstrated cost outcomes. Worksite-based, multifactorial cardiovascular intervention programs reviewed for this article varied widely in the comprehensiveness, intensity, and duration of both the interventions and evaluations. Results from randomized trials suggest that providing opportunities for individualized, cardiovascular risk reduction counseling for high-risk employees within the context of comprehensive programming may be the critical component of an effective worksite intervention. Despite the many limitations of the current methodologies of the 12 studies, the majority of the research to date indicates the following: (1) favorable clinical and cost outcomes; (2) that more recent and more rigorously designed research tends to support rather than refute earlier and less rigorously designed studies; and (3) that rather than interpreting the methodological flaws and diversity as inherently negative, one may consider it as indicative of a robust phenomena evident in many types of worksites, with diverse employees, differing interventions, and varying degrees of methodological sophistication. Results of these studies reviewed provide both cautious optimism about the effectiveness of these worksite programs and insights regarding the essential components and characteristics of successful programs.