"Employers have become increasingly aware that overweight and obesity, lack of physical activity, and tobacco use have a major impact not only on the health and productivity of their employees, but also on the financial 'health' of their businesses." - -U.S. Department of Health and Human Services. Prevention Makes Common "Cents," p. 22.
Chronic illnesses such as cardiovascular disease, cancer, and diabetes are the leading causes of death in the United States, and they do not affect just the elderly. In the general population younger than 65 years (i.e., the working age population), one third of the years of potential life lost are the result of chronic disease, making this a particularly salient issue for employers (1).
Sick employees cost employers more in terms of their direct and indirect expenditures (2). Direct costs include employer-based medical and health insurance expenses, short-term disability payments, workers' compensation, and life insurance. Indirect costs of employee illness include increased absenteeism, presenteeism (working at a diminished capacity because of illness), and the time and expense associated with employee replacement. It has been estimated that the indirect costs of poor health may be two to three times greater than the direct medical costs (3).
Poor health also is associated with higher rates of on-the-job injury and lower employee morale (4). It also has been argued that there are externalities associated with illness-related time loss. For example, absence or disability episodes by members of a job team can reduce the productivity of other members of the same team. Sean Nicholson, at Cornell University's Department of Policy Analysis and Management and the National Bureau of Economic Research, and colleagues (5) have illustrated this for several types of jobs (Table 1).
Many of the chronic conditions that lead to direct and indirect cost increases are the result of lifestyle factors and are largely amenable to behavior change. But what can employers do to improve the health of their employees, and why should they take the lead in these efforts? In this paper, we describe worksite health promotion (WHP) programs and why such programs benefit not just workers but their employers as well.
WORKSITE HEALTH PROMOTION
Working adults spend a substantial amount of their time at work, where they are influenced by the physical environment and social climate of the workplace. Many people find themselves confined to sedentary jobs that creep into their off hours, leaving them with little time or opportunity for exercise. Some eat in a cafeteria with a high-fat and high-cholesterol menu or snack on candy dispensed from the on-site vending machines. Over the past 30 years, the field of WHP has viewed the worksite as an opportune setting for improving employee health, pointing to the same forces that can negatively affect health behaviors as being potentially modifiable and useful for improving employee health.
The main objective of health promotion programs is to "optimize health and productivity while lowering total health-related costs" (6), so the employee and the employer stand to receive significant benefits for their efforts. Employees who participate in health promotion programs gain a better quality of life, increase their job and life satisfaction, and lower their out-of-pocket medical costs. Employers who offer WHP programs may gain a healthier and more productive work force while lowering their direct and indirect health-related costs.
In some cases, WHP programs may pay for themselves in reduced direct and indirect employer costs. In a 1999 article entitled "What's the ROI?" Ron Goetzel, Ph.D., and colleagues (7) calculated a median return-on-investment (ROI) for WHP programs of approximately 3 to 1, meaning that employers saved approximately $3.00 for every $1.00 that they spent on their programs. A more recent meta-analysis of WHP programs by Larry Chapman, M.P.H., (8) reported, on average, a 26% reduction in health costs, a 27% reduction in sick leave absenteeism, and a 32% reduction in workers' compensation and disability management claims costs, with an average ROI of $5.81 saved to every $1.00 spent on WHP programs. The estimated ROI is likely to vary, depending upon the comprehensiveness of the program implemented, but preventive programs have consistently been found to produce favorable returns, both in reported health improvement and costs savings.
How to design an effective worksite health promotion program
Depending upon an organization's specific health aims, a variety of components may be included in a WHP program. Some target changes that individuals, particularly individuals deemed to be at high risk for developing one or more chronic diseases, may choose to make. An employer who implements individual-level interventions may offer incentives to increase participation rates and motivate their employees to take advantage of health-promoting opportunities. Other WHP components address environmental changes that are likely to impact the broader range of employees. These types of changes may be mandated by the organization or even implemented without the employees' involvement (Table 2).
Individual-level interventions often start with an examination of the individuals themselves. This is accomplished by administering a health risk assessment. Health risk assessments, which often are combined with health screenings, assess an individual employee's health on key risk factors, such as weight, exercise routines, smoking, alcohol consumption, and stress (2,6,9). Depending upon the responses provided on the health risk assessment, employees will be identified by risk level (commonly high, moderate, or low), raising the employees' level of awareness and encouraging them to take action to either reduce their risk level or maintain it, if they are already classified as low risk. Health risk assessments are most beneficial in that they help employers assess the specific needs of their employee population, allowing them to tailor their WHP programs to those needs.
Other individual-level WHP interventions that may be implemented include tailored educational materials delivered by mail, internet, or telephone and seminars focused on such issues as weight loss, smoking cessation, physical fitness, stress reduction, and healthy cooking, among others (2,6). Increasingly, employers are integrating online materials and even online support groups and health coaching into their WHP offerings, allowing broader access to the materials and a cost-effective way to reach their employees. Individually tailored programs, whether based upon information and support provided via mail, telephone, in person, or online, have greater demonstrated effectiveness than nontailored approaches to health promotion. Often, the more feedback and encouragement individuals receive through the WHP program, the more effective they can be at improving their health behaviors.
Positive change should not stop with the employees, though. Lack of optimal health may be caused by, or exacerbated by, obstacles in the workplace that can be overcome by changes at the organizational level. One of the most influential, important, and cost-effective organizational-level changes that can be made is for the employer to focus on changing the culture and advocate for improved health as a corporate goal (6). This may be accomplished by incorporating the idea of optimal health into their mission statement, essentially telling employees, "We care about your health and we want to make it a part of our corporate identity." Corporate leaders need to publicly reiterate this message, encourage and reward (financially and otherwise) those who set a good example, and importantly set an example themselves. Although organizational culture is less tangible than the physical environment, it can have just as significant an impact on employee behaviors. It also may be easier to effect in smaller businesses (2,6).
Organizational-level changes include the adoption of policies, such as requiring the use of safety belts in company owned vehicles, restricting the use of tobacco products on company property, or even requiring that employees with physically demanding jobs to stretch their muscles before beginning work (10). Although these types of policies focus more on safety issues and may be required for all employees who perform certain types of jobs, other organizational interventions provide options for employees, such as requiring that there be healthy food choices in office vending machines and cafeterias or providing on-site exercise facilities (or subsidizing memberships to local fitness centers).
Comprehensive worksite health promotion
Optimal health promotion programs do not just aim to improve a single behavior or focus solely on behaviors that the employee should change but also will address a variety of behaviors known to negatively influence health and will do so at the individual employee level and at the organizational level (2,6,10), creating an environment saturated with consistently reinforcing health messages. By linking health with other aspects of the organization, such as safety policies and corporate missions, employers also reduce the likelihood of sending mixed messages to their employees.
The main difficulty associated with adopting an integrated approach to WHP is the degree to which differing aspects of an organization are forced to work together. Human resources, occupational medicine, employee assistance programs, disability management, health promotion, and other departments must agree on issues of resource allocation. However, if successful, such efforts should work in a coordinated fashion and reduce the duplication of services. All of these aspects, individual and organizational alike, can help create a culture of health, increasing WHP participation rates and improving employee job satisfaction levels (6,9). By implementing comprehensive WHP programs with demonstrated efficacy, employers are likely to achieve a more optimal return on their investment (7,8).
Integration also can occur from a data perspective. By bringing together information concerning an employee's health and health-care utilization, absenteeism, presenteeism, short- or long-term disability, and worker's compensation, an employer can gain a more comprehensive picture of that employee's needs, identify programs that are not being used to an optimal degree, and make changes accordingly (9).
The potential "value" of worksite health promotion
Economic issues have driven the development of WHP from the very beginning. In the face of rising health-care costs, U.S. employers are increasingly feeling the pinch and may believe that they cannot afford to implement WHP programs. We maintain that employers who provide health insurance for their employees cannot afford not to do so. A well-developed WHP program is likely to pay for itself in terms of saved direct and indirect costs in the short run and is likely to yield even greater savings over time (7). Chronic disease is not inevitable (1). It can be corrected or even prevented with focused and intensive effort, producing healthier employees and healthier businesses.
CONDENSED VERSION AND BOTTOM LINE
Employers who implement worksite health promotion programs can reduce the direct and indirect costs associated with employee health and improve the well-being, morale, and productivity of their workers, yielding a positive return-on-investment. Effective comprehensive programs target changes at the individual and environmental/organizational levels.
U.S. Centers for Disease Control and Prevention. The Power of Prevention: Reducing the Health and Economic Burden of Chronic Disease. Atlanta: U.S. Department of Health and Human Services, 2003.
Ozminkowski, R.J., R.Z. Goetzel, J. Santoro, et al. Estimating risk reduction required to break even in a health promotion program. American Journal of Health Promotion 18(4):316-325, 2004.
UCI Health Promotion Center. Workplace Health Promotion Information and Resource Kit: Helping You Help Your Employees to Better Health 1997. Available at http://www.healthpromotioncenter.uci.edu/infokit.htm.