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Six Trends Affecting the Business Case for Worksite Health Promotion

Pronk, Nico Ph.D., FACSM, FAWHP

doi: 10.1249/FIT.0b013e3181ed5b2f

Six Trends Affecting the Business Case for Worksite Health Promotion.

Nico Pronk, Ph.D., FACSM, FAWHP, is vice president for Health Management and Health Science Officer for JourneyWell at HealthPartners in Minneapolis, MN. Dr. Pronk is the current president of the International Association for Worksite Health Promotion, an ACSM affiliate society. He is the editor of ACSM's Worksite Health Handbook, second edition. Dr. Pronk is an associate editor for the ACSM's Health & Fitness Journal®.

The workplace is an important setting to consider when programs are implemented to improve the health of the population, including the broader community. Because of the significant reach and broad access to employees, the workplace offers a variety of advantages when attempting to engage the population. For example, every employee can be reached via the worksite; there is opportunity for frequent exposure of employees to interventions; and the employer can mobilize all sorts of tools, vehicles, and resources to build awareness and behavior change (e.g., email, team meetings, insurance benefits). Furthermore, through employer-sponsored programs, employees, as well as dependents and retirees, may be reached. As a result, the workplace represents an important setting for population health improvement. However, it is a setting that may be leveraged only if a business case for worksite health promotion is established.

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According to Kilpatrick et al. (3), a business case is defined as a scenario in which an organization realizes a positive return on investment for a particular intervention. Thus, effective interventions, measured and meaningful outcomes, and an appropriate "fit" of activities in the context of the specifics of the worksite are paramount to generating a successful business case. Because the business case for worksite health promotion is central to continued success in the field, six trends in worksite health promotion have been identified that are important to address and consider and will be discussed here. These trends are outlined below and are considered in context of each other and the workplace in the Figure:

1. a workplace culture of health

2. the role of incentives and communications

3. evidence-based programs

4. the emergence of program accreditation

5. social connections and networks

6. generating program outcomes

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Previously, a culture of health at the workplace has been defined as "a workplace ecology in which the dynamic relationship between human beings and their work environment nurtures personal and organizational values that support the achievement of a person's best self while generating exceptional business performance" (5, p. 224). Companies interested in achieving an alignment of employee values with company values while achieving strong business performance typically pursue their interest in achieving business excellence, not mediocrity. Company attributes that reflect a culture of health include leadership commitment and support (at a minimum at three levels of the organization: executive, mid-management, and frontline), management education and training, identified employee champions, supportive physical and psychosocial environments, company policies that advocate optimal health, and trust and mutual respect as foundational management principles (4). These attributes are achieved through an ongoing process in a company environment that is open, inviting, and safe and allows for the surfacing of ideas, opinions, and feedback; the communications of such findings; and the alignment of company policies, protocols, and actions with employee and company values. The workplace culture of health represents an axis around which other important trends rotate.

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Both incentives and communications, especially in the context of the workplace culture, are critical to generating levels of participation that meaningfully contribute to population health improvement. Financial incentives often are considered in prompting employees to adopt new behaviors, but in the absence of supportive, ongoing communications, such efforts often fail to achieve the desired outcomes. The impact of varying levels of incentives also has been shown to be important in terms of stimulating participation. For example, Wang et al. (8) compared participation rates in completing a health risk appraisal after a single mailing; two mailings; two mailings and a telephone call; and two mailings, a telephone call, and a $20 incentive. A graded increase in completion rates was observed ranging from 20% for a single mailing to 68% for those who received two mailings, a call, and $20. Combining strong incentives with strong and ongoing communications can generate participation rates in excess of 90% (7).

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When evidence of effectiveness exists for interventions, the likelihood that programs designed with such evidence in mind will generate positive outcomes is significantly increased. Many sources exist where information regarding the evidence of effectiveness of interventions may be found. The best evidence is based on systematic reviews. However, other sources include best practices and benchmark information, as well as comparative case studies. Outlined in the Table is a list of several excellent resources to consider when trying to locate information on evidence-based programs.

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As the prevalence of worksite health promotion programs increases, the need for credible programs and services to be identified also has increased. As a result, several organizations have introduced wellness and health promotion accreditations to help employers and other parties make informed comparisons when choosing among several service providers. The two organizations that have introduced accreditations specifically for health and wellness programs are the National Committee for Quality Assurance ( and URAC (formerly known as the Utilization Review and Accreditation Commission; Standards that are included in the accreditation of health and wellness vendors include privacy and confidentiality, engagement strategies and tactics, health assessments, processes to target groups and individuals, health coaching, support tools for self-management, measurement and reporting, and integration with other organizations.

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Social networks have become pervasive in society. They influence behavior of workers, their families, friends, and the community around us. Some of those networks are virtual, for example, online communities such as Facebook© or Twitter©, although these represent only recent innovative developments using new technologies - social networks have been around in other forms since the dawn of time. Social networks are ubiquitous and seem to have a profound influence on the people within them. For example, research from Cristakis and Fowler (2) at Harvard University shows that obese people tend to have more obese friends than their normal weight counterparts. Furthermore, their studies show that happiness is contagious, your future spouse is likely to be your friends' friend, and your friends' friends' friend can make you fat…or thin. In short, the real-life social networks in which we participate shape virtually every aspect of our lives. However, we are not necessarily aware of such networks because we do not necessarily know all the people who are connected to us at any given time or how (through whom) the influence of others reaches us. In the context of worksite health promotion, the introduction of social networks, real or virtual, can provide powerful means to connect employees to others with whom they share interests. As outlined by Sofian and Newton (6), for such networks to be conducive to healthy outcomes, they need to have trust (be a trusted source of information or interaction), be relevant (applies to "me"), have urgency (quick access, provide an emotional tie to issues), have chronicity (ongoing and merits involvement), provide personal benefit ("it's worth it"), and have serial reciprocity ("if I help others, they help someone else, and someone else may help me…").

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For the business case to be established, outcomes must be generated that have a direct line-of-sight to a positive return on investment. The industry has not been blind to this issue, and as a result, a clear directive exists to ensure positive outcomes directly related to program implementations. For this to occur, the measurement practices put in place must be able to show that the overall program generates strong participation, an excellent experience (for continued participation to occur), and impact on the population's health status and productivity. Once these outcomes are quantified, an assessment may be conducted to estimate the program's return on investment, which may be achieved by considering reductions in medical care use, improved levels of productivity, or other indicators of cost effectiveness.

A recent critical meta-analysis of the literature on costs and savings associated with worksite health promotion programs indicates that medical costs generate approximately $3.27 savings for every dollar invested. Furthermore, absenteeism costs fall by approximately $2.73 for every dollar invested (1). Hence, it seems that programs that generate strong outcomes also generate substantial savings for the employer, thereby confirming a strong business case for worksite health promotion.

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Currently, six important trends are actively travelling around the worksite health promotion industry. These trends are central to generating a strong business case that sits at the heart of long-term viability for worksite health promotion. It would behoove practitioners and program administrators to consider these trends and generate as many successful case studies as possible. Ensuring broad dissemination of such case studies also is important to contribute to the sharing of experiences and awareness of successes within our industry. To this end, the International Association for Worksite Health Promotion (IAWHP) has launched its publication called Worksite Health, which includes case studies and other newsworthy items. Issue 1 is currently available via the IAWHP Web site (see - check it out!

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1. Baicker K, Cutler D, Song Z. Workplace programs can generate savings. Health Aff. 2010;29(2):304-11.
2. Cristakis NA, Fowler JH. Connected. New York (NY): Little, Brown and Company; 2009.
3. Kilpatrick KE, Lohr KN, Pink G, Buckel JM, Legarde C, Whitener L. The insufficiency of evidence to establish the business case for quality. Int J Qual Health Care. 2005;17(4):347-55.
4. Pronk NP. A workplace culture of health. ACSM Health Fitness J. 2010;14(3):36-8.
5. Pronk NP, Allen CU. A culture of health: creating and sustaining supportive organizational environments for health. In: Pronk NP, editor. ACSM's Worksite Health Handbook. 2nd ed. Champaign (IL): Human Kinetics, Inc.; 2009. p. 224.
6. Sofian NS, Newton D. Online communities and worksite health management. In: Pronk NP, editor. ACSM's Worksite Health Handbook. 2nd ed. Champaign (IL): Human Kinetics, Inc.; 2009. p. 231-8.
7. VanWormer JJ, Pronk NP. Rewarding change: principles for implementing worksite incentive programs. In: Pronk NP, editor. ACSM's Worksite Health Handbook. 2nd ed. Champaign (IL): Human Kinetics, Inc.; 2009. p. 239-47.
8. Wang PS, Beck AL, McKenas DK, et al. Effects of efforts to increase response rates on a workplace chronic condition screening survey. Med Care. 2002;40:752-60.
© 2010 American College of Sports Medicine.