Recently, a series of opinion papers, Web blogs, newspaper, and formal research articles have scrutinized the approach to and effectiveness of workplace wellness programs (4,8,9,11,14). Whereas some objections to these arguments have been broadly disseminated (e.g., Goetzel (6)), one of the major underlying issues barely has been addressed. This issue refers to the underlying principles of program design that are needed to ensure a successful outcome. It is the purpose of this column to outline a broad set of best practices for worksite health promotion programs that have been shared in the literature, to distill these down into a manageable set of broad categories or dimensions, and thus to identify a short list of key design principles associated with successful worksite health and wellness program outcomes. This short set of best practice design principles can be used to (a) assess the likelihood that programs will drive successful outcomes and (b) make informed judgments about the true impact that worksite health promotion programs can deliver.
WHY BOTHER WITH BEST PRACTICES?
In recent years, worksite health promotion increasingly has been referred to as a means to better manage costs for employers through cost savings caused by medical care, lower absenteeism, and improved on-the-job performance. In addition, the introduction of the Patient Protection and Accountability Care Act (13) emphasizes the potential role of worksite health promotion in the context of broader community health efforts (12). As a result, increased attention and focus are placed on worksite health promotion efforts to ensure that the associated resource investments are sound. I take this to be a good thing — it will make the field stronger and more accountable. However, the process used to derive conclusions and form decisions should be transparent, be based on a clear delineation of what is being considered, and appreciate what the important contextual issues are. For example, a recent Kaiser Foundation employer health benefit survey noted that most firms surveyed (77%; including almost all large employers) continued to offer wellness programs to help manage costs (3). However, firms were counted as having a wellness program as long as they offered at least one program option out of a defined set of activities (i.e., weight loss, gym membership, smoking cessation, health coaching, nutrition class, biometric screening, Web-based resources, a wellness newsletter, flu shots, or an employee assistance program). It is hardly reasonable to expect workplace wellness programs that consist of, for example, a newsletter activity, to have as much impact on cost and productivity outcomes as a comprehensive multicomponent program.
These distinctions matter. In fact, the National Worksite Health Promotion Survey estimates that only 6.9% of all worksites in the United States offer a comprehensive worksite health promotion program, despite the fact that nearly all worksites (93.4%) indicated that they had a drug policy in effect (10). Comprehensive programs in that survey were defined as having five key components: health education, supportive physical and social environments, integration of the worksite program into the organization’s structure, linkage to related programs, and worksite screening programs. This kind of definition provides an important context in which to consider opinions about effectiveness and decision-making concerns related to worksite health promotion programs. It places importance on what we know about best practices and noncompromise design principles for highly effective programs.
IDENTIFICATION OF BEST PRACTICES
Best practices and benchmarks may be identified through literature reviews of the scientific literature and the so-called gray literature (less rigorous, non-peer-reviewed articles), as well industry reports and consensus statements. Several examples exist that provide an overview on this topic, including the ACSM’s Worksite Health Handbook (1). This text provides a summary of a small number of benchmarking and best practice projects and culls a list of 17 characteristics that may be considered best practices. Goetzel and Ozminkowski (5) provide a listing of best practices and promising practices as part of an overall review of the worksite health promotion literature. A data-driven article by Terry and coworkers (15) used a deductive approach to test the impact of commonly cited elements of best practice programs on outcomes. Berry and colleagues (7) conducted in-depth testing of 10 exemplar programs to identify underlying best practices directly related to the observed successes.
The approach used to identify best practice elements for this column was to review a reasonably comprehensive list of source materials that have been published on this topic and to include not only original research articles but also expert opinions and other summary articles. Although not an exhaustive list, several important sources from which data on best practices were derived are presented in Table 1.
BEST PRACTICE RESULTS
A set of 44 nonoverlapping unique best practice elements was derived from all sources outlined in Table 1. Many sources reported on similar elements, indicating that many of the same factors are identified across multiple assessments and situations. However, some sources identified more unique elements than others. For example, the World Health Organization’s (WHO) “model for action” identifies ethics and core values as important underlying principles and keys to success. The WHO placed these elements at the heart of their model (7). The WHO also explicitly calls out the need for worker involvement using a participatory approach to ensure that workers are represented through some collective means of expression, stronger than that of individual workers.
Table 2 provides the set of 44 identified best practice characteristics and further categorizes them into nine unique dimensions. It may be argued that some elements might fit in more than one dimension. For example, a health management program that is connected to the company mission, vision, and business objectives may be considered a leadership dimension because it reflects upper-level management focus and attention to set such a vision. Yet, it also may be considered an element of a comprehensive program design (comprehensiveness) as it reflects an integration of the program into the company structures. This overlapping fit among multiple dimensions argues that the list of dimensions taken together reflects an integrated approach, which in itself may be considered best practice.
BEST PRACTICE DIMENSIONS
The dimensions identified in Table 2, along with a brief description of what they represent, are provided here.
1. Leadership: Elements that set the vision for the program, assign accountability, ensure structural support for the program, engage leaders throughout the organization, set appropriate organizational policy to support health, and support the program’s need for resources.
2. Relevance: Elements that address factors critical to participation and engagement of employees and their families in the various program options. Relevance reflects the degree to which program options apply to the needs and interests of workers and their families. It is assumed that relevance is a critical factor in long-term engagement of employees.
3. Partnership: Elements that relate to efforts designed to integrate with multiple stakeholders including individual workers, employees as a population (representation), organized labor, community organizations, vendor companies, and other internal partners.
4. Comprehensiveness: Elements that, taken together, meet the definition of a comprehensive program (10) and include health education, supportive physical and social environments, integration of the worksite program into the organization’s structure, linkage to related programs, and worksite screening programs.
5. Implementation: Elements that ensure a planned, coordinated, and fully executed implementation of health management programs including ongoing monitoring and designated staff with clearly delineated accountabilities.
6. Engagement: Elements that promote respect throughout the organization, build trust, facilitate program co-ownership through participatory principles, ensure worker representation in decision-making processes, provide meaningful incentives that leverage intrinsic motivation and fit the company culture, and create a workplace environment in which health management programs thrive.
7. Communications: Elements that indicate the presence of a formal communication strategy that includes a branding approach for program visibility, ongoing communications using multiple delivery channels, and targeted and tailored messaging designed to reach specific subgroups.
8. Data Driven: Elements that represent the importance of informed decision making and providing guidance through ongoing measurement, evaluation, reporting, and analytics. Data need to be shared appropriately with other vendors for program integration purposes as well as to address comprehensive reporting needs. Not only is it important to ensure that data representing program experiences are relevant, clean, and representative, but also that they drive continuous program improvement.
9. Compliance: Elements that ensure the health management program meets regulatory requirements and safeguards individual-level data. Compliance may be considered a cornerstone element — without it, doubt may be cast on the ethical and legal status of the health management program.
HOW TO BEST USE BEST PRACTICE INFORMATION
Based on reports that organize their analysis by inclusion of best practice characteristics, worksite health promotion programs can generate savings — both from medical care cost as well as absenteeism reductions (2). When fewerbest practice characteristics are identified, the lower the impact of the program on engagement rates, health risk reduction, and cost savings (11,15). That being the case, it is important to manage expectations of program outcomes by reflecting on program design.
Therefore, best practice design context, as informed by the presence of the elements presented in Table 2, can be extremely helpful to any worksite health promotion manager to position their program in the best way possible. The investment made into the program by the company, the engagement of workers, and the expectations company leaders may have about what the program will deliver will in large part depend on the degree to which the design of the program aligns with the nine best practice dimensions outlined in this column. As such, this list provides a means to manage expectations, identify gaps in design, and inform decision making regarding resource allocation.
1. ACSM’s Worksite Health Handbook: A Guide to Building Healthy and Productive Companies. 2nd Edition. Pronk NP, editor. Champaign (IL): Human Kinetics; 2009. p. 8.
2. Baicker K, Cutler D, Song Z. Workplace wellness programs can generate savings. Health Aff. 2010; 29 (2): doi: 10.1377/hlthaff.2009.0626.
3. Claxton G, Rae M, Panchal N, et al Health benefits in 2013: Moderate premium increases in employer-sponsored programs. Health Aff. 2013; 32 (9): doi: 10.1377/hlthaff.2013.0644.
4. DiNardo J, Horwitz J, Kelly B. Toward a scientific approach to workplace wellness: A response to Ron Goetzel. Health Affairs Blog; [cited 2013 Aug 30]. Available from: http://healthaffairs.org/blog/2013/07/01/toward-a-scientific-approach-to-workplace-wellness-a-response-to-ron-goetzel/.
5. Goetzel R, Ozminkowski RJ. The health and cost benefits of work site health-promotion programs. Ann Rev Public Health. 2008; 29: 303–23.
6. Goetzel R. Workplace wellness programs: Continuing the discussion with DiNardo, Horwitz, and Kelly. Health Affairs Blog; [cited 2013 Aug 30]. Available from: http://healthaffairs.org/blog/2013/08/21/workplace-wellness-programs-continuing-the-discussion-with-dinardo-horwitz-and-kelly/.
7. World Health Organization. Healthy Workplaces: A Model for Action. Switzerland, Geneva: World Health Organization; 2010.
8. Horwitz JR, Kelly BD, DiNardo JE. Wellness incentives in the workplace: Cost savings through cost shifting to unhealthy workers. Health Aff. 2013; 32 (3): 468–76.
9. Lewis A, Khanna V. Here Comes ObamaCare’s “Workplace Wellness.” Wall Street J; [cited 2013 Aug 30]. Available from: http://online.wsj.com/article/SB10001424127887323501004578389673547444046.html.
10. Linnan L, Bowling M, Childress J, Lindsay G, Blakey C, Pronk S, Wieker S., Royal P. Results of the 2004 national worksite health promotion survey. Am J Public Health. 2008; 98: 1503–9.
11. Mattke S, Hangsheng L, Caloyeras JP, et al. Workplace Wellness Programs Study. RAND Health, 2013; [cited 2013 Aug 30]. Available from: http://http://www.rand.org
12. Pronk NP. Worker Health and Health Care Reform: The Patient Protection and Affordable Care Act at Work. ACSM’s Health Fitness J. 2013;17(5):42–4.
13. Pub. L. No. 111–148, 124 Stat. 119, to be codified as amended at scattered sections of the Internal Revenue Code and in 42 U.S.C. (March 23, 2010).
14. Stoddard M. Nebraska’s acclaimed wellness program under fire. World-Herald Bureau; [cited 2013 Aug 30]. Available from: http://dealsomaha.com/article/20130715/LIVEWELL01/707159943/1687.
15. Terry PE, Seaverson EL, Grossmeier J, Anderson DR. Association between nine quality components and superior worksite health management program results. J Occup Environ Med. 2008; 50: 633–41.