Journal of Occupational & Environmental Medicine:
Evaluation of a Best-Practice Worksite Wellness Program in a Small-Employer Setting Using Selected Well-being Indices
Merrill, Ray M. PhD, MPH; Aldana, Steven G. PhD; Pope, James E. MD; Anderson, David R. PhD, LP; Coberley, Carter R. PhD; Vyhlidal, Tonya P. MEd; Howe, Greg MS; Whitmer, R. William MBA
From the Department of Health Science (Dr Merrill), College of Life Sciences, Brigham Young University, Provo, Utah; Lifestyle Research Group (Dr Aldana), Mapleton, Utah; Center for Health Research, Healthways, Inc, World Headquarters (Drs Pope and Coberley), Franklin, Tenn; Health Enhancement Research Organization Research Committee (Dr Anderson), Saint Paul, Minn; Lincoln Industries (Messrs Vyhlidal and Howe), Lincoln, Neb; and Health Enhancement Research Organization (Mr Whitmer), Birmingham, Ala.
Address correspondence to: Ray M. Merrill, PhD, MPH, Department of Health Science, College of Life Sciences, Brigham Young University, 229-A Richards Building, Provo, UT 84602; E-mail: Ray_Merrill@byu.edu.
Objective: To measure the effectiveness of a wellness program in a small company using four well-being indicators designed to measure dimensions of physical health, emotional health, healthy behavior, and basic access to health-related conditions and services.
Methods: Indicator scores were obtained and compared between Lincoln Industries employees and workers in the neighboring Lincoln/Omaha community during 2009.
Results: Nearly all Lincoln Industries employees participated in the wellness program. Physical health, mental health, and healthy behavior were significantly greater for Lincoln Industries employees. Self-perceived access to basic needs was not significantly greater among Lincoln Industries employees.
Conclusion: Well-being index scores provide evidence for the effectiveness of the wellness program in this small company setting with respect to better dimensions of physical health, emotional health, and healthy behavior than geographically similar workers.
Employers are increasing their investment in worksite wellness programs to improve employee health and satisfaction, lower absenteeism, increase quality and productivity, and lower health care costs.1–14 The workplace is an effective setting for implementing wellness activities because there is access to individuals in a controlled environment through existing channels of communication and social support.15 The worksite is also a useful setting for disseminating health information and promoting improvements in health behaviors.16 With mounting evidence for the effectiveness of worksite wellness programs, national public health objectives have called for increasing the number of worksites offering comprehensive health promotion programs, as well as increasing the number of employees participating in these activities.17
Despite the existence of a large body of studies of the effectiveness of different types of worksite wellness programs,1–14 there is very little peer-reviewed research assessing small employer health promotion programs. This may be partially because many believe that it is not feasible for small employers to effectively implement worksite wellness programs because of limited expertise and resources. The purpose of the current study is to assess the effectiveness of an intensive wellness program in a small company using well-being indices designed to measure physical health; emotional health; health behaviors; and basic access to clean and safe drinking water, affordable fruits and vegetables, medicine, and a safe place for exercise.
Lincoln Industries is a supplier of products requiring high-performance metal finishing. The company is a small employer, with 479 employees in January 2009. The maximum number of employees for a company involved in metal works and manufacturing to be considered a small business is 500, as set forth by the North American Industry Classification System and modified by the Office of Management and Budget in 2007.18 Beginning in 2000, Lincoln Industries implemented an intensive wellness program, which now engages virtually all of its employees. The wellness program was developed not only to create greater awareness among employees of their current health status, but also to promote greater physical fitness, improved dietary behaviors, a heightened sense of community, and enhanced employee satisfaction. Approximately 99% of employees participate in quarterly screenings, and a majority of employees also engage in other wellness activities throughout the year.19 Previous evaluation of the program has demonstrated decreasing trends in tobacco use, workers compensation costs, and relatively stable health care costs per employee that compare favorably to escalating national cost trends.20,21 Consequently, the company's wellness program has received various national awards.22 To further understand the effects of this commitment to worksite wellness, health and well-being measures of Lincoln Industries employees were compared with those of other adult workers employed in the Lincoln/Omaha area.
On January 2, 2008, Gallup and Healthways formed a partnership to monitor health among employees and other individuals in communities throughout the United States. The Gallup-Healthways Well-being Index was developed to include a set of indices based on questions measuring broad conceptual domains impacting personal health, well-being, and quality of life. Gallup obtains complete interviews from 1000 US adults nationally, 7 d/wk, excluding national holidays. Standard survey methods rely on live (not automated) interviewers, dual-frame random-digit-dial sampling (which includes landlines as well as wireless phone sampling to reach those in wireless-only households), and a random selection method for choosing respondents within a household. In addition, daily tracking includes Spanish-language interviews for respondents who speak only Spanish, and relies on a multicall design to reach respondents not contacted on the initial attempt. The data are weighted daily to match targets from the US Census Bureau by age, sex, region, gender, education, ethnicity, and race. In addition to this standard interview methodology for establishing community and national norms, data may also be collected through self-report survey questionnaires. Detailed information on the development and implementation of the Well-being Index is available eslewhere.23
The current study focuses on four indices that assess physical health, emotional health, healthy behavior, and basic access to health-related conditions and services. The physical health index is based on questions related to estimated body mass index (calculated from self-reported height and weight), disease burden, sick days, physical pain, daily energy, history of disease, and daily health experiences. The emotional health index is a composite of participants’ daily experiences, which include an item that probes for prior history of diagnosed depression, and questions in which respondents are asked to think about yesterday, from morning through evening, and whom they were with, what they did, and how they felt. The index is based on the items measuring smiling or laughing; learning or doing something interesting; being treated with respect; and experiencing enjoyment, happiness, worry, sadness, anger, or stress. The health behavior index includes items that address lifestyle habits (eg, smoking and diet) that are related to selected health outcomes. Specific questions ask about smoking status, fruit and vegetable consumption, exercise frequency, and whether they ate healthy the previous day. The basic access index is based on items measuring people's access to clean and safe drinking water, affordable fruits and vegetables, medicine, and a safe place for exercise.
The survey response rate for Lincoln Industries was 87%. The survey methodology for obtaining data for the Lincoln/Omaha area is described earlier. The Lincoln Industries survey involved completing a self-reported questionnaire. The community sample was based on the same self-reported questionnaire, administered only over the telephone.
The well-being survey was scored on an individual basis, and individual values were aggregated to produce a set of domain scores for the population. The scoring rules rely on definitive answers. Only nonmissing scores are included in the aggregated scores. Index scores were obtained by summing the domain related items, dividing by the number of items considered in that domain, and multiplying the result by 100.
Frequency distributions and means were used to describe the data. Bivariate analyses were used to measure associations between selected variables with statistical significance based on the chi-squared test for independence. Prevalence rate ratios were used to compare personal health, well-being, and quality of life outcomes according to Lincoln or non-Lincoln employment status. Prevalence rate ratios were adjusted for age, gender, marital status, and income. Logistic multiple regression was used to simultaneously identify those variables that discriminate Lincoln employees from non-Lincoln employees, while adjusting for potential confounders. Two-sided tests of significance and confidence intervals were based on the 0.05 level. Analyses were performed using SAS version 9.2 (SAS Institute Inc, Cary, North Carolina, 2007).
Employees in Lincoln Industries compared with working individuals in the neighboring community were more likely to be male, younger, currently married or single/never married, and to have a lower annual household income (Table 1).
In general, employees at Lincoln Industries were satisfied with their overall quality of life. Employees were asked to rate their life on a scale from 0 (worst possible life) to 10 (best possible life). Mean rating was 9.4 for Lincoln Industries employees and 7.1 for other working individuals in the Lincoln/Omaha areas (P < 0.001).
Well-being indices were designed to measure individual perceptions. Well-being indices for physical health, emotional health, health behaviors, and basic access are presented according to company and selected demographic variables in Table 2. The results show that perceived physical, mental, and emotional health were significantly greater for Lincoln Industries employees; perceived healthy behaviors were significantly greater for Lincoln Industry employees; and perceived access to basic needs such as health care, food, shelter, and personal safety were not significantly different between Lincoln Industries and other employees in the Lincoln/Omaha area.
There were also significant demographic differences in the results. Perceived physical health was greater for men than women, but perceived healthy behaviors were greater for women than men; perceived physical health tended to be greater at younger ages, whereas perceived mental and emotional, health behaviors, and basic access tended to be greater at older ages; employees divorced, separated, or living with a domestic partner had lower perceived mental and emotional health and healthy behaviors than married and widowed employees; employees who were separated or divorced had the lowest perceived basic access; and, with the exception of the lowest income group, there was a tendency for each well-being domain score to increase with income.
In addition to the overall index scores, specific physical health, emotional health, healthy behaviors, basic access, and disease prevalence are compared between those working for Lincoln Industries and elsewhere (Table 3). Lincoln Industries employees were less likely to be obese and experience health problems that restricted their normal activities. They were also more likely to feel well rested and less likely to experience the flu. There was no significant difference in having sufficient energy, being sick with a cold or a headache, or feeling physical pain. Lincoln Industries employees were less likely to have been diagnosed with depression and to feel worried or sad or experience sadness. On the other hand, they were less likely to experience happiness. There was no significant difference in smiling, being treated with respect, or experiencing anger. Lincoln Industries employees were less likely to be current tobacco smokers; they were also more likely to eat five or more servings of fruit and vegetables per day and exercise 30 or more minutes per day. There was no difference in whether they perceived that they ate healthily. Lincoln Industries employees perceived that they had greater access to clean and safe drinking water, more affordable fruits and vegetables, and medicine. There was no difference in their perceived satisfaction in the area where they lived or whether they had a safe place available for exercise. Finally, Lincoln Industries employees were more likely to have been told by a nurse or physician that they have high cholesterol, but were less likely to have been told that they have diabetes or have experienced a myocardial infarction. There was no difference in the prevalence of high blood pressure, asthma, or cancer between the two groups.
In a multiple regression model containing all the variables listed in Tables 1 and 3, stepwise selection identified certain variables to simultaneously discriminate Lincoln from non-Lincoln employees. Consistent with the results shown in the first and last tables, Lincoln employees experienced fewer health restrictions and were more likely to feel well rested, less likely to have been treated with respect all day the previous day, less likely to have experienced sadness a lot of the previous day, and less likely to have felt happy a lot of the previous day. Lincoln employees were also less likely to be current smokers; more likely to exercise; more likely to feel that they had access to medicine; more likely to have been told by a physician or nurse that they had high cholesterol; and were generally younger, more likely to be married, and had a lower income.
The current study is an assessment of the effectiveness of Lincoln Industries Wellness Program. Evaluation involves a comparison of selected well-being indices between Lincoln Industries employees and workers in the surrounding Lincoln/Omaha area. The Lincoln Industries employees provided answers to the Gallup-Healthways Well-being Index. The participation rate was 87%. The workers in the surrounding Lincoln/Omaha areas provided information by participating in a Gallup-conducted survey. Lincoln Industries is unique in that nearly all of its employees participate in quarterly health screenings, and a high percentage of employees also participate in other company-sponsored wellness activities throughout the year.18 This high level of involvement in the wellness program may be at least partly because of the direct impact participation has on annual merit increases as well as cash and other incentives.
The results of the well-being analysis according to company and demographic factors showed that perceived physical, mental, and emotional health, as well as healthy behaviors was significantly better among Lincoln Industries employees than among other workers. Although Lincoln Industry employees’ emotional health was significantly better with respect to certain items (ie, lower depression, less worry, less sadness, less stress, and more happiness), employees were significantly less likely to feel that they were treated with respect throughout the previous day. The generally positive results are consistent with findings of improved job satisfaction and lower absenteeism rates in a 2008 meta-analysis of worksite wellness program studies.24 The lack of significant difference between groups concerning perceived access to basic needs may be due either to the general condition of the Omaha/Nebraska living community or to a need to improve safe worksite fitness and outdoor recreation facilities. In this study, perceived physical health was greater for men than women, while perceived healthy behaviors were greater for women than men. These results mirror a 1991 gender and exercise study showing that women were more likely to consider their weight unhealthy and to engage in diet and exercise to lose weight than men.25 This same gender study showed that young men were more likely to engage in and associate exercise with feelings of body satisfaction and good health than older individuals.25 Consistent with other research, physical health among respondents in this study was rated higher in younger age groups.26 Yet, perceived mental and emotional health, smoking and dietary behaviors, and basic access tended to be better for older employees, as also tends to be consistent with the literature.27–29 Employees divorced, separated, or living with a domestic partner had lower perceived mental and emotional health, basic access and healthy behaviors than married and widowed employees, which is similar to the finding from a 2004 study on marital status and depression showing that cohabiting individuals were more likely to experience poor mental health and depression than married individuals.30 The correlation between income and the well-being domain score agrees with findings from a 2006 analysis that physical and mental health improves with increasing levels of education and income in the United States.31 Therefore, although general findings by employer and demographic factors appear to agree with the published data, the lack of difference between groups concerning perceived basic access to needs may show an area of opportunity for this worksite-based public health program.
The data also suggest that the Lincoln Industries wellness program is meeting overarching health goals, even though some specific survey results displayed in Table 3 are mixed concerning employee health perception and status. For example, Lincoln Industries employees were less likely to experience the health problems associated with obesity, restriction of normal activities, flu, or a general feeling of poor health, even though their likelihood of feeling they had sufficient energy and prevalence of colds, headaches, and pain were similar to other workers in the Lincoln/Omaha area. Nevertheless, these mixed results are analogous to a 1998 Dutch study, where employees in a worksite wellness program experienced lower rates of cardiovascular disease than nonparticipants, but did not experience significantly lower stress rates that may have been influenced by non–employment-related factors.32 Although these two worksite programs improved some aspects of health, they did not impact all areas of health equally among individuals. Lincoln Industries employees were more likely to engage in healthy behaviors, such as consuming five or more servings of fruit and vegetables per day and exercising 30 or more minutes per day, while refraining from risky behaviors such as smoking. These results mirror data from a worksite wellness program cost-benefit analysis showing that wellness programs lead to healthier employee behaviors, such as smoking cessation and healthier eating.33 Finally, Lincoln Industries employees were more likely to have high cholesterol and just as likely to have high blood pressure as other workers, but they were less likely to have been told that they have diabetes or to have experienced a myocardial infarction. Since data for Lincoln Industries groups were compared with data for individuals of all job types, stress levels may have been a contributing factor in the analysis of certain health outcomes. Nevertheless, it is also possible that, like the same 1998 Dutch study, worksite health programs influence some aspects of health but not others.32
This study includes certain limitations. First, this survey-based study compared employees of the Lincoln Industries wellness program with other employees in the Lincoln/Omaha area. Nevertheless, the results of this study would be more applicable to other companies if data from a similar small corporation without a wellness program were available as a comparison group. By using all employees in the Lincoln/Omaha area as a comparison group, potential health benefits of working in a small company (more interaction with fellow employees and bosses and greater control over daily tasks) are diluted by the survey results of employees of large organizations. In addition, the dynamics of the type of labor performed by Lincoln employees are not being taken into account in this study. Consequently, the lack of a more specific comparison group should be considered when interpreting study results. Nevertheless, the analyses do adjust for potential confounding effects of selected demographic factors. Another limitation is that since participation in some aspects of the wellness program are mandatory and companywide, implementation of a similar wellness program on a broader scale may be more difficult because of lack of participation, and additional factors related to worker nonparticipation would need to be considered in effectiveness or cost-benefit analyses.34
This study of the Lincoln Industries wellness program provides valuable information about the effectiveness of this and similar worksite health and wellness programs. Using the well-being indices of physical health, emotional health, healthy behavior, and basic access from the Gallup-Healthways Well-being Index, results indicate that Lincoln Industry employees were more likely to report feelings of good physical and emotional health, as well as to report healthy behavior, compared with employees of other organizations in the Lincoln/Omaha area. Nevertheless, Lincoln Industries employees were not more likely than other employees to consider themselves as having access to basic needs, including satisfaction with their city or community and considering themselves as having a safe place to exercise. With this in mind, the Lincoln Industry wellness program has enabled its employees to live healthier and more productive lives. Nevertheless, further health and well-being enhancements may be achieved by increasing access to worksite exercise facilities, aesthetic properties in and around the worksite, and involvement in community improvement programs to increase employee satisfaction with their city. This information may be used to improve the quality of this and similar worksite wellness programs.
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