Public Health Worksite Health Promotion
by
Nell H. Gottlieb
  • LAST REVIEWED: 15 June 2015
  • LAST MODIFIED: 24 July 2012
  • DOI: 10.1093/obo/9780199756797-0031

Introduction

Worksite health promotion is a relatively young field, with employee fitness programs in the United States emerging in the 1960s and expanding in the 1980s to include other risk factors and wellness topics. The focus in this development was on personal lifestyle, and a primary driver was the rapid increase in employee health-care costs. In Europe, where health-care costs are not borne by employers, worksite health promotion began with a concern about the organization of work and how this influenced the worker. With the approach of the 21st century, these two threads began to come together in the social ecological model of health promotion in the United States and the settings approach of the World Health Organization, amid increasing concerns about productivity in the global economy. From a public health perspective, the workplace is an ideal setting for improving the health status of the population of workers, with spillover to their families. Social and organizational supports can facilitate well-being, healthful behaviors, and disease detection. The evidence base for worksite health promotion is strong and growing, and there is a deep experience base among large companies. The literature in health promotion reflects these roots, appearing both in scientific and professional journals and in corporate organization reports, such as those of the National Business Group on Health (which may not be generally available). The practice of health promotion has matured with a professional focus, a theoretical base, and planning and managerial frameworks. Worksite health promotion is an interdisciplinary endeavor grounded in health and behavioral science, public health, organizational change, and general management.

General Overviews

The need for health promotion is great. Huang, et al. 2011 found that, among employed adults in 2007–2008, 59.3 percent had no influenza vaccination, 49.2 percent were physically inactive, 27.0 percent were obese, and 19.2 percent smoked. The worksite has great potential to improve the health status of working adults. Linnan, et al. 2008 presents the results of the 2004 National Worksite Health Promotion Survey. Large businesses are much more likely than small businesses to have key elements of a comprehensive program, though only 24.1 percent of large businesses and 6.9 percent of the total sample had all five elements. Over 80 percent of worksites with 750 employees or more had employee assistance and back injury programs, blood pressure and blood cholesterol screening, smoking restrictions, prohibition of drug and alcohol use and firearms, and linkage to related health programs. Few overall had programs for physical activity (19.6 percent), weight management (21.4 percent), or smoking cessation (18.6 percent). The 2010 Health Care Cost Survey (Towers Watson 2010) showed large employers planning to increase employee health management, including health promotion and wellness programs and health risk assessment. The Healthy People 2020 Educational and Community Programs Objectives (US Department of Health and Human Services 2010) call for an increased proportion of worksites of all sizes that offer an employee health promotion program, and of employees who participate in a program. Other organizations, such as the American Heart Association, also recommend wellness programs (Carnethon, et al. 2009). The Commission to Build a Healthier America report Beyond Health Care: New Directions to a Healthier America (Robert Wood Johnson Foundation 2009) notes the importance of healthful work and recommends that safety and wellness be integrated into every aspect of community life, and the commission’s Issue Brief 4: Work and Health (Robert Wood Johnson Foundation 2008) provides a detailed review of the relation of work to health and strategies to improve health. Heinen and Darling 2009 describes the efforts of large US employers to address obesity, with 83 percent offering health risk appraisals and 74 percent offering weight management programs in 2008. The main points of leverage are health benefits design and incentives, environmental supports, a culture of health at work, and community and family connections.

Textbooks and Journals

For a professional seeking an orientation to the field of worksite health promotion, it is important to get an overview of the evidence base, the program planning models, program management, and evaluation. Anspaugh, et al. 2006 and Chenowith 2007 are basic textbooks for preparing the health promotion practitioner, while O’Donnell 2002 also includes in-depth reviews of intervention effectiveness. Pronk 2009 is a more technical edited volume briefly covering key issues and a comprehensive range of current topics in the context of health promotion, the evidence base, assessment of health, risk, organizations and productivity, and program design and implementation. Bartholomew, et al. 2011 is a general text for planning and adapting health promotion programs using theory and evidence regardless of setting. While articles relevant to worksite health promotion can be found in public health, health education, sports medicine, management, and organizational behavior journals, the American Journal of Health Promotion and the Journal of Occupational and Environmental Medicine publish much of the research on worksite health promotion.

  • American Journal of Health Promotion.

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    This journal, published bimonthly, aims to reduce the gap between the science and practice of health promotion and to provide interdisciplinary discussion. Every issue includes “The Art of Health Promotion,” targeted to the practice of health promotion.

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    • Anspaugh, D. J., M. B. Dignan, and S. L. Anspaugh. 2006. Developing Health Promotion Programs. 2d ed. Long Grove, IL: Waveland.

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      This is a general textbook covering intervention models and planning, managing, marketing, and evaluating worksite health promotion programs.

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      • Bartholomew, K., G. P. Parcel, G. Kok, N. H. Gottlieb, and M. E. Fernandez. 2011. Planning Health Promotion Programs: An Intervention Mapping Approach. 3d ed. San Francisco: Jossey-Bass.

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        This is a general textbook for systematically designing and adapting theoretical and evidence-based health promotion programs.

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        • Chenowith, D. H. 2007. Worksite Health Promotion. 2d ed. Champaign, IL: Human Kinetics.

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          This is a general textbook for initiating, planning, conducting, and evaluating worksite health promotion programs.

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          • Journal of Occupational and Environmental Medicine.

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            This official journal of the American College of Occupational and Environmental Medicine, published monthly, provides clinically oriented research and technical reports related to workplace health and medicine.

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            • O’Donnell, M. P., ed. 2002. Health Promotion in the Workplace. 3d ed. Albany, NY: Delmar Thomson.

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              Text covers program design, management, and evaluation, and it contains reviews of the effectiveness of interventions in all major health promotion areas.

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              • Pronk, N. P., ed. 2009. ACSM’s Worksite Health Handbook. 2d ed. Champaign, IL: Human Kinetics.

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                This book examines the history and current context for worksite health promotion, its evidence base, the assessment and evaluation of worker and organizational health, and program design and implementation. Case studies are included.

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                Reference Resources

                Because of the rapidly evolving research and practice in worksite health promotion, noncommercial public and private websites offer the best venue for staying informed regarding national and international developments in the field, and for accessing guidelines and best practices. The academic and research literature (see Textbooks and Journals) is also important, though it may not be as timely. The Centers for Disease Control and Prevention (CDC) has been a leader in translating science to health promotion practice, including the CDC sites Healthier Worksite Initiative and Workplace Health Promotion, which provide information, resources, toolkits, and programming guides. See also the Worksite Health Promotion page on the Guide to Community Preventive Services website (cited under Evidence-Based Practice), which provides systematic reviews of evidence-based practice. The website of the SAMHSA Division of Workplace Programs provides guidance from the Substance Abuse and Mental Health Services Administration for primary prevention of substance abuse through comprehensive worksite health promotion, as well as guidance for drug-free workplaces. The Partnership for Prevention, a public-private partnership, seeks to make prevention a national priority and provides resources for worksite health promotion. Websites of private membership organizations, such as the National Business Group on Health and the Wellness Council of America, provide resources to their member organizations, with some public access documents. The Public Health Agency of Canada’s Active Living at Work page and the European Network for Workplace Health Promotion provide an international perspective on workplace health promotion, with useful materials for programming and documentation of the extent of health promotion in Canada and Europe, respectively.

                Employee Wellness, Health, and Productivity

                Reviews of clinical and cost-effectiveness studies of health promotion programs, such as Pelletier 2005 and Aldana 2001, have found positive returns on investment. Baicker, et al. 2010, a meta-analysis of thirty-six studies of programs with treatment and comparison groups, found savings of $3.27 in medical costs and $2.73 in absenteeism costs for every dollar spent on wellness programs. Productivity, including decreased presenteeism, has become an important goal of health promotion. Johns 2009 reviews the organizational and occupational correlates of presenteeism (attending work while ill) and the consequent productivity loss. Schultz and Edington 2007, in a review of 113 studies of the link between health and presenteeism (on the job productivity), found allergies, arthritis, gastroespohageal reflux disease, mental health, and multiple health risk all had strong research linking them to presenteeism. Loeppke, et al. 2007 found that health-related productivity costs were more than four times higher than medical and pharmacy costs. By including productivity costs with the traditional costs, the ranking of conditions by cost are, in descending order, back and neck pain, depression, fatigue, other chronic pain, sleeping problems, high cholesterol, arthritis, hypertension, obesity, and anxiety. Such an analysis leads to a different focus for disease management. Goetzel, et al. 2007 found that promising practices included integration into organizational operations; addressing individual, environmental, policy, and cultural factors; targeting the continuum of health-care issues; tailoring programs to population needs; attaining high participation; evaluating programs based on clear definitions of success; and communicating successful outcomes to key stakeholders. Berry, et al. 2010 notes that employee wellness programs are a strategic imperative, with the return on investment (ROI) on comprehensive, well-managed programs to be as high as 6 to 1. Characteristics of successful programs include “engaged leadership at multiple levels; strategic alignment with the company’s identity and aspirations; a design broad in scope and high in relevance and quality; broad accessibility; internal and external partnerships; and effective communication.”

                • Aldana S. G. 2001. Financial impact of health promotion programs: A comprehensive review of the literature. American Journal of Health Promotion 15.5: 296–320.

                  DOI: 10.4278/0890-1171-15.5.296Save Citation »Export Citation »E-mail Citation »

                  Systematic review of the relationship between health risks and health-care costs and absenteeism and of the average cost savings per dollar spent on worksite health promotion programming. Correlational data indicate that high levels of stress, excess body weight, and multiple risk factors are associated with health-care costs and absenteeism. The average health-care cost savings due to programming was $3.48 (per dollar spent), with average absenteeism savings of $5.82, and health care/absenteeism combined savings of $4.30.

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                  • Baicker, K., D. Cutler, and Z. Song. 2010. Workplace wellness programs can generate savings. Health Affairs 29.2 (February): 304–311.

                    DOI: 10.1377/hlthaff.2009.0626Save Citation »Export Citation »E-mail Citation »

                    Critical meta-analysis of thirty-six studies (twenty-two examining health-care costs and absenteeism), showing a $3.27 return (per dollar spent) on investment in comprehensive worksite wellness programs for health-care costs and $2.73 for absenteeism.

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                    • Berry, L. L., A. M. Mirabito, and W. B. Baun. 2010. What’s the hard return on employee wellness programs? Harvard Business Review 88.12 (December): 104–112.

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                      Following a review of the literature and interviews with three hundred corporate leaders, six pillars of a successful strategically integrated wellness program were identified: multilevel leadership; alignment with the firm’s identity; comprehensive scope, relevance, and quality; accessibility; internal and external partnerships; and communication.

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                      • Goetzel, R. Z., D. Shechter, R. J. Ozminkowski, P. F. Marmet, M. J. Tabrizi, and E. C. Roemer. 2007. Promising practices in employer health and productivity management efforts: Findings from a benchmarking study. Journal of Occupational and Environmental Medicine 49.2: 11–130.

                        DOI: 10.1097/JOM.0b013e31802ec6a3Save Citation »Export Citation »E-mail Citation »

                        Results from a literature review, expert panel, survey of exemplar programs, and site visits reveal promising practices and characteristics of outstanding programs.

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                        • Johns, G. 2009. Presenteeism in the workplace: A review and research agenda. Journal of Organizational Behavior 31.4: 519–542.

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                          This overview article defines presenteeism as “attending work while ill,” and it examines research on the precursors of the act of presenteeism and its consequences, such as productivity loss or gain. Measures of presenteeism are reviewed, and a theory-driven research agenda from an organizational behavioral and health psychology perspective is suggested.

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                          • Loeppke, R. R., M. Taitel, D. E. Richling, et al. 2007. Health and productivity as a business strategy. Journal of Occupational and Environmental Medicine 49.7: 712–721.

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                            Authors found that health-related productivity costs are more than four times greater than medical and pharmacy costs. Consideration of productivity costs along with the traditional costs leads to a focus on different health conditions.

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                            • Pelletier, K. R. 2005. A review and analysis of the clinical and cost-effectiveness studies of comprehensive health promotion and disease management programs at the worksite: Update VI 2000–2004. Journal of Occupational and Environmental Medicine 47.10: 1051–1058.

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                              Sixth update of an analysis of clinical and cost-effectiveness of worksite health promotion, for a total of 122 studies overall. Clinical and cost outcomes continue to be positive, although the quality and quantity of research have declined.

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                              • Schultz, A. B., and D. W. Edington. 2007. Employee health and presenteeism: A systematic review. Journal of Occupational Rehabilitation 17.3: 547–579.

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                                This review of 113 manuscripts up to October 2006 found allergies, arthritis, gastroespohageal reflux disease, mental health, and multiple health risk had strong research linking each condition to presenteeism.

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                                Evidence-Based Practice

                                Ryan, et al. 2011 describes the movement for evidence-based programming, including its origins and use for practitioners. Systematic reviews of worksite interventions have been undertaken by both the Task Force on Community Preventive Services (see Guide to Community Preventive Services) and the Cochrane Collaboration. Effective interventions are available for health risk assessment and cancer screening, smoking cessation, reduction of exposure to secondhand smoke, physical activity, obesity prevention, and seasonal influenza vaccination. One Cochrane systematic review examines a structural intervention concerning the use of flexible working conditions. The Cochrane Reviews also include occupational health topics that could be integrated with health promotion. The Promising Practices page on the Partnership to Fight Chronic Disease website, the Research Tested Intervention Programs page on the National Cancer Institute website, and the National Registry of Evidence-Based Programs and Policies are web-based databases of evaluated programs. Mhurchu, et al. 2010 found moderate effects on dietary intake in a systematic review of sixteen programs with various interventions. Archer, et al. 2011, a systematic review, found that enhanced access to physical activity along with health education, exercise prescriptions, multicomponent education, weight loss competitions and incentives, and various behavioral interventions with and without incentives holds promise for worksite obesity prevention and control.

                                Research Trials

                                Three large worksite health promotion research initiatives have been undertaken since the early 1990s. Sorensen, et al. 1996 describes the findings from the Working Well Trial, funded by the National Cancer Institute. This trial was conducted in 111 worksites that included manufacturing, communications, public service, and utility companies. Significant but small changes were found for nutrition outcomes and nonsignificant but positive trends for smoking outcomes, perhaps due to secular changes in the targeted behaviors. Two special journal supplements, in Obesity in 2007 (Special Supplement: Worksite Studies) and the Journal of Occupational and Environmental Medicine in 2010 (Special Supplement: Worksite Environmental Interventions for Obesity Control), contain overviews and articles regarding the seven independent worksite health promotion research grants funded by the National Heart, Lung, and Blood Institute. All focused on multicomponent weight control interventions that included environmental changes, either alone or in combination with individual-level strategies. The 2007 articles describe baseline results and formative research, while the 2010 articles include environmental change assessment validation, initial outcomes, and a study of costs associated with obesity.

                                • Sorensen, G., B. Thompson, K. Glanz, et al. 1996. Work site-based cancer prevention: Primary results from the Working Well Trial. American Journal of Public Health 86.7: 939–947.

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                                  The Working Well Trial, funded by the National Cancer Institute, examined interventions in 111 worksites and found significant though small changes for nutrition, and nonsignificant but positive trends for smoking outcomes, perhaps due to secular changes in the targeted behaviors.

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                                  • Special supplement: Worksite environmental interventions for obesity control. 2010. Journal of Occupational and Environmental Medicine 52.1S.

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                                    Journal supplement devoted to findings from worksite weight control projects funded by the National Heart, Lung, and Blood Institute. An overview and eight other articles are included.

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                                    • Special supplement: Worksite studies. 2007. Obesity 15.1S.

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                                      Journal supplement devoted to articles describing the formative research and baseline results of studies from National Heart, Lung, and Blood Institute research projects using environmental or combined environmental and individual-level interventions for prevention and control of weight problems at worksites. An overview and eight other articles are included.

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                                      Program Adoption and Implementation

                                      The adoption of worksite health promotion activities, programs, and policy changes is the first step of diffusion across the population of worksites. Harris, et al. 2008 describes the increase in evidence-based practices through the marketing strategy Workplace Solutions, a program of the American Cancer Society. Health promotion textbooks (see Textbooks and Journals) describe the program planning cycle (planning, implementation, and evaluation), as do most general resource websites (see Reference Resources). The Partnership for Prevention’s Healthy Workforce 2010 and Beyond (Partnership for Prevention 2009), the CDC’s Healthier Worksite Initiative, Chapman 2008a, and Chapman 2008b provide easily accessible guidelines for engaging in this process. Weiner, et al. 2008 presents a model of implementation effectiveness, with a focus on the policies and practices themselves, organizational readiness to change, the implementation climate, innovation-values fit with employees, implementation effectiveness, and innovation efficacy and effectiveness. The authors applied this model to the Working Well trial at 111 worksites. Employee participation is critical to achieving the benefits of worksite health promotion. Sparling 2010 locates ten principles for successful programs. Robroek, et al. 2009, a systematic review, finds that participation levels vary from 10 percent to 64 percent, with a median of 33 percent, and with women more likely to participate than men. Linnan, et al. 2001 uses a political economy of health perspective to hypothesize determinants of low employee participation in worksite health promotion programs. These include power and social inequalities, management-labor relations, negative norms about health programs at work, and issues of confidentiality, privacy, and trust.

                                      Evaluation

                                      Evaluation is critical for program management and accountability. Evaluation for worksite health promotion builds on more general program evaluation, focusing on changes in health-care claims and productivity and the costs associated with them. The W. K. Kellogg Foundation Evaluation Handbook (W. K. Kellogg Foundation 2004) describes the planning, implementation, and utilization of evaluation results for three evaluation components: context, implementation, and outcome. Chenoweth 2002 is a basic textbook for worksite health promotion evaluation, covering the basic steps to plan, conduct, and report evaluations, along with claims data analysis and financial analysis. Chapters in general texts (see Textbooks and Journals) are also useful. A special issue of Absolute Advantage (Wellness Council of America 2006) provides a practitioner-accessible introduction to the process. Engbers 2008 reviews the literature on evaluation of diet and physical activity interventions to assess best practices in monitoring and evaluation, including indicators and the feasibility of their use, and concludes with recommendations to improve monitoring and evaluation of worksite health promotion programs. Leviton, et al. 2010 describes the evaluability assessment, which can be used for plausibility analysis, feedback on implementation, and use and adaptation of evidence-based programs in worksites prior to a conventional evaluation. Dout, et al. 2008 describes the Swift Worksite Assessment and Translation evaluation process, used to identify promising practices developed by the CDC. The process includes nomination of a site, examination of data and program materials, a site visit, feedback to sites, and translation and dissemination. O’Donnell 2011 describes the US health-care reform legislation mandate to CDC to provide technical assistance to employers on evaluations of their programs and to conduct periodic national surveys of worksite health promotion.

                                      Small Business

                                      As noted in the Introduction, small businesses have fewer resources and report the implementation of far fewer health promotion programs than large businesses. However, according to the U.S. Small Business Association, small businesses (the size varies by industry classification) represent 99.7 percent of all firms and employ over half of working adults in the United States, and generated 64 percent of new net jobs between 1996 and 2011 (see US Small Business Association 2011). McMahan, et al. 2001 surveys small businesses in Southern California, and confirms the lack of health promotion programming there, noting that the most frequent policies and programs relate to safety, which is required by law, and that the smallest businesses report higher employee participation rates than larger ones. Merrill, et al. 2011 finds a high level of participation (e.g., 99% for screening) in a wellness program integrated into a company’s culture and operation, and significant improvements in body fat, blood pressure, and flexibility, particularly among older employees and those with the highest baseline value. The Small, Healthy and Competitive report of the European Network for Workplace Health Promotion (ENWHP) points out differences from large organizations: an owner who exerts a dominant influence on the company; less developed long-term health promotion programs; strong social relationships among employees and with the owner; simple organizational structures; fewer routine activities; and a high degree of direct communication. The report’s recommendations include awareness-raising, marketing, and communication; building supportive environments; development of tailor-made preventive services; and integration of health promotion into existing occupational health and safety services. Two issues of the Wellness Council of America’s Absolute Advantage (Chapman 2008a, Chapman 2008b) provide program planning information specifically for small businesses, including partnering with other businesses and community health-care providers. Textbooks also offer information regarding health promotion in small businesses (see Textbooks and Journals). O’Donnell 2010 describes the US federal grant program for small employers to implement a comprehensive wellness program as part of health-care reform, noting that the incentives of saving money on medical costs and negotiating volume-based pricing discounts, as well as a large human resources department to organize a program, are not present in small businesses.

                                      Integration and Alignment of Workplace Programs

                                      The 21st century has brought renewed interest in programs, policies, and benefits related to the management of health and productivity and in creating a healthful environment at work. Stress and mental health are now receiving increased priority. Cherniack, et al. 2011 contains the national worklife priorities for the National Institute for Occupational Safety and Health, which call for program integration and the dissemination of effective practices. Henning, et al. 2009 and Punnett, et al. 2009 discuss participatory ergonomics as an example of health promotion integrated into occupational safety and health programming. According to the 2009/2010 Staying@Work Report (Towers Watson 2009), a survey of large employers, 57 percent of US and 45 percent of Canadian companies have a formal health and productivity strategy. Primary barriers are lack of budget, staff, employee engagement (US) and a lack of clarity on how to measure the program impact. Companies list excessive workloads, lack of a work-life balance, and job loss as the most important sources of stress and 21–41 percent of US and 35–52 percent of Canadian companies are taking action to reduce these stressors. The report Staying@Work: Effective Presence at Work 2007 (Watson Wyatt Worldwide 2007) highlights presenteeism, with 44 percent of employees saying they cut back on work when physically or mentally ill and 85 percent of employers stating that their employees stay home when they are ill. Stigma regarding mental illness is a barrier to absence and seeking care. The Center for Value-Based Health Management presents a model of using evidence-based guidelines across the health continuum through value-based benefit design, primary prevention, risk intervention, and chronic disease management. Program initiatives include a culture of health, human resources policy and procedures, benefit design and incentives, health promotion, demand management, disease management, occupational health and safety, employee assistance programs, work/life programs, and training and development. The National Business Coalition on Health assists purchaser-led coalitions, primarily of Fortune 500 companies, in controlling costs and managing health and productivity, particularly through benefit design and consumer engagement.

                                      Worksite Environmental Supports

                                      Environmental and policy supports are fundamental aspects of workplace settings and socioecological approaches to worker health. Brisette, et al. 2008 finds these supports to be more likely in large settings than in medium and small ones and, except for preventive screenings, to be less likely in nonwhite worksites. Models for environmental change in the worksite are presented in Chu, et al. 2000 and Paton, et al. 2005 in the context of the settings approach, and in Golaszewski, et al. 2008. Correlational evidence for worksite environmental supports increasing physical activity was found in Dodson, et al. 2008, a three-state survey. Examining the initial results of two of the National Heart, Lung and Blood Institute (NHLBI) environmental change projects, Beresford, et al. 2010 found only the informational environments for physical activity and nutrition to have changed in eighteen diverse worksites, while French, et al. 2010 found that a pricing and availability vending machine intervention in bus garages increased the purchase of healthful items. (See Research Trials for other NHLBI environmental change projects.) Engbers, et al. 2005, a systematic review of the impact of environment-focused worksite health promotion, found evidence of strong effects for dietary intake, inconclusive effects for physical activity, and no evidence for an effect on health risk indicators.

                                      • Beresford, S. A. A., S. K. Bishop, N. L. Brunner, et al. 2010. Environmental assessment at worksites after a multilevel intervention to promote activity and changes in eating: The PACE Project. Journal of Occupational and Environmental Medicine 52.1 (Suppl.): S22–S28.

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                                        After two years of intervention in diverse worksites, only the physical activity and nutrition information environments were significantly increased as a result of the intervention; the physical environment and resources were unchanged.

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                                        • Brisette, I., B. Fisher, D. A. Spicer, and L. King. 2008. Worksite characteristics and environmental and policy supports for cardiovascular disease prevention in New York State. Preventing Chronic Disease 5.2.

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                                          A state employer survey found more environmental and policy supports for physical activity, healthy eating, stress management, and preventive health screenings in large sites than in medium or small sites, and in sites with a wellness coordinator or committee, regardless of size.

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                                          • Chu, C., G. Breucker, N. Harris, et al. 2000. Health-promoting workplaces—International settings development. Health Promotion International 15.2: 155–167.

                                            DOI: 10.1093/heapro/15.2.155Save Citation »Export Citation »E-mail Citation »

                                            The emergence of the settings approach for worksite health promotion in the World Health Organization is described, and an integrated framework for workplace health assessment presented.

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                                            • Dodson, E. A., S. L. Lovegreen, M. B. Elliott, D. Haire-Joshu, and R. C. Brownson. 2008. Worksite policies and environments supporting physical activity in midwestern communities. American Journal of Health Promotion 23.1: 51–55.

                                              DOI: 10.4278/ajhp.07031626Save Citation »Export Citation »E-mail Citation »

                                              A random telephone survey of working adults from three states found that having multiple policies at a worksite, including accessible stairways and personal services (e.g., counseling and fitness testing), was associated with meeting physical activity recommendations, and having exercise facilities and equipment was associated with meeting recommendations through walking.

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                                              • Engbers, L. H., M. N. M. van Poppel, A. Chin, M. J. M. Paw, and W. van Mechelen. 2005. Worksite health promotion programs with environmental changes: A systematic review. American Journal of Preventive Medicine 29.1: 61–70.

                                                DOI: 10.1016/j.amepre.2005.03.001Save Citation »Export Citation »E-mail Citation »

                                                Findings from a systematic review of outcomes of control trials of worksite health promotion programs with environmental changes. Evidence of effects was strong for dietary intake and inconclusive for physical activity, and there was no evidence for an effect on health risk indicators.

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                                                • French, S. A., P. J. Hannan, M. Stat, et al. 2010. Pricing and availability intervention in vending machines at four bus garages. Journal of Occupational and Environmental Medicine 52.1 (Suppl.): S29–S30.

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                                                  Increasing availability of healthy items to 50 percent and lowering prices an average of 31 percent resulted in a 10 to 42 percent increase in sales of these items over an eighteen-month period.

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                                                  • Golaszewski, T., J. Allen, and D. Edington. 2008. Working together to create supportive environments in worksite health promotion. American Journal of Health Promotion 22.4: 1–10.

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                                                    A model for creating supportive environments is presented that includes work, structural, and cultural factors. Guidance for establishing a health-supporting organizational structure and culture is given.

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                                                    • Paton, K., S. Sengupta, and L. Hassan. 2005. Settings, systems and organizational development: The Healthy Living and Working Model. Health Promotion International 20.1: 81–89.

                                                      DOI: 10.1093/heapro/dah510Save Citation »Export Citation »E-mail Citation »

                                                      This paper applies management theory, specifically systems theory and organizational development, to the development of a model of workplace health promotion within the settings framework. Addressing the worksite’s organizing arrangements, physical setting, technology, and social factors are seen as key to worker health. This is contrasted with an individual-level approach.

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