Mission Lighten Up4Life December 10, 2009 Designing and Sustaining Effective Comprehensive Worksite Wellness Programs: Strategies for Success Laura Linnan, ScD, CHES Associate Professor The UNC Gillings School of Global Public Health WAY to Health Research Study Linnan, L (PI) R01 HL080656-01A1
Objectives Define what we mean by a comprehensive worksite health promotion program & understand relevant national benchmarks Showcase key strategies for success by reviewing the strategic planning approach used in the WAY to Health research study: Organize an Employee Wellness Committee Select evidence-based programs (& use incentives) Include both process and outcome evaluation Identify assets and cultivate strategic partnerships
Healthy People 2010 Worksite Health Promotion-Related Objectives At least 75% of worksites should offer a comprehensive worksite health promotion program How do we define comprehensive? What are the benefits of a comprehensive program? How many worksites offer a comprehensive program? At least 75% of employees should participate in health promotion programs offered at work How can we increase employee involvement & participation? What are the benefits of increased employee participation?
How Is A Comprehensive Worksite Health Promotion Program Defined? Health education programs Health and medical screenings with adequate followup and treatment Supportive social/physical environment Links to related health/benefit programs (e.g. EAP) Integration of health promotion into the organizational structure (e.g. staff, budget, space)
National Worksite Survey Results SO How Are We Doing?
Use of a Health Risk Appraisal 50 750+ EES (n=111) 45 40 35 30 25 20 15 10 5 0 Linnan, Bowling et al. (2008). AJPH. 250-749 EES (n=211) 100-249 EES (n=229) 50-99 EES (n=179) Total (n=730) Differences by worksite size statistically significant (p=0.0002)
Physical Activity and Nutrition Programs by Worksite Size 70 60 50 750+ EES (n=111) 40 250-749 EES (n=211) 30 100-249 EES (n=229) 20 50-99 EES (n=179) 10 Total (n=730) 0 *Physical Activity *Nutrition Linnan, Bowling et al, 2008 AJPH * statistically significant differences by worksite size (p<.001)
Select Environmental Programs by Worksite Size 100 90 80 70 60 50 750+ EES (n=111) 250-749 EES (n=211) 100-249 EES (n=229) 40 30 50-99 EES (n=179) 20 Total (n=730) 10 0 Onsite Fitness Center Fitness/Walking Trails Cafeteria Vending - food/beverages Linnan, Bowling et al, 2008 AJPH
Barriers To Health Promotion Program Success 70 60 50 40 30 20 10 0 Lack of Employee Interest Lack of Staff Resources Lack of Funding Lack of High-Risk Employee Participation Linnan, Bowling et al. 2008. AJPH Lack of Management Support No differences in barriers were reported based on industry type or worksite size except that worksites with 750+ employees were sig more likely to report lack of participation by high-risk employees (p=0.002).
How Integrated Are Wellness Efforts? Worksite health promotion supports organization s business strategy 69.1% Program integrated into health care strategy 67.5% Linked with other key organizational areas 66.2% Use data to guide program direction 49.5% Used a marketing approach 39.6% Have a 3-5 year strategic plan for worksite health promotion in place 30.2% Linnan, Bowling et al, 2008, AJPH
Methods for Evaluating Program Success 100 90 80 70 60 50 40 30 20 10 0 Employee Feedback Employee Participation Workers' Compensation Costs Health Care Claims Costs Time Lost / Absenteeism Linnan, Bowling et al, 2008 AJPH
How many employers are offering a comprehensive health promotion program?
KEY ELEMENTS of a COMPREHENSIVE PROGRAM OFFERED by WORKSITE SIZE 90 80 70 60 50 40 750+ (n=111) 250-749 (n=211) 100-249 (n= 229) 50-99 (n=179) 30 20 10 0 All 5 Elements Health Education Supportive Soc. & Phys. Enviro. Integration Linkage w/eap Worksite Screening *significant differences by worksite size ( p<.05) among all key elements Linnan, Bowling et al, 2008 AJPH
Who Is Likely To Have a Comprehensive Worksite Health Promotion Programming? Controlling for all factors (e.g. model adjusted for worksite size, staff, experience, industry type) we learned that: Worksites with 750+ employees were 4.4 times as likely to have a comprehensive program (p=.06) Worksites with a dedicated staff person were 10.3 times more likely to have a comprehensive program (p<.05) Finance/agriculture/mining industries remained significantly less likely to have a comprehensive worksite health promotion program (p<.05)
What Did We Learn? Larger worksites more likely to offer all types of health programs, policies and environmental supports Very few employers are offering a comprehensive program as defined by 5 key elements (6.9%) Only 1/3 of employers are doing strategic planning for wellness, and rely mostly on employee feedback to evaluate program success
Strategies for Success.Considering examples from the WAY to Health Research Study..
The WAY to Health Research Study (Worksite Activities for You!) (R01 HL080656-01A1) Funded by National Heart Lung and Blood Institute (2006 2011)
WAY to Health Study Overview CDC WAY to Health study produced positive outcomes (2004-2007) among 17 community colleges; approx 1000 employees NHLBI WAY is 5 year study (2006-2011) in14 participating North Carolina universities and community colleges (12 full participating campuses, 2 alternates); approx 1000 employees Study takes place in 2 Phases: Phase I Phase II Strategic Wellness Planning/ Employee Wellness Committees* Weight Loss Study
NHLBI WAY to Health Study Design Campuses enrolled (n=14) Campus kickoff event (Oct 2007) Employee Wellness Committees Phase I (Nov 2007) WAY to Health Fair Enroll Employees Phase II (Sept 2008) Complete Baseline Assessments & Randomize WEB CASH WEB + CASH USUAL CARE Program Specific Study Orientation Follow-up Assessments Employee (3, 6, 12, 18 mo.) Organization (annually) EWC (ongoing)
NHLBI WAY Research Questions MAIN RESEARCH QUESTIONS: Phase 1: To what extent can each campus organize an Employee Wellness Committee and do strategic planning to plan, implement and evaluate a comprehensive worksite wellness program? Phase 2: What are the effects of the following interventions on weight loss at 3, 6, 12 and 18 months: Web-based weight loss program (WEB); Cash incentives for weight loss (CASH); WEB + CASH; or Usual Care? OTHER RESEARCH QUESTIONS: Compare participation, retention/attrition rates by intervention condition Determine sickness costs, absenteeism and productivity over time Examine the costs and cost-effectiveness of each program Investigate important variables that are associated with or modify the effects of the interventions on weight loss over time
NC Office of State Personnel Worksite Wellness Mandate (Feb 2008) Each agency head shall designate a Wellness Leader at the management level Each agency shall establish an Employee Wellness Committee infrastructure Employee Wellness Committees should elect a wellness chair or co-chairs to conduct meetings and lead activities Each agency and its EWC shall offer health programming to promote employee wellness
NHLBI WAY to Health Campus Map University of North Carolina at Asheville Winston Salem State University Forsyth Technical Community College North Carolina Agricultural and Technical State University NC Central University Nash Community College Edgecombe Community College Western Carolina University University of at North Carolina Charlotte University of North Carolina at Pembroke Fayetteville State University Coastal Carolina Community College University of North Carolina at Wilmington Carteret Community College
Phase 1: Intervention Planning SS #1: Recruit and orient/train Employee Wellness Committees to facilitate program planning, implementation and evaluation SS#2: Use strategic planning approach to develop and implement a tailored Worksite Wellness Action Plan Watch for SS = Strategy for Success
Why Employee Wellness Committees? Help tailor HPPs programs to employees and to worksites (Baker et al, 1994; Grawitch et al., 2009) Increase participation in health promotion programs (Hunt et al., 2000; Linnan et al, 2001) Worksites with a wellness committee and coordinator were more likely to have environmental supports/policies for health (Brissette, 2008) and to have a comprehensive HPP (Linnan, 2008) Employee involvement in program development can enhance program benefits (Grawitch et al, 2007) EWCs increase the likelihood of wellness program sustainability (Sorenson et al. 2004)
SS#1: Strategic Planning for Wellness Organize an Employee Wellness Committee Assess Employee Health Needs/Interests Assess Management Expectations/Interests Review Health Care Claims/Costs Inventory Existing Organizational Assets Identify Local, State, National Health Promotion Resources & Select Evidence-Based Intervention Program, Policies & Environmental Supports Develop & Implement Strategic Wellness Action Plan
Who To Recruit For Your EWC? Managers and/or decision-makers Benefits and/or HR Marketing Food service/vending Facilities Interested employee volunteers Union Consider shifts, departments, types of workers
Phase 1: EWC Research Questions RQ1: To what extent can we successfully organize Employee Wellness Committees at each campus? RQ2: How functional are the EWCs over time? Dependent Variables (e.g. function) Number of process objectives achieved at 12 & 24 mo Submission of Wellness Action Plan (24 months) (Y/N) RQ3: What are the characteristics of low and high functioning EWCs?
WAY to Health Process Objectives 1 - Identify a WAY to Health EWC contact person 2 - Identify a WAY to Health EWC chair (or co-chairs) 3 - Create a committee 4 - EWC meets at least ten times per year 5 - Active EWC membership 6 - Conduct an inventory of campus-based resources for wellness 7 - Conduct an inventory of local/community resources for wellness 8 - Identify top 5 health care claims for chronic conditions and overall healthcare costs 9 - Conduct key stakeholder assessment on campus (WAY to complete) 10 - Assess employee needs, interests, and expectations for worksite wellness 11 - Draft an Action Plan for worksite wellness incorporating results from campus assessments 12 - Get 1 st year Action Plan approved for implementation 13 Action Plan is implemented 14 Overall marketing plan is implemented 15 Overall evaluation plan is implemented 16 2 nd year Action Plan is approved for implementation
Number of Meetings Held by Campus Total Meetings 20 18 16 14 12 10 8 6 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Campus 6 Months 12 Months 18 Months 24 Months
Getting EWCs Organized WAY Contact identified by 6 mo 100% of campuses EWC Chair identified 86% of campuses completed at 6 mo and 100% by 12 mo EWC organized 79% of campuses completed at 6 mo, 93% at 12 mo, 100% by 18 mo EWC Meetings & Attendance Ave # of meetings held per campus 6 mo = 2.4; 12 mo = 5.6; 18 mo = 8.7; 24 mo = 12.5 At least 50% attendance at EWC mtgs 12 mo = 50%; 18 mo = 50%
Results % of Campuses That Met Key Process Objectives Over Time Key Process Objectives Met Over Time 6 mo 12 mo 18 mo 24 mo Identify EWC Chair 86% 100% 100% 100% Create an EWC Committee 79% 93% 100% 100% EWC Meets 10/times per year n/a 7% n/a 0% Conduct Campus Inventory 57% 71% 86% 93% Conduct Local Community Inventory 14% 50% 57% 71% Assess Employee Interests 14% 79% 79% 93% Review Key Health Care Claims 57% 100% 100% 100% Draft Wellness Action Plan 0% 0% 0% 43% Get Wellness Action Plan Approved 0% 0% 0% 29% % of ALL Process Objectives Met 56% 63% 63% 81%
EWC Functioning Based on % of PO Achieved at 12 and 24 months % Process Objectives Achieved 100 90 80 70 60 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Campus 12 Months 24 Months
High Functioning EWC Community college located in rural part of state Small campus 8 buildings and 202 permanent employees Campus contact is also the HR Director. She is easily reachable, dedicated to wellness on campus, and is able to communicate with all staff. Administration believes it is extremely important to offer employees HPPs More than 20 individuals initially volunteered to serve on the EWC The EWC is comprised of employees from various departments and levels EWC actively looks for additional funds from mini-grants (campus foundation) Campus culture is very collaborative with strong communication at all levels Exercise room on campus that is available to all employees for free Cafeteria Manager is very dedicated to health and wellness and is an active member of the EWC The EWC has incorporated local resources into their Action Plan
RESULTS Summary EWC function as measured by # of Process Objectives Achieved Slow but steady progress observed over 6 (56%), 12 (63%), 18 (63%) and 24 mo (81%) At 12 months -- # EWC mtgs held (p=0.13) and # buildings (p=.06) were associated with achieving process objectives At 24 months -- # mtgs held (p=.02) and average attendance at meetings (p=0.10) were associated with progress No differences between HI/LO functioning sites by type of campus, EWC Chair, Chair Turnover, History of EWC or HPPs EWC function as measured by Wellness Action Plan submitted (43% or n=6/14 sites at 24 months only) Only # of meetings held (p=.003) was significantly associated with completion of Wellness Action Plan at 24 months
Implications EWCs are important for encouraging employee participation and long term effectiveness & sustainability of programs At 12 mo, the number of buildings on campus was an indicator of progress toward achieving objectives but this dissipated over time suggesting that communication efforts may bridge this gap Number of EWC meetings and average attendance at meetings was important at 24 months for achieving key process objectives consider ways to keep EWC members active/engaged At 24 mo, nearly half of campuses had completed Wellness Action Plan & only # mtgs held was sig associated with submission
SS#2: Strategic Wellness Action Plan Integrated/approved mission Measurable goals/objectives Marketing plan Evidence- based programs, policies, environmental supports campaign format? Incentives Timetable & budget Evaluation plan
Marketing Plan Do we have an overall presence (logo/branding)? Is wellness linked to the organizational mission? Who are the customers? Top management, middle management or line supervisors Employees healthy, high-risk, by age, gender, job category, by shift What channels of communication are available to reach customer groups? Managers quarterly meetings, email Employees website, bulletin boards, email, pay-stuffers
Implementing Plans With Success Management support at all levels!! See Linnan, Weiner et al, 2007, AJHP Incentives participation & outcomes Marketing plan Key elements choose evidence-based programs Educational programs Environmental support Policy support Evaluation plan process & outcomes
Phase 2: Weight Loss Study Compare the independent and combined effects of the following on weight change over 3, 6, 12, 18months: Usual Care work of the EWCs Cash Incentives Web-Based Weight Loss Program Cash + Web-Based Weight Loss Program
SS#3: Choose Evidence-based Interventions Ask: What intervention will have the most/best effect on intended outcomes? (e.g. weight?) How much dose of intervention is needed to get a desired effect? For the Phase 2 Weight Loss Study: Cash Incentives for Weight Loss Web-Based Weight Loss Program Combined Cash + Web-Based Program
Cash Incentive Payout Matrix* 3 Month Payout 6 Month Payout 12 Month Payout 18 Month Payout TOTAL Weight Gain* $10 $10 $30 $30 $80 0%-2% $15 $20 $40 $40 $115 3%-5% $25 $30 $50 $50 $155 6%-10% $40 $45 $65 $65 $215 >10% $60 $65 $85 $85 $295 *employees receive stipend just for coming back to do weigh-in and completing the surveys
Tate s research studies published in top medical journals show that her Internet-based program is effective for producing weight loss and helping people maintain weight loss Tate et al., JAMA, 2001: 285: 1172-1177; Tate, et al., JAMA, 2003; 289: 1833-1836; Tate, et al., Archives of Internal Medicine, 2006; Wing, Tate, et al., NEJM 2006
Web-based Weight Loss Program Lifestyle Change Diet and Exercise Self-monitoring Goal setting Support Delivered over Internet Convenient & Private 18 months of Ix Developed and tested in 8+ studies with proven effects by Dr. Deb Tate
Online Food Diary Keep track of your weight, diet and physical activity. Online calorie database with over 65,000 foods and beverages. Online diary where your foods and calories are stored and calculated for you. Report on the website
Weight Loss Team Participants can create or join peer support groups with up to 4-6 others Create an individualized weight loss blog to share only with team members Track progress of other team members Provide messages of feedback and support to team on private team message boards
Selecting Evidence-Based Programs Published literature Ongoing research NIH CRISP database CDC Community Guide to Preventive Services Government websites Cancer Control Planet AHRQ NCI Rtips North Carolina Prevention Partners website
Policies & Environmental Supports Healthy Eating Policy healthy catering policies, no food dumping Supports access to healthy options in cafeteria/vending Smoking Policy smoke-free; enforcement Supports discounts on NRTs Physical Activity Policy walking meetings, fitness breaks Supports walking trails, discounts on gym memberships
SS #4: Evaluation Plan Key Questions Outcome Evaluation Did employees become healthier (e.g. RFs, biomarkers)? What was the cost of the program? Did we get a return on our investment re: health care savings? Absenteeism? Presenteeism? Process Evaluation Did we implement the plan as intended? Did employees participate? Which employees participated (or did not?) Were employees satisfied with the programs? Did we meet management expectations?
Data What Do You Need? Employee Level Data Health risk data (or state estimates e.g. BRFSS) Employee focus groups Organizational Level Measurement Tools Interviews with key leadership (President, HRD, Wellness Coordinator, Facilities Mgr, Food Service/Vending Mgrs) Campus contact/logistics planning survey Environmental scans Employee Wellness Committee Survey Program/Participant Tracking Database** Health Care Costs/Claims Data
Data When Do You Need It? As critical part of the strategic planning process! During program implementation Immediately following program implementation Longer-term maintenance of effects And Immediately prior to when the organization is doing budget planning! Whenever there are questions how are we doing??
SS#5: Identify Assets & Cultivate Partnerships Employee/worksite-specific assets and strengths Do employees have special expertise to share? What does the worksite have to offer/already in place? Local community assets and strengths Local hospitals, voluntary health agencies, healthrelated businesses, YMCAs Insurance providers or health plans University partners Local farmers and other business owners
Re-Cap on Strategies for Success Organize Employee Wellness Committee Develop, implement and evaluate Wellness Plan using a strategic process Gather appropriate data and use it tell a story that demonstrates success over time process and outcome Engage all levels of management early & often Select evidence-based programs, policies, supports Include program mission, measurable objectives, marketing & evaluation plans, budget, timeline Identify & cultivate partnerships
Goal: Comprehensive & Effective (or Avoid Spray & Pray Approaches )! Integrate worksite health promotion into the mission and in all layers of the organization (e.g. safety, benefits, marketing) Move beyond individual employee health to whole worksite create health-supportive work environments! Let data drive decision-making strategic planning, revision, future directions based on results Be visible and share successes w/employees & managers Leverage opportunities within larger community (e.g. coalitions, chambers of commerce, state/local health departments, hospitals voluntary health organizations, universities)
North Carolina Institute of Medicine Recommendation 12.3: Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for Small Businesses The North Carolina General Assembly should direct the North Carolina Public Health Foundation to establish the North Carolina Worksite Wellness Collaborative to promote evidence-based strategies to support the optimal health and wellbeing of North Carolina s workforce. The collaborative should help businesses implement healthy workplace policies and benefits, implement health risk appraisals, develop comprehensive employee wellness programs, and implement data systems that track outcomes at the organizational and employee level. The North Carolina General Assembly should provide start-up funding of $800,000 in SFY 2011, with a reduced amount over the next four years, to support this collaborative. In addition, the North Carolina General Assembly should provide a tax credit to businesses with 50 or fewer employees that have implemented a comprehensive worksite wellness program for their employees.
Questions??? Laura Linnan, ScD, CHES Associate Professor UNC Gillings School of Global Public Health Phone: 919.843.8044 Email: linnan@email.unc.edu