Health promotion in the public sector: a case study from policy to practice.
|Abstract:||Employee wellness programs are popular among employers because they have the potential to lead to positive outcomes for the employees and the organization. Moving from a public policy to local implementation, or the process of 'operationalizing, 'presents a challenge within most organizations. The case study presented here provides an illustration of one public university's attempt to interpret and apply a state policy to implement a wellness program for its employees. It features a description of the policy, a description of the context in which the policy is implemented and provides observations of the challenges and successes implementing the policy, lessons learned, and future directions.|
Associations, institutions, etc. (Case studies)
Employers (Case studies)
Wellness programs (Case studies)
Physical fitness (Case studies)
Universities and colleges (Case studies)
Bibeau, Daniel L.
Evans, William Myles
Cathorall, Michelle L.
Strack, Robert W.
Mattocks, Amelia D.S.
|Publication:||Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 American Journal of Health Studies ISSN: 1090-0500|
|Issue:||Date: Summer, 2009 Source Volume: 24 Source Issue: 3|
|Product:||Product Code: 8220000 Colleges & Universities NAICS Code: 61131 Colleges, Universities, and Professional Schools SIC Code: 8221 Colleges and universities|
|Organization:||Organization: University of North Carolina at Greensboro|
HEALTH PROMOTION IN THE PUBLIC SECTOR: A CASE STUDY FROM POLICY TO
Employee wellness programs are popular among employers because they have the potential to lead to positive outcomes for employees and the organization (e.g. Goetzel & Ozminkowski 2008, Goetzel, Schecter, Ozminkowski, et al 2007, Chapman 2005). In the private sector, it is a matter of executives or business owners buying into the notion that health promotion is something that will benefit their company's bottom line and their employees. For example, employers hope that health promotion programs will help them reduce health care costs by improving the health of employees, and in some cases families, as a way to maintain their commitment to providing health care coverage.
Public organizations face some different obstacles than private companies in implementing health promotion programs, even though the same economic pressures are at work. For instance, the use of tax money for health promotion programs may not always be seen as a high priority use of State funds. Each public institution has health care costs borne by the taxpayer, who could accrue the same reduction in health care costs realized by the private sector. Thus more public entities are looking to offer health promotion programs for employees. This case study provides an illustration of one public university's implementation of a state policy requiring an employee wellness program. It features a description of the policy, a description of the context in which the policy was implemented at the University of North Carolina at Greensboro (UNCG), observations of the challenges and successes implementing the policy, lessons learned, and future directions.
DESCRIPTION OF THE POLICY
On March 3, 2008, the North Carolina Office of State Personnel (OSP) sent a letter to all state agencies (e.g. Dept. of Revenue, Department of Justice) and university heads announcing a worksite wellness policy that had become effective February 1, 2008 (North Carolina State Office of Personnel, 2008). The policy required that all state agencies and universities offer health promotion programs for state employees. The details of the creation and rollout of this policy are beyond the scope of this paper, but a few points must be included as a frame of reference.
The elements of the policy can be seen in Figure 1. The Worksite Wellness Policy establishes the foundation for state agencies and universities to create programs, specifying that each agency or university head has the responsibility to create and participate in a program in partnership with the OSP and the North Carolina Department of Health and Human Services' Division of Public Health (DPH). The programs are to focus on healthy lifestyles, work environments, and polices that may impact the health of employees. The OSP, DPH, State Health Plan (SHP), and other government partners are to assist agencies and universities in developing the programs. In support of the policy, the OSP issued a set of policy guidelines to help agency heads, wellness leaders, and wellness committees implement the programs (see Figure 2). The State also supplied online resources for wellness leaders and committees of each agency or university.
The State did not leave it up to each agency and university to implement the policy alone. First, the OSP created the Health Benefits Collaboration Team (HBCT) to provide guidance for the implementation of the policy statewide. Under the direction of the HBCT, the Worksite Wellness Policy Advisory Team (PAT) was appointed to operationalize the policy by:
1. developing guidelines, resources, communication plans, implementation strategies, and evaluation measures for the OSP Worksite Wellness Policy;
2. providing training to wellness leaders on the policy;
3. assisting OSP in monitoring implementation of the policy in agencies and universities; and
4. identifying organizational members, organize, staff, and, provide oversight to policy implementation.
The PAT created Guideline Development, Training, and Evaluation subcommittees to accomplish its work. The first action was to develop a set of advisory notes for the policy to guide wellness leaders in policy implementation. To guide its work, the PAT is using a goal that focuses on the outcome of better health for employees resulting in reduced absenteeism, disability, and health care costs while increasing productivity and improving the quality of life for employees.
Each state agency and university head was asked to announce the policy to their employees and designate a Wellness Leader (Leader). The letter stated that the wellness leaders would receive guidelines and training for their roles. The training, done by a person from DPH was also intended for the agency and university heads to help everyone understand what it takes to implement an effective program.
With the policy and resources in place, the agencies and universities were poised to carry out the assignment. We will now focus on the challenges and accomplishments of UNCG in policy implementation.
The University of North Carolina at Greensboro is one of 16 institutions in the University of North Carolina System. The Carnegie Foundation for the Advancement of Teaching has classified UNCG as a research university with "high research activity." The University's enrollment in the fall term of 2009 was about 18,600 students, including approximately 3,800 graduate students. The university employs roughly 2,500 faculty and staff personnel.
During the 2008-09 academic year, the University was in the midst of developing its five-year strategic plan. The University's plan was being developed with an eye toward UNC Tomorrow, a report from the University of North Carolina General Administration that specified the foci expected of higher education institutions in the State. Health and Wellness was one of the five focus areas in the UNCG plan, which aligned with the foci of UNC Tomorrow. Thus, it was premature to make decisions about the Worksite Wellness program until the plan was finalized because it was still unknown to what extent resources would be allocated for this focus area. The planning process took the better part of the academic year and did include a goal related to the health and wellbeing of university employees.
Like other states during the 2008-09 budget year, North Carolina experienced serious budget shortfalls. Not only were tax revenues behind schedule, but also the State Health Plan (SHP) had taken losses in the hundreds of millions of dollars. Changes were made to the health plan that would affect all covered employees. In a speech to the UNC Board of Governors, the head of the SHP outlined several steps taken to deal with the shortfall, concluding with a call for health promotion to be the major long-range strategy to lower costs in the future. With the budget crisis, each agency and university was taking a budget cut during the 2008-09 fiscal year with projections for further cuts for the 201011 fiscal year. As a result of the budget shortfalls, the University budget included cuts to personnel and the operating budget. The context above provides a framework for discussing the implementation of the policy at the University.
The University moved toward implementation of a worksite health promotion program after the Chancellor received the letter from OSP in early March 2008. The Chancellor appointed a faculty member from the Department of Public Health Education (PHE) to the position of Wellness Leader in late March 2008. This appointment occurred very late in the budget year when all segments of the University were spending down their budgets, with no allocation for the program. At the time, the University was in the middle of a search for a new Chancellor. In addition, the current Chancellor was on medical leave diverting her attention from many University issues, including the startup of the health promotion program. Due to the Chancellor's leave, the Provost, an ardent supporter of the University's engagement in health promotion, had little time to devote to the new effort. The Leader and Provost held two meetings where they discussed the timing and scope of the program. Because of the University's academic year schedule, and the fact that a new Chancellor would be coming, the Leader and Provost determined that implementation would need to wait until the beginning of the fall term. In addition, the Provost supported the notion that the scope of the program would be more than educational or raising health awareness and would include foci on risk reduction and disease management and that the program should be integrated with the teaching, scholarship, and service activities of the University.
To get the program underway, the Leader, a doctoral student and a faculty member, all from the Department of Public Health Education formed a program Leadership Committee (LC). This committee would be responsible for providing leadership for the program as well as carrying out day-to-day operations. The LC met weekly to report on work done and to give new work assignments for the following week. Eventually the LC grew to include graduate students from PHE and an administrative staff person from the business school. This combination of perspectives led to interesting dialogues in the planning process and proved useful in operations because graduate students were able to develop practical experiences outside the classroom and research the literature for best practices in university settings. The administrative staff person, who was also a member of the Staff Senate, acted as the Advisory Committee (AC) chair and served as a pulse for what types of wellness activities were being offered on campus by community health organizations. The Leader and faculty member guided the committee toward program planning.
Initial tasks of the LC included a literature review of successful programs and gathering information from university wellness programs in the Southeastern part of the U.S. to answer the following questions:
1. What is their budget?
2. How many people does the campus wellness program employ?
3. Which department on campus houses the wellness program?
4. Do they have a web site?
5. What are their wellness activities for employees?
6. What are their goals?
7. What measurements do they have in place to deem the program successful?
For communication purposes, the LC created a centralized intranet site using Blackboard space for the LC and the AC. Several papers were posted on worksite health promotion in an attempt to get everyone on the AC to a baseline understanding of the scope of worksite health promotion. The space included meeting minutes, worksite health promotion newsletters from the State, a wellness committee toolkit, and other documents. Using the Blackboard space allowed communication by any member of the committees with all others and has the potential to be used for discussions or to serve as a meeting facilitation space.
The fall 2008 term welcomed a new Chancellor to the university and the continued development of the five-year strategic plan. The Chancellor decided to delay announcement of the program in her startup address to employees, wanting the strategic planning process to conclude first. Thus, the Leader sought to use the fall term as one of program infrastructure development. In compliance with the policy, a campus-wide Advisory Committee representing the diverse perspectives and departments needed to be appointed in order to gain support across the university. Administrative and academic units on campus were asked to identify people who were respected by their peers and who had an interest in wellness to serve on the program's AC. Once identified, these people were invited to join the committee.
An initial meeting of the AC was held to introduce the policy, review the charge to the committee from the policy, and examine the elements of effective programs. The AC discussed how to carry out its charge. The AC struggled to define its role, the focus and scope of the program, and how to move forward, mainly because most committee members had little background in health promotion. There was uncertainty about how much university administrators supported the initiative, given that there were only volunteers participating in and leading the effort and there was no budget. Still, the AC was engaged in looking at different options for implementing program activities.
The Leader was reluctant to commit too much in the way of marketing the program due to the shortage of resources and the potential to not meet the needs or demands of employees. The Leader did not want to set employee expectations and then fail to deliver, thus losing the trust of employees in the program. In this situation, the AC decided to seek out free services available in the community and to build a more solid infrastructure for the future. As an example, the committee chair contacted the American Heart Association, which provided free marketing and educational materials for a blood pressure screening on campus. The campus health center provided nursing staff to take attendees' blood pressures and students in the Department of Public Health Education provided educational services for the screening. The newly elected chair of the committee, who is also a member of the university Staff Senate, had recently created a community health resource guide for the Senate and extended that guide for the purposes of the AC.
Members of the AC also were assigned to find programs or services on campus already available to employees. As suspected, several activities currently existed, but there were no coordination efforts in the campus community. Also, there was no one "brand" that communications flowed through to promote the activities and there were often duplicate activities sponsored by different departments.
As a way of summarizing the work of the AC for the year, meeting agendas for the committee and outcomes from the meetings are described below:
Meeting 1: September 23, 2008
b. Review of the state policy
c. Review of committee roles
d. Committee chair
e. Key elements of worksite health promotion
f. Overview of an ecological approach
g. Setting meeting frequency
The committee spent time getting to know who the members were, including their work units. There was a presentation about the state policy and the role of the committee in the implementation of the policy. A call was issued for volunteers to run for election as chair of the committee. There were presentations about the elements of successful worksite health promotion programs and how UNCG would use an ecological approach to develop its program. The committee decided to meet twice per academic term.
Meeting 2: November 17, 2008
a. fining our charge
b. Organizing the committee
c. Resource audit discussion
Committee members felt ambivalent about how much they could influence the health outcomes of employees because there was no commitment to a budget and no paid employees to oversee the program. The members agreed to find free or inexpensive local health promotion services and compile them in a resource manual. It was decided that subcommittees were not necessary at this time and once an assessment was made of available resources, subcommittees could be chartered. Members volunteered to develop a list of current campus resources and a centralized intranet site was to be developed for communications and information sharing in the future.
Meeting 3: February 23, 2009
a. Planning the "Go Red" Event
b. UNCG Employee Survey Results
c. State Health Plan Financial Overview
d. Develop a Mission Statement
Information about the "Go Red" employee activity for heart screening was discussed. The UNCG employee health interest survey results were shared. Most respondents wanted access to indoor fitness equipment and healthy food options. Respondents said that "time" was an issue during lunch and breaks to get enough exercise and participate in activities. Employees said it was best to send information through email, although a committee member expressed concern that her hourly employees did not always have access to a computer. The financial problems of the state health plan were discussed as a factor now driving the state policy mandate. The committee agreed on the following mission statement:
The committee's charge is to guide and oversee a UNCG wellness program that supports healthy lifestyles through social, mental and physical well-being of state employees. In addition to the benefits for employees, positive benefits are likely to accrue to families of employees. (Meeting 3 Minutes, 2009 pp. 4)
The LC agreed to draft an initial program plan based on the toolkit offered by the State Health Plan for review at the next meeting.
Meeting 4: April 27, 2009
a. Reports on assessment activities
b. Report on plans to gain new resources
c. Scope of work for next year
Reports were made about the results of the different health and risk assessments undertaken January through April 2009. A presentation to be delivered to the Chancellor asking for resources for the program for the academic year 2009-10 was reviewed. Finally, the committee held a short discussion of a reasonable scope of work for the 2009-10 academic year based on various resource scenarios.
During the 2008-09 academic year, the program undertook needs assessment and program delivery activities. Each is discussed below.
During October 2008 the SHP disseminated an online statewide survey through the appointed wellness leaders to all employees at their workplaces. The survey sought input from employees about their health interests, concerns, and conditions surrounding participation in program activities. The Chancellor sent out an email to employees asking them to complete the survey and announced that a university-wide committee would be formed to guide the UNCG program. More than 50% of UNCG employees responded to the survey. The questionnaire asked employees about the following:
* interest in learning about various health topics,
* communication channel preferences,
* program activity participation preferences,
* participation in any programs at work over the past 12 months,
* barriers to participation,
* use of the State Health Plan wellness resources,
* participation time preferences,
* willingness to pay for services, and
* their work environments.
HEALTH PROMOTION EVENTS
Since the LC and AC had no budget, they used free resources to deliver two health promotion events. These events were "Go Red," a blood pressure screening (cosponsored with student health center and the School of Nursing) and a hearing screening (delivered by and cosponsored with the Department of Communication Sciences and Disorders). Other units on campus developed events in support of the program. The library held a stair climbing challenge for students and employees. The Office of Human Resources offered a Weight Watchers[R] program to employees at the employees' expense. Stress management workshops were held by the psychology clinic, part of the Psychology Department. Again, the LC did not want to move too fast in terms of events until the future of the program was more secure.
NEEDS AND RESOURCE ASSESSMENT
The LC initiated a variety of needs assessment activities. One source of data was obtained via the statewide survey mentioned above. The LC also obtained and analyzed data from the State Health Plan about UNCG employees' medical care claims data. Unfortunately, the data were grouped in such large categories as to be of little use. In addition, the data did not distinguish between utilization by employees and their dependents. Because UNCG is a large employer, the LC used the website of the State Center for Health Statistics to obtain and analyze state level data to predict the types of health promotion and disease prevention programs that may benefit employees. Although, statewide data are not perfectly translated to a specific local setting, they did give some insight and direction.
The LC reviewed the literature on the effectiveness of worksite health promotion programs to determine what types of efforts would be most likely to lead to the outcomes desired by the State and the AC. The LC then used this information to prepare presentations for resources and to make plans for program activities.
The AC and LC assessed the resources available to the program. Committee members identified resources on campus, in the local community, and those available online. The chair of the AC prepared a resource guide to be used by any employee or in program planning. The LC began a process to determine how UNCG might fill in service and product gaps among the resources through internal means.
The MPH students conducted a final form of assessment. One student developed and implemented an online survey of UNCG staff members focusing on diabetes and pre-diabetes. Two students worked together to perform an organizational analysis by asking employees what they knew about health-related facilities, services, and policies at UNCG (Fisher & Golaszewski, 2008). One of the students used a health risk appraisal (HRA) with a small number of employees to assess and interpret their health risks, and to help the LC and AC plan program activities. The diabetes survey was distributed via email through the Staff Senate contact list. These contacts were to encourage staff employees in their work areas to complete the survey. In all, 236 employees responded. The data will allow the LC to target some diabetes education and support activities during the 2009-10 year. The organizational analysis had too few responses to be useful, and the LC will try another method for conducting this assessment in the coming year. Further discussion of the HRA is found below in the section about student involvement.
As stated before, the 2008-09 academic year was used mainly for organizing the committees, gathering some initial data, and conducting a few events. The Leader saw the year as one of development and was not willing to go too far with so few resources. The LC spent a good part of the year developing the foundation for a resource request. The LC drafted a proposal to send to the Chancellor that set forth the structure, function, and financial support needed for a successful employee health promotion program at UNCG. To develop the proposal the LC obtained programmatic, structural, and budget information from other university-based programs, including some in the UNC System. Before the proposal was completed, the Leader was asked by the Chancellor to make a presentation to the University Executive Committee (the Chancellor, all Vice Chancellors, and the Athletic Director). In the presentation on March 30, 2009, the Leader laid out what had been accomplished in the past year, the direction the program should take to have an expected health effect for employees, and the resources needed to carry out this program. The Leader covered the links between the program and the UNCG Strategic Plan and UNC Tomorrow directions, levels of programming and their effectiveness, organizing options, timeframes and potential activities, and options for health care cost containment. No resource decisions regarding the program were made at this meeting.
During July 2009, the Leader was asked to meet with the Chancellor and Provost to discuss the program options further. In preparation, the Leader provided two documents that gave different perspectives on how to proceed. One document reviewed and updated the information delivered to the Executive Committee; the other was a table that focused on a four-category framework around which the program could be organized: infrastructure, educational programs, services, and policies.
Infrastructure included items such as organizational buy-in by the Chancellor, Deans and Department Heads, and Supervisors, personnel including a fulltime director and graduate assistant support, an operating budget, and communication vehicles such as a website. The original Leadership and Advisory committees would continue to oversee and guide the program. As part of the infrastructure, a new committee would be formalized to integrate the teaching, research, and service missions of the University into the program. With the blessing of the Chancellor, this committee would be made up of faculty members from departments that had some health promotion focus. This committee would also establish a data system for program evaluation and planning (including the HRA data), oversee Institutional Review Board approval for using the data from the program, and encourage faculty and students to contribute their knowledge and skills to the program. Compliance with HIPPA regulations would have to be put in place and overseen by the designated personnel in the university.
The educational programs would have to focus on the four state priorities of healthy eating, physical activity, smoking cessation, and stress reduction. However, the foci would also include programs to address the HRA results, health services consumerism, work ergonomics, conflict resolution, a variety of programs based on the results of the statewide survey, and others as needed.
Although services offered by the program would include activities that could be partially educational, education is not the primary focus. Examples of potential services that could be offered include:
* a telephone advice line,
* smoking cessation advice and self help materials,
* disease management strategies,
* health risk appraisal with interpretation and follow-up,
* environmental scans/audits, safety and ergonomic programs from the Safety Office,
* an employee assistance program,
* counseling services in the Psychology and Counseling and Educational Development Departments,
* health coaching from a variety of departments,
* health activity programs and services (e.g. walking trails and clubs, social support teams, fitness assessments and prescriptions, etc.), and
* healthy food options
Finally, the Chancellor needed to understand the policy foci of the program, since policies can be seen as one type of program resource. The most obvious example could be the need for a policy regarding time for employee participation in program activities that is congruent with the state policy. Since the university hopes to use internal expertise for programs, it would have to be determined to what extent employees with expertise could be offered supplemental compensation for their time, especially if their work was outside normal work hours. As a final example, there would need to be policies to clarify ownership and uses of products developed by faculty, students, and staff for the program, especially since such products could have a market value beyond the institution.
After going over the scope of infrastructure, educational programs, services, and policy, a budget was presented by the Leader. Due to the budget cuts already known and those yet to be determined, the Chancellor decided a program director could not be hired. Thus the program would have to function using the time of the two faculty members with the support of two graduate students and a small operating budget targeted to conducting health risk assessments with employees as a means for planning future policy, educational, and service interventions.
Three MPH students joined the LC during the 2008 fall term to plan their internships that would be part of the UNCG health promotion program. In addition, the students reviewed literature on worksite health promotion, gathered information from other universities about their programs, and worked on a proposal for the Chancellor and Provost. The students spent a good deal of time locating and processing literature on program elements necessary for a positive return on investment, including disease management activities that produce positive health outcomes. They met each week as part of the LC and as a result, had the opportunity to learn many aspects of bringing a health promotion program to life in a workplace. One student went above and beyond and became a leader in the effort by engaging in a variety of duties beyond what was assigned and as a result, this person had an even richer learning experience. The project of this student will be highlighted as an example of how combining our teaching and learning, service, and research activities can have a meaningful impact on employees.
Later as interns, these three students took on a specific focus for their internship, which included assessment and program recommendations. One intern focused on diabetes and surveyed staff members about diabetes and pre-diabetes. Two hundred thirty-six staff members responded to the survey and most of them included contact information for follow-up. One MPH student used a health risk assessment (HRA) which assessed family history of chronic disease, current symptoms, eating habits, physical activity, substance use, safety practices, emotional health, and health views. The HRA is based on guidelines and research from government agencies (NIH, CDC) and professional organizations (American Heart Association, American College of Sports Medicine, American Diabetes Association). Readiness to change behaviors was measured using questions based on the Stages of Change Model. To garner support for this initiative, a presentation on the benefits of HRAs was made to the director and supervisors in an administrative department. Management personnel indicated their support of the initiative, notified their staff and provided them with time to participate.
Four sessions were held for employees to complete the HRA. The leadership sought volunteers from the School of Nursing to take blood pressure, height and weight. The Nutrition Department made food models available to facilitate the completion of the section on food intake. A weighing scale was borrowed from the Department of Kinesiology. Volunteer readers were on hand to assist individual HRA participants. After analyzing the responses, four sessions were held to assist employees in interpreting the results. In these sessions employees had a printout of their results and were free to ask questions at any time. Employees were given a telephone number they could call later to ask for more information or get further advice. Based on the interaction during the interpretations sessions, the employees indicated they would respond favorably to health promotion initiatives. A final group report was delivered to the department (no individual data).
Using the HRA was labor intensive. Even though there were between 4-6 volunteers for each session of 25 people, more assistance was needed. Several participants required that the entire form be read to them. The HRA itself was written at above a 10th grade reading level based on a common reading level assessment. For two participants, English was not their primary language and were unable to participate because there were no appropriate interpreters. Also, equipment had to be borrowed from several different departments adding to the preparation and end time for each session.
MOVING FROM POLICY TO PRACTICE: CHALLENGES
As with any worksite health promotion program, events happen that are unexpected. Invariably, when people are volunteering, policies, objectives, strategies and activities are interpreted in different ways. Below is a categorization and discussion of a list of challenges that were faced in developing the UNCG program to date.
The LC faced several challenges in bringing the program to life at the university. The first challenge was to interpret the policy and understand how it could be implemented at UNCG. Part of this challenge was made easier by the PAT, which added several advisory notes to the policy to guide implementation. These were not finalized until November 2008; eight months after the original policy took effect.
It became apparent early that people interested in "wellness" are not necessarily experts at developing worksite wellness programs. There was a challenge in educating the two committees about the process of developing effective programs versus exclusively coordinating activities like health fairs and deeming the program successful by the number of people screened at an event. Sometimes developing a wellness program by committee is much harder than it might appear on paper because well intended people want to organize activities, yet assessment of the employee population should occur before planning interventions. Interventions should not necessarily be wellness events for employees, but rather a combination of best practices in primary, secondary and even tertiary prevention strategies. While a quick offering of activities may be popular among employees, they may or may not work to improve health or risk status. There were several members of the AC who saw the program as a set of activities such as screenings and didactic educational programs, regardless of their reach or effectiveness. Those members with health profession backgrounds favored assessing the population to guide program development and the types of activities that could affect employees' health status. This difference in views was not initially anticipated. However, it did guide the committees toward a few compromises. The AC and LC decided they needed to communicate with employees that the program was doing something, so to give visibility to the work of the committee, a few activities such as the blood pressure and hearing screenings were held. During the spring term of 2009, the interns from Public Health Education carried out risk assessments of some employees and employees' perceptions of the health-related resources available at UNCG. Each of these projects could be done because they did not require new funds.
Another challenge in the program implementation was effective communication. While the LC recruited members from across the various university divisions, it was difficult to communicate well with all members. The preferred method of communication was electronic, mainly via email. This proved to be challenging because even though every employee has an email account, not all have access to computers routinely in their jobs. Thus it was difficult to include these committee members in electronic discussions, to send them updates about program developments, and to communicate with them about scheduling and holding committee meetings. This led to problems with meeting attendance and compliance with the policy in terms of having broad representation of the workforce on the committee. Even though there were message systems in place to use telephonic communications, these did not always work for the committee's purposes due to the lag time between the call being placed and when people actually received their messages. This made time sensitive communication difficult. The access to computers exacerbated problems of information sharing and education of committee members in other ways. For example, a Blackboard* organization was created for the committee, but some members could not access this site at work. The greatest effect of this communication challenge was everyone not being equally informed about the work of the committee, or being at the same level of understanding about worksite health promotion.
The third challenge was insufficient staff and budget tasked to mount a significant program that could lead to the desired goal of reducing absenteeism, disability, and health care costs for employers and employees while increasing productivity and improving the quality of life for employees. As stated before, there were reasons for this challenge, which included hiring a new chancellor, the strategic planning process, and the shortfalls in the state budget. During the 2008-09 academic year, the Provost allocated money to reduce the Leader's teaching load by two courses in order to allow part of his time to be devoted to the program. The Leader still had teaching, advising, research, and service duties. The other staff members were the graduate assistant and the volunteer faculty member from Public Health Education. In terms of operating budget, there was none. The policy states that free or discounted resources should be used and that State agencies and the legislature can provide fiscal support for the committees and activities. In addition, all agencies and universities are encouraged to use resources within State government. Since most of the States resources are located 75 miles away in the capital city of Raleigh, this was not a logical option for significant program support. Beyond that, any activities sponsored by the AC used current University resources supported by some free resources available in the community.
During the first full academic year (2008-09) some committee members were either too busy to participate, or their interest waned, and thus the AC had to be reconstituted. As a result, new committee members had to be oriented to the charge, work performed, and accomplishments to date. Some of the new committee members were recruited for their expertise and others for their reach with colleagues. While getting new members up to speed with the others was a challenge, some of the new members brought new vigor to the committee's functioning and vision, which helped energize the other members.
As one can see, there were many challenges. Some of the challenges were more difficult to manage than others, and some were out of the authors' control, such as the State mandates and budget crisis. From the challenges, several lessons were learned which are described below.
The first step in having adequate resources is recruiting financial and other support. It is imperative to layout the scope of the program early in the process so a case can be made for support. This helps the administration commit the resources needed to accomplish the program's goals. The timing of this policy for UNCG and the State was unfortunate. Still, many agencies and universities could use State resources to get their programs started. At UNCG it was not until the fall term of 2009 that the administration could support the program. In fall, supported by the Chancellor and Provost, the program has an operating budget of $10,000 and two graduate assistants. Most of the budget resources will go toward assessment using a health risk appraisal. The AC continues to look for free or discounted resources locally, and has been successful in obtaining some free materials and programs.
Based on experiences to date, it is believed that the program needs a full time person to lead and manage the effort. According to the policy, the Leader is responsible for creating a worksite wellness infrastructure, overseeing the development and implementation of employee wellness policies and committees, and providing ongoing assessment/ monitoring of the effectiveness of the program. Right now part of a faculty member's time is spent as the Leader. The Leader's job duties are too varied to be successful in this role part time. In addition, it is probable that a full time leader will still need the graduate assistants to have enough personnel time to be effective in meeting the goals of the institution as they pertain to employee wellness. One strategy for resource development is to continually promote the program and its successes to garner resources and win champions. Segments of the university are more likely to put resources into the program if they are aware of it and think it is making a difference.
ADHERING TO THE POLICY
State policies cover most contingencies, but some latitude exists in how the policies are implemented in each site. The training of the wellness leaders in the agencies and universities included strategies to develop and implement programs that met the policy guidelines. In other words, it was shown that there are multiple ways to plan program development and delivery. Each institution could make adjustments to fit its particular needs and modes of operation, while still following the policy and adhering to state personnel policies.
DO NOT RUSH
It takes time to do things well. In building its program, UNCG started with no resources. The Committees had to find a balance between providing activities and services to be visible and doing adequate assessment and planning to be effective. By taking a longer view in program development, the Committees are targeting some early visible activity while doing assessment and planning for more focused programming in the future.
Multiple channels of communication will have to be found and used to reach the whole workforce. Even though UNCG is one site, people are spread across many buildings, working in several different environments. Program leaders need to appreciate the diversity of employees and how their jobs and responsibilities vary. Broad-brush programs are challenged to reach those groups of workers who may be the workers with the greatest health disparities. The disparities are often found among populations, which include those of lower income, people of color, and those with literacy and language barriers. Paying attention to the communication challenge puts any program on track to address one of the major Healthy People 2010 goals for the nation, eliminating health disparities (U.S. Department of Health and Human Services, 2000).
Worksite health promotion programs in universities can have as part of their mission the value of supporting the teaching, research, and service missions of the institution. The program to date has contributed to the university mission by involving students in internship and volunteer learning experiences. In terms of teaching, there have been MPH and Nursing students as interns and volunteers who have been able to apply their professional skills and knowledge through participation in the program. It was an opportunity for them to carry out professional responsibilities and obtain feedback about their performance. Students and faculty members worked together to develop data collection protocols for health-related assessments of employees. It has become clear that health promotion programs offer faculty and students opportunities to engage in teaching/learning, research, and service. There will be efforts to develop such links more formally and extensively over the next year of operation at UNCG.
This paper has presented the efforts of one university to implement a new state policy requiring that health promotion programs be offered to employees. The policy was reviewed and several implementation decisions and actions were recounted. The challenges faced in implementation were many, but they did not deter the effort to get some elements of a program in place. The lessons learned are not novel in worksite health promotion to this situation, but the experiences here may help others succeed.
If there is one overarching lesson here it is that policies must be implemented to have an effect. Policies have embedded hypotheses about how the end goal is to be achieved (Longest, 2006). Those overseeing this policy have some expectation of a positive result from the policy being established. In this case, the goal specified by the Policy Advisory Team stated earlier suggests that the outcomes (e.g. lower health care costs, lower absenteeism) can be achieved through implementation of this policy. However, there are always challenges inherent in bringing any worksite health promotion policy to life given institutional resources, culture and commitment.
In this case, there are challenges at multiple levels. First, there is the state level where the policy had to be developed and put in place. At this level few new resources were committed to the policy relative to its significant goal. The second level of implementation occurs at the agency and university level, as in the case presented in this paper. Due to budget and other constraints, the program struggled to mount any effort that could be considered best practice during its first year. Thus at all levels, there seems to be a challenge in meeting the intent of the policy in ways that can achieve the goal. That does not mean that the policy is inherently flawed; it is often the case that policies and laws do not specify the exact nature of solutions, and they sometimes have vague or conflicting elements in their wording (Longest, 2006). Thus, there is a continued need to study best processes for implementing worksite health promotion policies. UNCG will continue to refine its approach for translating a state-wide policy within the constraints of existing resources, and will be ready to share what is learned.
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Longest, B. B. (2006). Health Policymaking in the United States, 4th edition. Health Administration Press, Chicago, IL/AUPHA Press, Washington, DC.
North Carolina State Office of Personnel (2008). OSP Worksite Wellness Policy. Raleigh.
Meeting 3 Minutes (2009). Unpublished Meeting Minutes. UNCG Employee Health Promotion Advisory Committee.
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Daniel L. Bibeau, PhD
William Myles Evans, MPH, CHES
Michelle L. Cathorall, MPH, CHES
Eileen Miller, MPH
Robert W. Strack, PhD, MBA
Amelia D. S. Mattocks, BS, BA
Daniel L. Bibeau, is a Professor of Department of Public Health Education, The University of North Carolina at Greensboro. Correspondence concerning this article should be sent to: Daniel L. Bibeau, 437 HHP Building, Greensboro, NC 27402, Phone: (336) 334-3240, Fax: (336) 334-3238, Email: bibeau@ uncg.edu
Figure 1: Worksite Wellness Policy STATE PERSONNEL MANUAL Work Environment and Health Section 8, Page 45 October 1, 2008 Worksite Wellness Policy Purpose The Worksite Wellness Policy provides the foundation for state entities to develop activities and modify work environments and policies to support the health and well-being of state employees. In addition to the benefits for employees, positive benefits are likely to accrue to families of employees, resulting in better health for families and the community. Policy In partnership with the Office of State Personnel (OSP) and the NC Department of Health and Human Services' Division of Public Health (DPH)each agency head has the responsibility to create and participate in a Worksite Wellness program within his or her own agency or university. The Worksite Wellness initiatives shall address the primary components of a healthy lifestyle including healthy eating, physical activity, tobacco use cessation, and stress management. The State Health Plan for Teachers and State Employees (SHP) and DPH have developed a Worksite Wellness model to assist agencies in the establishment of their programs. Administration Advisory Role: OSP and the DPH, with assistance from the SHP and other state government partners, will guide and assist agencies in the development of a comprehensive Worksite Wellness Program for State employees. The NC HealthSmart Worksite Wellness Toolkit and Web site, available at http://wTvvv.shpnc .org will serve as a resource for administering and implementing the program. Components Wellness Leader: Each agency head shall designate a Wellness Leader at the management level who has direct access to the agency head. In collaboration with management and employees, this person is responsible for creating a Worksite Wellness infrastructure overseeing the development and implementation of employee wellness policies and committees, and providing ongoing assessment/ monitoring of the effectiveness of Worksite Wellness Programs. Components Wellness Committees: Each agency shall establish a (continued) wellness committee infrastructure. A wellness committee is a team of employees that meet formally and have identified aims, goals, and implementation strategies to encourage healthy behaviors at the workplace, advocate for policy change, and create health-friendly work environments. A wellness committee should be comprised of employees who represent a cross section of the employee population. Multiple committees may be necessary depending on the size and number of locations of the agency. Committee Chair(s) and Members Responsibilities: Committees should elect a wellness chair or co-chairs to conduct meetings and lead activities. Regarding time commitment. Committee members may need as much and implement the agency's strategic wellness plan. (As appropriate, these activities should be included in an employee's work plan.) For more information on establishing committees, organizations are encomaged to use the NC HealthSmart Worksite Wellness Toolkit found online at http://www.shpnt;.org/worksite-\vellness.html.. Revision No. 31 October 29, 2008 Figure 2: North Carolina work environment and health policy guidelines I NORTH CAROLINA WORK ENVIRONMENT AND HEALTH POLICY GUIDELINES I. Creating an Employee Worksite Wellness Infrastructure Measurable wellness program objectives Each agency encouraged to develop measurable goals within their own strategic plan Financial resources Each agency encouraged to utilize existing resources and gratis/discounted services from private sector. Additional state legislative support possible but not promised. Fund Raising Agency fund raising efforts to support local wellness efforts encouraged within established fund raising guidelines. Communication, promotion and computer access Agencies encouraged to facilitate the use of existing communication channels for employee wellness programming and promotion. Quality and Accessibility Routine monitoring encouraged to assess access to and quality of wellness programming. Wellness Leader charged with overseeing and sharing data with agency staff. Liability Issues Wellness activities should be viewed as voluntary and should take place outside of work hours, thus releasing state of injury liability. Liability release forms required of all employees participating in worksite wellness activities. II. Supporting Employee Participation in Wellness Activities Incentives Guidelines given for limiting scope and size of incentives for participation in wellness activities. Wellness-related Vendors Agencies charged with monitoring the qualifications of vendors providing wellness programming. III. Increasing Employee Levels of Physical Activity in the Workplace Agencies encouraged to utilize state owned/leased worksite space for wellness activities IV. Improving Access to Healthier Food in the Workplace Agencies encouraged to monitor and address availability of healthy food options at worksite. V. Reducing and Managing Stress in the Work Place Appropriate work breaks and annual stress and conflict management skill building activities encouraged for each agency. VI. Supporting Tobacco Cessation Each agency required to enforce state prohibition of tobacco use in state government buildings, within ranges of buildings, and in motor fleet vehicles. Agencies encouraged to use existing tobacco cessation supports and offer worksite programming.
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