Worksite health promotion: a practical strategy for obesity prevention.
Abstract: Obesity is a major public health problem with one of the at-risk groups identified as employees at worksites. Behavioral and environmental influences have played the largest role in the contribution to obesity, and have been stressed to be the greatest areas for prevention efforts. Benefits of worksite wellness programs include cost containment, reduced absenteeism, higher productivity, reduced injuries, decline in worker's compensation/disability, increased employee morale, loyalty and sense of self responsibility. The article presents ten practical steps to implementing a worksite health promotion program, and gives examples related to obesity prevention. Some of the salient lessons for obesity prevention programs in worksite settings include using a participatory approach, using theory, having comprehensive and integrated programs, including one-on-one outreach and motivation and incorporating "challenge" activities.
Subject: Cost control (Health aspects)
Wellness programs (Health aspects)
Physical fitness (Health aspects)
Obesity (Prevention)
Obesity (Health aspects)
Worker absenteeism (Health aspects)
Public health (Health aspects)
Workers (Beliefs, opinions and attitudes)
Workers (Health aspects)
Authors: Ickes, Melinda
Sharma, Manoj
Pub Date: 06/22/2009
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
Topic: Canadian Subject Form: Absenteeism (Labour) Computer Subject: Cost reduction
Product: Product Code: 9915140 Cost Control Techniques; 9918630 Absenteeism; 9918660 Unauthorized Leave; 8000120 Public Health Care; 9005200 Health Programs-Total Govt; 9105200 Health Programs NAICS Code: 62 Health Care and Social Assistance; 923 Administration of Human Resource Programs; 92312 Administration of Public Health Programs
Organization: Government Agency: United States. Department of Health and Human Services
Accession Number: 308743743
Full Text: Introduction: Implications of Obesity

Obesity has been regarded as a significant public health threat with serious implications for the health and well-being of the population (Ogden, Flegal, Carroll, & Johnson, 2002). Globally, approximately 1.6 billion adults (age 15+) were classified as overweight and of those at least 400 million were obese (World Health Organization, 2005). The World Health Organization projects these statistics to increase, with approximately 2.3 billion adults all over the world overweight and more than 700 million obese by 2015. In the United States, obesity prevalence doubled among adults between 1980 and 2004. Over 72 million people, or over one-third of adults, were obese in 2005-2006. This included 33.3% among adult men and 33.2% among adult women (U.S. Department of Health and Human Services, 2007). The Healthy People 2010 objectives included efforts to reduce the proportion of adults who were obese to 15% (U.S. Department of Health and Human Services, 2000). Estimated obesity prevalence among U.S. adults in 2007 indicated that no state met the Healthy People 2010 objective. In fact, 30 states were 10% or more away from meeting the objective (U.S. Department of Health and Human Services, 2007), reinforcing the threat to public health (Ogden et al., 2002).

Due to these alarming rates, the physical and psychological consequences of obesity must be considered. In the United States, it is estimated that approximately 300,000 deaths annually are attributed to obesity-related conditions (U.S. Department of Health and Human Services, 2007). The U.S. Department of Health and Human Services also indicated the increased risk obesity has on a variety of physical consequences including cardiovascular disease, high blood pressure, high cholesterol, type 2 diabetes, stroke, certain types of cancer, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems. The psychological factors related to obesity, including depression and low self-esteem, cannot go unmentioned as serious implications exist.

These severe consequences magnify the importance of targeting obesity.

However, it has been considered a complex issue to address due to the numerous behavioral, environmental, and genetic contributing factors. Although genetic factors do exist, behavioral and environmental influences seem to play the largest role with the increase in obesity, and were therefore stressed to be the greatest areas for prevention efforts (U.S. Department of Health and Human Services, 2007). Behavioral factors include dietary patterns, sedentary behaviors, and participation in physical activity. Environmental factors include access to quality foods, the infrastructure to participate in physical activity, as well as cultural norms and group influences.

Although all individuals are at-risk when considering these behavioral and environmental factors, employees who work in a variety of work-settings, particularly office jobs and manufacturing companies, have been identified as having an increased risk for obesity. There has been a high correlation between the behavioral and environmental factors known to contribute to obesity, and those behaviors common in worksites (Gates, Brehm, Hutton, Singler, & Poeppelman, 2006). Inactivity related to many of the jobs, the lack of availability of healthy food choices, and space and time related to participation in physical activity all directly correspond to an increased risk of obesity. It is important to remember that most unhealthy behavioral choices are usually the product of habit, cultural norms, time, or ignorance and therefore are appropriate targets for worksite wellness programs (The Wellness Council of America, 2006a).

OBESITY PREVENTION

Supported by the American Medical Association (Goutham, 2008), four well-recognized behaviors have the capability of offsetting the development and treatment of obesity. These behaviors include participating in at least 60 minutes of moderate to vigorous physical activity per day; limiting screen time (television, video game, and computer use) to less than two hours per day; increasing water consumption in relation to the amount of sweetened beverages consumed; and eating five or more servings of fruit and vegetables daily. Determinants of obesity considered modifiable, prevalent, and relatively easy to change should directly relate to the treatment and prevention of obesity in adults. According to the Partnership for Prevention (2001), prevention holds "the promise of improving American lives; making them longer, healthier, and more productive" (p. 1).

The role of worksites in the prevention efforts has not gone unnoticed. The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity (2001) identified the importance of individuals, families, communities, schools, organizations, government, the media, and worksites to work together to build solutions to prevent and control overweight and obesity. The prevention of weight gain and the maintenance of a healthy weight in people with a healthy weight or modest weight loss in overweight individuals tends to be easier, less expensive, and potentially more effective than the treatment of obesity after it has fully developed (Partnership for Prevention, 2001).

PURPOSE

Therefore, the purpose of this article is to present ten practical steps to implementing a worksite health promotion program, and give specific examples for obesity prevention. In addition, significant lessons for obesity prevention programs in worksite settings will be highlighted.

WHY WORKSITE WELLNESS?

Worksite wellness programs have been in existence for quite some time. In the 1970s, the occupational safety and health movement (OSH) and the worksite health promotion movement (WHP) were driving forces behind the initiation of these programs. The popularity of worksite wellness programs was also influenced by the culture change regarding fitness, the industrial health care burden, and research revealing the cost of unhealthy employee behaviors (Reardon, 1998). It was then that the approach towards health shifted to one of wellness as opposed to merely the absence of disease. The Wellness Council of America (2006a) has defined wellness as, "An intentional choice of a lifestyle characterized by personal responsibility, moderation, and maximum personal enhancement of physical, mental, emotional and spiritual health" (p. 4).

This "wellness" mentality was adopted by several workplace health promotion programs as a way to contain some of the costs associated with health care (Reardon, 1998). Health care costs have been going up more than 10% each year for several years (Rees & Finch, 2004). Employers paid an estimated 30% of the national health care bill, which was estimated to be $1.4 trillion a year. Health care costs related to obesity have been extremely high, with reports that excess weight and a sedentary lifestyle directly cost the U.S. more than $90 billion a year (Haines, Davis, Rancour, Robinson, Neel-Wilson, & Wagner, 2003). According to a U.S. Department of Health and Human Services report (2003), worksite wellness programs were shown to yield a return on investment ranging from $1.49 to $4.91 (median of $3.14) in benefits for every dollar spent on the program.

Targeting worksites has become ideal, as one-third of the U.S. population's waking hours were spent at work. Over 131 million individuals comprise the U.S. work force, with the capability of reaching an additional 55-65 million through family relationships or those who have retired (Wellness Council of America, 2006a). In addition to the time people spend at work each week, worksites were seen as primary venues for implementation of obesity prevention-related health programming due to the supportive infrastructure and encouraging social environment.

The stance on the potential impact of worksite wellness was indicated by the inclusion in Healthy People 2010 (U.S. Department of Health and Human Services, 2000). The first related objective is to increase the proportion of worksites that offer a comprehensive employee health promotion program to their employees (from 34% to 75%). As defined by Healthy People 2010, a comprehensive worksite health promotion program contains five elements: health education which focuses on skill development, behavior change, awareness building, and information dissemination; supportive social and physical environments; integration of the worksite program into the organization's structure; linkage to related programs for employees; and offering worksite screening programs to ensure follow-up and appropriate treatment as necessary. The second objective relates to worksite wellness was to increase the proportion of employees who participate in employer-sponsored health promotion activities (from 61% to 75%). Employee participation is crucial if employers are to realize the impact worksite wellness can have and thus are encouraged to develop a system to track program participation (Partnership for Prevention, 2001).

The benefits of instilling worksite wellness programs go beyond cost containment, as summarized in Table 1. The possible benefits can be seen by the employer, employee, and surrounding community (Wellness Council of America, 2006a). Implementing worksite wellness programs engages all employees, even those who do not necessarily practice disease prevention behaviors, minorities and those with lower socioeconomic status (Thompson, Smith, & Bybee, 2005). The many benefits to having healthier employees include: reduced absenteeism; higher productivity; reduced injuries; decline in worker's compensation/disability; increased employee morale, loyalty, and sense of self-responsibility (Chapman, 2003; Joslin, Lowe, & Peterson, 2006; U.S. Department of Health and Human Services, 2000; Wellness Council of America, 2005, 2006a). Overall, employees viewed wellness programs positively, and as an indication of the employer's commitment to their well-being (Young, 2006). Community perception of the employer/company was also positively influenced (Rees & Finch, 2004), and contributes to establishing good health as the norm throughout the community (Wellness Councils of America, 2006a). Thus implementing worksite wellness programs has been described as a win-win situation: healthy individuals mean healthy companies.

LESSONS LEARNED FROM WORKSITE WELLNESS PROGRAMS

Three levels of worksite wellness programs have been described: level one addresses awareness, level two concerns lifestyle change, and level three relates to the environment (Reardon, 1998; Rees & Finch, 2004). Awareness programs aide in delivering knowledge in the form of classes, posters, and health fairs without follow-up. Levels two and three aim to change behavior through knowledge dissemination and follow-up. All three levels have been implemented in varying degrees across worksites and have exhibited success. A review of the literature was conducted to gain salient lessons from several worksite wellness programs which specifically targeted nutrition and physical activity behaviors related to obesity prevention (Table 2).

A participatory approach has been successful in empowering employees, and increasing the "buy-in" of the program (Thompson, Smith & Bybee, 2005). Gates et al. (2006) used a community-based participatory research (CBPR) model to bring together individuals in academia, certified health educators, and managers from manufacturing companies to aid in planning and implementing environmental approaches to decrease obesity. According to Polacsek, O'Brien, Lagasse, and Hammar (2006), the CBPR approach involved community members as equal partners. This improved the commitment from both the employers and employees involved and was greatly associated with program sustainability (Gates et al., 2006; Kruger, Yore & Bauer, 2007).

Beyond creating commitment from the employers and employees is the importance of design and implementation of the program. The utilization of theory throughout this process has been related to programs citing successful behavior change. Theory provides a framework for effective programming strategies, and increases the likelihood of successful replication (Glanz, Rimer, & Lewis, 2002). The Diffusion of Innovations Theory was used to help design the Gates et al. (2006) worksite wellness program intending to increase healthy eating and physical activity, with the understanding that effective adoption goes beyond education dissemination." It involves a planned implementation of strategies, with attention to attributes of the system and communication about innovations" (p. 516). The use of this theory helped to focus on the needs, attitudes, and values of the target population. In turn, this was thought to increase adoption of the targeted behaviors, as well as overcome potential barriers that may prevent such adoption.

Another theory that has been widely used when addressing behavior change, particularly those related to the modifiable behaviors related to obesity, was the transtheoretical model/stage of change theory. When incorporated into a physical activity worksite wellness program, Peterson and Aldana (1999) confirmed that stage-based messages were more effective than generic messages or no information at all. In fact, the stage-based message group had a 13% increase in physical activity, and were 2.1 times more likely to move at least one stage closer to maintenance. As indicated, the use of theory aids in identifying appropriate programming strategies when designing worksite wellness programs. However, use of theory does not guarantee success. Time must be spent thoroughly developing the best approach for each worksite population.

Comprehensive and integrated worksite wellness obesity prevention programs have been recommended (Young, 2006) to achieve a greater impact. Successful programs included a variety of activities at different intensities, commitment levels and perceived costs to the participants (Thompson et al., 2005). The more employees targeted, the more likely it was for success to occur. Keeping the interest of employees by incorporating a plethora of educational methods that appeal to different learning styles also related to success (Birken & Linnan, 2006). Thompson et al. also stressed that programs should be culturally appropriate, in order to make the information relevant to the employees and their specific concerns related to obesity prevention.

Considering a lack of physical activity has been linked to the prevalence of obesity (U.S. Department of Health and Human Services, 2007), the fact that worksite wellness programs have helped to eliminate traditional barriers to exercise such as inaccessibility to exercise facilities and lack of time after work (Lawrence, 2002), is promising. Heirich, Foote, Erfurt, and Konopka (1993) compared the effectiveness of four different approaches to increasing physical activity in four automotive manufacturing plants. Site A offered health education classes and special events for health awareness. Site B established a fitness facility in the plant with both cardio and weight equipment. Site C had two wellness counselors who provided direct outreach and one-on-one counseling for employees who were at high risk. Site D offered one-on-one outreach and counseling to all employees, as well as organized physical fitness activities during lunch and before and after shifts. At the three year follow-up, the authors concluded that those sites with one-on-one outreach were most effective in getting employees to exercise. The addition of a fitness facility did not necessarily increase physical activity among employees. This indicates the important role outreach and motivation can have on the outcome of worksite wellness programs targeting behaviors related to obesity prevention.

Two additional worksite wellness programs, Active for Life and Move & Improve, which targeted physical activity were also successful. The American Cancer Society's Active for Life 10-week program was implemented in multiple facilities to increase physical activity (Green, Cheadle, Pellegrini, & Harris, 2007). Newsletters, email messages, posters, word of mouth, and health fairs were used to notify employees of the start date and to encourage enrollment. An internal website was developed for the program to increase modes of communication and tracking among employees. Strategies utilized included the use of incentives, a team approach, and the targeting of social norms related to physical activity. An increase in physical activity was found at the end of the intervention: those who were sedentary decreased from 23% to 6%, and those meeting recommended physical activity guidelines increased from 35% to 48%.

The Move & Improve program has been in existence since 1997 and has continued to grow, with more than 11,000 participants in 2004 (Polacsek, O'Brien, Lagasse & Hammar, 2006). The 12-week program used community-based participatory research (CBPR) to encourage employees to increase their physical activity and to make healthier lifestyle choices. Participants tracked their physical activity and received encouraging tips for continued participation. Three months before participating in the program, more than half of all participants reported no regular exercise. After the program, only about 5% of participants remained inactive.

Although physical activity behaviors tend to be targeted in worksite wellness programs, nutrition behaviors cannot be overlooked. Boeckner and Tando (1996) implemented a nutrition worksite wellness challenge among three small community worksites. Components included a six-week series of classes, monthly newsletters, worksite displays, and "challenge" activities between worksites. Employees showed improvements in four of six behaviors related to general nutrition habits, five of seven related to reducing fat through food selection, and two of five related to reducing fat through food preparation. Participants reportedly enjoyed the worksite concept, as they were able to use peer support and sharing to enhance motivation for behavior changes. They also directly related the "challenge' mentality and related incentives to their enhanced enthusiasm for such a program. From the worksite wellness programs presented, success has been reported, indicating the plausibility such obesity prevention programs may have.

How to Implement a Worksite Wellness Program

The Partnership for Prevention (2001) created a manual for employers to use as a guide when implementing a worksite wellness program. Healthy Workforce 2010 simplified the process into 10 steps (Table 3).

(1) Establish a planning committee. This advisory group (of workers) will help the planning and implementation process. In essence, the planning committee will become the "voice" of the employers and employees, in which questions and concerns can be expressed. Along with this, it is necessary to initiate management support, which is very important in the potential success of the program (Wellness Council of America, 2006a).

(2) Assess the interests and needs of corporate leaders and other employees. It is important to gain information on interests, needs, and perceived barriers from employees and employers. Assessing the following will set the program up for success: What are the organizational issues facing the employer; What is the level of management support for a health promotion program; What are the most prevalent employee disease and injury risks; What health issues are employees interested in addressing? (Partnership for Prevention, 2001). This can be done through the use of questionnaires, interviews and/or focus groups. The perception of the program is integral to its future success and overall employee participation. Characteristics you want both employers and employees to take away from the planning process include flexibility, user-friendly, and organized in a compassionate, confidential and sensitive manner (Wellness Council of America, 2006a).

(3) Develop mission statement, goals and objectives, and design the program. The mission statement should reflect the goals of the program, as well as the needs and interests of the employees, and the core philosophies of the organization (Wellness Council of America, 2006b). Goals and objectives which address the needs of the population must be identified in order to measure and evaluate outcomes. According to the Wellness Council of America (2005), objectives should be quantitative rather than qualitative so they are consistently measurable over time. Defining objectives which are measurable, time-limited, feasible and slightly challenging for the program each year will aid in the remaining steps when implementing a worksite wellness program (Wellness Council of America, 2006a).

(4) Develop a timeline and budget. It is important to have a timeline which includes the planning, implementation, and evaluation processes. This helps to keep all involved on task. The use of a quarterly calendar has been recommended as an effective way of breaking down the program activities. The quarterly plan can then be broken down into monthly increments, enabling all involved to see the entire scope of the program timeline (Wellness Council of America, 2006a). In addition, a clear budget should be developed for approval before implementation occurs. Worksites are not created equal, so allotted resources must be taken into consideration before counting on specific funding. Staffing, programming, space and time are all areas of the budget which need to be considered (Wellness Council of America, 2006b).

(5) Select incentives. Incentives have been noted to increase participation. Smaller incentives provided throughout worksite wellness programs have been shown to exhibit more positive effects than large, material incentives offered at the end of the program. However, the Wellness Challenge* Program found success in giving out a cash reward of up to $325 to employees who met a set of wellness criteria (Wellness Council of America, 2005). With the use of incentives, it has been shown to be helpful if they are related to the desired behaviors attempting to be changed (healthy food coupons, physical activity gear, gym memberships, etc.). Incentives must be integrated into the program design carefully, as not to confuse participants about what is really important.

(6) Acquire programmatic and/or human resources support. Culturally and developmentally appropriate program materials should be developed with collaboration from various health professionals (health educators, physicians, dietitians, exercise physiologists). Seeking free or low cost materials from voluntary health organizations, local health departments, and state or national government agencies can reduce cost (Partnership for Prevention, 2001).

(7) Promoting the program. Creating awareness is an important component to having a successful worksite wellness program. A creative program name and logo will help increase awareness (Partnership for Prevention, 2001). Utilizing a variety of appropriate strategies will help to set the program up for success. Circulation of informational flyers, use of employee newsletters, bulletin boards, posters, and sending emails to all employees are all means of stimulating interest (Wellness Council of America, 2006a). Also, publicizing a kick-off event improves the likelihood of early buy-in to the program. Program participation is crucial to not only the success of the program, but the likelihood of behavior change (Wellness Council of America, 2005). Suggested tips to increase participation include: involve people in the planning, ask people what they want and give it to them, make the program fun, incorporate incentives, remove barriers, provide various program choices, and ask how the program is doing and/or why people are not participating.

(8) Implement the program. Once attention has been brought to the issue, it is necessary to help the population change their habits and lifestyle. Examples include: offering one-on-one counseling from a registered dietitian and a personal trainer; monthly small-group educational series; making healthier choices available on site including cafeterias and/or vending machines; developing safe walking paths; and starting company intramural teams and activities. It is important to incorporate a positive and supportive environment throughout the worksite. Diverse strategies should be used to facilitate involvement and encourage employees to buy into the program. According to the Partnership for Prevention (2001), "A good rule of thumb is to begin the program slowly and to lead off with those activities most likely to succeed" (p. 29).

(9) Evaluate the program. As indicated previously, it is important to regularly evaluate the program to see which elements of the program are working and which need attention. The Wellness Council of America (2006b) indicated eight targets to evaluate: participation; participant satisfaction; improvements in knowledge, attitudes, and behaviors; changes in biometric measures; risk factors; physical environment and corporate culture; productivity; and return on investment.

(10) Modify the program (continuous quality assurance). Worksite wellness programs should not be static, but change along with the needs and interests of employees and employers (Partnership for Prevention, 2001). The evaluation data provides crucial information related to possible program changes. Focus groups can also be conducted with those who have and have not participated in the program to see what modifications may be beneficial.

CHALLENGES OF WORKSITE WELLNESS PROGRAMS

Many challenges have been cited when deciding whether to implement worksite wellness programs. These included limited purchasing power, which made the provision of health promotion services particularly difficult for worksites with only a few employees. A proposed solution was for employers to take advantage of community agency programs and services and by collaborating with other small worksites (Birken & Linnan, 2006).

Participation rates in worksite health promotion programs generally have been low. Most worksite statistics indicate that enrollees in worksite health promotion programs tend to be salaried employees whose general health was better than average. Employees working in administrative support, service, crafts, and trades often had greater health risks and higher rates of illness and injury than professional and administrative workers did, making exclusion of those workers from worksite health promotion programs a concern (Thompson, et al., 2005; U.S. Department of Health and Human Services, 2000). The characteristics of participants taking part in various programs are important in understanding the potential for program success.

The 2004 National Worksite Health Promotion Survey reported the common barriers or challenges to worksite health promotion programs were: lack of interest among employees (63.5%); lack of staff resources (50.1%); lack of funding (48.2%); lack of participation among high-risk employees (48.0%); and lack of management support (37.0%). Employees may have been disinterested for a variety of reasons: skepticism of such programming; angry if programs were prioritized ahead of addressing work conditions; and afraid of employer "intrusion" or an attempt to "control" their health (Birken & Linnan, 2006). These need to be addressed when designing and implementing a worksite wellness program.

When targeting obesity prevention, specific barriers employees have cited include: lack of time, inadequate access to convenient and affordable physical activity areas/nutritious food, lack of knowledge or motivation. In the worksite setting, addressing these barriers and including means to overcome them will increase the likelihood of success of the program. Table 4 gives specific suggestions related to overcoming some of these barriers.

CONCLUSION

Obesity is a major public health problem with one of the at-risk groups identified as employees at worksites (Gates et al., 2006). Behavioral and environmental influences have played the largest role in the contribution to obesity, and have been stressed to be the greatest areas for prevention efforts (U.S. Department of Health and Human Services, 2007). Targeting the prevention of obesity in worksites seems ideal due to the supportive infrastructure, encouraging social environment, and ability to target modifiable behaviors which have been directly related to obesity (Wellness Council of America, 2006a).

Worksite wellness programs have the ability to generate savings for employers, but equally rewarding relates to the ability to influence the employee's

quality of life. Benefits of worksite wellness programs include reduced absenteeism, higher productivity, reduced injuries, decline in worker's compensation/ disability, increased employee morale, loyalty and sense of self responsibility (Chapman, 2003; Joslin et al., 2006; U.S. Department of Health and Human Services, 2000; Wellness Council of America, 2005, 2006a). This seems to be a win-win situation, as healthy individuals mean healthy companies.

Planning, implementing and evaluating a worksite wellness program takes time and effort. Using a CBPR approach enabled programs to be individualized to each population and their needs (Gates et al., 2006). Commitment from worksites (management and employees) was attained when they were involved in the planning and implementation process. When designing and implementing programs, considering perceived barriers and incentives to enhance employee participation becomes important (Kruger et al., 2007). Worksite wellness programs which employed motivation and encouragement strategies to keep participants inspired ultimately led to the achievement of results (Lawrence, 2002). Reaching individuals with different goals and readiness to change was correlated with success (Peterson & Aldana, 1999).

As worksite wellness programs target the issue of obesity, there is a need for regular monitoring and implementation of these programs. Lessons must be learned from what is working and what is not, building the evidence-base for obesity prevention worksite wellness programs. Employers can then use this information to help build a program around their employees, and monitor progress toward achieving the objectives of Healthy People 2010 (Thompson et al., 2005).

REFERENCES

Birken, B., & Linnan, L. (2006). Implementation challenges in worksite health promotion programs. North Carolina Medical Journal, 67, 438-440.

Boeckner, L., & Tando, K. (1996). Developing nutrition education programs for small worksites. Journal of Wellness Perspectives, 12, page.

Chapman, L. S. (2003). Meta evaluation of worksite health promotion and economic return studies. The Art of Health Promotion, 6, 1-16.

Gates, D., Brehm, B., Hutton, S., Singler, M., & Poppelman, A. (2006). Changing the work environment to promote wellness. AAOHN Journal, 54, 515-520.

Glanz, K., Rimer, B. K., & Lewis, F. M. (2002). Health behavior and health education. Theory, research, and practice 1rd ed. San Francisco, CA: Jossey-Bass.

Goutham, R. (2008). Childhood obesity: Highlights of AMA expert committee recommendations. American Family Physician, 78, 56-64.

Green, B., Cheadle, A., Pellegrini, A., & Harris, J. (2007). Active for life: A work-based physical activity program. Public Health Research, Practice, and Policy, 4, 1-7.

Haines, D., Davis, L., Rancour, P., Robinson, M., Neel-Wilson, T., & Wagner, S. (2003). A pilot intervention to promote walking and wellness and to improve the health of college faculty and staff. Journal of American College Health, 55, 219-225.

Heirich, M., Foote, A., Erfurt, J., & Konopka, B. (1993). Work-site physical fitness programs: Comparing the impact of different program designs on cardiovascular risks. Journal of Occupational Medicine, 35, 510-517.

Joslin, B., Lowe, J., & Peterson, A. (2006). Employee characteristics and participation in a worksite wellness programme. Health Education Journal, 65, 308-318.

Kruger, J., Yore, M., & Bauer, D. (2007). Selected barriers and incentives for worksite health promotion services and policies. American Journal of Health Promotion, 21, 439-447.

Lawrence, S. A. (2002). Behavioral interventions to increase physical activity. Journal of Human Behavior in the Social Environment, 6, 25-44.

Office of the Surgeon General. (2001). The Surgeon General's call to action to prevent and decrease overweight and obesity. Rockville, MD: Author.

Ogden, C. L., Flegal, K. M., Carroll, M. D., & Johnson, C. L. (2002). Prevalence and trends in overweight among U.S. children and adolescents, 1999-2000. Journal of the American Medical Association, 288, 1728-1732.

Partnership for Prevention. (2001). Healthy workforce 2010: An essential health promotion sourcebook for employers, large and small. Washington, DC: Author.

Peterson, T., & Aldana, S. (1999). Improving exercise behavior: An application of the stages of change model in a worksite setting. American Journal of Health Promotion, 11, 229-234.

Polacsek, M., O'Brien, L., Lagasse, W., & Hammar, N. (2006). Move & improve: A worksite wellness program in Maine. Preventing Chronic Disease, 1(1), 1-7.

Reardon, J. (1998). The history and impact of worksite wellness. Nursing Economics, 16, 117-121.

Rees, C., & Finch, R. (2004). Health Improvement: A comprehensive guide to designing, implementing and evaluating worksite programs. Center for Prevention and Health Services, 1, 1-16.

Thompson, S., Smith, B., & Bybee, R. (2005). Factors influencing participation in worksite wellness programs among minority and underserved populations. Family Community Health, 28, 267-273.

U.S. Department of Health and Human Services. (2000). Healthy People 2010, 2nd ed. Washington, DC:

U.S. Government Printing Office. Retrieved December 13, 2008 from www.healthypeople.gov

U.S. Department of Health and Human Services. (2003). Prevention makes common "cents." Retrieved July 17, 2008 from http://aspe.hhs.gov/health/

U.S. Department of Health and Human Services. (2007). Overweight and obesity. Washington, DC: U.S. Government Printing Office. Retrieved July 9, 2008 from http://www cdc.gov/ nccdphp/dnpa/obesity/childhood/index.htm

The Wellness Council of America. (2005). Designing wellness incentives. Absolute Advantate: The Workplace Wellness Magazine, 4, 1-64. The Wellness Council of America. (2006a). Planning wellness: Getting off to a good start. Absolute Advantate: The Workplace Wellness Magazine, 5, 1-88.

The Wellness Council of America. (2006b). WELCOA's 7 benchmarks of success. Absolute Advantate, The Workplace Wellness Magazine, 6, 1-36.

World Health Organization. (2005). Obesity and overweight. Retrieved April 1, 2009 from http://www. who.int/dietphysicalactivity/publications/facts/obesity/en/print.html

Young, J. (2006). Promoting health at the workplace: Challenges of prevention, productivity, and program implementation. North Carolina Medical Journal, 67, 417-424.

Melinda Ickes, MEd, is a Graduate Assistant in Health Promotion and Education at University of Cincinnati. Manoj Sharma, PhD, is a Professor in Health Promotion and Education at University of Cincinnati. Please address all correspondence to Melinda Ickes, MEd, Health Promotion and Education, University of Cincinnati, PO Box 210068, Cincinnati, OH 45221-0068, Tel: (937) 321-7557, Fax: (513) 556-3898, E-mail: ickesmj@ucmail.uc.edu
Table 1: Benefits of worksite wellness programs

What are the Benefits?

[check]   Cost containment
[check]   Reduced absenteeism
[check]   Higher productivity
[check]   Reduced injuries
[check]   Decline in worker's compensation/disability
[check]   Increased employee morale, loyalty, and sense of
          self-responsibility

Table 2: Lessons from worksite wellness programs targeting behaviors

Successful        Main Points                   Source(s)
Lessons

Participatory     --Successful in empowering    Gates et al., 2006;
  approach        employees and increasing      Kruger et al., 2007;
                  the buy-in of the program
                  --Improved commitment from    Polacsek et al., 2006;
                  both the employers and        Thompson et al., 2005
                  employees involved
                  --Greater sustainability
Use of theory     --Has been linked to          Glanz et al., 2002;
                  successful behavior change
                  --Helps to focus on the       Peterson & Aldana,
                  needs, attitudes, and         1999
                  values of the target
                  population
                  --Provides a framework for
                  effective programming
                  strategies
                  --Increases the likelihood
                  of successful replication
Comprehensive     --Achieve greater impact      Birkan & Linnan,
  and             --Include a variety of        2006; Thompson et al.,
  integrated      activities at different       2005; Young, 2006;
  programs        intensities and commitment
                  levels
                  --Inclusion of culturally
                  appropriate materials and
                  programming
Including         --More successful than        Heirich et al., 1993
  one-on-one      addition of facilities and
  outreach and    programs alone in
  motivation      increasing physical
                  activity
Motivation        --More successful than        Boeckner & Tando,
                  addition of facilities and    1996; Heirich et al.,
                  programs alone
                  --Enhances likelihood of      1993
                  behavior change
Incorporating     --Increased motivation to     Boeckner & Tando,
  "challenge"     continue with the program     1996
  activities

Table 3: Steps to implement a worksite
wellness program 10 Steps to Implement
a Worksite Wellness Program

[]   Establish a planning committee
[]   Assess the interests and needs
     of corporate leaders and other
     employees
[]   Develop mission statement, goals
     and objectives, and design the
     program
[]   Develop a timeline and budget
[]   Select incentives
[]   Acquire resources
[]   Promote the program
[]   Implement the program
[]   Evaluate the program
[]   Modify the program (continuous
     quality assurance)

Source: Partnership for Prevention (2001)

Table 4: Overcoming Barriers Related to Obesity Prevention

Barriers         Physical Activity            Nutrition

Lack of time     Sponsor company fitness      Institute
                 challenges.                  flexible work
                                              Institute
                                              flexible work
                                              can participate
                 Support lunchtime            in weight-loss
                 walking/running clubs        programs. Provide
                 or company sports team.      nutrition education

Inadequate       Create accessible            Provide healthy
  access to      walking trails and/or        meal choices in
  convenient     bike routes.                 cafeterias and
  and
  affordable     Provide facilities for       Provide healthy
  physical       workers to keep bikes        snacks in
  activity       secure and provide           vending machines,
  areas/         worksite showers and         in break rooms,
  nutritious     lockers.
  food           Contract with health         Offer individual and
                 plans that offer free or     group counseling to
                 reduced-cost memberships     those struggling with
                 to health clubs.             weight loss.

Lack of          Provide periodic incentive   Disseminate nutrition
  knowledge/     programs to promote          information to
  motivation     physical activity.           employees. For
                                              example, work with a
                                              weight management
                                              vendor to provide
                                              information about
                                              the nutritional
                                              content of cafeteria
                                              foods.

                 Ask personal trainers,       Ask voluntary health
                 exercise physiologists       associations, health
                 and/or                       care providers,
                 others involved              and/or public
                 with physical
                 activity to offer onsite     health agencies
                                              to offer
                 physical activity            onsite nutrition
                 education/classes.           education classes.

                 Offer a health risk          Offer a health risk
                 appraisal E(HRA)
                 to all employees and         appraisal (HRA) to
                 follow-up with               all employees, and
                 sedentary employees.         follow-up with those
                                              at risk.

                 Discount health              Offer financial
                 insurance                    incentives
                 premiums and/or reduce       for employee
                 copayments and               participation
                 deductibles in
                 return for an
                 employees
                 participation in
                 specified health
                 promotion or disease
                 prevention program.
Gale Copyright: Copyright 2009 Gale, Cengage Learning. All rights reserved.