Worksite Wellness – Working with Small Businesses

17th Annual Healthy Carolinians & NCIOM Prevention Summit

Laura A. Linnan, ScD, CHESThe UNC Gillings School of Global Public Health

Thursday, October 8, 2009

Objectives

• Offer a brief overview of the importance of worksite health promotion and its prevalence among small employers

• Provide a rationale for offering comprehensive HPPs among small employers

• Identify strengths/assets of small employers for promoting employee health

• Share some promising intervention strategies – including those recommended by the NC IOM -- for increasing the prevalence of small employers which offer comprehensive HPPs

Why Worksite Health Promotion?

• More than 60% of US adults are employed • Employees spend a considerable number of waking

hours working• Health care for US adults is directly linked with

employer-provided health insurance; many working adults are without health insurance

• Many leading causes of death (CVD, cancer, stroke) are preventable through lifestyle behavior changes (smoking, diet, PA)

Why Should Employers Be Interested in Worksite Health Promotion?

• Preventable illness makes up 70% of the total burden of disease and their associated costs; employers pay for these costs

• 10 modifiable risk factors account for approximately 25% of all employer healthcare expenditures (Anderson, 2000)

• Employer medical costs average $7910/employee annually (O’Donnell, 2007)

• Effective worksite health promotion programs have demonstrated a positive impact on employee morale, employee health and risk behaviors, productivity, and health care costs

What is a “small” business?

• US Small Business Administration defines “small” business as an employer with 500 employees or less

• SBA estimates there are 25.8 million small businesses in the US– They employee nearly 50% of the working adults!– Employed adults spend about ½ of their waking

hours at work

Not all “small” employers are equal… but they are important!

• Among small employers, there is great heterogeneity

• The smaller the employer, the less likely it is to offer health insurance or any health programming for employees..• 98% of employers with at least 200 employees offer some

type of health insurance while only 59% of those under 200 employees do

• One serious health problem represents financial disaster for an employee and his/her family

Healthy People 2010 – Worksite-Related National Health Objective

• “75% of employers (of all sizes) should offer a comprehensive worksite health promotion program,” which includes 5 key elements:

• Health education programming• Supportive physical/social environment• Links to other health-related programs in the organization• Screening programs and appropriate follow-up• Integration of the program into the administrative structure

(e.g. budget, staffing, etc.)

How many employers are offering a “comprehensive” health promotion

program?

• And, are small employers different from other employers in what they offer?

Use of a Health Risk Appraisal

Linnan, Bowling et al. (2008). AJPH.

Differences by worksite size statistically significant (p=0.0002)

0

5

10

15

20

25

30

35

40

45

50750+ EES (n=111)

250-749 EES (n=211)

100-249 EES (n=229)

50-99 EES (n=179)

Total (n=730)

Physical Activity and Nutrition Programs by Worksite Size

0

10

20

30

40

50

60

70

*Physical Activity *Nutrition

750+ EES (n=111)

250-749 EES (n=211)

100-249 EES (n=229)

50-99 EES (n=179)

Total (n=730)

* statistically significant differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental Programs by Worksite Size

0

10

20

30

40

50

60

70

80

90

100

Onsite FitnessCenter

Fitness/WalkingTrails

Cafeteria Vending -food/beverages

750+ EES(n=111)

250-749 EES(n=211)

100-249 EES(n=229)

50-99 EES(n=179)

Total (n=730)

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling Services by Worksite Size

0102030405060708090

100

750+ (n=111)

250-749 (n=211)

100-249 (n=229)

50-99 (n=179)

Total (n=730)

Linnan, Bowling et al, 2008, AJPH

Predictors of Comprehensive Worksite Health Promotion Programs Overall, 6.9% of employers offered a

comprehensive program – smaller worksites were less likely to offer all elements/types of programs

Controlling for all factors (e.g. model adjusted for size, staff, experience, industry type), we found: Worksites with 750+ employees were 4.4 times

more likely to have a comprehensive program (p=.06).

Worksites with a dedicated staff person were 10.3 times more likely to have a comprehensive program (p<.05).

Why Do Small Employers Offer Fewer Programs?

• “Survival Mode” – HPP programs are costly– Direct Costs – of offering programs/services– Indirect Costs – time/resources – competing demands

• Lack of personnel dedicated to wellness• Small business culture/leadership

– “Leave it up to Workers” (Eakin)– Managers concerned about employee privacy (Linnan)

Barriers To Health Promotion Program Success

Linnan, Bowling et al. 2008. AJPH

0

10

20

30

40

50

60

70

Lack ofEmployee

Interest

Lack of StaffResources

Lack of Funding Lack of High-RiskEmployee

Participation

Lack ofManagement

SupportNo differences in barriers were reported based on industry type or worksite size except that worksites with 750+

employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

“When business survival is thefocus, any other costs, including those linked to employee health,may be seen as prohibitive.”

Linnan & Birken (2007)NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007

Sector Total

Employment-Based Coverage Individually

Purchased Public Uninsured

Own Name Dependent

Total 100.0 50.6 17.5 6.7 7.4 20.3

Self-employed 100.0 22.9 25.7 20.0 7.1 26.4

Wage-and-Salary Workers 100.0 54.1 16.5 5.1 7.5 19.5

Firm Employment Size < 10 Employees 100.0 26.6 21.9 9.5 10.1 34.3

10-24 Employees 100.0 38.3 20.3 6.3 7.8 28.9

25-99 Employees 100.0 52.0 17.3 5.2 6.9 20.8

100-499 Employees 100.0 62.1 14.8 3.6 6.5 15.4

< 500 Employees 100.0 45.2 18.5 6.1 7.8 24.6

500+ Employees 100.0 65.7 13.8 3.7 7.0 12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths

• Often, there is a family focus• Fewer organizational layers – less complexity

re: decision-making• Less complexity re: implementation• Understand that each individual employee

and his/her health is important • Understand that health influences the

“bottom line” of the company

Multiple Level Intervention for Small Employers

Level of Intervention Strategy

Intrapersonal/ Interpersonal

-Briefings (print) and Web-based resources -Leading by Example – employers-CEO breakfast meetings-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational -Free or low-cost HPPs + TA to implement them from community, hospitals, voluntary health organizations…-TA from State Health Department and/or insurers

Community -Business Groups on Health – leverage for purchasing power-University partnerships to get student help, grant funding

Policy -National or state-level tax credits for small employers who adopt HPPs-Purchasing agreements for health-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*

Individual Level- Periodic health assessments tied to personalized feedback and individual coaching and motivational interviewing - Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with all employees and is available to discuss health concerns-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and meet monthly with participants to collect program activity points and measure progress (eg, changes in weight and blood pressure) toward positive health outcomes-Strong linkage of wellness program with worker safety, including group stretching to promote model of an “industrial athlete”-Health coaches who travel among a company’s worksites to meet with employees

Environmental Level-Strong support from wellness committee for establishing culture of wellness -Inclusion of healthy food in criteria for selecting cafeteria vendor-Free access to onsite physical activity facilities-Provision of bicycles for travel between buildings

Organizational Level-Incentive of paid day of leave to encourage program participation -Reallocation of existing benefits to provide incentives for participating in screening activities and attaining wellness goals-Strong financial disincentives for employees and spouses with health insurance through the company who do not participate in wellness program-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:

Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for Small Businesses

The North Carolina General Assembly should direct the North Carolina Public Health Foundation to establish the North Carolina Worksite Wellness Collaborative to promote evidence-based strategies to support the optimal health and well-being of North Carolina’s workforce. The collaborative should help businesses implementhealthy workplace policies and benefits, implement health risk appraisals, developcomprehensive employee wellness programs, and implement data systems that track outcomes and the organizational and employee level.

The North Carolina General Assembly should provide start-up funding of $800,000 in SFY 2011, with a reduced amount over the next four years, to support this collaborative.

In addition, the North Carolina General Assembly should provide a tax credit to businesses with 50 or fewer employees that have implemented a comprehensive worksite wellness program for their employees.

Key Considerations

• Get employees involved! Get dedicated staff!• Management support is necessary but not sufficient• Offer a comprehensive program with all 5 elements• Offer incentives for participation/behavior change• Provide links to local health care systems/providers• Address social contextual factors influencing health• Support research that builds evidence base and then

offer evidence-based programs• Special focused activities for small employers

Related Information• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small

manufacturing worksites that employ multiethnic, low-wage workforces into a cancer prevention research trial. Prev Chronic Dis. 2004;1(3):A04.

• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change among working-class, multiethnic workers: results of the healthy directions—small business study. Am J Public Health. 2005;95(8):1389-1395.

• Divine RL. Determinants of small business interest in offering a wellness program to their employees. Health Mark Q. 2005;22(3):43-58.

• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of healthy weight at small and medium-sized US worksites. Prev Chronic Dis 2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.

• Linnan L & Birken B. Small businesses, worksite wellness and public health: A time for action. NC Med J. 2006;67(6):433-438.