TABLE 1.

Studies Assessing Adoption of Wellness Programs

Rigor Score	Author	Design	Modality	Subject(s)	Number of Employees	Key Findings	Limitations
High	Linnan et al3	Descriptive	Comprehensive wellness program	1553 businesses	Categories: 50–99, 100–249, 250–749, ≥750	Business size was negatively correlated with the number of worksite wellness programs. Top barriers to program implementation (regardless of the size): lack of employee interest (63.5%), staff resources (50.1%), funding (48.2%), participation on the part of high-risk employees (48.0%), and management support (37.0%)	Variability of weights in 1 yr, less than ideal confidence intervals for industry comparisons, moderate nonresponse rates (yet nonresponse adjustments made)
Intermediate	Hersey et al17	Descriptive	Obesity prevention	16 worksites	Categories: 1–300 and 301–5000	Important features of successful wellness programs included managerial support (8 of 9 businesses), use of health risk assessment (5 of 9 businesses), and creating a culture of health (9 of 9 businesses). Rapid implementation of programs was deemed an important advantage for small businesses	Only the highest-ranked businesses confirmed with on-site visits, data gathered by peers, small sample size
Intermediate	Hannon et al20	Capacity and readiness assessment	Multiple wellness programs	145 (small), 134 (medium)	Small (100–250), medium (250–4999)	In low-wage industries, capacity to implement WHP was very low; nearly half the sample reported no capacity. Smaller companies report less capacity and offer fewer programs than larger companies. Most respondents agreed a worksite wellness program would be beneficial, but fewer agreed one would be feasible, citing low capacity as one of the primary barriers	Presence of the program was self-reported. Response rate was 33.2%. Possible response bias. Implementation measures dichotomous, employers received equal treatment if the program reached all employees or only some
Intermediate	Jung et al40	Interviews	Multiple wellness programs	522 chief executive officers in Germany	Small (10–49), medium (50–249), large (≥250)	40% of small companies had a positive attitude toward health promotion, 56% of medium, and 67% of large employers. This attitude has positive associations with company size, number of hierarchical levels, percentage of academically educated employees, and presence of employee management committee. Companies with a mid-market and upper-market position had a 90% higher odds of a positive health promotion attitude than lower-positioned companies. Study concludes that small companies with lower market positions and employees with lower education should be prioritized in establishing a positive attitude toward health promotion	21% response rate (nonresponse analysis showed no difference) and limited transferability
Intermediate	Wilson et al19	Descriptive	Descriptive	2680 businesses	Categories: 15–50 and 51–99	Worksites with 51–99 employees are twice as likely to offer a health promotion activity than worksites with 15–50employees. Breadth and depth of programs is lesser in worksites with 15–50employees. The programs offered at smaller businesses are focused on job-related hazards, as opposed to lifestyle topics. No significant difference for policies (smoking, alcohol, and drugs) between the two size groups	Not enough diversity in industry type to stratify for smaller businesses, did not examine businesses with fewer than 15 or greater than 100 employees
Intermediate	Smogor and Macrina18	Descriptive	Multiple wellness programs	204 businesses	<500	A paper-based questionnaire found 87% did not have wellness programming. Programs most reported were first aid, safety and accident prevention, stress management, drug/alcohol abuse, and emotional health. Most reported reasons for not having a program: cost, perceived lack of employee interest, lack of facilities, and lack of expertise. The “major” reasons for discontinuing health promotion were lack of employee interest and participation, in addition to scheduling difficulties	Outcomes self-reported, some conclusions drawn from nonrigorous evidence
Low	Escoffery et al41	Qualitative: semistructured interviews	Obesity prevention	33 employees (over 50 yrs)0	<50	Qualitative themes reported: lack of a wellness program, no vending machines or cafeterias at work, not enough time to eating healthy, and lack of conversations with coworkers about health. Reported barriers to exercise included sedentary nature of work, or schedule that does not permit physical activity	Self-reported responses not validated, sample not representative, small sample size
Low	Divine27	Descriptive, including the focus group	Multiple wellness programs	187 business managers	<200	The focus group reported humanitarian argument as more influential than financial motive: “letting employees know the company cares” and “improving employees’ quality of life” were two notable objectives. Interest in wellness programs about perceived effectiveness rather than meeting business’s needs	Low response rate
Low	Dubuy et al39	Intervention evaluation (nonrandomized)	Bike-to-work program	12 businesses (7 adopted programs) in Belgium	Small <100, medium <800	Company size and sector had no statistical difference on adoption of the program comparing adopting and nonadopting businesses. Among employees, there was 65% awareness of the program. Those aware reported significantly more commuter cycling and a more positive view of cycling than unaware employees. The most reported barrier to participation was distance to work (20%)	Nonrandomized, no control group. Intervention implemented by the biased biking advocacy group. Initial participation fee, changed midway through study. Low response rate (23%), self-reported
Low	Kuehl et al42	Study on adoption	Wellness and injury prevention	12 fire departments	40–140	Adoption most dependent on the presence of both a willing fire chief and a firefighter to champion the wellness program. Organizational factors: finances, previous or existing wellness programs, and resistance to change, had little to no effect on adoption. Size did not significantly correlate with adoption	Nonrandomized, industry-specific, geographically limited, small sample size, self-reported
Low	Thompson26	Descriptive	Multiple wellness programs	64 businesses	<50	Worksite size was a strong indicator of the number of wellness programs offered. Small companies on average offered fewer programs than large companies. Top reasons for implementing included: 83% improve health and decrease health problems, 70% decrease health care costs, 70% improve employee morale, and 53% improve productivity. Top barriers included: 38% too costly, 35% employees do not show an interest	Low response rate, only one industry
Low	McMahan et al 31	Descriptive	Health promotion	2000 businesses	<500	84% of businesses had at least one health promotion activity. Among those offered, the most common were safety related (67%), emergency training (52%), and hazardous materials training (48%). Only 51% offered a program involving fitness, nutrition of smoking cessation. Company size was a strong predictor of the number of health promotion activities offered. Small companies were less likely to offer every type of health activity. Businesses with 2–14 employees reported higher participation rates than businesses with 15–19 or 100–500 employees	Low response rate, limited geographic sampling
Very low	Yum43	Descriptive	Multiple wellness programs	2958 businesses in Korea	<300	41% of businesses expressed that periodical consultation and education were beneficial. The highest satisfaction was with consultation and education, in addition to the occupational disease screening service. The conclusion indicates that industrial workers prefer medical care services rather than health promotion (such as smoking cessation programs)	Inadequate explanation of research process, no assessment of nonresponse population, self-report of satisfaction
Very low	Tampson44	Observational/descriptive case study	Multiple wellness programs	One business: 140 employees (204 white-collar and 179 manufacturing)	<500	There was higher overall participation among office employees than among manufacturing employees. Overall, 50% of the company’s employees participated at least once. Over 2 yrs, the number of workouts declined, yet there was no trend in the number of participants	No control group, intervention not randomized, low external validity because of only one business