Promoting Health and Wellness in the Workplace: A Unique Opportunity to Establish Primary and Extended Secondary Cardiovascular Risk Reduction Programs

Abstract

Given the burden of cardiovascular disease (CVD), increasing the prevalence of healthy lifestyle choices is a global imperative. Currently, cardiac rehabilitation programs are a primary way that modifiable risk factors are addressed in the secondary prevention setting after a cardiovascular (CV) event/diagnosis. Even so, there is wide consensus that primary prevention of CVD is an effective and worthwhile pursuit. Moreover, continual engagement with individuals who have already been diagnosed as having CVD would be beneficial. Implementing health and wellness programs in the workplace allows for the opportunity to continually engage a group of individuals with the intent of effecting a positive and sustainable change in lifestyle choices. Current evidence indicates that health and wellness programs in the workplace provide numerous benefits with respect to altering CV risk factor profiles in apparently healthy individuals and in those at high risk for or already diagnosed as having CVD. This review presents the current body of evidence demonstrating the efficacy of worksite health and wellness programs and discusses key considerations for the development and implementation of such programs, whose primary intent is to reduce the incidence and prevalence of CVD and to prevent subsequent CV events. Supporting evidence for this review was obtained from PubMed, with no date limitations, using the following search terms: worksite health and wellness, employee health and wellness, employee health risk assessments, and return on investment. The choice of references to include in this review was based on study quality and relevance.

Given the burden of cardiovascular disease (CVD),¹ increasing the prevalence of healthy lifestyle choices is a global imperative. It is widely recognized that cardiac rehabilitation (CR), a primary method for addressing modifiable cardiovascular (CV) risk factors, is an effective approach to positively altering lifestyle choices/habits.^2–4 Even so, there is wide consensus that primary prevention of CVD, specifically identifying and addressing modifiable risk factors before an initial event, is an effective and worthwhile pursuit.⁵ Moreover, continual engagement with individuals who have already been diagnosed as having CVD, ideally after a 12-week traditional CR program, would be beneficial. Given the emergence of the Affordable Care Act legislation^6,7 and its implications for a paradigm shift in health care delivery, the timing for programmatic creativity directed toward CV risk reduction seems highly appropriate.

Implementing health and wellness programs in the workplace allows for the opportunity to continually engage a group of individuals with the intent of effecting a positive and sustainable change in lifestyle choices. Current evidence indicates that health and wellness programs in the workplace provide numerous benefits with respect to altering CV risk factor profiles in apparently healthy individuals.^8,9 In addition, for individuals with a CVD diagnosis, worksite health and wellness programs may be the ideal setting to provide long-term care and support after discharge from traditional CR services or may serve as the sole means for providing such services after a CV event. This review summarizes the current body of evidence demonstrating the efficacy of worksite health and wellness interventions and discusses key considerations for the development and implementation of programs whose primary intent is to improve the CV risk profile and reduce the likelihood of initial or subsequent CV events. Supporting evidence for this review was obtained from PubMed, with no date limitations, using the following search terms: worksite health and wellness, employee health and wellness, employee health risk assessments, and return on investment. The choice of references to include in this review was based on study quality and relevance.

CURRENT STATE OF EVIDENCE SUPPORTING WORKSITE HEALTH AND WELLNESS PROGRAMS: FOCUS ON RETURN ON INVESTMENT

The return on investment (ROI) in worksite health and wellness programs has been measured in numerous ways.⁸ A variety of investigations have demonstrated meaningful changes in the health profile and behaviors of employees by using cost-efficient approaches, such as employee-directed health and wellness initiatives, Web-based self-management programs, and environmental/policy changes in the workplace.^10–12 Thus, at minimum, employers should establish a worksite health and wellness committee from its existing pool of interested employees to develop and implement a program that is focused on creating a cost-efficient healthy environment, advocating for health-specific policy changes, and planning/executing activities/events.

In a recent intervention study using CR staff, there were significant improvements in body fat content, blood pressure, plasma lipid levels, depression, anxiety, hostility, somatization, quality of life, and total health scores after a worksite health and wellness intervention.¹³ Of employees who were classified as high risk at baseline, 58% converted to low risk after the intervention program. In a multicenter, multilevel worksite health and wellness intervention directed toward CV risk factor reduction in India, Prabhakaran et al¹⁴ demonstrated reductions in body weight, blood pressure, blood glucose levels, and total cholesterol levels and an increase in high-density lipoprotein cholesterol levels in approximately 5000 participants. In addition, in February 2010, the Task Force on Community Preventive Services released their findings related to the health impact of worksite health and wellness programs¹⁵ suggesting effectiveness in reducing tobacco use, self-reported dietary fat consumption, the number of days lost from work, hypertension, and total serum cholesterol levels among participants. However, the Task Force did not find sufficient evidence of effectiveness for some outcomes, such as increasing dietary intake of fruits and vegetables, reducing overweightness/obesity, and improving physical fitness. However, other workplace studies demonstrate that substantial nutritional and exercise benefits may be achievable.^16,17 Thus, additional research is needed to elucidate optimal worksite health and wellness models whose goal is to improve as many lifestyle habits/choices as possible.

Financial return is a critical component used to judge the success of worksite health and wellness programs.⁸ Total medical claims were significantly reduced after a worksite health and wellness program using CR staff for the 12 months after the intervention compared with the 12 months before the intervention, with approximately $6 saved for every dollar invested in worksite health and wellness inititatives.¹³ This ROI is consistent with the rate of return reported for other medical care approaches, which range from $3 to $15 for each dollar invested over several years after program implementation.¹⁸ A review by Aldana¹⁹ demonstrated that worksite health and wellness interventions can produce 26% reductions in health care costs and 30% reductions in workers’ compensation and disability management claims costs. In a more recent meta-analysis, Baicker et al²⁰ found that medical costs decrease $3.27 for every dollar spent on worksite health and wellness. Last, Bolnick et al²¹ combined global burden of disease study and medical expenditure panel survey data to estimate annual savings that would result from lowering primarily CV risk factors through worksite health and wellness. If risk factors were reduced to their theoretical minimums, this group concluded that total medical care expenditures would be reduced by 18.4% per working-age adult.

Another major indirect expense of lost productivity from employees with various chronic diseases includes absenteeism and presenteeism. It was recently estimated that absenteeism represents approximately 6% of total direct and indirect medical costs and that presenteeism is responsible for more than 60% of these costs.²² In a cross-sectional analysis of 2264 employees at a single employer, the rates of absenteeism and presenteeism were estimated to range from 0% to 6.3% and from 1.3% to 25.9%, respectively, among employees with up to 8 risk factors.²³ Similar trends were demonstrated in a study of 2250 employees from a single petroleum plant.²⁴ In a review by Aldana¹⁹ of 14 absenteeism studies, all found reductions in absenteeism after a health and wellness intervention, with cost savings in the range of $2.50 to $10.10 for every dollar invested. Baicker et al²⁰ reported an absenteeism cost savings of $2.73 for every dollar invested. In a review by Chapman²⁵ of 56 qualifying financial impact studies conducted over 2 decades, participants in worksite health and wellness programs had 25% to 30% reductions in medical and absenteeism costs compared with nonparticipants over an average study period of 3.6 years. Pelletier et al²⁶ found that individuals who reduced one health care risk factor decreased presenteeism by as much as 1% and absenteeism by 2%. In another study by Burton et al,²⁷ each risk factor change was associated with a concomitant change in productivity of nearly 2% over time, with savings estimated to be approximately $1000 per year per risk factor reduced.

It is also estimated that there may be significant adverse consequences of chronic diseases on overall productivity, with various reviews suggesting that on-the-job productivity losses, depending on the specific analysis, are responsible for 20% to more than 60% of total health-related expenditures.⁸ In fact, a recent American Heart Association (AHA) Policy Statement suggested that health-related productivity losses cost US employers more than $200 billion per year and more than $1500 per employee per year, of which more than 70% was due to reduced performance at work.^8,28 Estimations of productivity loss are 12% to 28% for employees who have 0 to 7 or more of the major health risk factors, respectively.²⁹ A recent economic analysis of 10 years of outcomes from more than 30 studies concluded that the overall evidence in support of worksite health and wellness programs is powerful, leading to average reductions in sick leave, health plan costs, workers’ compensation costs, and disability costs of slightly greater than 25% compared with organizations that do not have worksite health and wellness programs.³⁰

Besides the impact of worksite health and wellness programs on reducing employee health risks, reducing absenteeism/presenteeism, improving productivity, and lowering health care costs, there is also evidence that such initiatives may improve job satisfaction and employee morale, which may be beneficial in the recruitment and retention of top employees and for the overall corporate image.^8,28

Although there is evidence to suggest a valuable ROI when a worksite health and wellness program is implemented, there is wide variability with respect to the type and degree of ROI that may be achieved (Table 1). Moreover, the worksite health and wellness delivery models demonstrating ROI vary considerably, making it difficult to define a more precise ROI for a given program. Therefore, although numerous studies demonstrate that worksite health and wellness programs generate an ROI, the wide variability in findings indicates that it may be prudent at this time for employers to project more conservative ROI estimates (eg, 10%−15% reductions in health care expenditures). Thus, future research is needed to address this important topic with hopes of better defining the expected ROI for a given worksite health and wellness model. Moreover, it would be beneficial to gain a better understanding of all the attributes (ie, attribution modeling) associated with eventual ROI to gain a better understanding of the most important factors associated with an optimal worksite health and wellness program.

TABLE 1.

Summary of Worksite Employee Health and Wellness Program Return on Investment Findings^a

Area of financial analysis	Reporting variability
Health care cost reductions	High variability in reporting
	- $3.27 to $6.00 saving for every dollar invested13,20
	- 18%−26% reduction in health care costs19,21
Absenteeism reductions	High variability in reporting
	- $2.50 to $10.00 saving for every dollar invested19,20
	- 25%−30% reduction in absenteeism costs25
Presenteeism reductions	High variability in reporting
	- 1% reduction with reduction in 1 health care risk factor26
	- $1000 saving per risk factor reduced27

^aReturn on investment data are derived from the cited references in the table.

ESSENTIAL COMPONENTS OF WORKSITE HEALTH AND WELLNESS PROGRAMS FOCUSED ON MONITORING AND REDUCING CV RISK PROFILES

Worksite health and wellness programs may take on many different forms, depending on the type of employees, the size of the company, the availability of resources, and many other factors. Figure 1 illustrates a conceptual model for worksite health and wellness focused on improving CV risk profiles.

FIGURE 1.

Forward-thinking model for comprehensive worksite wellness programs focusing on cardiovascular health. *A focused risk reduction program can be performed by worksites onsite (if expertise available), by partnering with external groups, or by a combination of both. CVD = cardiovascular disease.

Personnel Considerations

Dietitians, nurses, exercise physiologists, physical therapists, and other health professionals who are skilled in health education and behavior modification therapies are qualified to address CV risk factor reduction. However, at least in the United States, this group is rarely used in primary prevention settings, including worksite health and wellness programs.¹³ However, an estimated 30% of companies’ yearly medical expenditures are spent on employees with major CV risk factors.^8,31 Thus, an organization may find hiring qualified health professionals to improve CV risk factor profiles in its employees to be cost-effective. Moreover, it seems that one of the factors associated with delivering a successful worksite health and wellness program is partnering with community health organizations, that is, employee health professionals trained in CV risk factor reduction, to provide support, education, and treatment.⁹ Although it may be feasible for some employers to hire personnel with unique expertise (ie, dietitians, nurses, exercise physiologists, physical therapists, and other health professionals) to deliver a worksite health and wellness program, others may not have the financial resources to take such an approach. The inability of employers to hire uniquely trained health professionals should not be a deterrent to establishing worksite health and wellness initiatives. Last, irrespective of the background of the individuals chosen to deliver the worksite health and wellness program, applying cognitive and behavioral strategies in an attempt to make positive, lasting, and meaningful lifestyle changes may be advantageous.^32,33

Screening and Early Detection

Health risk assessments (HRAs) should be the initial component of a worksite health and wellness program. In addition to an assessment of overall health risk, HRAs provide an opportunity to increase the individual worker’s awareness of risk factors and suggest strategies for modifying health behaviors. A high percentage of employees are unaware that they have risk factors for CVD (eg, hypertension, lipid abnormalities, and physical inactivity), and even among those who are aware of their risk factors, risks are frequently inadequately treated.^34–37 Workplace HRAs can effectively identify high-risk individuals, direct appropriate treatment, and provide an opportunity to encourage high-risk employees to make lifestyle changes to reduce CV risk. The HRAs also serve to identify workers with latent disease, providing an opportunity to intervene early in the disease process, potentially preventing more serious complications and reducing health care costs.

Physical Activity

Regular physical activity is one of the most important components of a worksite health and wellness program; individuals who are habitually sedentary have significantly higher rates of CVD and metabolic conditions (eg, insulin resistance and obesity).^38,39 Moreover, relatively low levels of fitness have been shown to be among the strongest determinants of CV and all-cause mortality^40–42 and are associated with higher health care costs.^43–46 Even modest improvements in physical activity patterns or fitness among employees can have a major effect on health outcomes.^40,47

Many strategies to promote physical activity at the worksite have been successfully implemented, including educating employees about the benefits of activity, providing access to safe spaces for activity, and modifying the built environment so that employees can incorporate activity into their work days. For example, open and accessible stairwells and on-site physical activity facilities have been demonstrated to increase physical activity patterns of employees.^48,49

Last, technological advances have led to important opportunities to monitor exercise in ways that potentially reinforce other workplace health initiatives. Pedometers enhance exercise assessments, particularly because quantified stepping activity can be used to complement assessments relying on self-report or questionnaires.^50,51 Likewise, serial pedometer measurements may be used to track progressive improvements.⁵² Internet-based programs to promote physical activity, with the capability of reaching a larger number of employees if computer/Internet access is available, may also be advantageous.⁵³

Smoking Cessation

Tobacco use (direct andsecond-hand) is strongly associated with morbidity and mortality, higher health care utilization, and decreased productivity.^54–57 Stopping smoking is often considered the single most important behavior change to reduce morbidity and mortality, and, therefore, efforts to prevent and reduce smoking rates among employees is essential for worksite health and wellness programs.¹ Education targeted toward quitting and prevention of smoking, formal smoking cessation programs, pharmacological treatment, social support programs, and combinations of these have all been successfully used to reduce smoking rates among employees.^58,59 During the past 2 decades, clean indoor air laws resulting in smoke-free environments have had an important effect on reducing smoking rates and exposure to second-hand smoke.⁶⁰

Stress Management/Reduction

High levels of work-related stress have been associated with the development of CV risk factors and impaired job performance. Surveys have suggested that worldwide, approximately 25% of women and 18% of men report high levels of job-related stress.^61–63 Several studies have reported that job-related stress is associated with the development of CVD.⁶⁴ Employee-based worksite strategies designed to reduce job-related stress include cognitive behavior therapy, relaxation techniques, and individual counseling focused on adopting healthy lifestyles. Integration of short bouts of physical activity into the work day has been demonstrated to reduce job-related stress and increase productivity.⁶⁵ Other strategies have been supervisor based, involving training programs to facilitate better direct support, providing employees with clarity in goals and role expectations, better communication and feedback about performance, and encouraging employee participation and control. These supervisor-based approaches to reducing job-related stress have been associated with improvements in health outcomes.⁶⁶

Nutrition and Weight Management

Surveys of nutrition habits indicate that the typical diet of the US adult falls significantly short of the AHA, US Department of Health and Human Services, and other widely recognized recommendations.⁶⁷ For example, in the Nurses’ Health Study, only 12.7% of more than 84,000 participants met the minimal criteria for a healthy diet.⁶⁸ Among approximately 12,000 men and women from the Aerobics Center Longitudinal Study, only 4.2% met the AHA ideal dietary goals.⁶⁹ A 2010 Centers for Disease Control and Prevention report indicated that approximately 33% of US adults consume the recommended servings of fruit daily, and approximately 25% consume the recommended servings of vegetables.⁷⁰ Approximately 66% of US workers are overweight or obese, which underlies numerous comorbidities and has a profound effect on health care costs.⁷¹ Strategies for improving diet that can be adopted in the workplace include ensuring access to healthy foods (eg, fruits, vegetables, whole grains, skim milk dairy products, fish, leanmeats andpoultry, and plant-based meat alternatives); increasing offerings of food choices that are low in saturated fat, trans fat, sodium, added sugar, and calories; and providing nutrition labeling at the point of purchase (eg, in the cafeteria and vending machines).^72–74

Changes in the Work Environment

Numerous studies have been performed related to environmental modifications and their role in promoting health-related behavior change. Workplace education, such as raising awareness about health, is one important factor that can facilitate positive behavior change. Encouraging involvement in community-based outreach programs can facilitate education and healthy lifestyle choices for employees. Modifying the physical environment to encourage increases in physical activity or to ensure the availability of healthy food options in the cafeteria or vending machines has been shown to have favorable effects on CV risk factors.^72–75 Price reductions on lower-fat foods were demonstrated to result in higher sales of those items.⁷⁵ Moreover, numerous studies have reported that changes to the built environment (such as open and accessible stairwells and on-site physical activity facilities, as mentioned previously) significantly increase physical activity patterns of employees.^48,49,76

MODELS FOR WORKSITE HEALTH AND WELLNESS PROGRAMS FOCUSED ON CV RISK REDUCTION

Although there are common components of all worksite health and wellness programs, it is clear that these programs can be delivered in different ways. The American College of Sports Medicine’s Worksite Health Handbook: A Guide to Building Healthy and Productive Companies is a valuable resource in planning such a program.⁷⁷

Health and Wellness Culture

Employers need to establish a culture that makes it clear that worksite health and wellness are among the highest priorities for the organization.⁷⁸ This culture should be readily apparent to employees and customers of the organization. It is reflected in a leadership that champions and fully participates in the program,⁷⁹ which may have important implications for company productivity. The organization’s health and wellness goals should be clear and quantifiable. The physical environment of the company can play an important role in facilitating the culture by developing the facilities in a way to encourage an awareness of healthful behaviors.⁸ Beginning in 2014 pursuant to the Affordable Care Act, up to 30% of health insurance premiums will be allowed to be used for outcome-based wellness incentives.⁸⁰ Lack of incentives was shown to be the most common reason employees do not participate in a worksite health and wellness program.⁸¹ Thus, as a result of this new legislation, companies may offer more comprehensive health insurance discount packages similar to the model illustrated in Figure 2. There is evidence to suggest that such an incentive program increases participation in health risk assessments in the workplace.^82,83 However, although financial incentives seem to increase participation in a health and wellness program, its effect on further improving CV risk profiles is in question.⁸⁴ Although demonstrating initial promise, additional research is needed to determine the value of financial incentives for worksite health and wellness programs.

FIGURE 2.

Incentive-based model to support compliance with worksite health and wellness practices. Worksites qualify for incremental discounts (percentage premium reduction per health goal achieved) on their health insurance premiums. The major controllable health behaviors/cardiovascular disease risk factors are as follows: (1) smoke free: also qualifies if a current smoker and enrolled in a smoking cessation class; (2) hypertension: blood pressure less than 130/85 mm Hg and if medicated takes all prescribed medication; (3) hyperlipidemia: low-density lipoprotein cholesterol level less than 100 mg/dL, high-density lipoprotien cholesterol level greater than 50 mg/dL (to convert to mmol/L, multiply by 0.0259), and triglyceride level less than 150 mg/dL (to convert to mmol/L, multiply by 0.0113) and if medicated takes all prescribed medication; (4) diabetes: fasting blood glucose level less than 100 mg/dL (to convert to mmol/L, multiply by 0.0555), or hemoglobin A_1c level less than 5.6%, and if medicated takes all prescribed medication; (5) physical activity: more than 150 min/wk of moderate (or higher) intensity (objectively measured initially and documented monthly); (6) obesity: body mass index (calculated as weight in kilograms divided by height in meters squared) less than 30 and waist less than 102 cm in men and less than 88 cm in women or enrolled in a weight loss program with 5% or more body weight loss and after weight loss program completion participates in a regular physical activity program; (7) psychological health: free of anxiety and depression or if medicated takes all prescribed medication; (8) risk factor free: also qualifies if participates in regular health coaching for continued management of any risk factors; and (9) preventive medical status: has an annual flu shot, has all immunizations up-to-date, and completes all age- and sex-specific screening evaluations (colonoscopy, mammography, etc).

Key Program Elements

A company with a strong health and wellness culture will offer regular health-related initiatives to engage employees. It is important to develop the initiatives to meet the needs of the employee characteristics (age, sex, job classifications, etc) and interests (obtained via surveys and focus groups) and is based on employee health-related data (CV risk factor prevalence and insurance claims).⁸ One of the most recognized resources valued by employers and employees is time. Thus, the worksite health and wellness initiatives should be offered during the workday, with a cooperative flex-time approach.

As was previously overviewed, a key element for successful programs is to provide regular screenings to identify CV risk factors. Early detection is key for the primary and secondary prevention of CVD.⁸⁵ Those identified as low risk are provided positive feedback to maintain their favorable health status, in part through a reward system. These individuals can serve as role models and can also mentor other employees. Those identified with risk factors are referred to an appropriate health care professional to seek assistance in reversing or controlling the risk factor(s).

Patients with diagnosed CVD should be encouraged and supported to complete a hospital-based early outpatient CR program, if so referred by their treating physician.⁸⁶ On completion of this program, employees may continue to participate in the hospital-based maintenance CR program. However, they may choose instead to engage solely with the worksite health and wellness program. Although the latter would require worksites to have specific policies and procedures and appropriately trained personnel⁸⁷ to provide this higher level of service, the advantages to the employee make this a key component of a comprehensive worksite program.

Program Models: The Value of Strategic Partnering

Worksite health and wellness programs can be delivered by a company-run stand-alone internal program, can be outsourced to an external provider, or can be a hybrid of some internal and some external programming. Some institutions, such as health care systems and educational entities, may have most, if not all, of the necessary expertise to deliver the program with personnel already employed in the organization.⁸⁸

Regardless of the approach, all worksite health and wellness programs should use the resources developed by major clinical and health professional organizations. Many of these professional associations have had expert panels develop resources specific to CV risk factors, as shown in the examples provided in Table 2.

TABLE 2.

Examples of Resources for Cardiovascular Risk Factors From Clinical and Health Professional Organizations

Topic	Resource
CVD risk assessment	http://mylifecheck.heart.org
Tobacco-free workplace	http://www.cdc.gov/nccdphp/dnpao/hwi/toolkits/tobacco/index.htm
Beginning an exercise program	http://exerciseismedicine.org/index.htm
Hypertension control: diet	http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf
Cholesterol control: diet	http://www.nhlbi.nih.gov/cgi-bin/chd/step2intro.cgi
Diabetes management	http://www.diabetes.org/living-with-diabetes/treatment-and-care/247.html?loc=contentpage-promo-247
Weight loss	http://www.cdc.gov/healthyweight/losing_weight/getting_started.html

CVD = cardiovascular disease.

Development and implementation of different models for worksite health and wellness programs ideally entail strategic partnering. Strategic partners will likely include national and international associations with a common shared interest in health and wellness. Several key organizations and associations are listed in Table 3. Development of research initiatives in the area of worksite health and wellness is needed and could be championed by all of the previously mentioned organizations and associations. Moreover, although several of the organizations and associations listed in Table 3 do not primarily focus of CVD risk reduction, their established presence within worksite health and wellness in a broader context is nonetheless valuable in facilitating the model proposed in the present review.

TABLE 3.

Strategic Partners to Develop and Implement Worksite Health and Wellness for High-Risk Employees and Employees With Heart Disease

Organization	Acronym
International and national organizations
The Health Enhancement Research Organization	HERO
Institute for Health Productivity and Management	IHPM
International Association of Worksite Health Promotion	IAWHP
National Business Group on Health	NBGH
National Business Coalition on Health	NBCH
Society for Behavioral Medicine	SBM
World Health Organization	WHO
Centers for Disease Control and Prevention	CDC
National Institute for Occupational Safety and Health	NIOSH
National Institutes of Health	NIH
American Hospital Association
American Heart Association	AHA
American Lung Association	ALA
Professional organizations
American College of Sports Medicine	ACSM
American Association of Cardiovascular and Pulmonary Rehabilitation	AACVPR
American Occupational Therapy Association	AOTA
American Physical Therapy Association	APTA
American College of Cardiology	ACC
American College of Chest Physicians	ACCP
American Nurses Association	ANA
American College of Occupational and Environmental Medicine	ACOEM
European Association for Cardiovascular Prevention and Rehabilitation	EACPR

Although all of the previously mentioned organizations are likely to facilitate an agenda for worksite health and wellness programs, it is possible that the National Institute for Occupational Safety and Health (NIOSH) may have one of the most important roles in developing and advancing a worksite health and wellness program for employees with high risk of or known CVD.⁸⁹ In particular, the NIOSH has supported and facilitated the development of a campaign to improve worksite health entitled “Total Worker Health.” This NIOSH campaign provides employers, worksites, and health practitioners with key literature and resources to understand the need for optimal worker health as well as tools to develop a worksite health and wellness program.⁸⁹

It is also important to note that the AHA published a policy statement entitled “Worksite Wellness Programs for Cardiovascular Disease Prevention” in 2009 that provided a comprehensive overview of the need for worksite health and wellness programs.⁸ The article also described legislative and regulatory oversight issues, methods to provide worksite health and wellness, and the need to provide such a program to all employees regardless of sex, age, ethnicity, socioeconomic status, culture, job type, or physical or intellectual capacity. Provision of worksite health and wellness to employees with known CVD was not mentioned in this article. However, because of the prevalence of CVD, poor CR referral and participation rates, and the need identified by the AHA to provide a health and wellness program to all employees, worksite health and wellness seems to be a logical and important method to improve the health of employees at high risk for or with CVD.^8,89

In summary, strategic partnering is needed to develop and implement worksite health and wellness programs. Finally, further development of research initiatives in the area of worksite health and wellness is needed to identify the best methods and models of delivery. Currently, we are unaware of any analysis that has compared a broad array of worksite health and wellness delivery models in a meaningful way. A systematic review by Kaspin et al⁹ indicated that strong senior leadership support, a visible healthy worksite culture/environment, program flexibility to adapt to changing needs of employees, utilization of technology, and support from community health programs are essential to the success of worksite health and wellness programs. Thus, future analyses comparing the effectiveness of different worksite health and wellness programs should consider these seemingly essential attributes.

The Worksite Health and Wellness Committee: Key Organizational and Administrative Considerations

To optimize the likelihood of success, an institution should commit to the development and maintenance of a structured worksite health and wellness program.⁷⁹ Perhaps one of the most important first steps is ensuring that organizational leadership strongly supports worksite health and wellness.^78,90,91 This may involve an organization critically analyzing and potentially changing values, beliefs, and practices/policies to ensure a firm commitment to optimizing the health and wellness of its employees.⁷⁸ The Health Enhancement Research Organization has developed an employee health management scorecard allowing an organization to assess their baseline health and wellness culture and to assess change in status once a new program is initiated.⁹² A worksite health and wellness pledge is provided in the Supplemental Figure (available online at http://www.mayoclinicproceedings.org), serving as an example of a way organizational leadership can express strong support for worksite health and wellness initiatives. Once strong support for worksite health and wellness by organizational leadership is ensured, a committee should be formed to plan and oversee implementation of the program. The group of individuals selected to serve in this capacity may have various backgrounds, but all should have a strong commitment to health and wellness, both in their own lives and in the lives of their co-workers. Composition of the committee is also an important consideration, with care taken to ensure that all key organizational stakeholders are represented. Stakeholder buy-in and support is fundamentally important to the success of the program. Committee members can be obtained by either a call for volunteers or through a nomination process, the latter ideally being led by senior leadership. Note that the nomination process may send a stronger message of leadership support for health and wellness and, thus, lead to a greater sense of commitment by committee members. In larger organizations, with more than 300 employees, the committee will be composed of members with more specializations across the various organizational divisions and departments. It is to the benefit of the program to develop committee role nominations based on the specializations.⁷⁹ Most often, most committee members will be employees of the organization. However, opening one or more committee positions to individuals in the community, particularly if they have a unique expertise in health and wellness or CV risk reduction, is worth strong consideration if feasible. Soliciting worksite health and wellness committee members from the community may be particularly relevant for organizations whose normal business operations are not particularly relevant to health and wellness. In some instances, particularly if financial resources are available, key members of a worksite health and wellness committee may be hired for the sole purpose of running/working in such a program. The size of a worksite health and wellness committee varies, although a recommended range is 10 to 18 members.⁷⁹ A program manager should be hired or a chair nominated to lead the committee and oversee the implementation and execution of agreed on strategic initiatives. Ideally, the program manager or committee chair should hold a leadership position in the organization and have an excellent understanding of the organization’s culture, structure, and function. Initially, the committee should embark on examining the baseline health and wellness needs of the employees. This may be achieved through a variety of methods, including online/paper surveys and town hall meetings. Using established health metrics, such as the AHA’s Life’s Simple 7,⁸⁵ allows for the development of a survey that captures key health information. Once an accurate depiction of the health and wellness needs and interests of the organization has been captured, the committee should develop mission and vision statements that are consistent with the organization’s culture and broadly address employee needs. Sample mission and vision statements are listed in Table 4. Subsequently, short- and long-term goals should be established through a strategic planning process. Ideally, these goals should be objective and measureable and have the ability to reach the broadest number of employees. If feasible, the committee should secure fiduciary support from key leaders in the organization. Obtaining funding directly correlates with stakeholder buy-in and long-term program success. If the organization does not have funds available to support health and wellness initiatives, committee volunteers may offset the financial costs by seeking foundation support or grant opportunities. The allocation of financial resources should again be directed toward initiatives deemed to have the highest impact with the broadest reach. Collection of outcomes data is vital to demonstrating program efficacy to organizational leadership and to modifying future health and wellness initiatives as organizational needs and interests change over time.

TABLE 4.

Sample Mission and Vision Statements for Worksite Health and Wellness Programs

Mission statement	To create a community engaged in supporting personal wellness and a healthy, balanced lifestyle with a particular focus on cardiovascular health.
Vision statement	To provide integrated programs a d resources that promote quality of life and foster a culture of cardiovascular health, well-being, and balance.

CONCLUSION

Health and wellness, particularly from a CV standpoint, is becoming an ever-increasing concern on a global level. Key health metrics, particularly those associated with the risk of CVD and subsequent events, continue to demonstrate disconcerting trends.¹ A well-designed and organized worksite health and wellness program creates an opportunity to affect a large portion of the population. Given the societal burden of CVD, rethinking worksite health and wellness to focus on modifiable CV risk factor reduction may be highly advantageous.

ARTICLE HIGHLIGHTS.

• Cardiovascular disease continues to be a major health concern on a global scale.

• Worksite health and wellness programs provide the opportunity to identify and provide interventions to reduce modifiable cardiovascular risk factors in a larger portion of the population.

• Several investigations have demonstrated that worksite health and wellness programs are effective in reducing modifiable cardiovascular risk factors. Even so, optimal program delivery models have yet to be elucidated, warranting additional research in this area.

• The body of evidence for return on investment (ROI) for worksite health and wellness programs is compelling. However, there is a high degree of variability to which ROI is analyzed and reported. Future research is needed to better define worksite health and wellness ROI.

• Strong senior leadership support, a visible healthy worksite culture/environment, program flexibility to adapt to changing needs of employees, utilization of technology, and support from community health programs are essential to the success of worksite health and wellness.

Abbreviations and Acronyms:

AHA

American Heart Association

CR

cardiac rehabilitation

CV

cardiovascular

CVD

cardiovascular disease

HRA

health risk assessment

NIOSH

National Institute for Occupational Safety and Health

ROI

return on investment