Worksite Wellness – Working with Small Businesses 17 th Annual Healthy Carolinians & NCIOM Prevention Summit Laura A. Linnan, ScD, CHES The 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 (ODonnell, 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)

Physical Activity and Nutrition Programs by Worksite Size * statistically significant differences by worksite size DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental Programs by Worksite Size DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling Services by Worksite Size 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 AJPH No 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 the focus, 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 SectorTotal Employment-Based Coverage Individually Purchased PublicUninsured Own NameDependent Total Self-employed Wage-and-Salary Workers Firm Employment Size < 10 Employees Employees Employees Employees < 500 Employees Employees 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 InterventionStrategy 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, * 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 companys 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 Carolinas workforce. The collaborative should help businesses implement healthy workplace policies and benefits, implement health risk appraisals, develop comprehensive 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 directionssmall business study. Am J Public Health. 2005;95(8): Divine RL. Determinants of small business interest in offering a wellness program to their employees. Health Mark Q. 2005;22(3): 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). Linnan L & Birken B. Small businesses, worksite wellness and public health: A time for action. NC Med J. 2006;67(6):