Abstracts

Absenteeism & Productivity | Morale | Participation in Physical Activity | Accident & Injury Prevention | Financial Results | Health

Absenteeism and Productivity

The following summaries describe overseas (mainly US) research studies which have shown health promotion to be an effective way to reduce employee absenteeism and increase productivity.

1.1. Key Finding:

The Health Management Research Center at the University of Michigan has collected data on health risks, medical care costs and productivity measures for over 2,000,000 individuals. Absenteeism was higher, and productivity while at work was lower, for individuals with health risk factors. This suggests that workplace programmes designed to keep people healthy can reduce an individual's health risks, thus reducing their absenteeism.

Reference: Edington, D. W. - Emerging research: a view from one research center.
American Journal of Health Promotion. 2001, May-June 15(5). 341-349.

1.2. Key Finding:

Research examined whether employees with higher health risks also had higher rates of absenteeism, and whether a reduction in health risks would lead to a reduction in rates of absenteeism. Data concerning absenteeism and 10 behavioural health risk areas were collected from 35,451 employees. Results showed a significant relationship between health risks and absenteeism in eight of the ten risk areas; individuals at risk were more likely to be absent than were individuals at low risk. In addition, individuals who reduced their risk in the areas of mental health, stress and back pain were absent less often than individuals who remained at risk.

Reference: Serxner, S.A., Gold, D.B., Bultman, K.K. - The impact of behavioral health risks on worker absenteeism.
Journal of Occupational and Environmental Medicine. 2001, April 43 (4) 347-354.

1.3. Key Finding:

Researchers evaluated the influence of different levels of participation in a workplace fitness programme on employee absenteeism. These employees were evaluated for one year before and one year after the fitness programme was implemented. Researchers found that a high level of participation in the fitness programme was associated with a significant decline in sick days (average decline of 4.8 days). In contrast, the low and no-participation groups did not show a reduction in absenteeism.

Reference: Lechner, L., deVries, H., Adriaansen, S., Drabbels, L. - Effects of an employee fitness program on reduced absenteeism.
Journal of Occupational & Environmental Medicine. 1997, 39: 827-831

1.4. Key Finding:

A study of 4,972 Duke University, USA employees compared absenteeism among participants and non-participants in the "Live for Life" health promotion programme. The study covered a four-year period: one year before programme availability, and the first three years of programme availability. Data analysis controlled for baseline absenteeism, gender, race, education and age. Results showed that people who participated during any one of the three years had an average of 4.6 fewer absenteeism hours than people who had not participated at all, measured during the third year of programme availability. In addition, there was a significant linear trend showing absenteeism reduction with increasing years of programme participation.

Reference: Knight, KK., Goetzel, R.Z., Fielding, J.E. et al - An Evaluation of Duke University's LIVE FOR LIFE Health Promotion Program on changes in worker absenteeism.
Journal of Occupational Medicine. 36:5, May, 1994.

1.5. Key Finding:

Researchers studied a group of law enforcement officers in order to determine the effectiveness of health promotion programmes in improving cardiovascular fitness and thereby reducing absenteeism rates and health care costs. Based on data collected during a one-year period, researchers found that sedentary officers were absent significantly more often than were active officers. These researchers also measured the officers' fitness levels. They found that increased levels of fitness for male officers was related to decreased absenteeism, though this relationship did not hold true for female officers. Based on the results, it was concluded that rates of absenteeism were lower for active, physically fit officers than for sedentary officers, which suggests that a health promotion programme could be effective in reducing absenteeism.

Reference: Steinhardt, M. Greenhow, L, Stewart, J. - The relationship of physical activity and cardiovascular fitness to absenteeism and medical care claims among law enforcement officers.
American Journal of Health Promotion. 1991, July-August, 5 (6) 455-460.

1.6. Key Finding:

Researchers conducted a study of the comprehensive workplace health promotion programme implemented at a company with 110,000 employees at more than 100 locations. The health promotion programme focused on key areas of employees' health knowledge, attitudes and behaviour. The programme included a health risk assessment group and self-directed lifestyle change activities, recognition and awards, and workplace climate changes to include smoking policies that favoured non-smokers. One worksite that adopted the health promotion programme experienced a 47.5% reduction in hourly employee absenteeism over six years, in contrast to a 12.5% reduction in absenteeism among the total company hourly workforce.

Reference: Bertera, R.L. - Planning and implementing health promotion in the workplace: a case study of the Du Pont company experience.
Health Education Quarterly. 1990, Fall 17 (3): 307-327.

1.7. Key Finding:

A study examined changes in employee absenteeism after employees utilised a worksite fitness centre. The study included 2,232 white collar and clerical insurance company employees. Employees who enrolled voluntarily at the fitness centre were compared with employees who did not enrol (after controlling for pre-existing differences in these two groups). Researchers tracked the average number of employee absences due to illness one year into the programme, and again after two years. Men's and women's absenteeism decreased by an average of 1.2 days, with a greater decrease taking place in the second year of the programme than in the first year. The decrease in absenteeism was related to the employees' participation in the worksite fitness centre.

Reference: Lynch, W., Golaszewski, T., et at. - Impact of a facility-based corporate fitness programme on the number of absences from work due to illness.
Journal of Occupational Medicine. 1990, 32 (1) 9-12.

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Morale

Studies in this section show health and fitness promotion services contributing to significant positive changes in employee attitudes toward organisational commitment, co-workers, supervisors, working conditions, job competence and job security. In addition, employee attitudes toward personal health behaviours improve.

2.1. Key Finding:

A two-year study evaluated effects of a comprehensive health promotion programme on employees' work-related attitudes. The programme offered the following activities: a health screening, a lifestyle seminar, formal lifestyle improvement programmes and work environment improvements. There was significant positive change in the work-related attitudes of employees at the companies participating in the health promotion programme, compared to employees at the non-participating companies. There was significant positive change found in employee attitudes toward organisational commitment, supervision, working conditions, job competence, pay and fringe benefits and job security.

Reference: Holzbach, R.L., Piserchia, P.V., McFadden, D.W. et al - Effect of a comprehensive health promotion program on employee attitudes.
Journal of Occupation Medicine. 1990, 32 (10): 973-978.

2.2. Key Finding:

Beginning in 1982 AT&T Communications developed a comprehensive health promotion programme called the Total Life concept (TLC). A study group of employees was given a health risk assessment (HRA) as well as health education modules, and the effectiveness of the programme was evaluated. After a first-year evaluation of TLC it was found that study group participants felt significantly more positive toward AT&T, their co-workers and their supervisors. Participants became more committed to improving their health behaviours, while feeling generally more productive and energetic.

Reference: Spilman, M.A. Goetz, A., et al - Effects of a corporate health promotion program.
Journal of Occupational Medicine. 1986, 28 (4): 285-290.

2.3. Key Finding:

In a study designed to assess the impact of a school-based workplace health promotion programme on the morale of inner-city school teachers, teachers in 10 schools completed a questionnaire measuring the components of morale. Teachers completed the questionnaire once before and once after they were given the opportunity to participate in a series of health promotion programmes. Teachers were offered the following programmes: stress management, nutrition education, healthy back, fitness, weight control and recreational activities. Researchers collected data on teachers from a comparison group of schools in the same district (who were not offered the health promotion programme). Measures of the teachers' perceptions of the school environment (especially perceived control over work activities) and participation in the post-programme questionnaire, indicated morale was improved in schools which had implemented the health promotion programme.

Reference: Allegrante, J.P., Michela, J.L. - Impact of a school-based workplace health promotion program on morale of inner-city teachers.
The Journal of School Health. 1990, 60 (1) 25-28.

2.4. Key Finding:

The Health Systems Management Center of Case Western Reserve University conducted a survey of companies who had offered and evaluated programmes designed to reduce health care costs. The purpose of the survey was to identify seven companies who could serve as models for other corporations who wished to control health care costs. This article focuses on two companies: Johnson & Johnson and Metropolitan Life Insurance. After doing in-depth case studies of results from these two companies the author concludes that gains in employee morale was one of the most significant results of the health promotion programmes.

Reference: Manring, S.L. - Evaluating corporate wellness and promotion programs: the cases of Johnson & Johnson Corporation and Metropolitan Life Insurance Company.
Health Matrix. 1985, 3 (2): 28-34.

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Participation in Physical Activity

The scientific literature suggests that the following physical activity programming opportunities, when offered together, produce the best results in increasing employee physical activity:

• Active outreach to employees who are not physically active
• One-to-one behavioural counselling with employees who need to start or increase their physical activity
• Peer support, for example in the form of a buddy system or opportunities for employees to exercise together
• A corporate environment that encourages physical activity - this can involve visible management support for (and participation in) physical activity, highly visible special events, walking paths etc
• A moderately well-equipped, conveniently located fitness facility, which offers exercise classes (conveniently located usually means on-site).

In some studies the various elements above were compared with each other. The best results were obtained when counselling was offered to inactive employees, combined with peer support and opportunities to exercise with others at work. One-on-one counselling alone was second. Instructor-led classes, along with awareness-raising events, were somewhat helpful. The simple presence of an on-site facility, even when staffed, fully equipped and with lots of publicity, was least effective in improving activity in the population overall.

Education/motivational campaigns that include scheduled opportunities for fun and moderate group activity can be quite effective in increasing physical activity on a population-wide basis. A doctor's advice plus referral to a health or fitness educator for more information has also been found to be effective in improving patients' physical activity.

3.1. Key Finding:

As a result of the Johnson & Johnson 'Live for Life' programme, which included fitness centres and exercise programmes, daily energy expenditure in vigorous activities increased 104%. In companies where only an annual health screen was offered, there was only a 33% increase in daily energy expenditure in vigorous activities. These improvements (in both programmes) were distributed throughout the workforce and were corroborated by maximum oxygen uptake measures.

Reference: Blair, S.N., Piserchia, M.S., Wilbur, C.S., Crowder, J.H. - A public intervention model for work-site health promotion.
Journal of the American Medical Association. 1986, Feb. 255 (7) 921-926.

3.2. Key Finding:

Researchers evaluated the impact of Chevron Corporation's Health Quest Fitness Center programme on medical expenditures. Investigators compared inpatient and pharmacy expenditures for programme participants and non-participants over a 2.5 year time period. They found that compared with non-participants expenditures for participants were significantly lower for those who used a Health Quest fitness centre at least twice each week.

Reference: Goetzel, R.Z., Dunn,R.L., et al - Differences between descriptive and multivariate estimates of the impact of Chevron Corporation's Health Quest program on medical expenditures.
Journal of Occupational and Environmental Medicine. 1998, June 40 (6) 538-545.

3.3. Key Finding:

A study examined the incentives and barriers faced by working women in making regular physical activity part of their lives. The role of the workplace in encouraging a physically active lifestyle for its female employees was also examined. Results showed that women who were more physically active tended to expect positive benefits (incentives) as a result of physical activity; they expected that physical activity would be enjoyable, enhance their psychological or spiritual wellbeing, and help them maintain their weight. In terms of barriers to physical activity, the most often reported barriers were lack of time due to family, lack of time due to work, and lack of discipline, as well as cost of participation, lack of flexible work hours, and lack of support from management. Less active women reported more lack of discipline, lack of interest, lack of motivation, and being too tired, as well as lack of physical activity skill/experience, and feeling more self-conscious in a physical activity setting. Overall, the barrier reported most often by most women was lack of time in the work day for physical activity.

Reference: Laffee, L., Rex, L. - Incentives and barriers to physical activity: women's responses to a workplace fitness center.
Melpomene Journal. 1999, Sept 18 (3) 23.

3.4. Key Finding:

Researchers conducted a meta-analysis of 52 research studies on the impact of worksite fitness and exercise programmes. Overall, programme participants showed small but favourable changes in body mass, skinfold measurements, aerobic capacity, muscle strength and flexibility, overall risk-taking behaviour, blood pressure, cholesterol and smoking. Regarding different strategies for offering fitness programmes, the lead researcher concludes that the most effective and cost-effective option is to provide a moderately well-equipped facility, an active outreach to non-participants, one-to-one counselling, and a corporate environment that encourages a healthy lifestyle.

Reference: Shephard, R. J. (1996) - Worksite fitness & exercise programs: A review of methodology & health impact.
American Journal of Health Promotion, 10 (6), 436-452 and Shephard, R.J. - Do work-site exercise and health programs work?
Physician and Sports Medicine, Feb 1999, Vol. 27 (2) 48-50, 55-56, 59-62, 65, 69-70,72.

3.5. Key Finding:

In a review of the literature, researchers looked at a number of studies that focused on the efficacy of worksite health promotion programmes.

The first such study was conducted at the Exxon Physical Fitness Lab in 1974 where researchers made exercise accessible to the participants through a supervised schedule of activities with circuit interval training, journals for record-keeping, and an intensive series of goal-assessment techniques. Researchers reassessed participants after one year, and found that, on average, participants reduced their body fat by 25%, increased their grip strength by 7%, and decreased their exercise pulse rate by 13%. Results showed a substantial improvement in overall fitness, indicating that making exercise accessible to employees is effective in improving their health and fitness levels.

Another study, a seven-year case study published in 1992, was conducted at the Canadian Life Assurance company. This company established an employee-fitness programme that included an on-site fitness facility, exercise classes, and health-education materials. Results showed modest gains in long-term exercise adherence, with a moderate 13% effective participation rate. These rates were well maintained over the seven years of the study.

A 1993 study compared a number of auto-plant worksite wellness programme designs at General Motors. The following were the different programmes established, and their results:

• On-site fitness facility with a full set of equipment, substantial publicity for the fitness centre and no formal counselling
• Series of health-education classes with trained instructors and special events that encouraged greater awareness of health issues
• One-to-one counselling on active health-improvement techniques, a buddy system for workouts, and special programmes and events to participants.

Results:

• The second and third programmes were shown to be the most effective in increasing employees' exercise frequency, while the first programme showed no increase in exercise frequency.
• Participants in the third programme achieved the most significant weight loss, followed by those participating in the second programme.
• Those in the first programme achieved the least amount of weight loss.
• Researchers concluded that there was a significant positive effect of one-to-one counselling and encouragement on employees' long-term behaviour change.

Reference: McClaran, S.R., Jones, J., Aittama, T. - Making it stick: improving adherence to physical activity programs.
AWHP's Worksite Health. Summer 2001. 18-21.

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Accident & Injury Prevention

In New Zealand in the year 2001/02 the New Zealand Accident Compensation Corporation (ACC) received approximately 32,000 new work-related claims amounting to a cost of $127m. These new claims were added to ongoing claims from previous years amounting to $273m. Thus the cost of ACC work-related claims for 2001/02 amounted to $400m. This dollar value does not reflect the costs to the employer of sick leave, lost productivity and other impacts on the workplace.

Studies in this section show fitness and health promotion services reduce rates of injury. They impact on behaviours leading to injuries and reduce the overall costs of injury. However, it should be noted that the 'return on investment' values noted in these studies cannot be directly applied to the New Zealand context. In the USA employers are responsible for insuring their employees' health and medical costs, and the employer meets these costs directly. This is not the case in New Zealand where workplace accidents are covered by a state operated insurance scheme and individuals are directly responsible for insuring their own health and medical requirements.

4.1. Key Finding:

At Subaru-Isuzu Automotive (SIA) in Indiana, employees are encouraged to perform stretching exercises to music, twice daily before their shifts. Exercises were designed to harden workers for physical labour, in order to reduce the incidence of work-related injuries, especially strained muscles and repetitive-motion injuries. In addition, SIA has a two-week conditioning programme for new employees to prepare them for physical labour. These, and other measures taken at SIA including an on-site workout facility, two on-site physical therapists and one on-site physician, make a difference in preventing injuries. Managers estimate this work-hardening programme saves the company approximately 30-40% on rehabilitation costs, which outweighs the cost of the programme in the long run.

Reference: Gunsch, D. - Employees exercise to prevent injuries.
Personnel Journal. July, 1993. 58-62.

4.2. Key Finding:

Researchers examined on-the-job injuries among 3,338 workers at Xerox's manufacturing complex from 1996 to 1999. Of these workers, 943 participated in 1998 in the company's health risk appraisal programme, a key aspect of the employee wellness plan. The health risk appraisal evaluated the workers' health risks, including smoking, obesity, drug and alcohol use, high blood pressure and life and job dissatisfaction. Researchers found that among workers who participated in the health risk appraisal, only 5.6% made workers' compensation claims. In contrast, 8.9% of those who did not participate in the health risk appraisal made workers' compensation claims. In addition, workers who participated in the health risk appraisal had an average cost of US$6,506 per injury, when they got injured on the job, compared to an average cost of US$9,482 per injury for non-participants. Over the course of two years, the company saw a 5 to 1 return on investment. The study results suggest that employees who participate in a workplace wellness programme may have fewer workplace injuries, and have less costly workplace injuries, compared to employees who do not participate in such a programme.

Reference: Musich, S.A., Napier,D., Edington, D. - The association of health risks with workers' compensation costs.
Journal of Occupational & Environmental Medicine. 2001, 43 (6) 534-541.

4.3. Key Finding:

A one-year back pain/back injury prevention programme resulted in modest reductions in back pain, and significant improvements in risky behaviour and in job satisfaction. A cost-benefit analysis found a return on investment of US$1.79 for every programme dollar spent.

Reference: Shi, L. - A cost-benefit analysis of a California County's back injury prevention program.
Public Health Reports. March/April 1993. 108 (2) 204-211.

4.4. Key Finding:

Cigna Corporation implemented and evaluated a safety belt incentive programme in its Delaware office, as wearing a seat belt reduces the risk of motor vehicle deaths by 50% and reduces serious injuries by 65%. The programme succeeded in increasing employees' seat belt use by 48.7%. According to estimates by Cigna, the seat belt incentive programme would reduce injury costs by US$147,000 over a 10 year period.

Reference: Eddy, J.M., Marotto, D.A., Beltz, S.M. - Analysis of the effectiveness of a safety belt incentive program at CIGNA corporation.
American Journal of Health Promotion. Winter 1988. 31-38

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Financial Results

Most of the research studies on the financial benefits of worksite wellness programmes have been undertaken in Canada and USA. In some cases this information is not highly relevant to the New Zealand context because the overseas studies take into account the employers responsibility for insurance and expenditure on employee health and medical costs. This is not relevant to New Zealand, which operates on a highly unique state-operated accident compensation scheme run by the Accident Compensation Corporation (ACC). However, New Zealand employers will need to calculate their ACC premiums into their return on investment or cost/benefit analyses. Despite the lack of correlativity of workplace insurance schemes between New Zealand and the US, the following studies illustrate a direct link between employee health and employee productivity. Such findings can be extrapolated beyond the location of the research study and easily applied to the New Zealand context.

Studies on the financial impact of fitness and health promotion services fall into three broad categories:

Return-on-investment studies

Fitness and health promotion services have been found to show a return between US$1.49 and US$6.15 for every dollar spent. Disease management programmes have been found to show a return between US$7.33 and US$10.31 for every dollar spent.

Studies that show actual cost savings

Actual cost savings from fitness and health promotion services are measured in various ways. For example, some studies have shown savings in medical care costs per participant per year. Reported savings have ranged from US$357 to US$618. Other studies give a total yearly savings number for the organisation. These savings ranged from US$245,000 for Johnson & Johnson, to an estimated US$3.2-8.0 million for the California Public Employees Retirement System. Still other studies use percentages to measure their savings. For example, one company found that health care costs rose only 6.3% per year following the introduction of a health promotion programme, compared to a 20% increase per year before the programme.

Studies that show projected cost savings.

Cost savings projections are also implemented in various ways. One study projected a two-year cost-benefit of US$312.2 million for the 100,000 employees at AT&T, based on the difference in medical costs before and after the health promotion programme was implemented. Researchers found that by achieving 'best-practice' levels of performance, defined as expenditures in the 25th percentile for each of the 'health productivity management areas', employers could save US$2,562 per employee (a reduction of 26%).

Return on Investment Studies

5.1. Key Finding:

A comprehensive review of the literature on health promotion programmes and their results showed that of an initial 196 studies, 74 met stringent criteria for being well designed to produce credible results and conclusions. Of these 74, 18 studies examined the impact of health promotion programmes on absenteeism. All 18 found that absenteeism dropped after the introduction of a health promotion programme. Six of these 18 provided a cost-benefit ratio and there was an average savings of US$5.07 for every dollar invested. In addition, there were 32 studies that looked at the impact of an intervention on medical care costs [not relevant to the NZ context]. The researcher describes the overall quality of the literature as 'indicative', meaning that it is very likely that health promotion programmes actually cause cost savings. However, this conclusion cannot be absolutely drawn until and unless there are large-scale studies with randomised controlled designs.

Reference: Aldana, S.G. - Financial impact of health promotion programs: a comprehensive review of the literature.
American Journal of Health Promotion. May/June 2001. 15 (5) 296-320.

5.2. Key Finding:

A panel of experts was assembled to identify and rank the highest quality studies that have been published on the relationship between health risk, health promotion programmes and financial outcomes. Twelve studies were selected for intensive review based on the quality of methodology and the authors' efforts to present results from a broad range of intervention areas and programme settings. The panel drew the following conclusions based on its review: The research clearly supports a relationship between modifiable risk factors and health care costs. Health promotion programmes appear to provide positive financial returns, most strongly for health care costs and absenteeism reduction. Private section initiatives seem to be driving economic-based research. Overall, health promotion shows promising results for providing financial advantages for its sponsors. However, if health promotion is to show its true worth, considerable funding is needed from government or philanthropic sources to cover the large costs of quality research.

Reference: Golaszewski, T. - Shining lights: studies that have most influenced the understanding of health promotion's financial impact.
American Journal of Health Promotion. May/June 2001. 15 (5) 332-340.

5.3. Key Finding:

This article is a systematic review of highly credible 'return-on-investment' (ROI) studies regarding best-practice corporate health and productivity management initiatives. Results of the review indicate a wide range of ROI estimates, from a low of US$1.49 per dollar spent on the programme, to a high of US$13. In general, disease management programmes had the highest ROI estimates. Corporate health promotion/wellness programmes had ROI estimates between US$1.49 and US$3.14 in benefits per dollar spent. Demand management programmes, which typically focus on expanded self-care, produced ROI estimates from US$2.19 to US$13, with a median ROI of approximately US$4.50. Disease management programmes target specific diseases for which there are effective, evidence-based practice guidelines - for example, depression, diabetes, arthritis, high blood pressure, low back pain, and ischaemic heart disease. They may include educational programmes for both patients and providers, counselling and monitoring, and incentives for appropriate use of health care services. The ROI estimates on these programmes ranged from US$7.33 to US$10.31 per dollar spent.

Reference: Goetzel, R.Z., Juday, T.R., and Ozminkowski, R.J. - What's the ROI? A systematic review of return on investment (ROI) studies of corporate health and productivity management initiatives.
AWHP's Worksite Health., Summer, 1999.

5.4. Key Finding:

Researchers examined the financial impact of a comprehensive health demand and disease management programme at Citibank on medical expenditure. The programme components included an initial screening of employees (health risk assessment), placement of employees into higher and lower risk intervention programmes, extensive follow-up with high-risk participants, and general health education. The study involved 22,838 subjects (11,194 programme participants and 11,644 non-participants) who were followed for an average of 38 months before and after taking the health risk assessment. These researchers compared medical expenditures before and after the intervention, for participants and non-participants. Researchers found that the return on investment (ROI) was between US$4.56 and US$4.73 saved for every dollar spent on the programme. This ROI suggests that a health management programme that focuses on high-risk populations can result in financial savings to employers.

Reference: Ozminkowski, R.J., Dunn, R.L., Goetzel, R.Z. et al - A return on investment evaluation of the Citibank, N.A. health management program.
American Journal of Health Promotion. 14(1), 1999. 31-43.

5.5. Key Finding:

Much of the research on the economic impact of fitness and sport programmes has been initiated with a view to cost containment, or the justification of specific exercise initiatives. Care must be taken when evaluating such reports to consider any resultant biasing of conclusions. Analysis should conform to sound scientific and economic principles, with cost-effectiveness measures generally being more appropriate than cost-benefit analyses. Critical issues of measurement include opportunity costs, marginal and intangible costs, discount and inflation rates and programme participation rates. At the worksite, costs vary greatly with the scale of facilities and the level of programme supervision that are offered. Beyond a certain ceiling, further expenditures do not seem to enhance programme effectiveness. Likely benefits to a company include an improvement