Economic pressures attract employers to health promotion programming

Stages of change readiness take on growing importance

For years, many employers have remained skeptical of wellness programming, insisting that there was little evidence such programming could be cost-effective. However, with the convergence of crushing health care costs and a growing body of evidence that wellness can save money, more and more employers are coming on-board, according to occupational health experts.

At the same time, they note, wellness programming has become more sophisticated. The old straight-cash incentive has evolved into sometimes complicated formulas tied to insurance premiums, and the concept of employee readiness to change has taken center stage in many wellness campaigns.

"I think employers are definitely waking up to the fact that something has to be done," says Kay Gulick, executive director of the Wellness Council of Florida in Jacksonville. "With the astronomical increase in health care costs, it is definitely affecting their bottom line now, and they realize they have to do something." In reality, she says, employers have three options: "They can do nothing; they can shift [insurance] costs to the employees, which we see happening a lot more; or they can start aggressively looking at the problem and finding solutions within their companies."

However, she concedes, many companies still remain skeptical. "We have all these data that support wellness, but unless you take it down to a very personal level at the company, it still does not phase some of them as much."

"I would say there has been a positive change in employers’ attitudes," adds Marsha Kuhar, PhD, MSN, MPH, occupational health manager for Nationwide in Columbus, OH, and a national board member of the American Association of Occupational Health Nurses (AAOHN), based in Atlanta. "On the whole, employers have always been concerned about the health of employees, but that’s not the whole story. Wellness programs save money. You will see medical costs reduced, increased productivity, and you should see a decrease in indirect costs like absenteeism. It’s a win to embrace wellness.

"When you have double-digit inflation in health care costs, and you are putting a strain on a health care system that’s already strained, I don’t think there’s any alternative," she continues. "We will not be able to sustain the system if costs continue to rise at double-digits each year."

"I think I’ve seen a shift, with more people latching on to health promotion/wellness programs," adds Sandy Simpson, APRN, BC, MSN, RN-C, COHN-S, manager, occupational health services, Schering-Plough HealthCare Products in Memphis, TN, and also a board member of AAOHN. "Recent studies by organizations like Hewitt Associates verify that even more employers are embracing on-site programs."

Why the shift? "I think people are looking at bottom-line costs, productivity of workers, things that are related to changeable behaviors, to chronic diseases, to disability costs — and to lost work time and presenteeism," she asserts.

AAOHN considered employee wellness such an important issue that it added health promotion/disease management to its 2004 Public Policy Platform.

"One of the things we are good at is keeping people healthy at work, and we know the work force population is aging," notes Susan A. Randolph, MSN, RN, COHN-S, FAAOHN, president of AAOHN. "Certain health risks arise as a result of that, so we will continue to have an important focus on health promotion, wellness, and disease prevention, addressing diseases such as diabetes and stroke."

She agrees that "some employers are starting to realize there are benefits to having programs that support health, and they realize they might keep their employees more productive." However, Randolph declares, "More inroads could be made."

Different approaches work

The old adage about many ways to skin a cat was never truer than when applied to wellness. Part of the reason is that each employee population is unique.

"There is a lot of information available about leading health indicators," notes Kuhar. "You can find it in the literature. Healthy People 2010 [] identifies 10 of them, with physical activity, excess weight and obesity, tobacco use, and substance abuse among the top four. They are really the key to worksite programs having an impact. People pay attention to those indicators, so we should see how we can address them — what can we implement in the work site that can impact associates so they will be more active, or decrease use of tobacco or substance abuse? Those indicators can act as a pivot for good, strong wellness programming."

Most important, she adds, is the commitment of the company. "Somewhere in their core values wellness should be incorporated," she asserts. "Most companies don’t have that yet; it’s a top-down commitment."

As for her own organization, "We’re getting there," says Kuhar. In order for an occ-health person to succeed in such a transition, "You have to become the largest proponent of wellness you can be," she advises.

Kuhar uses what she calls a shared-business approach. "I look at how I can get other business units involved in being excited about wellness," she says.

As far as the programming itself, you can always offer wellness programs that have impact across the board, such as fitness centers or walking clubs, "But it may be you will want to look at targeting specific populations," says Kuhar. "I may develop a program for the younger population on ways to prevent risk-taking behavior. For middle-aged folks, I may focus on early detection. And for the more mature workers, I might be assisting them with managing chronic conditions."

Simpson recommends "looking at the stages of change model and making your program elements fit accordingly." (The stages of change model indicates employees’ readiness to change; e.g., if they are not yet ready to change, they may be in the pre-contemplative or contemplative stage.)

"When you look at the stages of change, you can reach out and touch people where they are," she continues. Simpson underscores the need for such programs by noting that, according to the National Center for Health Statistics (, the typical adult older than 18 has an average of seven chronic conditions.

One of the resources she uses to guide her programming is to see what is going on in the National Health Observance Calendar and, more importantly, what’s going on in the news media, such as the recent National Red Day, which brought attention to women’s health and, more specifically, heart disease. "Katie Couric [co-anchor of NBC’s Today Show] does a great job on colorectal cancer each March," she adds. "If you have something in print, maybe people in pre-contemplation may join next year. People watch the news all the time, so when you feed off of that it’s kind of like one big Aha!’ tied together."

Simpson’s program has moved away from a big-ticket focus to tokens that recognize improvement — such as losing 10 pounds or lowering cholesterol. "People are enjoying that personal success," she says. "It can just be a piece of paper posted in the boardroom, or it may be just a T-shirt."

The most important thing, she says, is to catch a disease before it becomes an issue for the employee or their family. "We did a community diabetes program, and people came who didn’t have diabetes, but who had a family member who did," Simpson recalls. "They wanted to learn to be able prepare special meals, and to help influence change in someone they loved. Disease impacts more than just the individual."

"Some of these diseases are lifestyle-based and workers have the capacity to control them, so, what we can do is to focus on those conditions, and talk to clients/workers about how they can reduce some of their health risks so they can live longer," says Randolph.

A new paradigm?

Gulick says that a new program from Blue Cross/Blue Shield of Rhode Island is a premier example of what she considers to be state-of-art of wellness — the current thinking about what types programs are most successful. "That seems to be more individualized intervention programs," she notes.

The concept behind the Rhode Island Blues program is as follows: If employees wish to continue to have their company pay their entire health care premium, they must fulfill certain responsibilities. "You must take an HRA [health risk appraisal], and then you are responsible for making decisions about the changes you have to make, such as losing weight or quitting smoking," Gulick explains.

The HRA also identifies the participant’s readiness to change, which, she says, is crucial. The employee sets a primary goal and a secondary goal, and based on the employee’s readiness to change, the health plan supports the worker in those endeavors.

"The information sent to that person is in line with their readiness to change," says Gulick. So, for example, in the case of smoking cessation, support is offered at the worksite, and appropriate meds are provided.

The third component of the program, and the one that is unique to the program according to Gulick, is that the employee has only a $2 copay for preventative pharmaceuticals. "This is revolutionary," she asserts.

In order to keep the benefit, the employee must be making satisfactory progress toward their goal. "If I need to lose 30 pounds and I lose 6 but I’m working at it, the company will recognize it," Gulick says. As long as the workers remains involved in the program, they keep their benefits. If they choose not to participate, they pay 15% of premium costs. "To me, this is the epitome of where we need to go," says Gulick.

The current trend is encouraging says Simpson. "I hope it continues. Some industry efforts are even impacting legislation, which has really brought the program issue to the forefront. On [HHS Secretary] Tommy Thompson’s web site, there’s an initiative to help people start walking. It’s important for these programs to be attacked from an epidemiological point of view."

In addition to educating members through targeted programs, AAOHN is working to influence change on a broader scale. "We are working to be involved with various organizations that have an interest in these areas and be at the table, to try to encourage the inclusion of workplace wellness in their deliberations," says Randolph, noting that this can include organizations involved with heart disease, asthma, tobacco usage, and so on.

AAOHN also is educating its members on specific wellness programs they can offer, and strategies they can present to management to win support for these programs.

"I see more dollars being spent than we’re seeing now, and more commitments to wellness by companies because of the payoff," says Kuhar. "I can’t imagine it being any other way."

[For more information, contact:

  • Kay Gulick, Executive Director, Wellness Council of Florida, 1300 Riverplace Blvd., Suite 200, Jacksonville, FL 32207. Telephone: (904) 306-0250. Fax: (904) 306-0237. E-mail:
  • Marsha Kuhar, PhD, MSN, MPH, Occupational Health Manager, Associate Health Services, Nationwide, One Nationwide Plaza, Columbus, OH 43215. Telephone: (614) 249-4520. E-mail:
  • Susan A. Randolph, MSN, RN, COHN-S, FAAOHN, President, American Association of Occupational Health Nurses, 2920 Brandywine Road, Suite 100, Atlanta, GA 30341. Telephone: (770) 455-7757. Web:
  • Sandra Simpson, APRN, BC, MSN, RN-C, COHN-S, Manager, Occupational Health Services, Schering-Plough HealthCare Products, 3030 Jackson Ave., Memphis, TN 38151. Telephone: (901) 320-5173. Fax: (901) 320-2378.]