In one way or another, the readers and writers of this journal all have an interest in promoting health. Whether we are researchers, educators, grant makers, healthcare providers, policy makers, or public health professionals, we spend our days providing direct healthcare or designing, implementing, studying, and evaluating programs to improve the health of people in our communities. However, we do not necessarily apply the things we know in our own workplaces. In this Management Moment column, we will explore why workplace wellness programs are important and how you-as a public health manager-can institute your own employee wellness programs and policies.
We all know why it is good for employers to support good nutrition and healthy behaviors. Both are known to be correlated with preventing chronic health problems, including heart disease, some cancers, diabetes and osteoporosis, stroke, and kidney disease. Workplaces are ripe for programs that improve health because most adults spend half of their waking time at work, and employers have a vested interest in keeping their employees well and at their jobs. Health problems can affect work attendance and job performance, and studies show that job satisfaction improves when workplace policies reflect that management values the employer as a person.
We also know a bit about how best to help people make these changes. Education is important, but it is very difficult to change behavior, even when people know all the facts about healthy living. We know that peer and group behavior has a lot to do with individual behaviors: People do what their friends and colleagues do. Thus it makes sense that workplaces might be a great place to introduce new, healthy behaviors. Ideally, such introduction should comprise informal and formal policies, educational events, engaging activities, and a preventative healthcare component.
Policies for Workplace Wellness
Workplace wellness policies are an important part of any workplace wellness program. Informal policies are not written down and enforced; rather they are the decisions made that will introduce ways for employees to make healthier choices. For example, you can include healthy food and beverage alternatives at worksite functions that involve food. If you offer food at meetings, trainings, or other events, why not offer healthy foods? At the North Carolina Institute for Public Health we celebrate birthdays once a month. Cake used to be the only option for food at these events; we have now added an attractive fruit salad to the table. Another example of an informal policy is to offer space and encouragement for weight management programs. This could mean physical space, such as a room in which employees could do a workout video after hours, or space in the schedule, such as time for employees to take daily walks without having to give up their lunch hour. Last winter, our staff undertook a "Biggest Loser" competition, with "weigh-ins" every Monday (costing a dollar for weight gained!!), and a cash payout to the individual who had lost the most weight at the end. The program was fun and entirely employee-organized and led, and many of the strategies used by "contestants" to lose weight have continued although the competition is over. There are a lot of ways to get your staff moving about during the day. One of our programs has "walking meetings" every week: Rather than sit around a table, the staff members walk around the block while discussing their agenda. "Standing" meetings (where you literally stand rather than sit during a meeting) have the added benefit of generally keeping meetings shorter.
Although informal policies are, by definition, not mandated from above, it is very important that management take the lead in establishing informal policies for healthy living within the organization. Managers make clear how work time can be used; whether you want to encourage employees to use their breaks to get exercise or to make sure they get their preventative healthcare needs taken care of, this encouragement should be clear and widely communicated. Model this behavior yourself by taking a walk during your own break or keeping up on your own preventative health checks. You could work with a local health club to offer cut-rate membership to your staff-and then join yourself. You can choose to have healthy food choices in the workplace vending machine, and work with the vendor on making the costs for healthy foods comparable to those for unhealthy foods. Finally, it is important to share information about available classes in healthy cooking or physical activity, sponsor speakers at staff retreats about the management of conditions affected by diet and physical activity, and take part in such events yourself.
If you want to make some of the changes above, you may have to create written formal policies. Obviously, formal policies won't work for everything; however, many workplaces already have some formal policies related to health. Most workplaces are now smoke-free, for example. At the University of North Carolina, a rule went into effect this year that prohibits smoking inside and within 100 feet (30.48 m) of university buildings. This rule eliminates the desirability of "stepping out for a smoke" for a lot of people. It also eliminates the cloud of smoke through which nonsmokers used to have to walk to get through the front door of some buildings. Not that long ago, such a law would have been unheard of in this tobacco state. A tipping point is being reached around eating as well, where, for example, restaurants are feeling pressure (of the law, in some places) to publish the calorie and nutritional content of their meals, and schools are being required to eliminate junk food from their cafeterias and vending machines.
Unlike smoking, most health-related behaviors are still difficult or impossible to regulate. In general, formal policies (except for those against smoking) regulate the organization, not the individual. For example, it can be organizational formal policy never to serve alcohol at sponsored events or always to offer healthy food choices at events with food. One of the programs here at the North Carolina Institute for Public Health, Active Living by Design, has an extensive list of workplace policies related to active living and healthy eating. Active Living by Design was established by the Robert Wood Johnson Foundation to work with local and national partners to build community-led programs for active living and healthy eating. Their workplace policies, both formal and informal, reflect the program's mission. For example, the office has a "no dumping" policy, meaning employees are asked not to bring candy, cookies, cakes, and other foods and beverages of limited nutritional value into the office for group consumption. Managers are asked never to use food as an enticement to attend a meeting and never to cancel a planned break for physical activity because of work-related interruptions.
Active Living by Design encourages routine physical activity in very concrete ways: It has located its office in a location conducive to walking or biking to work or during breaks; it keeps a fleet of bicycles at the workplace for employee use; it subsidizes gym memberships for employees as well as memberships in a local co-op health food store; it offers up to 2 hours weekly of paid work time for physical activity, including planned team-building exercises; it provides an on-site shower. These are great benefits to the employees who work at Active Living by Design.
On the one hand, this list highlights the challenges most organizations face: We may be located in spaces not conducive to walking or biking; it is not possible for every workplace to have a shower or maintain a fleet of bicycles. Americans drive everywhere, and that is a problem, but it is not realistic for everyone to bicycle or walk to work. On the other hand, this list highlights some of the things an organization can do if it thinks innovatively about health. If you can't walk outside at your organization, can you set up an indoor walking loop? Is there a nearby park to which employees could drive for their "walking meeting"? When you have an off-site meeting, can you choose one that has accessible options for routine physical activity? Do you have a sister organization with room for an exercise class or educational presentation? In these types of ways, you could augment the space if your organization is not ideally located for physical activity.
Worksite Wellness and the Public Health Department
Public health departments are particularly suited for instituting workplace wellness programs. Beyond the general interest in health that motivates many to seek careers in public health, health departments have the expertise to create comprehensive programs that address a range of health needs, not only health behaviors. Public health departments working with partners in business and industry could fulfill their mission to improve the health of their community by improving the health of organizations by changing behaviors and instituting preventative health programs within their walls.
Every year, several teams in our Management Academy for Public Health take up the cause of workplace wellness. For example, a team from Oklahoma that graduated in 2008 created a plan called "Make it Your Business Oklahoma," which involved a strategic alliance between government, health insurance, and business entities, to work with businesses to implement policies that encourage employees to eat better, move more, and be tobacco-free. In that case, the health insurance company would give a break in costs to organizations whose employees participated in the program. Another team, from Virginia, in 2005 created "Health Works for Everyone," a mobile medical clinic to provide medical screening and referral services to businesses. Businesses benefited from having it on-site on a regular basis, so that employees did not have to take time off for preventative healthcare appointments. "Fit for Work" was a similar plan created by a team from South Carolina in 2006. In all of these cases, the plan was to encourage businesses and industries in their communities to create healthy workplaces for their employees.
In these cases, the teams developed plans for their partners' workplaces: Businesses and industries in their community funded and benefited from the programs. One team, from New Hanover County, North Carolina, developed a plan for its own workplace, as well as others within the county government. The Wellness and You (WAY) program was launched in 2008 and is now run through the New Hanover County Human Resources Department. The program includes three elements: (1) an annual health risk assessment for all participants, (2) "lunch and learn" sessions on various health topics (participants attend at least three over the course of the year), and (3) a system by which participants report their physical activity and get a day of paid leave after a certain number of hours. In order to help participants fulfill the physical activity portion, the program sponsors several health "challenges," including walking programs and "Biggest Loser" competitions. About 500 out of 1 700 county employees participate in this voluntary program, which is really a pilot program for a larger plan in which the county would enroll local businesses in the program as well. It is supported by small fees paid by participants and in-kind donations from community partners and the health department.
The New Hanover County program is now run by former Management Academy teammates Debbie Nash, in County Human Resources, and Amy Cook, Health Promotion Supervisor at the health department. Ms Cook gives the following advice for making a worksite wellness program like this work:
1. Make exercise fun and engaging. WAY instituted a walking program called "Walk Across America." Located at the eastern terminus of Interstate 40 in Wilmington, North Carolina, planners tracked a route that would take walkers all the way to Barstow, California-the other end of Interstate 40, about 2 500 miles to the west. As walkers logged miles, program planners let them know where they had reached, sharing recipes from that part of the country as they "passed through," and sharing stories if anyone had been there before. The program was a big hit. Next, they're going to "climb Mount Everest" and "walk across Europe"!!There's not a "one size fits all" program that will be fun and engaging for every organization. You know your organization best. At New Hanover County, they found that employees valued camaraderie in their activities: The time for talking and bonding over sharing stories was as important as the miles walked. On the other hand, New Hanover WAY program planners consulted with another organization in Wilmington, in which the employees wanted something with a competition element to it. Program planners added a "race" element to the walking program they designed for that group.
2. Start by focusing on behaviors. Outcomes should come later. Participants in WAY now attend one health risk assessment per year and meet with healthcare staff to talk about the results. Planners hope to institute a program for follow-up health assessments and an individual "health plan" based on the health risk assessment-a sort of "work plan" for improving health that the participant would use going forward. At some point, plan evaluators will want to evaluate changes in rates of overweight, diabetes, and other health outcomes in individuals and the workforce as a whole. Now, however, the goal is to encourage participation through making the program as fun as possible and incentivizing it with immediate returns, such as coupons to the local health food store or other benefits related to participating.
3. Senior management support is crucial. Management team members participate in the WAY program; they clearly support the time and space it takes; and they have sent the message: "We're all in this together." Too often, public health educational programs can seem condescending or patronizing. Clients may feel as if their health behaviors, the way they've always lived, eaten, and taken care of themselves, are being criticized. Management participation can help alleviate these feelings, as well as giving the all-important stamp of approval to the activities.The other crucial role of management is in making sure that the program is supported financially. In general, the New Hanover program uses in-kind donations of expertise and time for the seminars. Coordination is now part of two existing employees' jobs, but ideally a coordinator would be hired to run the program. When you write up a plan for such a program, find out how much the elements would cost, even if you're receiving donated or in-kind space, time, services, and products. That way, you will have a good idea of the program's worth and understand its needs, should the "free" sources dry up, or you decide to look for partners to pay for part or all of it.
4. Develop strategic partnerships. The WAY program depends upon community participation and support to make the program work. The vendors who supply their vending machines and cater their events are on board with moving toward more healthful choices for foods. Several local health clubs offer reduced-cost memberships to participants in the program. The insurance company for the county employees, Blue Cross/Blue Shield, provides the technology needed for participants to register their physical activity and get rewards based on their level. The local optometrist's office gives free vision screening, a retired yoga instructor has offered to teach yoga if they can find space for it, and several health department employees have presented at "lunch and learn" sessions for the program. Besides enhancing the program, building these types of relationships strengthens the health department's standing in and connection to the community.
5. Meet people where they are. A good program begins with the understanding that everyone has different reasons for participating in a worksite wellness program. Not everyone wants to lose weight; so if all you do is a "Biggest Loser" competition, you may miss out on others. Some people want to quit smoking; others need help with learning how to cook healthy foods; others feel intimidated by going to a health club and need other outlets or guidance; others need yoga or meditation for mental relaxation and mindfulness. Some people may have disabilities that keep them from participating fully in some activities. The health risk assessment follow-up can be a good place for participants to talk about their concerns and goals with regard to health.
6. Incorporate healthcare components if possible. Your program can do more than provide chances for people to exercise or learn about healthy food choices. The WAY program incorporates health risk assessment. Other plans we have seen incorporate regular preventative checkups, flu (or other) vaccinations, and other healthcare components, including primary care. Obviously, such programs can be expensive, but public health departments have the expertise and the connections to incorporate healthcare into their wellness programs and should consider trying to do so.
Keep Your Eye on the Prize
My goal in this column is not to say what must be done to improve health in the workplace; rather, it is to show what can be done and to share what others have done. For more information about the programs mentioned here, visit the Web sites for Active Living by Design (http://www.activelivingbydesign.org), New Hanover County Health Department (http://www.nhcgov.com), and the Management Academy for Public Health (http://www.maph.unc.edu).