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15. Health Protection and Promotion

Chapter Editors: Jacqueline Messite and Leon J. Warshaw

Table of Contents

Figures and Tables

Health Protection and Promotion in the Workplace: An Overview
Leon J. Warshaw and Jacqueline Messite

Worksite Health Promotion
Jonathan E. Fielding

Health Promotion in the Workplace: England
Leon Kreitzman

Health Promotion in Small Organizations: The US experience
Sonia Muchnick-Baku and Leon J. Warshaw

Role of the Employee Health Service in Preventive Programmes
John W.F. Cowell

Health Improvement Programmes at Maclaren Industries, Inc.: A Case Study
Ian M.F. Arnold and Louis Damphousse

Role of the Employee Health Service in Prevention Programmes: A Case Study
Wayne N. Burton

Worksite Health Promotion in Japan
Toshiteru Okubo

Health Risk Appraisal
Leon J. Warshaw

Physical Training and Fitness Programmes: An Organizational Asset
James Corry

Worksite Nutrition Programmes
Penny M. Kris-Etherton and John W. Farquhar

Smoking Control in the Workplace
Jon Rudnick

Smoking Control Programmes at Merrill Lynch and Company, Inc.: A Case Study
Kristan D. Goldfein

Cancer Prevention and Control
Peter Greenwald and Leon J. Warshaw

Women’s Health
Patricia A. Last

Mammography Programme at Marks and Spencer: A Case Study
Jillian Haslehurst    

Worksite Strategies to Improve Maternal and Infant Health: Experiences of US Employers

Maureen P. Corry and Ellen Cutler

HIV/AIDS Education
B.J. Stiles

Health Protection and Promotion: Infectious Diseases
William J. Schneider

Protecting the Health of the Traveller
Craig Karpilow

Stress Management Programmes
Leon J. Warshaw

Alcohol and Drug Abuse
Sheila B. Blume

Employee Assistance Programmes
Sheila H. Akabas

Health in the Third Age: Pre-retirement Programmes
H. Beric Wright

Saul G. Gruner and Leon J. Warshaw


Click a link below to view table in the article context.

1. Health-related activities by workforce size
2. Breast & cervical cancer screening rates
3. Themes of “World No-Tobacco Days”
4. Screening for neoplastic diseases
5. Health insurance benefits
6. Services provided by the employer
7. Substances capable of producing dependence


Point to a thumbnail to see figure caption, click to see figure in article context.


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It has often been said that the workforce is the most critical element in the productive apparatus of the organization. Even in highly automated plants with their smaller number of workers, decrements in their health and well-being will sooner or later be reflected in impaired productivity or, sometimes, even in disasters.

Through governmental legislation and regulation, employers have been made responsible for maintaining the safety of the work environment and work practices, and for the treatment, rehabilitation and compensation of workers with occupational injuries and disease. In recent decades, however, employers have begun to recognize that disabilities and absences are costly even when they originate outside the workplace. Consequently, they have begun to provide more and more comprehensive health promotion and protection programs not only for employees but for their families as well. In opening a 1987 meeting of a World Health Organization (WHO) Expert Committee on Health Promotion in the Worksetting, Dr. Lu Rushan, Assistant Director-General of WHO, reiterated that WHO viewed workers’ health promotion as an essential component of occupational health services (WHO 1988).

Why the Workplace?

The rationale for employer sponsorship of health promotion programs includes preventing loss of worker productivity due to avoidable illnesses and disability and their associated absenteeism, improving employee well-being and morale, and controlling the costs of employer-paid health insurance by reducing the amount of health care services required. Similar considerations have stimulated union interest in sponsoring programs, particularly when their members are scattered among many organizations too small to mount effective programs on their own.

The workplace is uniquely advantageous as an arena for health protection and promotion. It is the place where workers congregate and spend a major portion of their waking hours, a fact that makes it convenient to reach them. In addition to this propinquity, their camaraderie and sharing of similar interests and concerns facilitate the development of peer pressures that can be a powerful motivator for participation and persistence in a health promotion activity. The relative stability of the workforce—most workers remain in the same organization for long periods of time—makes for the continuing participation in healthful behaviors necessary to achieve their benefit.

The workplace affords unique opportunities to promote the improved health and well-being of the workers by:

  • integrating the health protection and promotion programme into the organization’s efforts to control occupational diseases and injuries
  • modifying the structure of the job and its environment in ways that will make it less hazardous and less stressful
  • providing employer- or union-sponsored programmes designed to enable employees to cope more effectively with personal or family burdens that may impinge on their well-being and work performance (i.e., modified work schedules and financial assistance benefits and programmes that address alcohol and drug abuse, pregnancy, child care, caring for elderly or disabled family members, marital difficulties or planning for retirement).


Does Health Promotion Work?

There is no doubt of the efficacy of immunizations in preventing infectious diseases or of the value of good occupational health and safety programs in reducing the frequency and severity of work-related diseases and injuries. There is general agreement that early detection and appropriate treatment of incipient diseases will reduce mortality and lower the frequency and extent of residual disability from many diseases. There is growing evidence that elimination or control of risk factors will prevent or, at least, substantially delay the onset of life-threatening diseases such as stroke, coronary artery disease and cancer. There is little doubt that maintaining a healthy lifestyle and coping successfully with psychosocial burdens will improve well-being and functional capacity so as to achieve the goal of wellness defined by the World Health Organization as a state beyond the mere absence of disease. Yet some remain skeptical; even some physicians, at least to judge by their actions.

There is perhaps a higher level of skepticism about the value of worksite health promotion programs. In large part, this reflects the lack of adequately designed and controlled studies, the confounding effect of secular events such as the declining incidence of mortality from heart disease and stroke and, most important, the length of time required for most preventive measures to have their effect. However, in the Health Project report, Freis et al. (1993) summarize the growing literature confirming the effectiveness of worksite health promotion programs in reducing health care costs. In its initial review of over 200 workplace programs, the Health Project, a voluntary consortium of business leaders, health insurers, policy scholars and members of government agencies which advocate health promotion to reduce the demand and the need for health services, found eight with convincing documentation of savings in health care costs.

Pelletier (1991) assembled 24 studies of comprehensive worksite programs published in peer-review journals between 1980 and 1990. (Reports of single-focus programs, such as those dealing with hypertension screening and smoking cessation, even though demonstrated to have been successful, were not included in this review.) He defined “comprehensive programs” as those which “provide an ongoing, integrated program of health promotion and disease prevention that knits the particular components (smoking cessation, stress management, coronary risk reduction, etc.) into a coherent, ongoing program that is consistent with corporate objectives and includes program evaluation.” All of the 24 programs summarized in this review achieved improvement in employees’ health practices, reductions in absenteeism and disability, and/or increases in productivity, while each of these studies that analyzed for impact on health care and disability costs, cost-effectiveness or cost/benefit changes demonstrated a positive effect.

Two years later, Pelletier reviewed an additional 24 studies published between 1991 and the early part of 1993 and found that 23 reported positive health gains and, again, all of those studies which analyzed cost-effectiveness or cost/benefit effects indicated a positive return (Pelletier 1993). Factors common to the successful programs, he noted, included specific program goals and objectives, easy access to the program and facilities, incentives for participation, respect and confidentiality, support of top management and a corporate culture that encourages health promotion efforts (Pelletier 1991).

While it is desirable to have evidence confirming the effectiveness and value of worksite health promotion programs, the fact is that such proof has rarely been required for the decision to initiate a program. Most programs have been based on the persuasive power of the conviction that prevention does work. In some instances, programs have been stimulated by interest articulated by employees and, occasionally, by the unexpected death of a top executive or a key employee from cancer or heart disease and the fond hope that a preventive program will keep “lightning from striking twice”.

Structure of a Comprehensive Program

In many organizations, particularly smaller ones, the health promotion and disease prevention program consists merely of one or more largely ad hoc activities that are informally related to each other, if at all, that have little or no continuity, and that often are triggered by a particular event and abandoned as it fades into memory. A truly comprehensive program should have a formal structure comprising a number of integrated elements, including the following:

  • a clear statement of goals and objectives that are approved by management and acceptable to the employees
  • explicit endorsement by top management and, where they exist, the labour organizations involved, with the continuing allocation of resources adequate to achieve desired goals and objectives
  • appropriate placement in the organization, effective coordination with other health-related activities, and communication of programme plans across divisions and departments to mid-level managers and employees. Some organizations have found it expedient to create a labour-management committee comprising representatives from all levels and segments of the workforce for “political” reasons as well as to provide input on programme design
  • designation of a “programme director,” a person with the requisite administrative skills who also has had training and experience in health promotion or has access to a consultant who might supply the necessary expertise
  • a mechanism for feedback from participants and, if possible, non-participants as well, in order to confirm the validity of the programme design and to test the popularity and utility of particular programme activities
  • procedures for maintaining the confidentiality of personal information
  • systematic record-keeping to keep track of activities, participation and outcomes as a basis for monitoring and potential evaluation
  • compilation and analysis of available relevant data, ideally for a scientific evaluation of the programme or, when that is not feasible, to generate a periodic report to management to justify continuation of the resource allocation and to form a basis for possible changes in the programme.


Program Objectives and Ideology

The basic objectives of the program are to enhance and maintain the health and well-being of employees on all levels, to prevent disease and disability, and to ease the burden on individuals and the organization when disease and disability cannot be prevented.

The occupational health and safety program is directed to those factors on the job and in the workplace that may affect employees’ health. The wellness program recognizes that their health concerns cannot be confined within the boundaries of the plant or office, that problems arising in the workplace inevitably affect the health and well-being of workers (and, by extension, also their families) in the home and in the community and that, just as inevitably, problems arising outside of work affect attendance and work performance. (The term wellness can be considered the equivalent of the expression health promotion and protection, and has been used increasingly in the field during the last two decades; it epitomizes the World Health Organization’s positive definition of health.) Accordingly, it is quite appropriate for the health promotion program to address problems that some argue are not proper concerns for the organization.

The need to achieve wellness assumes greater urgency when it is recognized that workers with diminished capacities, however acquired, may be potentially hazardous to their co-workers and, in certain jobs, to the public as well.

There are those who hold that, since health is fundamentally a personal responsibility of the individual, it is inappropriate, and even intrusive, for employers or labor unions (or both) to undertake involvement with it. They are correct insofar as overly paternalistic and coercive approaches are employed. However, health-promoting adjustments of the job and the workplace along with enhanced access to health-promoting activities provide the awareness, knowledge and tools that enable employees to address that personal responsibility more effectively.

Program Components

Needs assessment

While the alert program director will take advantage of a particular event that will create interest in a special activity (e.g., the unexpected illness of a popular person in the organization, reports of cases of an infectious disease that raise fears of contagion, warnings of a potential epidemic), the comprehensive program will be based on a more formal needs assessment. This may simply consist of a comparison of the demographic characteristics of the workforce with morbidity and mortality data reported by public health authorities for such population cohorts in the area, or it may comprise the aggregate analyses of company-specific health-related data, such as health care insurance claims and the recorded causes of absenteeism and of disability retirement. Determination of the health status of the workforce through compilation of the results of health screenings, periodic medical examinations and health risk appraisal programs can be supplemented by surveys of employees’ health-related interests and concerns to identify optimal targets for the program. (It should be borne in mind that health problems affecting particular cohorts of employees that warrant attention may be obscured by relying only on data aggregated for the entire workforce.) Such needs assessments are not only useful in selecting and prioritizing program activities but also in planning to “market” them to the employees most likely to find them beneficial. They also provide a benchmark for measuring the effectiveness of the program.

Program elements

A comprehensive health promotion and disease prevention program includes a number of elements, such as the following.

Promoting the program

A constant stream of promotional devices, such as handbills, memoranda, posters, brochures, articles in company periodicals, etc., will serve to call attention to the availability and desirability of participating in the program. With their permission, stories of the accomplishments of individual employees and any awards for achieving health promotion goals they may have earned may be highlighted.

Health assessment

Where possible, each employee’s health status should be assessed on entering the program to provide a basis for a “prescription” of personal objectives to be achieved and of the specific activities that are indicated, and periodically to assess progress and interim changes in health status. The health risk appraisal may be used with or without a medical examination as comprehensive as circumstances permit, and supplemented by laboratory and diagnostic studies. Health screening programs can serve to identify those for whom specific activities are indicated.


There is a long list of activities that may be pursued as part of the program. Some are continuing, others are addressed only periodically. Some are targeted to individuals or to particular cohorts of the workforce, others to the entire employee population. Prevention of illness and disability is a common thread that runs through each activity. These activities may be divided into the following overlapping categories:

  • Clinical services. These require health professionals and include: medical examinations; screening programmes; diagnostic procedures such as mammography; Pap smears and tests for cholesterol level; immunizations and so forth. They also include counseling and behaviour modification in relation to weight control, fitness, smoking cessation and other lifestyle factors.
  • Health education. Education to promote awareness of potential diseases, the importance of controlling risk factors, and the value of maintaining healthy lifestyles, for instance, through weight control, fitness training and smoking cessation. Such education should also point the way to appropriate interventions.
  • Guidance in managing medical care. Advice should be given with regard to the following concerns: dealing with the health care system and procuring prompt and high-quality medical care; managing chronic or recurrent health problems; rehabilitation and return to work after disease or injury; treatment for alcohol and drug abuse; prenatal care and so on.
  • Coping with personal problems. Coping skills to be developed include, for example, stress management, pre-retirement planning and outplacement. Help can also be provided for workers who need to deal with work and family problems such as family planning, prenatal care, dependant care, parenting, and so forth.
  • Workplace amenities and policies. Workplace features and policies supplementary to those addressing occupational health and safety activities would include personal washing-up and locker facilities, laundry service where needed, catering facilities offering nutrition advice and helpful food choices, and the establishment of a smoke-free and drug-free workplace, among others.


In general, as programs have developed and expanded and awareness of their effectiveness has spread, the number and variety of activities have grown. Some, however, have been de-emphasized as resources have either been reduced because of financial pressures or shifted to new or more popular areas.


The tools employed in pursuing health promotion activities are determined by the size and location of the organization, the degree of centralization of the workforce with respect to geography and work schedules; the available resources in terms of money, technology and skills; the characteristics of the workforce (as regards educational and social levels); and the ingenuity of the program director. They include:

  • Information gathering: employee surveys; focus groups
  • Print materials: books; pamphlets (these may be distributed or displayed in take-away racks); pay envelope stuffers; articles in company publications; posters
  • Audiovisual materials: audiotapes; recorded messages accessible by telephone; films; videos for both individual and group viewing. Some organizations maintain libraries of audiotapes and videos which employees may borrow for home use
  • Professional health services: medical examinations; diagnostic and laboratory procedures; immunizations; individual counselling
  • Training: first aid; cardiopulmonary resuscitation; healthy shopping and cooking
  • Meetings: lectures; courses; workshops
  • Special events: health fairs; contests
  • Self-help and support groups: alcohol and drug abuse; breast cancer; parenting; eldercare
  • Committees: an intramural task force or committee to coordinate health-related programmes among different departments and divisions and a labour-management committee for overall programme guidance are often useful. There may also be special committees centred on particular activities
  • Sports programmes: intramural sports; the sponsoring of individual participation in community programmes; company teams
  • Computer software: available for individual personal computers or accessed through the organization’s network; health-promotion-oriented computer or video games
  • Screening programmes: general (e.g., health risk appraisal) or disease specific (e.g., hypertension; vision and hearing; cancer; diabetes; cholesterol)
  • Information and referral: employee assistance programmes; telephone resource for personal questioning and advice
  • Ongoing activities: physical fitness; healthful food selection in worksite catering facilities and vending machines
  • Special benefits: released time for health promotion activities; tuition reimbursement; modified work schedules; leaves of absence for particular personal or family needs
  • Incentives: awards for participation or goals achievement; recognition in company publications and on bulletin boards; contests and prizes.


Implementing the Program

In many organizations, particularly smaller ones, health promotion activities are pursued on an ad hoc, haphazard basis, often in response to actual or threatened health “crises” in the workforce or in the community. After a time, however, in larger organizations, they are often pulled together into a more or less coherent framework, labelled “a program,” and made the responsibility of an individual designated as program director, coordinator or given some other title.

Selection of activities for the program may be dictated by the responses to employee interest surveys, secular events, the calendar or the suitability of the available resources. Many programs schedule activities to take advantage of the publicity generated by the categorical voluntary health agencies in connection with their annual fund-raising campaigns, for example, Heart Month, or National Fitness and Sports Week. (Each September in the United States, the National Health Information Center in the Office of Disease Prevention and Health Protection publishes National Health Observances, a list of the designated months, weeks and days devoted to the promotion of particular health issues; it is now also available via electronic mail.)

It is generally agreed that it is prudent to install the program incrementally, adding activities and topics as it gains credibility and support among the employees and to vary the topics to which special emphasis is given so that the program does not become stale. J.P. Morgan & Co., Inc., the large financial organization based in New York City, has instituted an innovative “scheduled cyclical format” in its health promotion program that emphasizes selected topics sequentially over a four-year period (Schneider, Stewart and Haughey 1989). The first year (the Year of the Heart) focuses on cardiovascular disease prevention; the second (the Year of the Body) addresses AIDS and early cancer detection and prevention; the third (the Year of the Mind) deals with psychological and social issues; and the fourth (the Year of Good Health) covers such significant topics as adult immunization, arthritis and osteoporosis, accident prevention, diabetes and healthy pregnancy. At this point, the sequence is repeated. This approach, Schneider and his co-authors state, maximizes involvement of available corporate and community resources, encourages employee participation by sequential attention to different issues, and affords the opportunity for directing attention to program revisions and additions based on medical and scientific advances.

Evaluating the Program

It is always desirable to evaluate the program both to justify continuation of its resource allocations and to identify any need for improvement and to support recommendations for expansion. The evaluation may range from simple tabulations of participation (including drop-outs) coupled with expressions of employee satisfaction (solicited and unsolicited) to more formal surveys. The data obtained by all these means will demonstrate the degree of utilization and the popularity of the program as a whole entity and of its individual components, and are usually readily available soon after the end of the evaluation period.

Even more valuable, however, are data reflecting the outcomes of the program. In an article pointing the way to improving evaluations of health promotion programs, Anderson and O’Donnell (1994) offer a classification of areas in which health promotion programs may have significant results (see figure 1).

Figure 1. Categories of health promotion outcomes.


Outcome data, however, require an effort planned prior to the outset of the program, and they have to be collected over a time sufficient to allow the outcome to develop and be measured. For example, one can count the number of individuals who receive an influenza immunization and then follow the total population for a year to demonstrate that those inoculated had a lower incidence of influenza-like respiratory infections than those who refused the inoculation. The study can be enlarged to correlate rates of absenteeism of the two cohorts and compare the program costs with the direct and indirect savings accrued by the organization.

Furthermore, it is not too difficult to demonstrate individuals’ achievement of more desirable profiles of risk factors for cardiovascular disease. However, it will take at least one and probably several decades to demonstrate a reduction in morbidity and mortality from coronary heart disease in an employee population cohort. Even then, the size of that cohort may not be large enough to make such data significant.

The review articles cited above demonstrate that good evaluation research can be done and that it is increasingly being undertaken and reported. There is no question of its desirability. However, as Freis and his co-authors (1993) said, “There are already model programs that improve health and decrease costs. It is not knowledge that is lacking, but penetration of these programs into a greater number of settings.”








Comments and Caveats

Organizations contemplating the launching of a health promotion program should be cognizant of a number of potentially sensitive ethical issues to be considered and a number of pitfalls to avoid, some of which have already been alluded to. They are comprised under the following headings:

Elitism versus egalitarianism

A number of programs exhibit elitism in that some of the activities are limited to individuals above a certain rank. Thus, an in-plant physical fitness facility may be restricted to executives on the grounds that they are more important to the organization, they work longer hours, and they find it difficult to free up the time to go to an outside “health club”. To some, however, this seems to be a “perk” (i.e., a special privilege), like the key to the private washroom, admission to the free executive dining room, and use of a preferred parking space. It is sometimes resented by rank-and-file workers who find visiting a community facility too expensive and are not allowed the liberty of taking time during the working day for exercise.

A more subtle form of elitism is seen in some in-plant fitness facilities when the quota of available memberships is taken up by “jocks” (i.e., exercise enthusiasts) who would probably find ways to exercise anyway. Meanwhile, those who are sedentary and might derive much greater benefit from regular supervised exercise are denied entry. Even when they make it into the fitness program, their continued participation is often discouraged by embarrassment at being outperformed by lower-ranking workers. This is particularly true of the manager whose male self-image is tarnished when he finds that he cannot perform at the level of his female secretary.

Some organizations are more egalitarian. Their fitness facilities are open to all on a first-come, first-served basis, with continuing membership available only to those who use it frequently enough to be of value to them. Others go part of the way by reserving some of the memberships for employees who are being rehabilitated following an illness or injury, or for older workers who may require a greater inducement to participate than their younger colleagues.


In some areas, anti-discrimination laws and regulations may leave the organization open to complaints, or even litigation, if the health promotion program can be shown to have discriminated against certain individuals on the basis of age, sex or membership in minority or ethnic groups. This is not likely to happen unless there is a more pervasive pattern of bias in the workplace culture but discrimination in the health promotion program might trigger a complaint.

Even if formal charges are not made, however, resentment and dissatisfaction, which may be magnified as they are communicated informally among employees, are not conducive to good employee relations and morale.

Concern about allegations of sex discrimination may be exaggerated. For example, even though it is not recommended for routine use in asymptomatic men (Preventive Services Task Force 1989), some organizations offer screening for prostatic cancer to compensate for making Pap tests and mammography available to female employees.

Complaints of discrimination have come from individuals who are denied the opportunity of winning incentive awards because of congenital health problems or acquired diseases that preclude participation in health promotion activities or achieving the ideal personal health goals. At the same time, there is the equity issue of rewarding individuals for correcting a potential health problem (e.g., giving up smoking or losing excess weight) while denying such rewards to individuals who do not have such problems.

“Blaming the victim”

Growing out of the valid concept that health status is a matter of personal responsibility is the notion that individuals are culpable when health defects are found and are to be held guilty for failing to correct them on their own. This sort of thinking fails to take notice of the fact that genetic research is increasingly demonstrating that some defects are hereditary and, therefore, although they may sometimes be modified, are beyond the individual’s capacity to correct.

Examples of “blaming the victim” are (a) the too-prevalent attitude that HIV/AIDS is a fitting retribution for sexual “indiscretions” or intravenous drug use and, therefore, its victims do not deserve compassion and care, and (b) the imposition of financial and bureaucratic barriers that make it difficult for unmarried young women to get adequate prenatal care when they become pregnant.

Most important, focusing in the workplace on individuals’ responsibility for their own health problems tends to obscure the employer’s accountability for factors in job structure and work environment that may be hazardous to health and well-being. Perhaps the classic example is the organization that offers stress management courses to teach employees to cope more effectively but that does not examine and correct features of the workplace that are needlessly stressful.

It must be recognized that hazards present in the workplace may not only affect the workers, and by extension their families as well, but they may also precipitate and aggravate personal health problems generated away from the job. While retaining the concept of individual responsibility for health, it must be balanced by the understanding that factors in the workplace for which the employer is responsible may also have a health-related influence. This consideration highlights the importance of communication and coordination between the health promotion program and the employer’s occupational safety and  health and other health-related programs, especially when they are not in the same box on the organization chart.

Persuasion, not coercion

A cardinal tenet of worksite health promotion programs is that participation should be voluntary. Employees should be educated about the desirability of suggested interventions, provided with access to them, and persuaded to participate in them. There often is, however, a narrow margin between enthusiastic persuasion and compulsion, between well-meaning paternalism and coercion. In many instances, the coercion may be more or less subtle: e.g., some health promotion professionals tend to be overly authoritarian; employees may be fearful of embarrassment, being ostracized or even penalized if they reject the advice given them; a worker’s choices as to recommended health promotion activities may be overly limited; and executives may make it unpleasant for their subordinates not to join them in a favorite activity, such as jogging in the very early morning.

While many organizations offer rewards for healthy behavior, for instance, certificates of achievement, prizes, and “risk-rated” health insurance (involving, in the United States, for example, a reduction in the employee’s share of the premiums), a few impose penalties on those who do not meet their arbitrary standards of health behavior. The penalties may range from refusing employment, withholding advancement, or even dismissal or denying benefits that might otherwise be forthcoming. An example of an American firm levying such penalties is E.A. Miller, a meat-packing plant located in Hyrum, Utah, a town of 4,000 inhabitants located some 40 miles north of Salt Lake City (Mandelker 1994). E.A. Miller is the largest employer in this small community and provides group health insurance for its 900 employees and their 2,300 dependants. Its health promotion activities are typical in many ways except that there are penalties for not participating:

  • Employees and spouses who do not attend prenatal seminars are not reimbursed for the cost of obstetrical care or of the baby’s care in the hospital. Also, to qualify for the insurance benefits, the pregnant woman must visit a doctor during the first trimester.
  • If employees or their dependants smoke, they must contribute over twice as much to their share of group health insurance premiums: $66 per month instead of $30. The plant has had a smoke-free policy since 1991 and the company offers smoking cessation courses onsite or pays employees’ tuition if they take the course in the community.
  • The company will not cover any of the medical costs if a covered employee or dependant was injured in an automobile accident while driving under the influence of drugs or alcohol or was not wearing a seat belt, nor will it cover injuries sustained while riding a motorcycle without a helmet.


One form of coercion that has wide acceptance is “job jeopardy” for employees whose alcohol or drug abuse has had an impact on their attendance and work performance. Here, the employee is confronted with the problem and told that disciplinary actions will be stayed as long as he or she continues with the prescribed treatment and remains abstinent. With allowance for an occasional relapse (in some organizations, this is limited to a specific number), failure to comply results in dismissal. Experience has amply shown that the threat of job loss, regarded by some as the most potent stressor encountered in the workplace, is an effective motivator for many individuals with such problems to agree to take part in a program for their correction.

Confidentiality and privacy

Another hallmark of the successful health promotion program is that personal information about participating employees —and non-participants as well—must be kept confidential and, particularly, out of personnel files. To preserve the privacy of such information when it is needed for evaluative tabulations and research, some organizations have set up data bases in which individual employees are identified by code numbers or by some similar device. This is particularly relevant to mass screening and laboratory procedures where clerical errors are not unknown.

Who participates

Health promotion programs are criticized by some on the basis of evidence that participants tend to be younger, healthier and more health conscious than those who do not (the “coals to Newcastle” phenomenon). This presents to those designing and operating programs the challenge of involving those who have more to gain through their participation.

Who pays

Health promotion programs involve some costs to the organization. These may be expressed in terms of financial outlays for services and materials, time taken from work hours, distraction of participating employees, and the burden of management and administration. As noted above, there is increasing evidence that these are more than offset by reduced personnel costs and by improvements in productivity. There are also the less tangible benefits of embellishing the public relations image of the organization and of enhancing its reputation as a good place to work, thereby facilitating recruitment efforts.

Most of the time, the organization will cover the entire cost of the program. Sometimes, particularly when an activity is conducted off the premises in a community-based facility, the participants are required to share its cost. In some organizations, however, all or part of the employee’s portion is refunded on successful completion of the program or course.

Many group health insurance programs cover preventive services provided by health professionals including, for example, immunizations, medical examinations, tests, and screening procedures. Such health insurance coverage, however, presents problems: it may increase the cost of the insurance and the out-of-pocket costs of the deductible fees and co-payments usually required may constitute an effective obstacle to their use by low-salaried workers. In the last analysis, it may be less costly for employers to pay for preventive services directly, saving themselves the administrative costs of processing insurance claims and of reimbursement.

Conflicts of interest

While most health professionals exhibit exemplary integrity, vigilance must be exercised to identify and deal with those who do not. Examples include those who falsify records to make their efforts look good and those who have a relationship with an outside provider of services who provides kickbacks or other rewards for referrals. The performance of outside vendors should be monitored to identify those who underbid to win the contract and then, to save money, use poorly qualified personnel to deliver the services.

A more subtle conflict of interest exists when staff members and vendors subvert the needs and interests of employees in favor of the organization’s goals or the agenda of its managers. This sort of reprehensible action may not be explicit. An example is steering troubled employees into a stress management program without making a strenuous effort to persuade the organization to reduce inordinately high levels of stress in the workplace. Experienced professionals will have no difficulty in properly serving both the employees and the organization, but should be ready to move to a situation in which ethical values are more conscientiously observed whenever improper pressures on the part of management become too great.

Another subtle conflict that may affect employees adversely arises when a relationship of competition, rather than coordination and collaboration, develops between the health promotion program and other health-related activities in the organization. This state of affairs is found not infrequently when they are placed in different areas of the organization chart and report to different lines of management authority. As has been said before, it is critical that, even when part of the same entity, the health promotion program should not operate at the expense of the occupational safety and health program.


Stress is probably the most pervasive health hazard encountered both in the workplace and away from it. In a landmark survey sponsored by the St. Paul Fire and Marine Insurance Company and involving nearly 28,000 workers in 215 diverse American organizations, Kohler and Kamp (1992) found that work stress was strongly related to employee health and performance problems. They also found that among personal life problems, those created by the job are most potent, showing more impact than purely off-the-job issues such as family, legal or financial problems. This suggests, they said, that “some workers become caught in a downward spiral of work and home life problems—problems on the job create problems at home, which in turn are taken back to work, and so on.” Accordingly, while primary attention should be directed to the control of psychosocial risk factors intrinsic to the job, this should be complemented by health promotion activities aimed at personal stress factors most likely to affect work performance.

Access to health care

A subject worthy of attention in its own right, education in navigating the health care delivery system should be made part of the program with an eye to future needs for health services. This begins with self-care—knowing what to do when signs and symptoms appear and when professional services are needed—and goes on to selecting a qualified health professional or a hospital. It also includes inculcating both the ability to distinguish good from poor health care and an awareness of patients’ rights.

To save employees time and money, some in-plant medical units offer more or less extensive in-plant health services, (often including x rays, laboratory tests and other diagnostic procedures), reporting the results to the employees’ personal physicians. Others maintain a roster of qualified physicians, dentists and other health professionals to whom employees themselves and sometimes also their dependants may be referred. Time off from work to keep medical appointments is an important adjunct where health professional services are not available outside of working hours.

In the United States, even where there is a good group health insurance program, low-salaried workers and their families may find the deductible and coinsurance portions of covered charges to be barriers to procuring recommended health services in all but dire circumstances. Some employers are helping to overcome such obstacles by exempting these employees from such payments or by making special fee arrangements with their health care providers.

Worksite “climate”

Worksite health promotion programs are presented, often explicitly, as an expression of the employer’s concern for the health and well-being of the workforce. That message is contradicted when the employer is deaf to employees’ complaints about working conditions and does nothing to improve them. Employees are not likely to accept or participate in programs offered under such circumstances or at times of labor-management conflict.

Workforce diversity

The health promotion program should be designed to accommodate to the diversity increasingly characteristic of today’s workforce. Differences in ethnic and cultural background, educational levels, age and sex should be recognized in the content and presentation of health promotion activities.


It is clear from all of the above that the worksite health promotion program represents an extension of the occupational safety and health program which, when properly designed and implemented, can benefit individual employees, the workforce as a whole and the organization. In addition, it may also be a force for positive social change in the community.

Over the past few decades, worksite health promotion programs have increased in number and comprehensiveness, in small and medium-sized organizations as well as in larger ones, and in the private, voluntary and public sectors. As demonstrated by the array of articles contained in this chapter, they have also increased in scope, expanding from direct clinical services dealing, for example, with medical examinations and immunizations, to involvement with personal and family problems whose relationship to the workplace may seem more tenuous. One should allow one’s selection of program elements and activities to be guided by the particular characteristics of the workforce, the organization and the community, keeping in mind that some will be needed only by specific cohorts of employees rather than by the population as a whole.

In considering the creation of a worksite health promotion program, readers are advised to plan carefully, to implement incrementally, allowing room for growth and expansion, to monitor performance and program quality and, to the extent possible, evaluate outcomes. The articles in this chapter should prove to be uniquely helpful in such an endeavor.



Monday, 24 January 2011 18:37

Worksite Health Promotion


Occupational settings are appropriate sites for the furtherance of such health-related aims as assessment, education, counseling and health promotion in general. From a public policy perspective, worksites provide an efficient locus for activities such as these, involving as they often do a far-ranging aggregation of individuals. Moreover, most workers are in a predictable work location for a significant portion of time almost every week. The worksite is usually a controlled environment, where individuals or groups can be exposed to educational programming or receive counseling without the distractions of a home setting or the often hurried atmosphere of a medical setting.

Health is an enabling function, that is to say, one that permits individuals to pursue other goals, including successful performance in their work roles. Employers have a vested interest in maximizing health because of its tight linkage with productivity at work, as to both quantity and quality. Thus, reducing the occurrence and burden of diseases that lead to absences, disability or sub-par job performance is a goal that warrants a high priority and considerable investment. Worker organizations, established to improve the welfare of members, also have an inherent interest in sponsoring programs that can improve health status and quality of life.


Sponsorship by employers usually includes full or partial financial support of the program. However, some employers may support only planning or arranging for the actual health promotion activities for which individual workers must pay. Employer-sponsored programs sometimes provide employee incentives for participation, program completion, or successfully changing health habits. Incentives may include time off from work, financial rewards for participation or results, or recognition of achievement in reaching health-related goals. In unionized industries, particularly where workers are scattered among smaller workplaces too small to mount a program, health promotion programs may be designed and delivered by the labor organization. Although sponsorship of health education and counseling programs by employers or worker organizations commonly involves programs delivered at the worksite, they may take place in whole or in part at facilities in the community, whether run by government, non-profit-making or for-profit organizations.

Financial sponsorship needs to be complemented by employer commitment, on the part of top management and of middle management as well. Every employer organization has many priorities. If health promotion is to be viewed as one of these, it must be actively and visibly supported by senior management, both financially and by means of continuing to pay attention to the program, including the emphasizing of its importance in addressing employees, stockholders, senior managers and even the outside investment community.

Confidentiality and Privacy

While employee health is an important determinant of productivity and of the vitality of work organizations, health in itself is a personal matter. An employer or worker organization that wishes to provide health education and counseling must build into the programs procedures to ensure confidentiality and privacy. The willingness of employees to volunteer for work-related health education and counseling programs requires that employees feel that private health information will not be revealed to others without their permission. Of particular concern to workers and their representatives is that information obtained from health improvement programs not be utilized in any way in assessment of job performance or in managerial decisions about hiring, firing or advancement.

Needs Assessment

Program planning usually begins with a needs assessment. An employee survey is often performed to obtain information on such matters as: (a) self-reported frequency of health habits (e.g., smoking, physical activity, nutrition), (b) other health risks such as stress, hypertension, hypercholesterolemia, and diabetes, (c) personal priorities for risk reduction and health improvement, (d) attitude toward alternative program configurations, (e) preferred sites for health promotion programming, (f) willingness to participate in programmatic activities, and sometimes, (g) willingness to pay a portion of the cost. Surveys may also cover attitudes toward existing or potential employer policies, such as smoking bans or offering more nutritionally healthful fare in workplace vending machines or cafeterias.

The needs assessment sometimes includes analysis of the health problems of the employed group through examination of medical department clinical files, health care records, disability and worker’s compensation claims, and absenteeism records. Such analyses provide general epidemiological information on the prevalence and cost of different health problems, both somatic and psychological, allowing assessment of prevention opportunities from both the programmatic and financial point of view.

Program Structure

Results of needs assessments are considered in light of available monetary and human resources, past program experience, regulatory requirements and the nature of the workforce. Some of the key elements of a program plan that need to be clearly defined during a planning process are listed in figure 1. One of the key decisions is identifying effective modalities to reach the target population(s). For example, for a widely dispersed workforce, community-based programming or programming via telephone and mail may be the most feasible and cost-effective choice. Another important decision is whether to include, as some programmers do, retirees and spouses and children of employees in addition to the employees themselves.

Figure 1. Elements of a health promotion programme plan.


Responsibility for a worksite health promotion program can fall to any of a number of pre-existing departments, including the following: the medical or employee health unit; human resources and personnel; training; administration; fitness; employee assistance and others; or a separate health promotion department may be established. This choice is often very important to program success. A department with strong interest in doing its best for its clients, an appropriate knowledge base, good working relationships with other parts of the organization and the confidence of senior and line management has a very high likelihood of success in organizational terms. Employees’ attitudes toward the department in which the program is placed and their confidence in its integrity with particular reference to confidentiality of personal information may influence their acceptance of the program.







The frequency with which diverse health promotion topics is addressed based on surveys of private employers with 50 or more employees is shown in Figure 2. A review of results from comparable surveys in 1985 and 1992 reveals substantial increases in most areas. Overall in 1985, 66% of the worksites had at least one activity, whereas in 1992, 81% had one or more. Areas with the largest increases were those to do with exercise and physical fitness, nutrition, high blood pressure and weight control. Several topic areas queried for the first time in 1992 showed relatively high frequencies, including AIDS education, cholesterol, mental health and job hazards and injury prevention. Symptomatic of the expansion of areas of interest, the 1992 survey found that 36% of worksites provided education or other programs for abuse of alcohol and other drugs, 28% for AIDS, 10% for prevention of sexually-transmitted diseases, and 9% for prenatal education.

Figure 2. Health promotion information or activities offered by subject, 1985 and 1992.


A broad topic category increasingly included within worksite health promotion programming (16% of worksites in 1992) is health care mediated by self-help programs. Common to these programs are materials that address ways in which to treat minor health problems and to apply simple rules for judging the seriousness of various signs and symptoms in order to decide whether it may be advisable to seek professional help and with what degree of urgency.

Creating better-informed consumers of health care services is an allied program objective, and includes educating them such as how to choose a physician, what questions to ask the doctor, the pros and cons of alternative treatment strategies, how to decide whether and where to have a recommended diagnostic or therapeutic procedure, non-traditional therapies and patients’ rights.




Health Assessments

Regardless of mission, size and target population, multidimensional assessments of health are commonly administered to participating employees during the initial stages of the program and at periodic intervals thereafter. Data systematically collected usually cover health habits, health status, simple physiological measures, such as blood pressure and lipid profile, and (less commonly) health attitudes, the social dimensions of health, the use of preventive services, safety practices and family history. Computerized outputs, fed back to individual employees and aggregated for program planning, monitoring and evaluation, usually provide some absolute or relative risk estimates, which range from the absolute risk of having a heart attack during the ensuing ten-year period (or how an individual’s quantifiable risk of having a heart attack compares to the average risk for individuals of the same age and sex) to qualitative ratings of health and risks on a scale from poor to excellent. Individual recommendations are also commonly provided. For example, regular physical activity would be recommended for sedentary individuals, and more social contacts for an individual without frequent contact with family or friends.

Health assessments may be systematically offered at the time of hire or in association with specific programs, and thereafter at fixed intervals or with periodicity defined by age, sex and health risk status.


Another common element of most programs is counseling to effect changes in such deleterious health habits as smoking, poor nutritional practices or high-risk sexual behavior. Effective methods exist to assist individuals to increase their motivation and readiness to make changes in their health habits, to help them along in the actual process of making changes, and to minimize backsliding, often termed recidivism. Group sessions led by a health professional or lay person with special training are often used to help individuals make changes, while the peer support to be found in the workplace can enhance results in areas such as smoking cessation or physical activity.

Health education for workers may include topics that can positively influence the health of other family members. For example, education might include programming on healthy pregnancy, the importance of breast feeding, parenting skills, and how to effectively cope with the health care and related needs of older relatives. Effective counseling avoids stigmatizing program participants who have difficulty making changes or who decide against making recommended lifestyle changes.

Workers with Special Needs

A significant proportion of a working population, particularly if it includes many older workers, will have one or more chronic conditions, such as diabetes, arthritis, depression, asthma or low back pain. In addition, a substantial subpopulation will be considered at high risk for a serious future health problem, for example cardiovascular disease due to elevation of risk factors such as total serum cholesterol, high blood pressure, smoking, significant obesity or high levels of stress.

These populations may account for a disproportionate amount of health services utilization, health benefits costs and lost productivity, but these effects can be attenuated through prevention efforts. Therefore, education and counseling programs targeted at these conditions and risks have become increasingly common. Such programs often utilize a specially trained nurse (or less commonly, a health educator or nutritionist) to help these individuals make and maintain necessary behavioral changes and work more closely with their primary care physician to utilize appropriate medical measures, especially as regards the use of pharmaceutical agents.

Program Providers

Providers of employer-sponsored or worker-sponsored health promotion programming are varied. In larger organizations, particularly with significant geographic concentrations of employees, existing full- or part-time personnel may be the principal program staff—nurses, health educators, psychologists, exercise physiologists and others. Staffing can also come from outside providers, individual consultants or organizations providing personnel in a wide range of disciplines. Organizations offering these services include hospitals, voluntary organizations (e.g., the American Heart Association); for-profit health promotion companies offering health screening, fitness, stress management, nutrition and other programs; and managed care organizations. Program materials may also come from any of these sources or they may be developed internally. Worker organizations sometimes develop their own programs for their members, or may provide some health promotion services in partnership with the employer.

Many education and training programs have been established to prepare both students and health professionals to plan, implement and evaluate worksite health promotion programs. Many universities offer courses in these subjects and some have a special “worksite health promotion” major or area of specialization. A large number of continuing education courses on how to work in a corporate setting, program management and advances in techniques are offered by public and private educational institutions as well as professional organizations. To be effective, providers must understand the specific context, constraints and attitudes associated with employment settings. In planning and implementing programs they should take into account policies specific to the type of employment and worksite, as well as the relevant labor relations issues, work schedules, formal and informal organizational structures, not to mention the corporate culture, norms and expectations.


Applicable technologies range from self-help materials that include traditional books, pamphlets, audiotapes or videotapes to programmed learning software and interactive videodiscs. Most programs involve interpersonal contact through groups such as classes, conferences and seminars or through individual education and counseling with an onsite provider, by telephone or even via computer link. Self-help groups may also be utilized.

Computer-based data collection systems are essential for program efficiency, serving a variety of management functions—budgeting and use of resources, scheduling, individual tracking, and both process and outcome evaluation. Other technologies could include such sophisticated modalities as a direct bio-computer linkage to record physiological measures—blood pressure or visual acuity for instance—or even the subject’s participation in the program itself (e.g., attendance at a fitness facility). Hand-held computer-based learning aids are being tested to assess their ability to enhance behavioral change.


Evaluation efforts run the gamut from anecdotal comments from employees to complex methodologies that justify publication in peer-reviewed journals. Evaluations may be directed towards a wide variety of processes and outcomes. For example, a process evaluation could assess how the program was implemented, how many employees participated and what they thought of it. Outcome evaluations may target changes in health status, such as the frequency or level of a health risk factor, whether self-reported (e.g., level of exercise) or objectively evaluated (e.g., hypertension). An evaluation may focus upon economic changes such as the use and cost of health care services or upon absenteeism or disability, whether this may be related to the job or not.

Evaluations may cover only program participants or they may cover all at-risk employees. The former sort of evaluation can answer questions relating to the efficacy of a given intervention but the latter answers the more important question as to the effectiveness with which risk factors in an entire population may have been reduced. While many evaluations focus on efforts to change a single risk factor, others address the simultaneous effects of multicomponent interventions. A review of 48 published studies assessing outcomes of comprehensive health promotion and disease prevention in the worksite found that 47 reported one or more positive health outcomes (Pelletier 1991). Many of these studies have significant weaknesses in design, methodology or analysis. Nonetheless, their near-unanimity with respect to positive findings, and the optimistic results of the best designed studies, suggest that real effects are in the desired direction. What is less clear is the reproducibility of effects in replicated programs, how long the initially observed effects endure, and whether their statistical significance translates into clinical significance. In addition, evidence of effectiveness is much stronger for some risk factors, such as smoking and hypertension, than for physical activity, nutritional practices and mental health factors, including stress.


Worksite health promotion programs are expanding beyond the traditional topics of controlling alcohol and drug abuse, nutrition, weight control, smoking cessation, exercise and stress management. Today, activities generally cover a wider variety of health topics, ranging from healthy pregnancy or the menopause to living with chronic health conditions such as arthritis, depression or diabetes. Increased emphasis is being placed on aspects of good mental health. For example, under the rubric of employer-sponsored programs may appear courses or other activities such as “improving interpersonal communications”, “building self-esteem”, “improving personal productivity at work and home”, or “overcoming depression”.

Another trend is to provide a wider range of health information and counseling opportunities. Individual and group counseling may be supplemented with peer counseling, computer-based learning, and use of interactive videodiscs. Recognition of multiple learning styles has led to a broader array of delivery modes to increase efficiency with a better match between individual learning styles and preferences and instructional approaches. Offering this diversity of approaches allows individuals to choose the setting, intensity and educational form that best fits their learning habits.

Today, health education and counseling are being increasingly offered to employees of larger organizations, including those who may work at distant locations with few co-workers and those that work at home. Delivery via mail and phone, when possible, can facilitate this broader reach. The advantage of these modes of program delivery is greater equity, with field staff employees not disadvantaged compared to their home office counterparts. One cost of greater equity is sometimes reduced interpersonal contact with health professionals on health promotion issues.

Healthy Policies

Recognition is increasing that organizational policy and social norms are important determinants of health and of the effectiveness of health improvement efforts. For example, limiting or banning smoking at the workplace can yield substantial declines in per capita cigarette consumption among smoking workers. A policy that alcoholic beverages will not be served at company functions lays out behavioral expectations for employees. Providing food that is low in fat and high in complex carbohydrates in the company cafeteria is another opportunity to help employees improve their health.

However, there is also concern that healthful organizational policies or expressed social normative beliefs about what constitutes good health may stigmatize individuals who wish to engage in certain unhealthy habits, such as smoking, or those who have a strong genetic predisposition to an unhealthy state, such as obesity. It is not surprising that most programs have higher participation rates by employees with “healthy” habits and lower risks.

Integration with Other Programs

The promotion of health has many facets. It appears that growing efforts are being made to seek a closer integration among health education and counseling, ergonomics, employee assistance programs, and particular health-oriented benefits like screening and fitness plans. In countries where employers can design their own health benefit plans or can supplement a government plan with defined benefits, many are offering clinical preventive services benefits, particularly screening and health-enhancing benefits such as membership in community health and fitness facilities. Tax policies that permit employers to deduct these employee benefits from taxes provide strong financial incentives for their adoption.

Ergonomic design is an important determinant of worker health and involves more than just the physical fit of the employee to the tools employed on the job. Attention should be directed to the overall fit of the individual to his or her tasks and to the overall working environment. For example, a healthful job environment requires a good match between job autonomy and responsibility and effective adaptations among individual work style, family needs and the flexibility of work requirements. Nor should the relationship between work stresses and individual coping capacities be left out of this account. In addition, health can be promoted by having workers, individually and in groups, help mould job content in ways that contribute to feelings of self-efficacy and achievement.

Employee assistance programs, which generically speaking include employer-sponsored professionally directed activities that provide assessment, counseling and referral to any employee for personal problems, should have close ties with other health promoting programs, functioning as a referral source for the depressed, the overstressed and the preoccupied. In return, employee assistance programs can refer appropriate workers to employer-sponsored stress management programs, to physical fitness programs that help relieve depression, to nutritional programs for those overweight, underweight, or simply with bad nutrition, and to self-help groups for those who lack social support.


Worksite health promotion has come of age owing largely to incentives for employer investment, positive reported results for most programs, and increasing acceptance of worksite health promotion as an essential part of a comprehensive benefit plan. Its scope has broadened considerably, reflecting a more encompassing definition of health and an understanding of the determinants of individual and family health.

Well-developed approaches to program planning and implementation exist, as does a cadre of well-trained health professionals to staff programs and a wide variety of materials and delivery vehicles. Program success depends on individualizing any program to the corporate culture and to the health promotion opportunities and organizational constraints of a particular worksite. Results of most evaluations have supported movement toward stated program objectives, but more evaluations using scientifically valid designs and methods are needed.


Monday, 24 January 2011 18:45

Health Promotion in the Workplace: England

In its Health of the Nation policy declaration, the government of the United Kingdom subscribed to the twin strategy (to paraphrase their statement of aims) of (1) “adding years to life” by seeking an increase in life expectancy and a reduction in premature death, and (2) “adding life to years” by increasing the number of years lived free from ill-health, by reducing or minimizing the adverse effects of illness and disability, by promoting healthy lifestyles and by improving physical and social environments—in short, by improving the quality of life.

It was felt that efforts to achieve these aims would be more successful if they were exerted in already existent “settings”, namely schools, homes, hospitals and workplaces.

While it was known that there was considerable health promotion activity at the workplace (European Foundation 1991), no comprehensive baseline information existed on the level and nature of workplace health promotion. Various small-scale surveys had been conducted, but these had all been limited in one way or another, either by being concentrated on a single activity such as smoking, or restricted to a small geographical area or based on a small number of workplaces.

A comprehensive survey of workplace health promotion in England was undertaken on behalf of the Health Education Authority. Two models were used to develop the survey: the 1985 US National Survey of Worksite Health Promotion (Fielding and Piserchia 1989) and a 1984 survey carried out by the Policy Studies Institute of Workplaces in Britain (Daniel 1987).

The survey

There are over 2,000,000 workplaces in England (the workplace is defined as a geographically contiguous setting). The distribution is enormously skewed: 88% of workplaces employ fewer than 25 people onsite and cover about 30% of the workforce; only 0.3% of workplaces employ more than 500 people, yet these few very large sites account for some 20% of total employees.

The survey was originally structured to reflect this distribution by over-sampling the larger worksites in a random sample of all workplaces, including both the public and private sectors and all sizes of workplace; however, those who were self-employed and were working from home were excepted from the survey. The only other exclusions were various public bodies such as defense establishments, police and prison services.

In total 1,344 workplaces were surveyed in March and April of 1992. Interviewing was carried out by telephone, with the average completed interview taking 28 minutes. Interviews were held with whatever person was responsible for health-related activities. At smaller workplaces, this was seldom someone with a health specialization.

Findings of the survey

Figure 1 shows the spontaneous response to the inquiry as to whether any health-related activities had been undertaken in the past year and the marked size relationship to type of respondent.

Figure 1. Whether any health-related activities were undertaken in last 12 months.


A succession of spontaneous questions, and questions that were prompted in the course of interviewing, elicited from respondents considerably more information as to the extent and nature of health-related activities. The range of activities and incidence of such activity is shown in table 1. Some of the activities, such as job satisfaction (understood in England as a catch-all term covering such aspects as responsibility for both the pace and content of the work, self-esteem, management-worker relationships and skills and training) are normally regarded as outside the scope of health promotion, but there are commentators who believe that such structural factors are of great importance in improving health.

Table 1. Range of health-related activities by size of workforce.


Size of workforce (activity in %)







Smoking and tobacco






Alcohol and sensible drinking












Healthy catering






Stress management






HIV/AIDS and sexual health practices






Weight control






Exercise and fitness






Heart health and heart disease-related activities






Breast screening






Cervical screening






Health screening






Lifestyle assessment






Cholesterol testing






Blood pressure control






Drugs and alcohol abuse-related activities






Women’s health-related activities






Men’s health-related activities






Repetitive strain injury avoidance






Back care


















Desk and office layout design






Interior ventilation and lighting






Job satisfaction












Unweighted base = 1,344.

Other matters that were investigated included the decision-making process, budgets, workforce consultation, awareness of information and advice, benefits of health promotion activity to employer and employee, difficulties in implementation, and perception of the importance of health promotion. There are several general points to make:

  1. Overall, 40% of all workplaces undertook at least one major health related activity in the previous year. Apart from activity on smoking in workplaces with more than 100 employees, no single health promotion activity occurs in a majority of workplaces ranked by size. 
  2. In small workplaces the only direct health promoting activities of any significance are for smoking and alcohol. Even then, both are of minority incidence (29% and 13%).
  3. The immediate physical environment, reflected in such factors as ventilation and lighting, are considered to be substantively health related, as is job satisfaction. However, these are mentioned by less than 25% of workplaces with under 100 employees.
  4. As the workplace increases in size, it is not just that a higher percentage of workplaces undertake any activity, there is also a wider range of activity in any one workplace. This is shown in figure 15.5, which illustrates the likelihood of one or more of the major programmes. Only 9% of the largest workplaces have no programme at all and over 50% have at least three. In the smallest workplaces, only 19% have two or more programmes. In between, 35% of 25-99 workplaces have two or more programmes, while 56% of 100-499 workplaces have two or more programmes and 33% have three or more. However, it would be too much to read into these figures any semblance of what might be called a “healthy workplace”. Even if such a workplace were defined as one with 5+ programmes in place, there needs to a be an evaluation of the nature and intensity of the programme. In-depth interviewing suggests that in very few instances is the health activity integrated into a planned health promotion function and in even fewer cases, if any, is there modification of either the practices or objectives of the workplace to increase the emphasis on health enhancement.
  5. After smoking programmes, which get an 81% incidence in the largest workplaces, and alcohol, the next highest incidences are for eyesight testing, health screening and back care.
  6. Breast and cervical screening have a low incidence, even in workplaces with 60%+ of female employees (see table 2).
  7. Public sector workplaces show double the level of incidence for activities of those in the private sector. This holds across all the activities
  8. In regard to smoking and alcohol, foreign-owned companies have a higher incidence of workplace activity than British ones. However, the differential is relatively minor in most activities apart from health screening (15% against 5%) and the concomitant activities such as cholesterol and blood pressure.
  9. Only in the public sector is there a significant involvement in HIV/AIDS activity. In most of the activities the public sector outperforms the other industry sectors with the notable exception of alcohol.
  10. Workplaces which have no health promotion activity are virtually all small or medium-size in the private sector, British-owned and predominantly in the distribution and catering industries.


Figure 2. Likelihood of number of major health promotion programmes, by size of workforce.


Table 2. Participation rates in breast and cervical cancer screening (spontaneous and prompted) by percentage of female workforce.


Percentage of the workforce that is female


More than 60%

Less than 60%

Breast screening



Cervical screening



Unweighted base = 1,344.


The quantitative telephone survey and the parallel face-to-face interviewing revealed a considerable amount of information as to the level of health promotion activity at the workplace in England.

In a study of this nature, it is not possible to untangle all the confounding variables. However, it would seem that size of workplace, in terms of number of employees, public as opposed to private ownership, levels of unionization, and the nature of the work itself are important factors.

Communication of health promotion messages is largely through group methods such as posters, leaflets or videos. In larger workplaces there is a far greater likelihood of individual counseling being available, particularly for things like smoking cessation, alcohol problems and stress management. It is clear from the research methods used that health promotion activities are not “embedded” in the workplace and are highly contingent activities which, in the large majority of cases, are dependent for effectiveness on individuals. To date, health promotion has not made out the necessary cost/benefit base for its implementation. Such a cost/benefit calculation need not be a detailed and sophisticated analysis but simply an indication that it is of value. Such an indication may be of great benefit in persuading more private sector workplaces to increase their activity levels. There are very few of what might be termed “healthy workplaces”. In very few instances is the health promotion activity integrated into a planned health promotion function and in even fewer cases, if any, is there modification of either the practice or objectives of the workplace to increase emphasis on health enhancement.


Health promotion activities seem to be increasing, with 37% of respondents claiming that such activity had increased in the previous year. Health promotion is considered to be an important issue, with even 41% of small workplaces saying it was very important. Considerable benefits to employee health and fitness were ascribed to health promotion activities, as was reduced absenteeism and sickness.

However, there is little formal evaluation, and while written policies have been introduced, they are by no means universal. While there is support for the aims of health promotion and positive advantages are perceived, there is yet too little evidence of institutionalization of the activities into the culture of the workplace. Workplace health promotion in England seems to be contingent and vulnerable.



The rationale for worksite health promotion and protection programs and approaches to their implementation have been discussed in other articles in this chapter. The greatest activity in these initiatives has taken place in large organizations that have the resources to implement comprehensive programs. However, the majority of the workforce is employed in small organizations where the health and well-being of individual workers is likely to have a greater impact on productive capacity and, ultimately, the success of the enterprise. Recognizing this, small firms have begun to pay more attention to the relationship between preventive health practices and productive, vital employees. Increasing numbers of small firms are finding that, with the help of business coalitions, community resources, public and voluntary health agencies, and creative, modest strategies designed to meet their specific needs, they can implement successful yet low-cost programs that yield significant benefits.

Over the last decade, the number of health promotion programs in small organizations has increased significantly. This trend is important as regards both the progress it represents in worksite health promotion and its implication for the nation’s future health care agenda. This article will explore some of the varied challenges faced by small organizations in implementing these programs and describe some of the strategies adopted by those who have overcome them. It is derived in part from a 1992 paper generated by a symposium on small business and health promotion sponsored by the Washington Business Group on Health, the Office of Disease Prevention of the US Public Health Service and the US Small Business Administration (Muchnick-Baku and Orrick 1992). By way of example, it will highlight some organizations that are succeeding through ingenuity and determination in implementing effective programs with limited resources.

Perceived Barriers to Small Business Programs

While many owners of small firms are supportive of the concept of worksite health promotion, they may hesitate to implement a program in the face of the following perceived barriers (Muchnick-Baku and Orrick 1992):

  • “It’s too costly.” A common misconception is that worksite health promotion is too costly for a small business. However, some firms provide programmes by making creative use of free or low-cost community resources. For example, the New York Business Group on Health, a health-action coalition with over 250 member organizations in the New York City Metropolitan Area regularly offered a workshop entitled Wellness On a Shoe String that was aimed primarily at small businesses and highlighted materials available at little or no cost from local health agencies.
  •  “It’s too complicated.” Another fallacy is that health promotion programmes are too elaborate to fit into the structure of the average small business. However, small firms can begin their efforts very modestly and gradually make them more comprehensive as additional needs are recognized. This is illustrated by Sani-Dairy, a small business in Johnstown, Pennsylvania, that began with a home-grown monthly health promotion publication for employees and their families produced by four employees as an “ extracurricular” activity in addition to their regular duties. Then, they began to plan various health promotion events throughout the year. Unlike many small businesses of this size, Sani-Dairy emphasizes disease prevention in its medical programme.  Small companies can also reduce the complexity of health promotion programmes by offering health promotion services less frequently than larger companies. Newsletters and health education materials can be distributed quarterly instead of monthly; a more limited number of health seminars can be held at appropriate seasons of the year or linked to annual national campaigns such as Heart Month, the Great American Smoke Out or Cancer Prevention Week in the United States.
  • “It hasn’t been proven that the programmes work.” Small businesses simply do not have the time or the resources to do formal cost-benefit analyses of their health promotion programmes. They are forced to rely on anecdotal experience (which may often be misleading) or on inference from the research done in large-firm settings. “What we try to do is learn from the bigger companies,” says Shawn Connors, President of The International Health Awareness Center, “and we extrapolate their information. When they show that they’re saving money, we believe the same thing is happening to us.” While much of the published research attempting to validate the effectiveness of health promotion is flawed, Pelletier has found ample evidence in the literature to confirm impressions of its value (Pelletier 1991 and 1993).
  • “We don’t have the expertise to design a programme.” While this is true for most managers of small businesses, it need not present a barrier. Many of the governmental and voluntary health agencies provide free or low-cost kits with detailed instructions and sample materials (see figure 1) for presenting a health promotion programme. In addition, many offer expert advice and consulting services. Finally, in most larger communities and many universities, there are qualified consultants with whom one may negotiate short-term contracts for relatively modest fees covering onsite help in tailoring a particular health promotion programme to the needs and circumstances of a small business and guiding its implementation.
  • “We’re not big enough-we don’t have the space.” This is true for most small organizations but it need not stop a good programme. The employer can “buy into” programmes offered in the neighborhood by local hospitals, voluntary health agencies, medical groups and community organizations by subsidizing all or part of any fees that are not covered by the group health insurance plan. Many of these activities are available outside of working hours in the evening or on weekends, obviating the necessity of releasing participating employees from the workplace.


Figure 1. Examples of "do-it-yourself" kits for worksite health promotion programmes in the United States.

Advantages of the Small Worksite

While small businesses do face significant challenges related to financial and administrative resources, they also have advantages. These include (Muchnick-Baku and Orrick 1992):

  • Family orientation. The smaller the organization, the more likely it is that employers know their employees and their families. This can facilitate health promotion becoming a corporate-family affair building bonds while promoting health.     
  • Common work cultures. Small organizations have less diversity among employees than do larger organizations, making it easier to develop more cohesive programmes.    
  • Interdependency of employees. Members of small units are more dependent on each other. An employee absent because of illness, particularly if prolonged, means a significant loss of productivity and imposes a burden on co-workers. At the same time, the closeness of members of the unit makes peer pressure a more effective stimulant to participation in health promotion activities.    
  • Approachability of top management. In a smaller organization, management is more accessible, more familiar with the employees and more likely to be aware of their personal problems and needs. Furthermore, the smaller the organization, the more promptly the owner/chief operating officer is likely to become directly involved in making decisions about new programme activities, without the often stultifying effects of the bureaucracy found in most large organizations. In a small firm, that key person is more apt to provide the top-level support so vital to the success of worksite health promotion programmes.    
  • Effective use of resources. Because they are usually so limited, small businesses tend to be more efficient in the use of their resources. They are more likely to turn to community resources such as voluntary, government and entrepreneurial health and social agencies, hospitals and schools for inexpensive means of providing information and education to employees and their families (see figure 1).


Health Insurance and Health Promotionin Small Businesses

The smaller the firm, the less likely it is to provide group health insurance to employees and their dependants. It is difficult for an employer to claim concern for employees’ health as a basis for offering health promotion activities when basic health insurance is not made available. Even when it is made accessible, exigencies of cost restrict many small businesses to “bare bones” health insurance programs with very limited coverage.

On the other hand, many group plans do cover periodic medical examinations, mammography, Pap smears, immunizations and well baby/child care. Unfortunately, the out-of-pocket cost of covering the deductible fees and co-payments required before insured benefits are payable often acts as a deterrent to using these preventive services. To overcome this, some employers have arranged to reimburse employees for all or part of these expenditures; others find it less troublesome and costly simply to pay for them as an operating expense.

In addition to including preventive services in their coverage, some health insurance carriers offer health promotion programs to group policy holders usually for a fee but sometimes without extra charges. These programs generally focus on printed and audio-visual materials, but some are more comprehensive. Some are particularly suitable for small businesses.

In a growing number of areas, businesses and other types of organizations have formed “health-action” coalitions to develop information and understanding as well as responses to the health-related problems besetting them and their communities. Many of these coalitions provide their members with assistance in designing and implementing worksite health promotion programs. In addition, wellness councils have been appearing in a growing number of communities where they encourage the implementation of worksite as well as community-wide health promotion activities.

Suggestions for Small Businesses

The following suggestions will help to ensure the successful initiation and operation of a health promotion program in a small business:

  • Integrate the programme with other company activities. The programme will be more effective and less expensive when it is integrated with the employee group health insurance and benefit plans, the labour relations policies and the corporate environment, and the company’s business strategy. Most important, it must be coordinated with the company’s occupational and environmental health and safety policies and practices.    
  • Analyze cost data for both employees and the company. What employees want, what they need, and what the company can afford can be vastly different. The company must be able to allocate the resources required for the programme in terms of both the financial outlays and the time and effort of employees involved. It would be futile to launch a programme that could not be continued for lack of resources. At the same time, budget projections should include increases in resource allocations to cover expansion of the programme as it takes hold and grows.    
  • Involve employees and their representatives. A cross-section of the workforce-i.e., top management, supervisors and rank-and-file workers-should be involved in designing, implementing and evaluating the programme. Where there is a labour union, its leadership and shop stewards should be similarly involved. Often an invitation to co-sponsor the programme will defuse a union’s latent opposition to company programmes intended to enhance employee welfare if that exists; it may also serve to stimulate the union to work for replication of the programme by other companies in the same industry or area.    
  • Involve employees’ spouses and dependants. Health habits usually are characteristics of the family. Educational materials should be addressed to the home and, to the extent possible, employees’ spouses and other family members should be encouraged to participate in the activities.    
  • Obtain top management’s endorsement and participation. The company’s top executives should publicly endorse the programme and confirm its value by actually participating in some of the activities.    
  • Collaborate with other organizations. Wherever possible, achieve economies of scale by joining forces with other local organizations, using community facilities, etc.    
  • Keep personal information confidential. Make a point of keeping personal information about health problems, test results and even participation in particular activities out of personnel files and obviate potential stigmatization by keeping it confidential.
  • Give the programme a positive theme and keep changing it. Give the programme a high profile and publicize its objectives widely. Without dropping any useful activities, change the programme’s emphasis to generate new interest and to avoid appearing stagnant. One way to accomplish this is to “piggy back” on national and community programmes such as National Heart Month and Diabetes Week in the United States.
  • Make it easy to be involved. Activities that cannot be accommodated at the worksite should be located at convenient locations nearby in the community. When it is not feasible to schedule them during working hours, they may be held during the lunch hour or at the end of a work shift; for some activities, evenings or weekends may be more convenient.
  • Consider offering incentives and awards. Commonly used incentives to encourage programme participation and recognize achievements include released time, partial or 100% rebates of any fees, reduction in employee’s contribution to group health insurance plan premiums (“risk-rated” health insurance), gift certificates from local merchants, modest prizes such as T-shirts, inexpensive watches or jewelry, use of a preferred parking space, and recognition in company newsletters or on worksite bulletin boards.
  • Evaluate the programme. The numbers of participants and their drop-out rates will demonstrate the acceptability of particular activities. Measurable changes such as smoking cessation, loss or gain of weight, lower levels of blood pressure or cholesterol, indices of physical fitness, etc., can be used to appraise their effectiveness. Periodic employee surveys can be used to assess attitudes toward the programme and elicit suggestions for improvement. And review of such data as absenteeism, turnover, appraisal of changes in quantity and quality of production, and utilization of health care benefits may demonstrate the value of the programme to the organization.



Although there are significant challenges to be overcome, they are not insurmountable. Health promotion programs may be no less, and sometimes even more, valuable in small organizations than in larger ones. Although valid data are difficult to come by, it may be expected that they will yield similar returns of improvement with regard to employee health, well-being, morale and productivity. To achieve these with resources that are often limited requires careful planning and implementation, the endorsement and support of top executives, the involvement of employees and their representatives, the integration of the health promotion program with the organization’s health and safety policies and practices, a health care insurance plan and appropriate labor-management policies and agreements, and utilization of free or low-cost materials and services available in the community.



The primary functions of the employee health service are treatment of acute injuries and illnesses occurring in the workplace, conducting fitness-to-work examinations (Cowell 1986) and the prevention, detection and treatment of work-related injuries and illnesses. However, it may also play a significant role in preventive and health maintenance programs. In this article, particular attention will be paid to the “hands on” services that this corporate unit may provide in this connection.

Since its inception, the employee health unit has served as a focal point for prevention of non-occupational health problems. Traditional activities have included distribution of health education materials; the production of health promotion articles by staff members for publication in company periodicals; and, perhaps most important, seeing to it that occupational physicians and nurses remain alert to the advisability of preventive health counseling in the course of encounters with employees with incidentally observed potential or emerging health problems. Periodic health surveillance examinations for potential effects of occupational hazards have frequently demonstrated an incipient or early non-occupational health problem.

The medical director is strategically situated to play a central role in the organization’s preventive programs. Significant advantages attaching to this position include the opportunity to build preventive components into work-related services, the generally high regard of employees, and already established relationships with high-level managers through which desirable changes in work structure and environment can be implemented and the resources for an effective prevention program obtained.

In some instances, non-occupational preventive programs are placed elsewhere in the organization, for example, in the personnel or human resources departments. This is generally unwise but may be necessary when, for example, these programs are provided by different outside contractors. Where such separation does exist, there should at least be coordination and close collaboration with the employee health service.

Depending upon the nature and location of the worksite and the organization’s commitment to prevention, these services may be very comprehensive, covering virtually all aspects of health care, or they may be quite minimal, providing only limited health information materials. Comprehensive programs are desirable when the worksite is located in an isolated area where community-based services are lacking; in such situations, the employer must provide extensive health care services, often to employees’ dependants as well, to attract and retain a loyal, healthy and productive workforce. The other end of the spectrum is usually found in situations where there is a strong community-based health care system or where the organization is small, poorly resourced or, regardless of size, indifferent to the health and welfare of the workforce.

In what follows, neither of these extremes will be the subject of consideration; instead, attention will be focused on the more common and desirable situation where the activities and programs provided by the employee health unit complement and supplement services provided in the community.

Organization of Preventive Services

Typically, worksite preventive services include health education and training, periodic health assessments and examinations, screening programs for particular health problems, and health counseling.

Participation in any of these activities should be viewed as voluntary, and any individual findings and recommendations must be held confidential between the employee health staff and the employee, although, with the consent of the employee, reports may be forwarded to his or her personal physician. To operate otherwise is to preclude any program from ever being truly effective. Hard lessons have been learned and are continuing to be learned about the importance of such considerations. Programs which do not enjoy employees’ credibility and trust will have no or only half-hearted participation. And if the programs are perceived as being offered by management in some self-serving or manipulative way, they have little chance of achieving any good.

Worksite preventive health services ideally are provided by staff attached to the employee health unit, often in collaboration with an in-house employee education department (where one exists). When the staff lacks time or the necessary expertise or when special equipment is required (e.g., with mammography), the services may be obtained by contracting with an outside provider. Reflecting the peculiarities of some organizations, such contracts are sometimes arranged by a manager outside the employee health unit—this is often the case in decentralized organizations when such service contracts are negotiated with community-based providers by the local plant managers. However, it is desirable that the medical director be responsible for setting out the framework of the contract, verifying the capabilities of potential providers and monitoring their performance. In such instances, while aggregate reports may be provided to management, individual results should be forwarded to and retained by the employee health service or maintained in sequestered confidential files by the contractor. At no time should such health information be allowed to form part of the employee’s human resources file. One of the great advantages of having an occupational health unit is not only being able to keep health records separate from other company records under the supervision of an occupational health professional but, also, the opportunity to use this information as the basis of a discreet follow-up to be sure that important medical recommendations are not ignored. Ideally, the employee health unit, where possible in concert with the employee’s personal physician, will provide or oversee the provision of recommended diagnostic or therapeutic services. Other members of the employee health service staff, such as physical therapists, massage therapists, exercise specialists, nutritionists, psychologists and health counselors will also lend their special expertise as required.

The health promotion and protection activities of the employee health unit must complement its primary role of preventing and handling work-related injury and illness. When properly introduced and managed, they will greatly enhance the basic occupational health and safety program but at no time should they displace or dominate it. Placing responsibility for the preventive health services in the employee health unit will facilitate the seamless integration of both programs and make for optimal utilization of critical resources.

Program Elements

Education and training

The goal here is informing and motivating employees—and their dependants—to select and maintain a healthier lifestyle. The intent is to empower the employees to change their own health behavior so they will live longer, healthier, more productive and enjoyable lives.

A variety of communication techniques and presentation styles may be used. A series of attractive, easy-to-read pamphlets can be very useful where there are budget constraints. They may be offered in waiting-room racks, distributed by company mail, or mailed to employees’ homes. They are perhaps most useful when handed to the employee as a particular health issue is being discussed. The medical director or the person directing the preventive program must take pains to be sure that their content is accurate, relevant and presented in language and terms understood by the employees (separate editions may be required for different cohorts of a diverse workforce).

In-plant meetings may be arranged for presentations by employee health staff or invited speakers on health topics of interest. “Brown bag” lunch hour meetings (i.e., employees bring picnic lunches to the meeting and eat while they listen) are a popular mechanism for holding such meetings without interfering with work schedules. Small interactive focus groups led by a well-informed health professional are especially beneficial for workers sharing a particular health problem; peer pressure often constitutes a powerful motivation for compliance with health recommendations. One-on-one counseling, of course, is excellent but very labor-intensive and should be reserved for special situations only. However, access to a source of reliable information should always be available to employees who may have questions.

Topics may include smoking cessation, stress management, alcohol and drug consumption, nutrition and weight control, immunizations, travel advice and sexually-transmitted diseases. Special emphasis is often given to controlling such risk factors for cardiovascular and heart disease as hypertension and abnormal blood lipid patterns. Other topics often covered include cancer, diabetes, allergies, self-care for common minor ailments, and safety in the home and on the road.

Certain topics lend themselves to active demonstration and participation. These include training in cardiopulmonary resuscitation, first aid training, exercises to prevent repetitive strain and back pain, relaxation exercises, and self-defense instruction, especially popular among women.

Finally, periodic health fairs with exhibits by local voluntary health agencies and booths offering mass screening procedures are a popular way of generating excitement and interest.

Periodic medical examinations

In addition to the required or recommended periodic health surveillance examinations for employees exposed to particular work or environmental hazards, many employee health units offer more or less comprehensive periodic medical check-ups. Where personnel and equipment resources are limited, arrangements may be made to have them performed, often at the employer’s expense, by local facilities or in private physicians’ offices (i.e., by contractors). For worksites in communities where such services are not available, arrangements may be made for a vendor to bring a mobile examination unit into the plant or set up examination vans in the parking area.

Originally, in most organizations, these examinations were made available only to executives and senior managers. In some, they were extended down into the ranks to employees who had rendered a required number of years of service or who had a known medical problem. They frequently included a complete medical history and physical examination supplemented by an extensive battery of laboratory tests, x-ray examinations, electrocardiograms and stress tests, and exploration of all available body orifices. As long as the company was willing to pay their fees, examination facilities with an entrepreneurial bent were quick to add tests as new technology became available. In organizations prepared to offer even more elaborate service, the examinations were provided as part of a short stay at a popular health resort. While they often turned up important and useful findings, false positives were also frequent and, to say the least, examinations conducted in these surroundings were expensive.

In recent decades, reflecting growing economic pressures, a trend toward egalitarianism and, particularly, the marshalling of evidence regarding the advisability and utility of the different elements in these examinations, have led to their being simultaneously made more widely available in the workforce and less comprehensive.

The US Preventive Services Task Force published an assessment of the effectiveness of 169 preventive interventions (1989). Figure 1 presents a useful lifetime schedule of preventive examinations and tests for healthy adults in low-risk managerial positions (Guidotti, Cowell and Jamieson 1989) Thanks to such efforts, periodic medical examinations are becoming less costly and more efficient.

Figure 1. Lifetime health monitoring programme.


Periodic health screening

These programs are designed to detect as early as possible health conditions or actual disease processes which are amenable to early intervention for cure or control and to detect early signs and symptoms associated with poor lifestyle habits, which if changed will prevent or delay the occurrence of disease or premature aging.

The focus is usually towards cardiorespiratory, metabolic (diabetes) and musculoskeletal conditions (back, repetitive strain), and early cancer detection (colorectal, lung, uterus and breast).

Some organizations offer a periodic health risk appraisal (HRA) in the form of a questionnaire probing health habits and potentially significant symptoms often supplemented by such physical measurements as height and weight, skin-fold thickness, blood pressure, “stick test” urinalysis and “finger-stick” blood cholesterol. Others conduct mass screening programs aimed at individual health problems; those aimed at examining subjects for hypertension, diabetes, blood cholesterol level and cancer are most common. It is beyond the scope of this article to discuss which screening tests are most useful. However, the medical director may play a critical role in selecting the procedures most appropriate for the population and in evaluating the sensitivity, specificity and predictive values of the particular tests being considered. Particularly when temporary staff or outside providers are employed for such procedures, it is important that the medical director verify their qualifications and training in order to assure the quality of their performance. Equally important are prompt communication of the results to those being screened, the ready availability of confirmatory tests and further diagnostic procedures for those with positive or equivocal results, access to reliable information for those who may have questions, and an organized follow-up system to encourage compliance with the recommendations. Where there is no employee health service or its involvement in the screening program is precluded, these considerations are often neglected, with the result that the value of the program is threatened.

Physical conditioning

In many larger organizations, physical fitness programs constitute the core of the health promotion and maintenance program. These include aerobic activities to condition the heart and lungs, and strength and stretching exercises to condition the musculoskeletal system.

In organizations with an in-plant exercise facility, it is often placed under the direction of the employee health service. With such a linkage, it becomes available not only for fitness programs but also for preventive and remedial exercises for back pain, hand and shoulder syndromes, and other injuries. It also facilitates medical monitoring of special exercise programs for employees who have returned to work following pregnancy, surgery or myocardial infarction.

Physical conditioning programs can be effective, but they must be structured and guided by trained personnel who know how to guide the physically unfit and impaired to a state of proper physical fitness. To avoid potentially adverse effects, each individual entering a fitness program should have an appropriate medical evaluation, which may be performed by the employee health service.

Program Evaluation

The medical director is in a uniquely advantageous position to evaluate the organization’s health education and promotion program. Cumulative data from periodic health risk appraisals, medical examinations and screenings, visits to the employee health service, absences due to illness and injury, and so on, aggregated for a particular cohort of employees or the workforce as a whole, can be collated with productivity assessments, worker’s compensation and health insurance costs and other management information to provide, over time, an estimate of the effectiveness of the program. Such analyses may also identify gaps and deficiencies suggesting the need for modification of the program and, at the same time, may demonstrate to management the wisdom of continuing allocation of the required resources. Formulas for calculating the cost/benefit of these programs have been published (Guidotti, Cowell and Jamieson 1989).


There is ample evidence in the world literature supporting worksite preventive health programs (Pelletier 1991 and 1993). The employee health service is a uniquely advantageous venue for conducting these programs or, at the very least, participating in their design and monitoring their implementation and results. The medical director is strategically placed to integrate these programs with activities directed at occupational health and safety in ways that will promote both aims for the benefit of both individual employees (and their families, when included in the program) and the organization.




The organization

James Maclaren Industries Inc., the industrial setting used for this case study, is a pulp and paper company located in the western part of the Province of Quebec, Canada. A subsidiary of Noranda Forest, Inc., it has three major divisions: a hardwood pulp mill, a groundwood newsprint mill and hydroelectric energy facilities. The pulp and paper industry is the predominant local industry and the company under study is over 100 years old. The work population, approximately 1,000 employees, is locally based and, frequently, several generations of the same family have worked for this employer. The working language is French but most employees are functionally bilingual, speaking French and English. There is a long history (over 40 years) of company-based occupational health services. While the services were initially of an older “traditional” nature, there has been an increasing trend towards the preventive approach during recent years. This is consistent with a “continual improvement” philosophy being adopted throughout the Maclaren organization.

Provision of occupational health services

The occupational health physician has corporate and site responsibilities and reports directly to the directors of health, safety and continuous improvement. The last position reports directly to the company president. Full-time occupational health nurses are employed at the two major sites (the pulp mill has 390 employees and the newsprint mill has 520 employees) and report directly to the physician on all health-related issues. The nurse working at the newsprint division is also responsible for the energy/forest division (60 employees) and the head office (50 employees). A full-time corporate hygienist and safety personnel at all three facilities round out the health, and health-related, professional team.

The Preventive Approach

Prevention of disease and injury is driven by the occupational health and industrial hygiene and safety team with input from all interested parties. Methods used frequently do not differentiate between work-related and non-work-related prevention. Prevention is considered to reflect an attitude or quality of an employee—an attitude that does not cease or start at the plant fence line. A further attribute of this philosophy is the belief that prevention is amenable to continual improvement, a belief furthered by the company’s approach to auditing its various programs.

Continual improvement of prevention programs

Health, industrial hygiene, environment, emergency preparedness, and safety audit programs are an integral part of the continuous improvement approach. The audit findings, although addressing legal and policy compliance concerns, also stress “best management practice” in those areas which are felt to be amenable to improvement. In this way, prevention programs are being repeatedly assessed and ideas presented which are used to further the preventive aims of occupational health and related programs.

Health assessments

Pre-placement health assessments are carried out for all new employees. These are designed to reflect the exposure hazards (chemical, physical, or biological) present in the workplace. Recommendations indicating fitness to work and specific job restrictions are made based on the pre-placement health assessment findings. These recommendations are designed to decrease the risk of employee injury and illness. Health teaching is part of the health assessment and is intended to better acquaint the employees with the potential human impact of workplace hazards. Measures to decrease risk, particularly those related to personal health, are also stressed.

Ongoing health assessment programs are based on hazard exposure and workplace risks. The hearing conservation program is a prime example of a program designed to prevent a health impact. Emphasis is on noise reduction at the source and employees participate in the evaluation of noise reduction priorities. An audiometric assessment is done every five years. This assessment provides an excellent opportunity to counsel employees on the signs and symptoms of noise-induced hearing loss and preventive measures while assisting in the evaluation of the efficacy of the control program. Employees are advised to follow the same advice off the job—that is, to use hearing protection and to diminish their exposure.

Risk-specific health assessments are also carried out for workers involved in special job assignments such as fire fighting, rescue work, water treatment plant operations, tasks requiring excessive heat exposure, crane operation and driving. Similarly, employees who use respirators are required to undergo an assessment to determine their medical fitness to use the respirator. Exposure risks incurred by contractors’ employees are also assessed.

Health hazard communication

There is a statutory requirement to communicate health hazard and health risk information to all employees. This is an extensive task and includes teaching employees about the health effects of designated substances to which they may be exposed. Examples of such substances include a variety of respiratory hazards which may be either byproducts of other materials’ reactions or may represent a direct exposure hazard: one might name in this connection such materials as sulphur dioxide; hydrogen sulphide; chlorine; chlorine dioxide; carbon monoxide; nitrogen oxides and welding fumes. Material Safety Data Sheets (MSDSs) are the prime source of information on this subject. Unfortunately, the suppliers’ MSDSs often lack the necessary quality of health and toxicity information and may not be available in both official languages. This deficiency is being addressed at one of the company’s sites (and will be extended to the other sites) through the development of one-page health information sheets based on an extensive and well-respected database (using a commercially available MSDS generation software system). This project was undertaken with company support by members of the joint labor-management health and safety committee, a process which not only solved a communication problem, but encouraged participation by all workplace parties.

Cholesterol screening programs

The company has made a voluntary cholesterol screening program available to employees at all sites. It offers advice on the health ramifications of high cholesterol levels, medical follow-up when indicated (done by family physicians), and nutrition. Where onsite cafeteria services exist, nutritious food alternatives are offered to the employees. The health staff also makes pamphlets on nutrition available for employees and their families to assist them to understand and diminish personal health risk factors.

Blood pressure screening programs

Both in conjunction with annual community programs (“Heart Month”) on heart health, and on a regular basis, the company encourages employees to have their blood pressure checked and, when necessary, monitored. Counseling is provided to employees to assist them, and indirectly their families, to understand the health concerns surrounding hypertension and to seek help through their community medical resources if further follow-up or treatment is needed.

Employee and family assistance programs

Problems that have an impact on employee performance are frequently the result of difficulties outside the workplace. In many cases, these reflect difficulties related to the employee’s social sphere, either home or community. Internal and external referral systems exist. The company has had a confidential employee (and, more recently, family) assistance program in place for over five years. The program assists about 5% of the employee population annually. It is well publicized and early use of the program is encouraged. Feedback received from the employees indicates that the program has been a significant factor in minimizing or preventing deterioration of work performance. The primary reasons for using the assistance program reflect family and social issues (90%); alcohol and drug problems account for only a small percentage of the total cases assisted (10%).

As part of the employee assistance program, the facility has instituted a serious-incident debriefing process. Serious incidents, such as fatalities or major accidents, can have an extremely unsettling effect on employees. There is also the potential for significant long-term consequences, not only to the efficient functioning of the company but, more particularly, to the individuals involved in the incident.

Wellness programs

A recent development has been the decision to take the first steps towards the development of a “wellness” program that targets disease prevention in an integrated approach. This program has several components: cardiorespiratory fitness; physical conditioning; nutrition; smoking cessation; stress management; back care; cancer prevention and substance abuse. Several of these topics have been mentioned previously in this case study. Others (not discussed in this article) will, however, be implemented in a stepwise fashion.

Special communication programs

  1. HIV/AIDS. The advent of HIV/AIDS in the general population signalled a need to communicate information to the workplace community for two reasons: to allay fear of contagion should a case become known from among the employee population and to ensure that employees are cognizant of preventive measures and the “real” facts about communicability. A communication programme was organized to meet these two objectives and made available to the employees on a voluntary basis. Pamphlets and literature could also be obtained from the health centers.
  2. Communication of research study results. The following are examples of two recent communications about health research studies in areas that were considered to be of special concern to employees.
  3. Electromagnetic field studies. The results of the electromagnetic field study undertaken by Electricitй (E.D.F.), Hydro Quebec, and Ontario Hydro (Thйriault 1994), were communicated to all exposed and potentially exposed employees. The objectives behind the communication were to prevent unwarranted fear and to ensure that employees had firsthand knowledge of issues affecting their workplace and, potentially, their health.
  4. Health outcome studies. Several studies in the pulp and paper industry relate to health outcomes from working in this industry. The outcomes being investigated include cancer incidence and cancer mortality. Communications to employees are planned to ensure their awareness of the existence of the studies, and, when available, to share the results. The objectives are to alleviate fear and ensure that employees have the opportunity to know the results of studies pertinent to their occupations.
  5. Community interest topics. As part of its preventive approach, the company has reached out to community physicians and invited them to tour the workplace and meet with the occupational health and hygiene staff. Presentations related to issues relevant to health and the pulp and paper industry have been made at the same time. This has assisted the local physicians to understand the working conditions, including potential hazardous exposures, as well as the job requirements of the employees. As a result, the company and the physicians have worked in concert to diminish the potential ill effects of injury and illness. Community meetings have also been held to provide the communities with information on environmental issues related to the company’s operations and to give the local citizens an opportunity to ask questions on matters of concern (including health issues). Prevention is thus carried to the community level.
  6. Future trends in prevention. Behaviour modification techniques are being considered to further improve the overall level of worker health and to diminish injuries and illness. Not only will these modifications have a positive effect on the health of the worker in the workplace, they will also carry over to the home environment.


Employee involvement in safety and health decision making already exists through the Joint Health and Safety Committees. Opportunities to extend the partnership to employees in other areas are being actively pursued.


The essential elements of the program at Maclaren are:

  • a firm management commitment to health promotion and health protection
  • integration of occupational health programs with those aimed at non-occupational health problems
  • involvement of all workplace parties in program planning, implementation and evaluation
  • coordination with community-based health care facilities and providers and agencies
  • an incremental approach to program expansion
  • audits of program effectiveness to identify problems that need addressing and areas where programs may be strengthened, combined with action plans to ensure appropriate follow-up activities
  • effective integration of all environmental, health, hygiene and safety activities.


This case study has focused on existing programs designed to improve employee health and prevent unnecessary and unwanted health effects. The opportunities to further enhance this approach are boundless and particularly amenable to the company’s continual improvement philosophy.




First Chicago Corporation is the holding company for the First National Bank of Chicago, the eleventh largest bank in the United States. The corporation has 18,000 employees, 62% of whom are women. The average age is 36.6 years. Most of its employees are based in the states of Illinois, New York, New Jersey and Delaware. There are approximately 100 individual worksites ranging in size from 10 to over 4,000 employees. The six largest, each with over 500 employees (comprising in aggregate 80% of the workforce), have employee health units managed by the head office Medical Department in collaboration with the local manager for human resources. The small worksites are served by visiting occupational health nurses and participate in programs via printed materials, videotapes, and telephone communication and, for special programs, by contract with providers based in the local community.

In 1982, the company’s Medical and Benefits Administration Departments established a comprehensive Wellness Program that is managed by the Medical Department. Its goals included improving the overall health of employees and their families in order to reduce unnecessary health and disability costs as much as possible.

Need for Health Care Data

For First Chicago to gain any degree of control over the escalation of its health care costs, the company’s Medical and Benefits Departments agreed that a detailed understanding of the sources of expense was required. By 1987, its frustration with the inadequate quality and quantity of the health care data that were available led it to strategically design, implement and evaluate its health promotion programs. Two information system consultants were hired to help construct an in-house database which eventually became known as the Occupational Medicine and Nursing Information (OMNI) System (Burton and Hoy 1991). To maintain its confidentiality, the system resides in the Medical Department.

OMNI databases include claims for inpatient and outpatient health services and for disability and worker’s compensation benefits, services provided by the Bank’s employee assistance program (EAP), absenteeism records, wellness program participation, health risk appraisals (HRAs), prescription medications, and findings of laboratory tests and physical examinations. The data are analyzed periodically to evaluate the impact of the Wellness Program and to indicate any changes that may be advisable.

First Chicago’s Wellness Program

The Wellness Program comprises a broad range of activities that include the following:

  • Health education. Pamphlets and brochures on a wide range of topics are made available to employees. A Wellness Newsletter sent to all employees is supplemented by articles which appear in the Bank’s publications and on cafeteria table cards. Videotapes on health topics may be viewed at the workplace and many are available for home viewing. Lunchtime workshops, seminars, and lectures on topics such as mental wellness, nutrition, violence, women’s health and cardiovascular disease are offered weekly at all major worksites.
  • Individual counselling. Registered nurses are available in person to answer questions and provide individual counselling at the employee health units and by telephone to employees at the smaller worksites.
  • Health risk assessment. A computerized health risk appraisal (HRA), including blood pressure and cholesterol testing, is offered to most new employees and periodically to current employees where there is an employee health unit. It is also offered periodically to employees of some satellite bank facilities.
  • Periodic physical examinations. These are offered on a voluntary basis to management employees. Annual health examinations, including Pap smears and breast examinations, are available to female employees in Illinois. Mass screenings for hypertension, diabetes, breast cancer and cholesterol levels are conducted at worksites that have employee health units.
  • Pre-retirement. Pre-retirement physical examinations are offered to all employees, starting at age 55 and continuing every three years thereafter until retirement. A comprehensive pre-retirement workshop is offered that includes sessions on healthy ageing.
  • Health promotion programmes. Discounted fees are negotiated with community providers for employees participating in physical fitness programmes. Worksite programmes on prenatal education, smoking cessation, stress management, weight reduction, childhood wellness, cardiovascular risk factor reduction, and training for skin cancer and breast self-examination are provided at no cost.
  • Cardiopulmonary resuscitation (CPR) and first aid training. CPR training is provided to all security personnel and designated employees. Infant CPR and first aid classes are also offered.
  • Immunization programmes. Hepatitis B vaccination is offered to all health service workers who may become exposed to blood or body fluids. Foreign travellers are provided with immunizations, including routine tetanus-diphtheria boosters, as dictated by the risk of infection in the areas they will visit. Education is provided to employees on the value of flu shots. Employees are referred to their primary care physician or the local health department for this immunization.


Women’s Health Program

In 1982, The First National Bank of Chicago found that over 25% of health care costs for employees and their families were related to women’s health. In addition, over 40% of all employee short-term disability absences (i.e., lasting up to six months) were due to pregnancy. To control these costs by helping to ensure low-cost, high-quality health care, a comprehensive program was developed to focus on prevention and early detection and control of women’s health problems (Burton, Erikson, and Briones 1991). The program now includes these services:

  • Worksite obstetrical and gynaecologic programme. Since 1985, the Bank has employed a part-time consulting gynaecologist from a major university teaching hospital at its home office in Chicago. Periodically, this service has been offered at two other locations and plans are in progress to establish the programme at another health service location. Voluntary annual health examinations are offered at the home office Medical Department to all female employees enrolled in the Bank’s self-insured benefit plan (employees electing enrolment in a health maintenance organization (HMO) may have these examinations carried out by their HMO doctors). The examination includes a medical history, gynaecological and general physical examinations, laboratory tests such as a Pap smear for cervical cancer, and other testing as may be indicated. In addition to providing examinations and consultations, the gynaecologist also conducts seminars on women’s health concerns. The worksite gynaecological programme has proven to be a convenient and cost-effective way to encourage preventive health care for women.
  • Preconception and prenatal education. The United States ranks twenty-fourth among developed nations in infant mortality. At First Chicago, pregnancy-related claims accounted for about 19% of all health care costs in 1992 paid by the medical plan for employees and dependants. In 1987, to address this challenge, the Bank, in cooperation with the March of Dimes, began to offer a series of worksite classes led by a specially trained occupational health nurse. These are held during working hours and emphasize prenatal care, healthy lifestyles, proper nutrition, and indications for Caesarean section. On entering the programme, employees complete a pregnancy-related health risk appraisal questionnaire which is analysed by computer; both the women and their obstetricians receive a report highlighting potential risk factors for complications of pregnancy, such as adverse lifestyles, genetic diseases and medical problems. To encourage participation, female employees or spouses who complete the classes by the sixteenth week of pregnancy are eligible to have the 400 US$ deductible fee for the newborn’s health costs waived. Preliminary results of the prenatal education programme for employees in the Chicago, Illinois, area include the following:
    • The Caesarean section rate is 19% for employees who participated in the worksite prenatal education programme compared to 28% for nonparticipants. The regional average Caesarean section rate is about 24%.
    •  The average cost of delivery in the Chicago, Illinois, area for employees who participated in the prenatal education classes was $7,793 compared to $9,986 for employees who did not participate.
    •  Absences from work for pregnancy (short-term disability) tend to be slightly reduced for employees who participate in the prenatal education classes.
  • Breast feeding (lactation) programme. The Medical Department offers a private room and refrigerator to store breast milk to employees who wish to breast feed. Most employee health units have electric breast pumps and provide lactation supplies to employees in the Bank’s medical plan at no cost (and at cost to employees who are enrolled in HMOs).
  • Mammography. Since 1991, mammography screening for breast cancer has been offered at no cost at employee health units in the United States. Mobile mammography units from fully accredited local providers are brought to all the six sites with employee health units from one to several times per year depending on need. Approximately 90% of eligible employees are within a 30 minute automobile drive of a screening mammography location. Female employees and wives of employees and of retirees are eligible to participate in the programme.


Employee Assistance Program and Mental Health Care

In 1979, the Bank implemented an employee assistance program (EAP) that provides consultation, counseling, referral, and follow-up for a wide range of personal problems such as emotional disorders, interpersonal conflict, alcohol and other drug dependencies and addictive disorders in general. Employees may refer themselves for these services or they may be referred by a supervisor who discerns any difficulties that they may be experiencing in performance or interpersonal relationships in the workplace. The EAP also provides workshops on a variety of topics such as stress management, violence and effective parenting. The EAP, which is a unit of the Medical Department, is now staffed by six full and part-time clinical psychologists. The psychologists are located at each of the six medical departments and in addition travel to satellite bank facilities where there is a need.

In addition, the EAP manages psychiatric short-term disability cases (up to six months of continuous absence). The goal of EAP management is to ensure that employees receiving disability payments for psychiatric reasons are receiving appropriate care.

In 1984, a comprehensive program was initiated to provide quality and cost-effective mental health care services for employees and dependants (Burton et al. 1989; Burton and Conti 1991). This program includes four components:

  • the EAP for prevention and early intervention
  • a review of the patient’s possible need for inpatient psychiatric hospitalization
  • case management of mental health-related short-term disability by the EAP staff
  • a network of selected mental health professionals who provide outpatient (i.e., ambulatory) services.


Despite enhancement of mental health insurance benefits to include 85% (instead of 50%) reimbursement for alternatives to inpatient hospitalization (e.g., partial hospitalization programs and intensive outpatient programs), First Chicago’s mental health care costs have dropped from nearly 15% of total medical costs in 1983 to under 9% in 1992.


More than a decade ago, First Chicago initiated a comprehensive wellness program with a motto—“First Chicago is Banking on Your Health”. The Wellness Program is a joint effort of the Bank’s Medical and Benefits Departments. It is regarded as having improved the health and productivity of employees and reduced avoidable health care costs for both the employees and the Bank. In 1993, First Chicago’s Wellness Program was awarded the C. Everett Koop National Health Award named in honor of the former Surgeon General of the United States.



Monday, 24 January 2011 19:34

Worksite Health Promotion in Japan

Health promotion in the workplace in Japan was substantially improved when the Occupational Health and Safety Law was amended in 1988 and employers were mandated to introduce health promotion programs (HPPs) in the workplace. Although the law as amended makes no provision for penalties, the Ministry of Labor at this time began actively encouraging employers to establish health promotion programs. For instance, the Ministry has provided support for training and education to increase the numbers of specialists qualified to work in such programs; among the specialists are occupational health promotion physicians (OHPPs), health care trainers (HCTs), health care leaders (HCLs), mental health counselors (MHCs), nutrition counselors (NCs) and occupational health counselors (OHCs). While employers are encouraged to establish health promotion organizations within their own enterprises, they can also elect to procure service from outside, especially if the business is small and it cannot afford to provide a program in-house. The Ministry of Labor furnishes guidelines for the operation of such service institutions. The newly conceived and mandated occupational health promotion program authorized by the Japanese government is called the “total health promotion” (THP) plan.

Recommended Standard Health Promotion Program

If an enterprise is sufficiently large to provide all the specialists listed above, it is strongly recommended that the company organize a committee comprising those specialists and make it responsible for the planning and execution of a health promotion program. Such a committee must first analyze the health status of the workers and determine the highest priorities that are to guide the actual planning of an appropriate health promotion program. The program should be a comprehensive one, based on both group and individual approaches.

On a group basis various health education classes would be offered, for example, on nutrition, life style, stress management and recreation. Cooperative group activities are recommended in addition to lectures in order to encourage workers to become involved in actual procedures so that information provided in class can result in behavioral changes.

As the first step to the individual approach, a health survey should be conducted by the OHPP. The OHPP then issues a plan to the individual based on the results of the survey after taking into account information obtained through counseling by the OHC or MHC (or both). Following this plan, relevant specialists will supply the necessary instructions or counseling. The HCT will design a personal physical training program based on the plan. The HCL will provide practical instruction to the individual in the gym. When necessary, an NC will teach personal nutrition and the MHC or OHC will meet the individual for specific counseling. The results of such individual programs should be evaluated periodically by the OHPP so the program can be improved over time.

Training of Specialists

The Ministry has appointed the Japan Industrial Safety and Health Association (JISHA), a semi-official organization for the promotion of voluntary safety and health activities in the private sector, to be the official body for conducting the training courses for health promotion specialists. To become one of the above six specialists a certain background is required and a course for each specialty must be completed. The OHPP, for instance, must have the national license for physicians and have completed a 22-hour course on conducting the health survey that will direct the planning of the HPP. The course for the HCT is 139 hours, the longest of the six courses; a prerequisite for taking the course is a bachelor’s degree in health sciences or athletics. Those who have three or more years’ practical experience as an HCL are also eligible to take the course. The HCL is the leader responsible for actually teaching workers according to the prescriptions drawn up by the HCT. The requirement for becoming an HCL is that he or she be 18 years of age or older and have completed the course, which covers 28.5 hours. To take the course for the MHC, one of the following degrees or experience is required: a bachelor’s degree in psychology; social welfare or health science; certification as a public health or registered nurse; HCT; completion of JISHA’s Health Listener’s Course; qualification as a health supervisor; or five or more years’ experience as a counselor. The length of the MHC course is 16.5 hours. Only qualified nutritionists can take the NC course, which is 16.0 hours long. Qualified public health nurses and nurses with three or more years of practical experience in counseling can take the OHC course, which is 20.5 hours long. The OHC is expected to be a comprehensive promoter of the health promotion program in the workplace. As of the end of December 1996, the following numbers of the specialists were registered with the JISHA as having completed the assigned courses: OHPP—2,895; HCT—2,800; HCL— 11,364; MHC—8,307; NC—3,888; OHC—5,233.

Service Institutions

Two kinds of health promotion service institutions are approved by JISHA and a list of the registered institutions is available to the public. One kind is authorized to conduct health surveys so that the OHPP can issue a plan to the individual. This type of institution can provide comprehensive health promotion service. The other kind of service institution is only permitted to provide physical training service in accordance with a program developed by an HCT. As of the end of March 1997 the number qualifying as the former type was 72 and that as the latter was 295.

Financial Support from the Ministry

The Ministry of Labor has a budget to support the training courses offered by JISHA, the establishment of new programs by enterprises and the acquisition by service institutions of equipment for physical exercise. When an enterprise establishes a new program, the expenditure will be supported by the Ministry through JISHA for a maximum of three years. The amount depends on size; if the number of employees of an enterprise is less than 300, two-thirds of the total expenditure will be met by the Ministry; for businesses of over 300 employees, financial support covers one-third of the total.


It is too early in the history of the THP project to make a reliable evaluation of its effectiveness, but a consensus prevails that THP should be part of any comprehensive occupational health program. The general status of Japanese occupational health service is still undergoing improvement. In advanced workplaces, that is, chiefly those of the large companies, THP has already developed to a level that an evaluation of the degree of health promotion among the workers and of the extent of improvement in productivity can be done. However, in smaller enterprises, even though the major part of the necessary expenditures for THP can be paid for by the government, the health care systems that are already in place very frequently are not able to undertake the introduction of additional health maintenance activities.



Tuesday, 25 January 2011 14:03

Health Risk Appraisal


Over the last few decades, the health risk appraisal (HRA), also known as a health hazard appraisal or a health risk assessment, has become increasingly popular, primarily in the United States, as an instrument for promoting health awareness and motivating behavioral change. It is also used as an introduction to periodic health screening or as a substitute for it and, when aggregated for a group of individuals, as the basis for identifying targets for a health education or health promotion program to be designed for them. It is based on the following concept:

  • Ostensibly healthy, asymptomatic individuals may be at risk of developing a disease process that can cause morbidity in the future and may lead to premature death.
  • Factors that lead to such risk can be identified.
  • Some of those risk factors can be eliminated or controlled thereby preventing or attenuating the disease process and preventing or delaying the morbidity and mortality.


The development of the HRA in the 1940s and 1950s is credited to Dr. Lewis Robbins, working at the Framingham prospective study of heart disease and later at the National Cancer Institute (Beery et al. 1986). The 1960s saw additional models developed and, in 1970, Robbins and Hall produced the seminal work that defined the technique, described the survey instruments and the risk computations, and outlined the patient feedback strategy (Robbins and Hall 1970).

Interest in HRA and health promotion in general was stimulated by a growing awareness of the importance of risk factor control as a basis element in health promotion, the evolving use of computers for data compilation and analysis and, especially in the United States, increasing concern over the escalating cost of health care and the hope that preventing illness might slow its upward spiral of growth. By 1982, Edward Wagner and his colleagues at the University of North Carolina were able to identify 217 public and private HRA vendors in the United States (Wagner et al. 1982). A good many of these have since faded from the scene but they have been replaced, at least to a limited extent, by new entrants into the marketplace. According to a 1989 report of a survey of a random sample of US worksites, 29.5% have conducted HRA activities; for worksites with more than 750 employees, this figure rose to 66% (Fielding 1989). HRA use in other countries has lagged considerably.

What is the HRA?

For purposes of this article, an HRA is defined as a tool for assessing health risks that has three essential elements:

  1. A self-administered questionnaire inquiring about the individual’s demographic profile, medical background, family history, personal habits and lifestyle. This information is frequently supplemented by biomedical measurements such as height, weight, blood pressure, and skin-fold thickness, and data regarding the results of urinalysis, blood cholesterol level and other laboratory tests, either as reported by the individual or taken as part of the process.
  2. A quantitative estimation of the individual’s future risk of death or other adverse outcomes from specific causes based on a comparison of the individual’s responses to epidemiological data, national mortality statistics and actuarial calculations. Some questionnaires are self-scored: points are assigned to the response to each question and then added to derive a risk score. With the appropriate computer software, the responses may be entered into a microcomputer that will calculate the score. Most often the completed questionnaires are forwarded to a central point for batch processing and the individual results are mailed or delivered to the participants.
  3. Feedback to the individual with suggestions for changes in lifestyle and other actions that would improve well-being and reduce the risk of disease or premature death.


Originally, the total risk estimate was presented as a single number that could be targeted for reduction to a “normal” value or even to lower-than-normal values (vis-à-vis the general population) by implementing the suggested behavioral changes. To make the results more graphic and compelling, the risk is now sometimes expressed as a “health age” or “risk age” to be compared with the individual’s chronological age, and an “achievable age” as the target for the interventions. For example, a report might say, “Your present age is 35 but you have the life expectancy of a person aged 42. By following these recommendations, you could reduce your risk age to 32, thereby adding ten years to your projected life span.”

Instead of comparing the individual’s health status with the “norm” for the general population, some HRAs offer an “optimal health” score: the best attainable score that might be achieved by following all of the recommendations. This approach appears to be particularly useful in guiding young people, who may not yet have accumulated significant health risks, to an optimally desirable lifestyle.

The use of a “risk age” or a single number to represent the individual’s composite risk status may be misleading: a significant risk factor may be statistically offset by “good” scores on most other areas and lead to a false sense of security. For example, a person with normal blood pressure, a low blood cholesterol level, and a good family history who exercises and wears automobile seat belts may earn a good risk score despite the fact that he smokes cigarettes. This suggests the desirability of focusing on each “greater than average” risk item instead of relying on the composite score alone.

The HRA is not to be confused with health status questionnaires that are used to classify the eligibility of patients for particular treatments or to evaluate their outcomes, nor with the variety of instruments used to assess degree of disability, mental health, health distress or social functioning, although such scales are sometimes incorporated into some HRAs.

HRA Questionnaire

Although the HRA is sometimes used as a prelude to or part of a periodic, pre-employment or pre-placement medical examination, it is usually offered independently as a voluntary exercise. Many varieties of HRA questionnaires are in use. Some are limited to core questions that feed directly into the risk age calculations. In others, these core questions are interspersed with additional medical and behavioral topics: more extensive medical history; stress perceptions; scales to measure anxiety, depression and other psychological disorders; nutrition; use of preventive services; personal habits and even interpersonal relationships. Some vendors allow purchasers to add questions to the questionnaire, although responses to these are not usually incorporated into the health-risk computations.

Almost all HRAs now use forms with boxes to be checked or filled in by pencil for computer entry by hand or by an optical scanner device. As a rule, the completed questionnaires are collected and batch-processed, either in-house or by the HRA vendor. To encourage trust in the confidentiality of the program, completed questionnaires are sometimes mailed directly to the vendor for processing and the reports are mailed to the participants’ homes. In some programs, only “normal” results are mailed to participants, while those employees with results calling for intervention are invited for private interviews with trained staff persons who interpret them and outline the corrective actions that are indicated. Greater access to personal computers and more widespread familiarity with their use have led to the development of interactive software programs that allow direct entry of the responses into a microcomputer and immediate calculation and feedback of the results along with risk reduction recommendations. This approach leaves it up to the individual to take the initiative of seeking help from a staff person when clarification of the results and their implications is needed. Except when the software program allows storage of the data or their transfer to a centralized data bank, this approach does not provide information for systematic follow-up and it precludes the development of aggregate reports.

Managing the Program

Responsibility for managing the HRA program is usually assigned to the respective directors of the employee health service, the wellness program or, less frequently, the employee assistance program. Quite often, however, it is arranged and supervised by the personnel/human resources staff. In some instances, an advisory committee is created, often with employee or labor union participation. Programs incorporated into the organization’s operating routine appear to run more smoothly than those that exist as somewhat isolated projects (Beery et al. 1986). The organizational location of the program may be a factor in its acceptance by employees, particularly when confidentiality of personal health information is an issue. To preclude such a concern, the completed questionnaire is usually mailed in a sealed envelope to the vendor, who processes the data and mails the individual report (also in a sealed envelope) directly to the participant’s home.

To enhance participation in the program, most organizations publicize the program through preliminary hand-outs, posters and articles in the company newsletter. Occasionally, incentives (e.g., T-shirts, books and other prizes) are offered for completion of the exercise and there may even be monetary awards (e.g., reduction in the employee’s contribution to health insurance premiums) for successful reduction of excess risk. Some organizations schedule meetings where employees are told about the program’s purposes and procedures and are instructed in completing the questionnaire. Some, however, simply distribute a questionnaire with written instructions to each employee (and, if included in the program, to each dependant). In some instances, one or more reminders to complete and mail the questionnaire are distributed in order to increase participation. In any case, it is important to have a designated resource person, either in the organization or with the HRA program provider, to whom questions can be directed in person or by telephone. It may be important to note that, even when the questionnaire is not completed and returned, merely reading it can reinforce information from other sources and foster a health consciousness that may favorably influence future behavior.

Many of the forms call for clinical information that the respondent may or may not have. In some organizations, the program staff actually measures height, weight, blood pressure and skin-fold thickness and collects blood and urine samples for laboratory analysis. The results are then integrated with the questionnaire responses; where such data are not entered, the computer processing program may automatically insert figures representing the “norms” for persons of the same sex and age.

Turnaround time (the time between completing the questionnaire and receiving the results) may be a significant factor in the value of the program. Most vendors promise delivery of the results in ten days to two weeks, but batch processing and post office delays may extend this period. By the time the reports are received, some participants may have forgotten how they responded and may have disassociated themselves from the process; to obviate this possibility, some vendors either return the completed questionnaire or include key responses of the individual in the report.

Reports to the Individual

The reports may vary from a single-page statement of results and recommendations to a more than 20-page brochure replete with multicolor graphs and illustrations and extended explanations of the relevance of the results and the importance of the recommendations. Some rely almost entirely on preprinted general information while in others the computer generates an entirely individualized report. In some programs where the exercise has been repeated and the earlier data have been retained, comparisons of current results with those recorded earlier are provided; this may provide a sense of gratification that can serve as further motivation for behavior modification.

A key to the success of a program is the availability of a health professional or trained counselor who can explain the importance of the findings and offer an individualized program of interventions. Such personalized counseling can be extremely useful in allaying needless anxiety that may have been generated by misinterpretation of the results, in helping individuals establish behavioral change priorities, and in referring them to resources for implementation.

Reports to the Organization

In most programs, the individual results are summarized in an aggregate report sent to the employer or sponsoring organization. Such reports tabulate the demography of the participants, sometimes by geographic location and job classification, and analyze the range and levels of health risks discovered. A number of HRA vendors include projections of the increased health care costs likely to be incurred by high-risk employees. These data are extremely valuable in designing elements for the organization’s wellness and health promotion program and in stimulating consideration of changes in job structure, work environment and workplace culture that will promote the health and well-being of the workforce.

It should be noted that the validity of the aggregate report depends on the number of employees and the level of participation in the HRA program. Participants in the program tend to be more health conscious and, when their number is relatively small, their scores may not accurately reflect the characteristics of the entire workforce.

Follow-up and Evaluation

The effectiveness of the HRA program may be enhanced by a system of follow-up to remind participants of the recommendations and encourage compliance with them. This can involve individually addressed memoranda, one-on-one counseling by a physician, nurse or health educator, or group meetings. Such follow-up is particularly important for high-risk individuals.

HRA program evaluation should start with a tabulation of the level of participation, preferably analyzed by such characteristics as age, sex, geographic location or work unit, job and educational level. Such data may identify differences in acceptance of the program that might suggest changes in the way it is presented and publicized.

Increased participation in risk-reduction elements of the wellness program (e.g., a fitness program, smoking cessation courses, stress management seminars) may indicate that HRA recommendations are being heeded. Ultimately, however, evaluation will involve determination of changes in risk status. This may involve analyzing the results of the follow-up of high-risk individuals or repetition of the program after an appropriate interval. Such data may be fortified by correlation with data such as utilization of health benefits, absenteeism or productivity measures. Appropriate recognition, however, should be given to other factors that may have been involved (e.g., bias reflecting the sort of person who returns for retest, regression to the mean, and secular trends); truly scientific evaluation of the program impact requires a randomized prospective clinical trial (Schoenbach 1987; DeFriese and Fielding 1990).

Validity and Utility of the HRA

Factors that may affect the accuracy and validity of an HRA have been discussed elsewhere (Beery et al. 1986; Schoenbach 1987; DeFriese and Fielding 1990) and will only be listed here. They represent a checklist for workplace decision makers evaluating different instruments, and include the following:

  • accuracy and consistency of self-reported information
  • completeness and quality of the epidemiological and actuarial data on which the risk estimates are based
  • limitations of the statistical methods for calculating risk, including combining risk factors for different problems into a single composite score and the distortions produced by substituting “average” values either for missing responses in the questionnaire or for measurements not taken
  • reliability of the method for calculating the benefits of risk reduction
  • applicability of the same mortality calculations to the young whose death rates are low and to older individuals for whom age alone may be the most significant factor in mortality. Furthermore, the validity of the HRA when applied to populations different from those on whom most of the research has been done (i.e., women, minorities, people of different educational and cultural backgrounds) must be regarded from a critical point of view.


Questions have also been raised about the utility of the HRA based on considerations such as the following:

  1. The primary focus of HRA is on life expectancy. Until recently, little or no attention has been paid to factors primarily influencing morbidity from conditions that are not usually fatal but which may have an even greater impact on well-being, productivity and health-related costs (e.g., arthritis, mental disorders, and long-term effects of treatments intended to reduce specific risks). The problem is the lack of good morbidity databases for the general population, to say nothing of subgroups defined by age, sex, race or ethnicity.
  2. Concern has been expressed about the ill effects of anxiety generated by reports of high-risk status reflecting factors which the individual is unable to modify (e.g., age, heredity, and past medical history), and about the possibility that reports of “normal” or low-risk status may lead individuals to ignore potentially significant signs and symptoms that were not reported or which developed after the HRA was completed.
  3. Participation in an HRA programme is usually voluntary, but allegations of coercion to participate or to follow the recommendations have been made.
  4. Charges of “blaming the victim” have rightfully been levelled at employers who offer HRA as part of a health promotion programme but do little or nothing to control health risks in the work environment.
  5. Confidentiality of personal information is an ever-present concern, especially when an HRA is conducted as an in-house programme and abnormal findings appear to be a trigger for discriminatory actions.PP9


Evidence of the value of health-risk reduction has been accumulating. For example, Fielding and his associates at Johnson and Johnson Health Management, Inc., found that the 18,000 employees who had completed the HRA provided through their employers used preventive services at a considerably higher rate than a comparable population responding to the National Health Interview Survey (Fielding et al. 1991). A five-year study of almost 46,000 DuPont employees demonstrated that those with any of the six behavioral cardiovascular risk factors identified by an HRA (e.g., cigarette smoking, high blood pressure, high cholesterol levels, lack of exercise) had significantly higher rates of absenteeism and use of health care benefits as compared to those without such risk factors (Bertera 1991). Furthermore, applying multivariate regression models to 12 health-related measures taken mainly from an HRA allowed Yen and his colleagues at the University of Michigan Fitness Research Center to predict which employees would generate higher costs for the employer for medical claims and absenteeism (Yen, Edington and Witting 1991).

Implementing an HRA Program

Implementing an HRA program is not a casual exercise and should not be undertaken without careful consideration and planning. The costs of an individual questionnaire and its processing may not be great but the aggregate costs to the organization may be considerable when such items as staff time for planning, implementation and follow-up, employee time for completing the questionnaires, and adjunct health-promotion programs are included. Some factors to be considered in implementation are presented in figure 1.

Figure 1. Checklist for health risk appraisal (HRA) implementation.


Should we have an HRA program?

An increasing number of companies, at least in the United States, are answering this question in the affirmative, abetted by the growing number of vendors energetically marketing HRA programs. The popular media and “trade” publications are replete with anecdotes describing “successful” programs, while in comparison there is a paucity of articles in professional journals offering scientific evidence of the accuracy of their results, their practical reliability and their scientific validity.

It seems clear that defining one’s health risk status is a necessary basis for risk reduction. But, some ask, does one need a formal exercise like the HRA to do this? By now, virtually everyone who persists in cigarette smoking has been exposed to evidence of the potential of adverse health effects, and the benefits of proper nutrition and physical fitness have been well publicized. Proponents of HRA counter by pointing out that receiving an HRA report personalizes and dramatizes the risk information, creating a “teachable moment” that can motivate individuals to take appropriate action. Further, they add, it can highlight risk factors of which the participants may have been unaware, allowing them to see just what their risk reduction opportunities are and to develop priorities for addressing them.

There is general agreement that HRA has limited value when used as a stand-alone exercise (i.e., in the absence of other modalities) and that its utility is fully realized only when it is part of an integrated health promotion program. That program should offer not only individualized explanations and counseling but also access to intervention programs that address the risk factors that were identified (these interventions may be provided in-house or in the community). Thus, the commitment to offer HRA must be broadened (and perhaps may become more costly) by offering or making available such activities as smoking cessation courses, fitness activities and nutrition counseling. Such a broad commitment should be made explicitly in the statement of objectives for the program and the budget allocation requested to support it.

In planning an HRA program, one must decide whether to offer it to the entire workforce or only to certain segments (e.g., to salaried or hourly workers, to both, or to workers of specified ages, lengths of service or in specified locations or job categories); and whether to extend the program to include spouses and other dependants (who, as a rule, account for more than half of the utilization of health benefits). A critical factor is the need to secure the availability of at least one person in the organization sufficiently knowledgeable and appropriately positioned to supervise the design and implementation of the program and the performance of both the vendor and the in-house staff involved.

In some organizations in which full-scale annual medical examinations are being eliminated or offered less frequently, HRA has been offered as a replacement either alone or in combination with selected health screening tests. This strategy has merit in terms of enhancing the cost/benefit ratio of a health promotion program, but sometimes it is based not so much on the intrinsic value of the HRA but on the desire to avoid the ill-will that might be generated by what could be perceived as elimination of an established employee benefit.


Despite its limitations and the paucity of scientific research that confirms the claims for its validity and utility, the use of HRA continues to grow in the United States and, much less rapidly, elsewhere. DeFriese and Fielding, whose studies have made them authorities on HRA, see a bright future for it based on their prediction of new sources of risk-relevant information and new technological developments such as improvements in computer hardware and software that will permit direct computer entry of questionnaire responses, allow modeling of the effects of changes in health behavior, and produce more effective full-color reports and graphics (DeFriese and Fielding 1990).

HRA should be used as an element in a well-conceived, continuing program of wellness or health promotion. It conveys an implicit commitment to provide activities and changes in the workplace culture that offer opportunities to help control the risk factors it will identify. Management should be aware of such a commitment and be willing to make the requisite budget allocations.

While much research remains to be done, many organizations will find HRA a useful adjunct to their efforts to improve the health of their employees. The implicit scientific authority of the information it provides, the use of computer technology, and the personalized impact of the results in terms of chronological versus risk age seem to enhance its power to motivate participants to adopt healthy, risk-reducing behaviors. Evidence is accumulating to show that employees and dependants who maintain healthy risk profiles have less absenteeism, demonstrate enhanced productivity, and use less medical care, all of which have a positive effect on the organization’s “bottom line”.



Physical training and fitness programs are generally the most frequently encountered element in worksite health promotion and protection programs. They are successful when they contribute to the goals of the organization, promote the health of employees, and remain pleasing and useful to those participating (Dishman 1988). Because organizations around the world have widely diverse goals, workforces and resources, physical training and fitness programs vary greatly in how they are organized and in what services they provide.

This article is concerned with the reasons for which organizations offer physical training and fitness programs, how such programs fit within an administrative structure, the typical services offered to participants, the specialized personnel who offer these services, and the issues most often involved in worksite fitness programming, including the needs of special populations within the workforce. It will focus primarily on programs conducted onsite in the workplace.

Quality and Fitness Programming

Today’s global economy shapes the goals and business strategies of tens of thousands of employers and affects millions of workers around the world. Intense international competition requires organizations to offer products and services of higher value at ever lower costs, that is, to pursue so-called “quality” as a goal. Quality-driven organizations expect workers to be “customer oriented,” to work energetically, enthusiastically and accurately throughout the entire day, to continually train and improve themselves professionally and personally, and to take responsibility for both their workplace behavior and their personal well-being.

Physical training and fitness programs can play a role in quality-driven organizations by helping workers to achieve a high level of “wellness”. This is particularly important in “white-collar” industries, where employees are sedentary. In manufacturing and heavier industries, strength and flexibility training can enhance work capacity and endurance and protect workers from occupational injuries. In addition to physical improvement, fitness activities offer relief from stress and carry a personal sense of responsibility for health into other aspects of lifestyle such as nutrition and weight control, avoidance of alcohol and drug abuse, and smoking cessation.

Aerobic conditioning, relaxation and stretching exercises, strength training, adventure and challenge opportunities and sports competitions are typically offered in quality-driven organizations. These offerings are often structured within the organization’s wellness initiatives—“wellness” involves helping people to actualize their full potential while leading a lifestyle that promotes health—and they are based on the awareness that, since sedentary living is a well-demonstrated risk factor, regular exercise is an important habit to foster.

Basic Fitness Services

Participants in fitness programs should be instructed in the rudiments of fitness training. The instruction includes the following components:

  • a minimum number of exercise sessions per week to achieve fitness and good health (three or four times a week for 30 to 60 minutes per session)
  • learning how to warm up, exercise and cool down
  • learning how to monitor heart rate and how to safely raise one’s heart rate to a training level appropriate for one’s age and fitness level
  • graduating training from light to heavy to ultimately achieve a high level of fitness
  • techniques for cross training
  • The principles of strength training, including resistance and overload, and combining repetitions and sets to achieve strengthening goals
  • strategic rest and safe lifting techniques
  • relaxation and stretching as an integral part of a total fitness programme
  • learning how to customize workouts to suit one’s personal interests and lifestyle
  • achieving an awareness of the role that nutrition plays in fitness and overall good health.


    Besides instruction, fitness services include fitness assessment and exercise prescription, orientation to the facility and training in the use of the equipment, structured aerobic classes and activities, relaxation and stretching classes, and back-pain prevention classes. Some organizations offer one-on-one training, but this can be quite expensive since it is so staff-intensive.

    Some programs offer special “work hardening” or “conditioning,” that is, training to enhance workers’ capacities to perform repetitive or rigorous tasks and to rehabilitate those recovering from injuries and illnesses. They often feature work breaks for special exercises to relax and stretch overused muscles and strengthen antagonistic sets of muscles to prevent overuse and repetitive injury syndromes. When advisable, they include suggestions for modifying the job content and/or the equipment used.

    Physical Training and Fitness Personnel

    Exercise physiologists, physical educators, and recreational specialists make up the majority of the professionals working in worksite physical fitness programs. Health educators and rehabilitation specialists also participate in these programs.

    The exercise physiologist designs personalized exercise regimens for individuals based on a fitness assessment which generally includes a health history, a health risk screening, assessment of fitness levels and exercise capacity (essential for those with handicaps or recovering from injury), and confirmation of their fitness goals. The fitness assessment includes the determination of resting heart rate and blood pressure, body composition. muscle strength and flexibility, cardiovascular efficiency and, often, blood lipid profiles. Typically, the findings are compared with norms for people of the same sex and age.

    None of the services offered by the physiologist are meant to diagnose disease; employees are referred to the employee health service or their personal physicians when abnormalities are found. In fact, many organizations require that a prospective applicant obtain clearance from a physician before joining the program. In the case of employees recovering from injuries or illness, the physiologist will work closely with their personal physicians and rehabilitation counselors.

    Physical educators have been trained to lead exercise sessions, to teach the principles of healthy and safe exercise, to demonstrate and coach various athletic skills, and to organize and administer a multifaceted fitness program. Many have been trained to perform fitness assessments although, in this age of specialization, that task is performed more often by the exercise physiologist.

    Recreational specialists carry out surveys of participants’ needs and interests to determine their lifestyles and their recreational requirements and preferences. They may conduct exercise classes but generally focus on arranging trips, contests and activities that instruct, physically challenge and motivate participants to engage in wholesome physical activity.

    Verifying the training and competence of physical training and fitness personnel often presents problems to organizations seeking to staff a program. In the United States, Japan and many other countries, government agencies require academic credentials and supervised experience of physical educators who teach in school systems. Most governments do not require certification of exercise professionals; for example, in the United States, Wisconsin is the only state that has enacted legislation dealing with fitness instructors. In considering an involvement with health clubs in the community, whether voluntary like the YMCAs or commercial, special caution should be taken to verify the competence of the trainers they provide since many are staffed by volunteers or poorly trained individuals.

    A number of professional associations offer certification for those working in the adult fitness field. For example, the American College of Sports Medicine offers a certificate for exercise instructors and the International Dance Education Association offers a certificate for aerobics instructors. These certificates, however, represent indicators of experience and advanced training rather than licenses to practice.

    Fitness Programs and the Organization’s Structure

    As a rule, only medium-sized to large-sized organizations (500 to 700 employees is generally considered the minimum) can undertake the task of providing physical training facilities for their employees at the worksite. Major considerations other than size include the ability and willingness to make the necessary budgetary allocations and availability of space to house the facility and whatever equipment it may require, including dressing and shower rooms.

    Administrative placement of the program within the organization usually reflects the goals set for it. For example, if the goals are primarily health-related (e.g., cardiovascular risk reduction, reducing illness absences, prevention and rehabilitation of injuries, or contributing to stress management) the program will usually be found in the medical department or as a supplement to the employee health service. When the primary goals relate to employee morale and recreation, it will usually be found in the human resources or employee relations department. Since human resources departments are usually charged with implementing quality improvement programs, fitness programs with a wellness and quality focus will often be located there.

    Training departments rarely are assigned responsibility for physical training and fitness programs since their mission is usually limited to specific skill development and job training. However, some training departments offer outdoor adventure and challenge opportunities to employees as ways to create a sense of teamwork, build self-confidence and explore ways to overcome adversity. When jobs involve physical activity, the training program may be responsible for teaching proper work techniques. Such training units will often be found in police, fire and rescue organizations, trucking and delivery firms, mining operations, oil exploration and drilling companies, diving and salvage organizations, construction firms, and the like.

    Onsite or Community-based Fitness Programs

    When space and economic considerations do not allow comprehensive exercise facilities, limited programs may still be conducted in the workplace. When not in use for their designed purposes, lunch and meeting rooms, lobbies and parking areas may be used for exercise classes. One New York City-based insurance company created an indoor jogging track in a large storage area by arranging a path between banks of filing cabinets containing important but infrequently consulted documents. In many organizations around the world, work breaks are regularly scheduled during which employees stand at their work stations and do calisthenics and other simple exercises.

    When onsite fitness facilities are not feasible (or when they are too small to accommodate all the employees who would use them), organizations turn to community-based settings such as commercial health clubs, schools and colleges, churches, community centers, clubs and YMCAs, town- or union-sponsored recreation centers, and so on. Some industrial parks house an exercise facility shared by the corporate tenants.

    On another level, fitness programs may consist of uncomplicated physical activities practiced in or about the home. Recent research has established that even low to moderate levels of daily activity may have protective health effects. Activities like recreational walking, biking or stair-climbing which require the person to dynamically exercise large muscle groups for 30 minutes five times a week, may prevent or delay the advance of cardiovascular disease while providing a pleasant respite from daily stress. Programs that encourage walking and bicycling to work can be developed for even very small companies and they cost very little to implement.

    In some countries, workers are entitled to leaves that may be spent at spas or health resorts which offer a comprehensive program of rest, relaxation, exercise, healthful diet, massage and other forms of restorative therapy. The aim, of course, is to have them maintain such a healthful lifestyle after they return to their homes and jobs.

    Exercise for Special Populations

    Older workers, the obese and especially those who have been sedentary for long can be offered low-impact and low-intensity exercise programs in order to avert orthopedic injuries and cardiovascular emergencies. In onsite facilities, special times or separate workout spaces may be arranged to protect the privacy and dignity of these populations.

    Pregnant women who have been physically active may continue to work or exercise with the advice and consent of their personal physicians, keeping in mind the medical guidelines concerning exercise during pregnancy (American College of Obstetricians and Gynecologists 1994). Some organizations offer special reconditioning exercise programs for women returning to work after delivery.

    Physically challenged or handicapped workers should be invited to participate in the fitness program both as a matter of equity and because they may accrue even greater benefits from the exercise. Program staff, however, should be alert to conditions that may entail greater risk of injury or even death, such as Marfan’s syndrome (a congenital disorder) or certain forms of heart disease. For such individuals, preliminary medical evaluation and fitness assessment is particularly important, as is careful monitoring while exercising.

    Setting Goals for the Exercise Program

    The goals selected for an exercise program should complement and support those of the organization. Figure 1 presents a checklist of potential program goals which, when ranked in order of importance to a particular organization and aggregated, will help in shaping the program.

    Figure 1. Suggested organizational goals for a fitness and exercise programme.


    Eligibility for the Exercise Program

    Since the demand may exceed both the program’s budget allocation and the available space and time, organizations have to carefully consider who should be eligible to participate. It is prudent to know in advance why this benefit is being offered and how many employees are likely to take advantage of it. Lack of preparation in this regard may lead to embarrassment and ill will when those who desire to exercise cannot be accommodated.

    Particularly when providing an onsite facility, some organizations limit eligibility to managers above a certain level in the organization chart. They rationalize this by arguing that, since such individuals are paid more, their time is more valuable and it is proper to give them priority of access. The program then becomes a special privilege, like the executive dining room or a conveniently located parking space. Other organizations are more even-handed and offer the program to all on a first-come, first-served basis. Where demand exceeds the facility’s capacity, some use length of service as a criterion of priority. Rules setting minimum monthly use are sometimes used to help manage the space problem by discouraging the casual or episodic participant from continuing as a member.

    Recruiting and Retaining Program Participants

    One problem is that the convenience and low cost of the facility may make it particularly attractive to those already committed to exercise, who may leave little room for those who may need it much more. Most of the former will probably continue to exercise anyway while many of the latter will be discouraged by difficulties or delays in entering the program. Accordingly, an important adjunct to recruiting participants is simplifying and facilitating the enrolment process.

    Active efforts to attract participants are usually necessary, at least when the program is initiated. They include in-house publicity via posters, flyers and announcements in available intramural communications media, as well as open visits to the exercise facility and the offer of experimental or trial memberships.

    The problem of dropout is an important challenge to program administrators. Employees cite boredom with exercise, muscular aches and pains induced by exercise, and time pressure as the major reasons for dropping out. To counter this, facilities entertain members with music, videotapes and television programs, motivational games, special events, awards such as T-shirts and other gifts and certificates for attendance or reaching individual fitness goals. Properly designed and supervised exercise regimens will minimize injuries and aches and pains and, at the same time, make the sessions efficient and less time-consuming. Some facilities offer newspapers and business publications as well as business and training programs on television and videotape to be accessed while exercising to help justify the time spent in the facility.

    Safety and Supervision

    Organizations offering worksite fitness programs must do so in a safe manner. Potential members must be screened for medical conditions that might be affected adversely by exercise. Only well-designed and well-maintained equipment should be available and participants must be properly instructed in its use. Safety signs and rules on the appropriate use of the facility should be posted and enforced, and all staff should be trained in emergency procedures, including cardiopulmonary resuscitation. A trained exercise professional should oversee the operation of the facility.

    Record Keeping and Confidentiality

    Individual records containing information about health and physical status, fitness assessment and exercise prescription, fitness goals and progress toward their accomplishment and any relevant notes should be maintained. In many programs, the participant is allowed to chart for himself or herself what was done on each visit. At a minimum, the content of records should be kept secure from all but the individual participant and members of the program staff. Except for the staff of the employee health service, who are bound to the same rules of confidentiality and, in an emergency, the participant’s personal physician, details of the individual’s participation and progress should not be revealed to anyone without the individual’s express consent.

    Program staff may be required to make periodic reports to management presenting aggregate data regarding participation in the program and the results.

    Whose Time, Who Pays?

    Since most worksite exercise programs are voluntary and established to benefit the worker, they are considered an extra benefit or privilege. Accordingly, the organization traditionally offers the program on the worker’s own time (during lunch time or after hours) and he or she is expected to pay all or part of the cost. This is generally applicable also to programs provided offsite in community facilities. In some organizations, the employees’ contributions are indexed to salary level and some offer “scholarships” to those who are low paid or those with financial problems.

    Many employers allow participation during working hours, usually for higher-level employees, and pick up most if not all of the cost. Some refund employees’ contributions if certain attendance or fitness goals are attained.

    When program participation is mandatory, as in training to prevent potential work injuries or to condition workers to perform certain tasks, government regulations and/or labor union agreements require it to be provided during work hours with all costs borne by the employer.

    Managing Participants’ Aches and Pains

    Many people believe that exercise must be painful in order to be beneficial. This is frequently expressed by the motto “No pain, no gain”. It is incumbent on the program staff to counter this erroneous belief by changing the perception of exercise through awareness campaigns and educational sessions and by ensuring that the intensity of the exercises is graduated so that they remain pain-free and enjoyable while still improving the participant’s level of fitness.

    If participants complain of aches and pains, they should be encouraged to continue to exercise at a lower level of intensity or simply to rest until healed. They should be taught “RICE,” the acronym for the principles of treating sports injuries: Rest; Ice down the injury; Compress any swelling; and Elevate the injured body part.

    Sports Programs

    Many organizations encourage employees to participate in company-sponsored athletic events. These may range from softball or football games at the yearly company picnic, to intramural league play in a variety of sports, to inter-company competitions such as the Chemical Bank’s Corporate Challenge, a competitive distance run for teams of employees from participating organizations that originated in New York City and now has spread to other areas, with many more corporations joining as sponsors.

    The key concept for sports programs is risk management. While the gains from competitive sports can be considerable, including better morale and stronger “team” feelings, they inevitably entail some risks. When workers engage in competition, they may bring to the game work-related psychological “baggage” that can cause problems, particularly if they are not in good physical condition. Examples include the middle-aged, out-of-shape manager who, seeking to impress younger subordinates, may be injured by exceeding his or her physical capabilities, and the worker who, feeling challenged by another in competing for status in the organization, may convert what is meant to be a friendly game into a dangerous, bruising mêlée.

    The organization wishing to offer involvement in competitive sports should seriously consider the following advice:

    • Be sure that participants understand the purpose of the event and remind them that they are employees of the organization and not professional athletes.
    • Establish firm rules and guidelines governing safe and fair play.
    • Although signed informed consent and waiver forms do not always protect the organization from liability in the event of injury, they help participants to comprehend the extent of the risk associated with the sport.
    • Offer conditioning clinics and practice sessions prior to the opening of the competition so that participants can be in good physical shape when they begin to play.
    • Require, or at least encourage, a complete physical examination by the employee’s personal physician if not available in the employee health service. (Note: the organization may have to accept financial responsibility for this.)
    • Perform a safety inspection of the athletic field and all of the sports equipment. Provide or require personal protective equipment such as helmets, clothing, safety pads and goggles.
    • Make sure that referees and security personnel as needed are on hand for the event.
    • Have first aid supplies on hand and a pre-arranged plan for emergency medical care and evacuation if needed.
    • Be sure that the organization’s liability and disability insurance coverage covers such events and that it is adequate and in force. (Note: it should cover employees and others who attend as spectators as well as those on the team.)



      For some companies, sports competition is a major source of employee disability. The above recommendations indicate that the risk may be “managed,” but serious thought should be given to the net contribution that sports activities can reasonably be expected to provide to the physical fitness and training program.


      Well-designed, professionally managed workplace exercise programs benefit employees by enhancing their health, well-being, morale and work performance. They benefit organizations by improving productivity qualitatively and quantitatively, preventing work-related injuries, accelerating employees’ recovery from illness and injury, and reducing absenteeism. The design and implementation of each program should be individualized in accord with the characteristics of the organization and its workforce, with the community in which it operates, and with the resources that can be made available for it. It should be managed or at least supervised by a qualified fitness professional who will consistently be mindful of what the program contributes to its participants and to the organization and who will be ready to modify it as new needs and challenges arise.



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