Monday, 24 January 2011 18:56

Health Promotion in Small Organizations: The US Experience

Written by
Rate this item
(0 votes)

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.

 

Conclusion

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.

 

Back

Additional Info

Read 4038 times Last modified on Friday, 05 August 2011 00:48

" DISCLAIMER: The ILO does not take responsibility for content presented on this web portal that is presented in any language other than English, which is the language used for the initial production and peer-review of original content. Certain statistics have not been updated since the production of the 4th edition of the Encyclopaedia (1998)."

Contents

Preface
Part I. The Body
Part II. Health Care
First Aid & Emergency Medical Services
Health Protection & Promotion
Occupational Health Services
Part III. Management & Policy
Part IV. Tools and Approaches
Part V. Psychosocial and Organizational Factors
Part VI. General Hazards
Part VII. The Environment
Part VIII. Accidents and Safety Management
Part IX. Chemicals
Part X. Industries Based on Biological Resources
Part XI. Industries Based on Natural Resources
Part XII. Chemical Industries
Part XIII. Manufacturing Industries
Part XIV. Textile and Apparel Industries
Part XV. Transport Industries
Part XVI. Construction
Part XVII. Services and Trade
Part XVIII. Guides

Health Protection and Promotion References

Adami, HG, JA Baron, and KJ Rothman. 1994. Ethics of a prostate cancer screening trial. Lancet (343):958-960.

Akabas, SH and M Hanson. 1991. Workplace drug and alcohol programmes in the United States. Working paper given at Proceedings of the Washington Tripartite Symposium on Drug and Alcohol Prevention and Assistance Programmes at the Workplace. Geneva: ILO.

American College of Obstetricians and Gynecologists (ACOG). 1994. Exercise during Pregnancy and the Postpartum Period. Vol. 189. Technical Bulletin. Washington, DC: DCL.

American Dietetic Association (ADA) and Office of Disease Prevention and Health Promotion. 1994. Worksite Nutrition: A Guide to Planning, Implementation, and Evaluation. Chicago: ADA.

American Lung Association. 1992. Survey of the public’s attitudes toward smoking. Prepared for the Gallup Organization by the American Lung Association.

Anderson, DR and MP O’Donnell. 1994. Toward a health promotion research agenda: “State of the Science” reviews. Am J Health Promot (8):482-495.

Anderson, JJB. 1992. The role of nutrition in the functioning of skeletal tissue. Nutr Rev (50):388-394.

Article 13-E of the New York State Public Health Law.

Baile, WF, M Gilbertini, F Ulschak, S Snow-Antle, and D Hann. 1991. Impact of a hospital smoking ban: Changes in tobacco use and employee attitudes. Addict Behav 16(6):419-426.

Bargal, D. 1993. An international perspective on the development of social work in the workplace. In Work and Well-Being, the Occupational Social Work Advantage, edited by P Kurzman and SH Akabas. Washington, DC: NASW Press.

Barr, JK, KW Johnson, and LJ Warshaw. 1992. Supporting the elderly: Workplace programs for employed caregivers. Milbank Q (70):509-533.

Barr, JK, JM Waring, and LJ Warshaw. 1991. Employees’ sources of AIDS information: The workplace as a promising educational setting. J Occup Med (33):143-147.

Barr, JK and LJ Warshaw. 1993. Stress among Working Women: Report of a National Survey. New York: New York Business Group on Health.

Beery, W, VJ Schoenbach, EH Wagner, et al. 1986. Health Risk Appraisal: Methods and Programs, with Annotated Bibliography. Rockville, Md: National Center for Health Services Research and Health Care Technology Assessment.

Bertera, RL. 1991. The effects of behavioral risks on absenteeism and healthcare costs in the workplace. J Occup Med (33):1119-1124.

Bray, GA. 1989. Classification and evaluation of the obesities. Med Clin North Am 73(1):161-192.

Brigham, J, J Gross, ML Stitzer, and LJ Felch. 1994. Effects of a restricted worksite smoking policy on employees who smoke. Am J Public Health 84(5):773-778.

Bungay, GT, MP Vessey, and CK McPherson. 1980. Study of symptoms of middle life with special reference to the menopause. Brit Med J 308(1):79.

Bureau of National Affairs (BNA). 1986. Where There’s Smoke: Problems and Policies Concerning Smoking in the Workplace. Rockville, Md: BNA.

—. 1989. Workplace smoking, corporate practices and developments. BNA’s Employee Relations Weekly 7(42): 5-38.

—. 1991. Smoking in the workplace, SHRM-BNA survey no. 55. BNA Bulletin to Management.

Burton, WN and DJ Conti. 1991. Value-managed mental health benefits. J Occup Med (33):311-313.

Burton, WN, D Erickson, and J Briones. 1991. Women’s health programs at the workplace. J Occup Med (33):349-350.

Burton, WN and DA Hoy. 1991. A computer-assisted health care cost management system. J Occup Med (33):268-271.

Burton, WN, DA Hoy, RL Bonin, and L Gladstone. 1989. Quality and cost effective management of mental health care. J Occup Med (31):363-367.

Caliber Associates. 1989. Cost-Benefit Study of the Navy’s Level III Alcohol Rehabilitation Programme Phase Two: Rehabilitation vs Replacement Costs. Fairfax, Va: Caliber Associates.

Charafin, FB. 1994. US sets standards for mammography. Brit Med J (218):181-183.

Children of Alcoholics Foundation. 1990. Children of Alcoholics in the Medical System: Hidden Problems, Hidden Costs. New York: Children of Alcoholics Foundation.

The City of New York. Title 17, chapter 5 of the Administration Code of the City of New York.

Coalition on Smoking and Health. 1992. State Legislated Actions On Tobacco Issues. Washington, DC: Coalition on Smoking and Health.

Corporate Health Policies Group. 1993. Issues of Environmental Tobacco Smoke in the Workplace. Washington, DC: National Advisory Committee of the Interagency Committee on Smoking and Health.

Cowell, JWF. 1986. Guidelines for fitness-to-work examinations. CMAJ 135 (1 November):985-987.

Daniel, WW. 1987. Workplace Industrial Relations and Technical Change. London: Policy Studies Institute.

Davis, RM. 1987. Current trends in cigarette advertising and marketing. New Engl J Med 316:725-732.

DeCresce, R, A Mazura, M Lifshitz, and J Tilson. 1989. Drug Testing in the Workplace. Chicago: ASCP Press.

DeFriese, GH and JE Fielding. 1990. Health risk appraisal in the 1990s: Opportunities, challenges, and expectations. Annual Revue of Public Health (11):401-418.

Dishman, RH. 1988. Exercise Adherence: Its Impact On Public Health. Champaign, Ill: Kinetics Books.

Duncan, MM, JK Barr, and LJ Warshaw. 1992. Employer-Sponsored Prenatal Education Programs: A Survey Conducted By the New York Business Group On Health. Montvale, NJ: Business and Health Publishers.

Elixhauser, A. 1990. The costs of smoking and the effectiveness of smoking-cessation programs. J Publ Health Policy (11):218-235.

European Foundation for the Improvement of Living and Working Conditions.1991. Overview of innovative action for workplace health in the UK. Working paper no. WP/91/03/EN.

Ewing, JA. 1984. Detecting alcoholism: The CAGE questionnaire. JAMA 252(14):1905-1907.

Fielding, JE. 1989. Frequency of health risk assessment activities at US worksites. Am J Prev Med 5:73-81.

Fielding, JE and PV Piserchia. 1989. Frequency of worksite health promotion activities. Am J Prev Med 79:16-20.

Fielding, JE, KK Knight, RZ Goetzel, and M Laouri. 1991. Utilization of preventive health services by an employed population. J Occup Med 33:985-990.

Fiorino, F. 1994. Airline outlook. Aviat week space technol (1 August):19.

Fishbeck, W. 1979. Internal Report and Letter. Midland, Michigan: Dow Chemical Company, Corporate Medical Dept.

Food and Agriculture Organization of the United Nations (FAO) and World Health Organization (WHO). 1992. International Conference on Nutrition: Major Issues for Nutrition Strategies. Geneva: WHO.

Forrest, P. 1987. Breast Cancer Screening 1987. Report to the Health Ministers of England, Wales, Scotland, and Ireland. London: HMSO.

Freis, JF, CE Koop, PP Cooper, MJ England, RF Greaves, JJ Sokolov, D Wright, and Health Project Consortium. 1993. Reducing health care costs by reducing the need and demand for health services. New Engl J Med 329:321-325.

Glanz, K and RN Mullis. 1988. Environmental interventions to promote healthy eating: A review of models, programs, and evidence. Health Educ Q 15:395-415.

Glanz, K and T Rogers. 1994. Worksite nutrition programs in health promotion in the workplace. In Health Promotion in the Workplace, edited by MP O’Donnell and J Harris. Albany, NY: Delmar.

Glied, S and S Kofman. 1995. Women and Mental Health: Issues for Health Reform. New York: The Commonwealth Fund.

Googins, B and B Davidson. 1993. The organization as client: Broadening the concept of employee assistance programs. Social Work 28:477-484.

Guidotti, TL, JWF Cowell, and GG Jamieson. 1989. Occupational Health Services: A Practical Approach. Chicago: American Medical Association.

Hammer, L. 1994. Equity and gender issues in health care provision: The 1993 World Bank Development Report and its implications for health service recipients. Working Paper Series, no.172. The Hague: Institute of Social Studies.

Harris, L et al. 1993. The Health of American Women. New York: The Commonwealth Fund.

Haselhurst, J. 1986. Mammographic screening. In Complications in the Management of Breast Disease, edited by RW Blamey. London: Balliere Tindall.

Henderson, BE, RK Ross, and MC Pike. 1991. Toward the primary prevention of cancer. Science 254:1131-1138.

Hutchison, J and A Tucker. 1984. Breast screening results from a healthy, working population. Clin Oncol 10:123-128.

Institute for Health Policy. October, 1993. Substance Abuse: The Nation’s Number One Health Problem. Princeton: Robert Wood Johnson Foundation.

Kaplan, GD and VL Brinkman-Kaplan. 1994. Worksite weight management in health promotion in the workplace. In Health Promotion in the Workplace, edited by MP O’Donnell and J Harris. Albany, NY: Delmar.

Karpilow, C. 1991. Occupational Medicine in the Industrial Workplace. Florence, Ky: Van Nostrand Reinhold.

Kohler, S and J Kamp. 1992. American Workers under Pressure: Technical Report. St. Paul, Minn.: St. Paul Fire and Marine Insurance Company.

Kristein, M. 1983. How much can business expect to profit from smoking cessation? Prevent Med 12:358-381.

Lesieur, HR and SB Blume. 1987. The South Oaks Gambling Screen (SOGS): A new instrument for the identification of pathological gamblers. Am J Psychiatr 144(9):1184-1188.

Lesieur, HR, SB Blume, and RM Zoppa. 1986. Alcoholism, drug abuse and gambling. Alcohol, Clin Exp Res 10(1):33-38.

Lesmes, G. 1993. Getting employees to say no to smoking. Bus Health (March):42-46.

Lew, EA and L Garfinkel. 1979. Variations in mortality by weight among 750,000 men and women. J Chron Dis 32:563-576.

Lewin, K. [1951] 1975. Field Theory in Social Science: Selected Theoretical Papers by Kurt
Lewin, edited by D Cartwright. Westport: Greenwood Press.

Malcolm, AI. 1971. The Pursuit of Intoxication. Toronto: ARF Books.
M
andelker, J. 1994. A wellness program or a bitter pill. Bus Health (March):36-39.

March of Dimes Birth Defects Foundation. 1992. Lessons Learned from the Babies and You Program. White Plains, NY: March of Dimes Birth Defects Foundation.

—. 1994. Healthy Babies, Healthy Business: An Employer’s Guidebook on Improving Maternal and Infant Health. White Plains, NY: March of Dimes Birth Defects Foundation.

Margolin, A, SK Avants, P Chang, and TR Kosten. 1993. Acupuncture for the treatment of cocaine dependence in methadone-maintained patients. Am J Addict 2(3):194-201.

Maskin, A, A Connelly, and EA Noonan. 1993. Environmental tobacco smoke: Implications for the workplace. Occ Saf Health Rep (2 February).

Meek, DC. 1992. The impaired physician programme of the Medical Society of the District of Columbia. Maryland Med J 41(4):321-323.

Morse, RM and DK Flavin. 1992. The definition of alcoholism. JAMA 268(8):1012-1014.

Muchnick-Baku, S and S Orrick. 1992. Working for Good Health: Health Promotion and Small Business. Washington, DC: Washington Business Group on Health.

National Advisory Council for Human Genome Research. 1994. Statement on use of DNA testing for presymptomatic identification of cancer risk. JAMA 271:785.

National Council on Compensation Insurance (NCCI). 1985. Emotional Stress in the Workplace—New Legal Rights in the Eighties. New York: NCCI.

National Institute for Occupational Safety and Health (NIOSH). 1991. Current Intelligence Bulletin 54. Bethesda, Md: NIOSH.

National Institutes of Health (NIH). 1993a. National High Blood Pressure Education Program Working Group Report on Primary Prevention of Hypertension. National High Blood Pressure Education Program, National Heart, Lung, and Blood Institute. NIH publication No. 93-2669. Bethesda, Md: NIH.

—. 1993b. Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP II). National Cholesterol Education Program, National Institutes of Health, National Heart, Lung, and Blood Institute. NIH publication no. 93-3095. Bethesda, Md: NIH.

National Research Council. 1989. Diet and Health: Implications for Reducing Chronic Disease Risk. Washington, DC: National Academy Press.

New York Academy of Medicine. 1989. Drugs in the workplace: Proceedings of a symposium. B NY Acad Med 65(2).

Noah, T. 1993. EPA declares passive smoke a human carcinogen. Wall Street J, 6 January.

Ornish, D, SE Brown, LW Scherwitz, JH Billings, WT Armstrong, TA Ports, SM McLanahan, RL Kirkeeide, RJ Brand, and KL Gould. 1990. Can lifestyle changes reverse coronary heart disease? The lifestyle heart trial. Lancet 336:129-133.

Parodi vs. Veterans Administration. 1982. 540 F. Suppl. 85 WD. Washington, DC.

Patnick, J. 1995. NHS Breast Screening Programmes: Review 1995. Sheffield: Clear Communications.

Pelletier, KR. 1991. A review and analysis of the cost effective outcome studies of comprehensive health promotion and disease prevention programs. Am J Health Promot 5:311-315.

—. 1993. A review and analysis of the health and cost-effective outcome studies of comprehensive health promotion and disease prevention programs. Am J Health Promot 8:50-62.

—. 1994. Getting your money’s worth: The strategic planning programme of the Stanford Corporate Health Programme. Am J Health Promot 8:323-7,376.

Penner, M and S Penner. 1990. Excess insured health costs from tobacco-using employees in a large group plan. J Occup Med 32:521-523.

Preventive Services Task Force. 1989. Guide to Clinical Preventive Services: An Assessment of the Effectiveness of 169 Interventions. Baltimore: Williams & Wilkins.

Richardson, G. 1994. A Welcome for Every Child: How France Protects Maternal and Child Health-A New Frame of Reference for the United States. Arlington, Va: National Center for Education in Maternal and Child Health.

Richmond, K. 1986. Introducing heart healthy foods in a company cafeteria. J Nutr Educ 18:S63-S65.

Robbins, LC and JH Hall. 1970. How to Practice Prospective Medicine. Indianapolis, Ind: Methodist Hospital of Indiana.

Rodale, R, ST Belden, T Dybdahl, and M Schwartz. 1989. The Promotion Index: A Report Card on the Nation’s Health. Emmaus, Penn: Rodale Press.

Ryan, AS and GA Martinez. 1989. Breastfeeding and the working mother: A profile. Pediatrics 82:524-531.

Saunders, JB, OG Aasland, A Amundsen, and M Grant. 1993. Alcohol consumption and related problems among primary health care patients: WHO collaborative project on early detection of persons with harmful alcohol consumption-I. Addiction 88:349-362.

Schneider, WJ, SC Stewart, and MA Haughey. 1989. Health promotion in a scheduled cyclical format. J Occup Med 31:482-485.

Schoenbach, VJ. 1987. Appraising health risk appraisal. Am J Public Health 77:409-411.

Seidell, JC. 1992. Regional obesity and health. Int J Obesity 16:S31-S34.

Selzer, ML. 1971. The Michigan alcoholism screening test: The quest for a new diagnostic instrument. Am J Psychiatr 127(12):89-94.

Serdula, MK, DE Williamson, RF Anda, A Levy, A Heaton and T Byers. 1994. Weight control practices in adults: Results of a multistate survey. Am J Publ Health 81:1821-24.

Shapiro, S. 1977. Evidence of screening for breast cancer from a randomised trial. Cancer:2772-2792.

Skinner, HA. 1982. The drug abuse screening test (DAST). Addict Behav 7:363-371.

Smith-Schneider, LM, MJ Sigman-Grant, and PM Kris-Etherton. 1992. Dietary fat reduction strategies. J Am Diet Assoc 92:34-38.

Sorensen, G, H Lando, and TF Pechacek. 1993. Promoting smoking cessation at the workplace. J Occup Med 35(2):121-126.

Sorensen, G, N Rigotti, A Rosen, J Pinney, and R Prible. 1991. Effects of a worksite smoking policy: Evidence for increased cessation. Am J Public Health 81(2):202-204.

Stave, GM and GW Jackson. 1991. Effect of total work-site smoking ban on employee smoking and attitudes. J Occup Med 33(8):884-890.

Thériault, G. 1994. Cancer risks associated with occupational exposure to magnetic fields among electric utility workers in Ontario and Quebec, Canada, and France. Am J Epidemiol 139(6):550-572.

Tramm, ML and LJ Warshaw. 1989. Screening for Alcohol Problems: A Guide for Hospitals, Clinics, and Other Health Care Facilities. New York: New York Business Group on Health.

US Department of Agriculture: Human Nutrition Information Service. 1990. Report of the Dietary Guidelines Advisory Committee On Dietary Guidelines for Americans. Publication no. 261-495/20/24. Hyattsville, Md: US Government Printing Office.

US Department of Health, Education and Welfare. 1964. Smoking and Health Report of the Advisory Committee to the Surgeon General of the Public Health Service. PHS Publication No. 1103. Rockville, Md: US Department of Health, Education, and Welfare.

US Department of Health and Human Services (USDHHS). 1989. Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. USDHHS publication no.10 89-8411.Washington, DC: US Government Printing Office.

—. 1990. Economic Costs of Alcohol and Drug Abuse and Mental Illness. DHHS publication no. (ADM) 90-1694. Washington, DC: Alcohol, Drug Abuse, and Mental Health Administration.

—. 1991. Environmental Tobacco Smoke in the Workplace: Lung Cancer and Other Effects. USDHHS (NIOSH) publication No. 91-108. Washington, DC: USDHHS.
US Food and Drug Administration (FDA). 1995. Mammography quality deadline. FDA Med Bull 23: 3-4.

US General Accounting Office. 1994. Long-Term Care: Support for Elder Care Could Benefit the Government Workplace and the Elderly. GAO/HEHS-94-64. Washington, DC: US General Accounting Office.

US Office of Disease Prevention and Health Promotion. 1992. 1992 National Survey of Worksite Health Promotion Activities: Summary Report. Washington, DC: Department of Health and Human Services, Public Health Service.

US Public Health Service. 1991. Healthy People 2000: National Health Promotion and Disease Prevention Objectives—Full Report With Commentary. DHHS publication No. (PHS) 91-50212. Washington, DC: US Department of Health and Human Services.

Voelker, R. 1995. Preparing patients for menopause. JAMA 273:278.

Wagner, EH, WL Beery, VJ Schoenbach, and RM Graham. 1982. An assessment of health hazard/health risk appraisal. Am J Public Health 72:347-352.

Walsh, DC, RW Hingson, DM Merrigan, SM Levenson, LA Cupples, T Heeren, GA Coffman, CA Becker, TA Barker, SK Hamilton, TG McGuire, and CA Kelly. 1991. A randomized trial of treatment options for alcohol-abusing workers. New Engl J Med 325(11):775-782.

Warshaw, LJ. 1989. Stress, Anxiety, and Depression in the Workplace: Report of the NYGBH/Gallup Survey. New York: The New York Business Group on Health.

Weisman, CS. 1995. National Survey of Women’s Health Centers: Preliminary Report for Respondents. New York: Commonwealth Fund.

Wilber, CS. 1983. The Johnson and Johnson Program. Prevent Med 12:672-681.

Woodruff, TJ, B Rosbrook, J Pierce, and SA Glantz. 1993. Lower levels of cigarette consumption found in smoke-free workplaces in California. Arch Int Med 153(12):1485-1493.

Woodside, M. 1992. Children of Alcoholics At Work: The Need to Know More. New York: Children of Alcoholics Foundation.

World Bank. 1993. World Development Report: Investing in Health. New York: 1993.

World Health Organization (WHO). 1988. Health promotion for working populations: Report of a WHO expert committee. Technical Report Series, No.765. Geneva: WHO.

—. 1992. World No-Tobacco Day Advisory Kit 1992. Geneva: WHO.

—. 1993. Women and Substance Abuse: 1993 Country Assessment Report. Document No. WHO/PSA/93.13. Geneva: WHO.

—. 1994. A Guide On Safe Food for Travellers. Geneva: WHO.

Yen, LT, DW Edington, and P Witting. 1991. Prediction of prospective medical claims and absenteeism for 1,285 hourly workers from a manufacturing company, 1992. J Occup Med 34:428-435.