Slide 1

Worksite Wellness – Working
with Small Businesses
17th Annual Healthy Carolinians &
NCIOM Prevention Summit
Laura A. Linnan, ScD, CHES
The UNC Gillings School of Global Public Health
Thursday, October 8, 2009

Objectives
• Offer a brief overview of the importance of worksite
health promotion and its prevalence among small
employers
• Provide a rationale for offering comprehensive HPPs
among small employers
• Identify strengths/assets of small employers for
promoting employee health
• Share some promising intervention strategies –
including those recommended by the NC IOM -- for
increasing the prevalence of small employers which
offer comprehensive HPPs

Why Worksite Health Promotion?
• More than 60% of US adults are employed
• Employees spend a considerable number of waking
hours working
• Health care for US adults is directly linked with
employer-provided health insurance; many working
adults are without health insurance
• Many leading causes of death (CVD, cancer, stroke)
are preventable through lifestyle behavior changes
(smoking, diet, PA)

Why Should Employers Be Interested in Worksite
Health Promotion?
• Preventable illness makes up 70% of the total burden
of disease and their associated costs; employers pay
for these costs
• 10 modifiable risk factors account for approximately
25% of all employer healthcare expenditures
(Anderson, 2000)
• Employer medical costs average $7910/employee
annually (O’Donnell, 2007)
• Effective worksite health promotion programs have
demonstrated a positive impact on employee morale,
employee health and risk behaviors, productivity, and
health care costs

What is a “small” business?
• US Small Business Administration defines
“small” business as an employer with 500
employees or less
• SBA estimates there are 25.8 million small
businesses in the US
– They employee nearly 50% of the working adults!
– Employed adults spend about ½ of their waking
hours at work

Not all “small” employers are
equal… but they are important!
• Among small employers, there is great
heterogeneity
• The smaller the employer, the less likely it is to
offer health insurance or any health
programming for employees..
• 98% of employers with at least 200 employees offer some
type of health insurance while only 59% of those under
200 employees do
• One serious health problem represents financial disaster
for an employee and his/her family

Healthy People 2010 – WorksiteRelated National Health Objective
• “75% of employers (of all sizes) should offer a
comprehensive worksite health promotion
program,” which includes 5 key elements:
•
•
•
•
•

Health education programming
Supportive physical/social environment
Links to other health-related programs in the organization
Screening programs and appropriate follow-up
Integration of the program into the administrative structure
(e.g. budget, staffing, etc.)

How many employers are offering a
“comprehensive” health promotion
program?
• And, are small employers different from other
employers in what they offer?

Use of a Health Risk Appraisal
50

750+ EES (n=111)

45
40

250-749 EES (n=211)

35
30
25

100-249 EES (n=229)
50-99 EES (n=179)

20
15
10
5
0

Linnan, Bowling et al. (2008). AJPH.

Total (n=730)

Differences
by worksite
size
statistically
significant
(p=0.0002)

Physical Activity and Nutrition
Programs by Worksite Size
70
60
50

750+ EES (n=111)

40

250-749 EES (n=211)

30

100-249 EES (n=229)

20

50-99 EES (n=179)

10

Total (n=730)

0
*Physical Activity

*Nutrition

* statistically significant
differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental
Programs by Worksite Size
100
90
80

750+ EES
(n=111)

70

250-749 EES
(n=211)

60
50

100-249 EES
(n=229)

40
30

50-99 EES
(n=179)

20
10
0

Total (n=730)

Onsite Fitness Fitness/Walking
Center
Trails

Cafeteria

Vending food/beverages

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling
Services by Worksite Size
100
90
80
70
60
50
40
30
20
10
0

750+ (n=111)
250-749 (n=211)
100-249 (n=229)
50-99 (n=179)
Total (n=730)

Can
cer
S

Dia
be

cree
n

ing

tes

HBP
Scr

Scr

een
ing

HBC
een
in

g

Sc r

Alco

een
in

Linnan, Bowling et al, 2008, AJPH

g

hol

or D
r

ug

Abu
se

Sup
por

t

Predictors of Comprehensive
Worksite Health Promotion Programs


Overall, 6.9% of employers offered a
comprehensive program – smaller worksites were
less likely to offer all elements/types of programs
 Controlling for all factors (e.g. model adjusted for
size, staff, experience, industry type), we found:
 Worksites with 750+ employees were 4.4 times
more likely to have a comprehensive program
(p=.06).
 Worksites with a dedicated staff person were
10.3 times more likely to have a comprehensive
program (p<.05).

Why Do Small Employers Offer
Fewer Programs?
• “Survival Mode” – HPP programs are costly
– Direct Costs – of offering programs/services
– Indirect Costs – time/resources – competing
demands

• Lack of personnel dedicated to wellness
• Small business culture/leadership
– “Leave it up to Workers” (Eakin)
– Managers concerned about employee privacy
(Linnan)

Barriers To Health Promotion Program Success
70
60
50
40
30
20
10
0
Lack of
Employee
Interest

Lack of Staff
Resources

Lack of Funding Lack of High-Risk
Employee
Participation

Lack of
Management
Support

No differences in barriers were reported based on industry type or worksite size except that worksites with 750+
employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

Linnan, Bowling et al. 2008. AJPH

“When business survival is the
focus, any other costs, including
those linked to employee health,
may be seen as prohibitive.”
Linnan & Birken (2007)
NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007
Employment-Based
Coverage
Sector

Individually
Purchased

Total
Own Name

Public

Uninsured

Dependent

Total

100.0

50.6

17.5

6.7

7.4

20.3

Self-employed

100.0

22.9

25.7

20.0

7.1

26.4

Wage-and-Salary Workers

100.0

54.1

16.5

5.1

7.5

19.5

Firm Employment Size
< 10 Employees

100.0

26.6

21.9

9.5

10.1

34.3

10-24 Employees

100.0

38.3

20.3

6.3

7.8

28.9

25-99 Employees

100.0

52.0

17.3

5.2

6.9

20.8

100-499 Employees

100.0

62.1

14.8

3.6

6.5

15.4

< 500 Employees

100.0

45.2

18.5

6.1

7.8

24.6

500+ Employees

100.0

65.7

13.8

3.7

7.0

12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the
president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths
• Often, there is a family focus
• Fewer organizational layers – less complexity
re: decision-making
• Less complexity re: implementation
• Understand that each individual employee
and his/her health is important
• Understand that health influences the
“bottom line” of the company

Multiple Level Intervention for
Small Employers
Level of Intervention

Strategy

Intrapersonal/
Interpersonal

-Briefings (print) and Web-based resources
-Leading by Example – employers
-CEO breakfast meetings
-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational

-Free or low-cost HPPs + TA to implement them from
community, hospitals, voluntary health organizations…
-TA from State Health Department and/or insurers

Community

-Business Groups on Health – leverage for purchasing power
-University partnerships to get student help, grant funding

Policy

-National or state-level tax credits for small employers who
adopt HPPs
-Purchasing agreements for health
-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US
Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*
Individual Level
- Periodic health assessments tied to personalized feedback and individual coaching and motivational
interviewing
- Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with
all employees and is available to discuss health concerns
-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and
meet monthly with participants to collect program activity points and measure progress (eg, changes in
weight and blood pressure) toward positive health outcomes
-Strong linkage of wellness program with worker safety, including group stretching to promote model of an
“industrial athlete”
-Health coaches who travel among a company’s worksites to meet with employees
Environmental Level
-Strong support from wellness committee for establishing culture of wellness
-Inclusion of healthy food in criteria for selecting cafeteria vendor
-Free access to onsite physical activity facilities
-Provision of bicycles for travel between buildings
Organizational Level
-Incentive of paid day of leave to encourage program participation
-Reallocation of existing benefits to provide incentives for participating in screening activities and attaining
wellness goals
-Strong financial disincentives for employees and spouses with health insurance through the company who
do not participate in wellness program
-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:
Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for
Small Businesses
The North Carolina General Assembly should direct the North Carolina Public Health
Foundation to establish the North Carolina Worksite Wellness Collaborative to
promote evidence-based strategies to support the optimal health and well-being of
North Carolina’s workforce. The collaborative should help businesses implement
healthy workplace policies and benefits, implement health risk appraisals, develop
comprehensive employee wellness programs, and implement data systems that
track outcomes and the organizational and employee level.
The North Carolina General Assembly should provide start-up funding of $800,000 in
SFY 2011, with a reduced amount over the next four years, to support this
collaborative.
In addition, the North Carolina General Assembly should provide a tax credit to
businesses with 50 or fewer employees that have implemented a comprehensive
worksite wellness program for their employees.

Key Considerations
•
•
•
•
•
•
•

Get employees involved! Get dedicated staff!
Management support is necessary but not sufficient
Offer a comprehensive program with all 5 elements
Offer incentives for participation/behavior change
Provide links to local health care systems/providers
Address social contextual factors influencing health
Support research that builds evidence base and then
offer evidence-based programs
• Special focused activities for small employers

Related Information
• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small manufacturing
worksites that employ multiethnic, low-wage workforces into a cancer
prevention research trial. Prev Chronic Dis. 2004;1(3):A04.
• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change
among working-class, multiethnic workers: results of the healthy
directions—small business study. Am J Public Health. 2005;95(8):13891395.
• Divine RL. Determinants of small business interest in offering a wellness
program to their employees. Health Mark Q. 2005;22(3):43-58.
• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of
healthy weight at small and medium-sized US worksites. Prev Chronic Dis
2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.
• Linnan L & Birken B. Small businesses, worksite wellness and public
health: A time for action. NC Med J. 2006;67(6):433-438.


Slide 2

Worksite Wellness – Working
with Small Businesses
17th Annual Healthy Carolinians &
NCIOM Prevention Summit
Laura A. Linnan, ScD, CHES
The UNC Gillings School of Global Public Health
Thursday, October 8, 2009

Objectives
• Offer a brief overview of the importance of worksite
health promotion and its prevalence among small
employers
• Provide a rationale for offering comprehensive HPPs
among small employers
• Identify strengths/assets of small employers for
promoting employee health
• Share some promising intervention strategies –
including those recommended by the NC IOM -- for
increasing the prevalence of small employers which
offer comprehensive HPPs

Why Worksite Health Promotion?
• More than 60% of US adults are employed
• Employees spend a considerable number of waking
hours working
• Health care for US adults is directly linked with
employer-provided health insurance; many working
adults are without health insurance
• Many leading causes of death (CVD, cancer, stroke)
are preventable through lifestyle behavior changes
(smoking, diet, PA)

Why Should Employers Be Interested in Worksite
Health Promotion?
• Preventable illness makes up 70% of the total burden
of disease and their associated costs; employers pay
for these costs
• 10 modifiable risk factors account for approximately
25% of all employer healthcare expenditures
(Anderson, 2000)
• Employer medical costs average $7910/employee
annually (O’Donnell, 2007)
• Effective worksite health promotion programs have
demonstrated a positive impact on employee morale,
employee health and risk behaviors, productivity, and
health care costs

What is a “small” business?
• US Small Business Administration defines
“small” business as an employer with 500
employees or less
• SBA estimates there are 25.8 million small
businesses in the US
– They employee nearly 50% of the working adults!
– Employed adults spend about ½ of their waking
hours at work

Not all “small” employers are
equal… but they are important!
• Among small employers, there is great
heterogeneity
• The smaller the employer, the less likely it is to
offer health insurance or any health
programming for employees..
• 98% of employers with at least 200 employees offer some
type of health insurance while only 59% of those under
200 employees do
• One serious health problem represents financial disaster
for an employee and his/her family

Healthy People 2010 – WorksiteRelated National Health Objective
• “75% of employers (of all sizes) should offer a
comprehensive worksite health promotion
program,” which includes 5 key elements:
•
•
•
•
•

Health education programming
Supportive physical/social environment
Links to other health-related programs in the organization
Screening programs and appropriate follow-up
Integration of the program into the administrative structure
(e.g. budget, staffing, etc.)

How many employers are offering a
“comprehensive” health promotion
program?
• And, are small employers different from other
employers in what they offer?

Use of a Health Risk Appraisal
50

750+ EES (n=111)

45
40

250-749 EES (n=211)

35
30
25

100-249 EES (n=229)
50-99 EES (n=179)

20
15
10
5
0

Linnan, Bowling et al. (2008). AJPH.

Total (n=730)

Differences
by worksite
size
statistically
significant
(p=0.0002)

Physical Activity and Nutrition
Programs by Worksite Size
70
60
50

750+ EES (n=111)

40

250-749 EES (n=211)

30

100-249 EES (n=229)

20

50-99 EES (n=179)

10

Total (n=730)

0
*Physical Activity

*Nutrition

* statistically significant
differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental
Programs by Worksite Size
100
90
80

750+ EES
(n=111)

70

250-749 EES
(n=211)

60
50

100-249 EES
(n=229)

40
30

50-99 EES
(n=179)

20
10
0

Total (n=730)

Onsite Fitness Fitness/Walking
Center
Trails

Cafeteria

Vending food/beverages

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling
Services by Worksite Size
100
90
80
70
60
50
40
30
20
10
0

750+ (n=111)
250-749 (n=211)
100-249 (n=229)
50-99 (n=179)
Total (n=730)

Can
cer
S

Dia
be

cree
n

ing

tes

HBP
Scr

Scr

een
ing

HBC
een
in

g

Sc r

Alco

een
in

Linnan, Bowling et al, 2008, AJPH

g

hol

or D
r

ug

Abu
se

Sup
por

t

Predictors of Comprehensive
Worksite Health Promotion Programs


Overall, 6.9% of employers offered a
comprehensive program – smaller worksites were
less likely to offer all elements/types of programs
 Controlling for all factors (e.g. model adjusted for
size, staff, experience, industry type), we found:
 Worksites with 750+ employees were 4.4 times
more likely to have a comprehensive program
(p=.06).
 Worksites with a dedicated staff person were
10.3 times more likely to have a comprehensive
program (p<.05).

Why Do Small Employers Offer
Fewer Programs?
• “Survival Mode” – HPP programs are costly
– Direct Costs – of offering programs/services
– Indirect Costs – time/resources – competing
demands

• Lack of personnel dedicated to wellness
• Small business culture/leadership
– “Leave it up to Workers” (Eakin)
– Managers concerned about employee privacy
(Linnan)

Barriers To Health Promotion Program Success
70
60
50
40
30
20
10
0
Lack of
Employee
Interest

Lack of Staff
Resources

Lack of Funding Lack of High-Risk
Employee
Participation

Lack of
Management
Support

No differences in barriers were reported based on industry type or worksite size except that worksites with 750+
employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

Linnan, Bowling et al. 2008. AJPH

“When business survival is the
focus, any other costs, including
those linked to employee health,
may be seen as prohibitive.”
Linnan & Birken (2007)
NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007
Employment-Based
Coverage
Sector

Individually
Purchased

Total
Own Name

Public

Uninsured

Dependent

Total

100.0

50.6

17.5

6.7

7.4

20.3

Self-employed

100.0

22.9

25.7

20.0

7.1

26.4

Wage-and-Salary Workers

100.0

54.1

16.5

5.1

7.5

19.5

Firm Employment Size
< 10 Employees

100.0

26.6

21.9

9.5

10.1

34.3

10-24 Employees

100.0

38.3

20.3

6.3

7.8

28.9

25-99 Employees

100.0

52.0

17.3

5.2

6.9

20.8

100-499 Employees

100.0

62.1

14.8

3.6

6.5

15.4

< 500 Employees

100.0

45.2

18.5

6.1

7.8

24.6

500+ Employees

100.0

65.7

13.8

3.7

7.0

12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the
president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths
• Often, there is a family focus
• Fewer organizational layers – less complexity
re: decision-making
• Less complexity re: implementation
• Understand that each individual employee
and his/her health is important
• Understand that health influences the
“bottom line” of the company

Multiple Level Intervention for
Small Employers
Level of Intervention

Strategy

Intrapersonal/
Interpersonal

-Briefings (print) and Web-based resources
-Leading by Example – employers
-CEO breakfast meetings
-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational

-Free or low-cost HPPs + TA to implement them from
community, hospitals, voluntary health organizations…
-TA from State Health Department and/or insurers

Community

-Business Groups on Health – leverage for purchasing power
-University partnerships to get student help, grant funding

Policy

-National or state-level tax credits for small employers who
adopt HPPs
-Purchasing agreements for health
-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US
Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*
Individual Level
- Periodic health assessments tied to personalized feedback and individual coaching and motivational
interviewing
- Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with
all employees and is available to discuss health concerns
-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and
meet monthly with participants to collect program activity points and measure progress (eg, changes in
weight and blood pressure) toward positive health outcomes
-Strong linkage of wellness program with worker safety, including group stretching to promote model of an
“industrial athlete”
-Health coaches who travel among a company’s worksites to meet with employees
Environmental Level
-Strong support from wellness committee for establishing culture of wellness
-Inclusion of healthy food in criteria for selecting cafeteria vendor
-Free access to onsite physical activity facilities
-Provision of bicycles for travel between buildings
Organizational Level
-Incentive of paid day of leave to encourage program participation
-Reallocation of existing benefits to provide incentives for participating in screening activities and attaining
wellness goals
-Strong financial disincentives for employees and spouses with health insurance through the company who
do not participate in wellness program
-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:
Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for
Small Businesses
The North Carolina General Assembly should direct the North Carolina Public Health
Foundation to establish the North Carolina Worksite Wellness Collaborative to
promote evidence-based strategies to support the optimal health and well-being of
North Carolina’s workforce. The collaborative should help businesses implement
healthy workplace policies and benefits, implement health risk appraisals, develop
comprehensive employee wellness programs, and implement data systems that
track outcomes and the organizational and employee level.
The North Carolina General Assembly should provide start-up funding of $800,000 in
SFY 2011, with a reduced amount over the next four years, to support this
collaborative.
In addition, the North Carolina General Assembly should provide a tax credit to
businesses with 50 or fewer employees that have implemented a comprehensive
worksite wellness program for their employees.

Key Considerations
•
•
•
•
•
•
•

Get employees involved! Get dedicated staff!
Management support is necessary but not sufficient
Offer a comprehensive program with all 5 elements
Offer incentives for participation/behavior change
Provide links to local health care systems/providers
Address social contextual factors influencing health
Support research that builds evidence base and then
offer evidence-based programs
• Special focused activities for small employers

Related Information
• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small manufacturing
worksites that employ multiethnic, low-wage workforces into a cancer
prevention research trial. Prev Chronic Dis. 2004;1(3):A04.
• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change
among working-class, multiethnic workers: results of the healthy
directions—small business study. Am J Public Health. 2005;95(8):13891395.
• Divine RL. Determinants of small business interest in offering a wellness
program to their employees. Health Mark Q. 2005;22(3):43-58.
• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of
healthy weight at small and medium-sized US worksites. Prev Chronic Dis
2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.
• Linnan L & Birken B. Small businesses, worksite wellness and public
health: A time for action. NC Med J. 2006;67(6):433-438.


Slide 3

Worksite Wellness – Working
with Small Businesses
17th Annual Healthy Carolinians &
NCIOM Prevention Summit
Laura A. Linnan, ScD, CHES
The UNC Gillings School of Global Public Health
Thursday, October 8, 2009

Objectives
• Offer a brief overview of the importance of worksite
health promotion and its prevalence among small
employers
• Provide a rationale for offering comprehensive HPPs
among small employers
• Identify strengths/assets of small employers for
promoting employee health
• Share some promising intervention strategies –
including those recommended by the NC IOM -- for
increasing the prevalence of small employers which
offer comprehensive HPPs

Why Worksite Health Promotion?
• More than 60% of US adults are employed
• Employees spend a considerable number of waking
hours working
• Health care for US adults is directly linked with
employer-provided health insurance; many working
adults are without health insurance
• Many leading causes of death (CVD, cancer, stroke)
are preventable through lifestyle behavior changes
(smoking, diet, PA)

Why Should Employers Be Interested in Worksite
Health Promotion?
• Preventable illness makes up 70% of the total burden
of disease and their associated costs; employers pay
for these costs
• 10 modifiable risk factors account for approximately
25% of all employer healthcare expenditures
(Anderson, 2000)
• Employer medical costs average $7910/employee
annually (O’Donnell, 2007)
• Effective worksite health promotion programs have
demonstrated a positive impact on employee morale,
employee health and risk behaviors, productivity, and
health care costs

What is a “small” business?
• US Small Business Administration defines
“small” business as an employer with 500
employees or less
• SBA estimates there are 25.8 million small
businesses in the US
– They employee nearly 50% of the working adults!
– Employed adults spend about ½ of their waking
hours at work

Not all “small” employers are
equal… but they are important!
• Among small employers, there is great
heterogeneity
• The smaller the employer, the less likely it is to
offer health insurance or any health
programming for employees..
• 98% of employers with at least 200 employees offer some
type of health insurance while only 59% of those under
200 employees do
• One serious health problem represents financial disaster
for an employee and his/her family

Healthy People 2010 – WorksiteRelated National Health Objective
• “75% of employers (of all sizes) should offer a
comprehensive worksite health promotion
program,” which includes 5 key elements:
•
•
•
•
•

Health education programming
Supportive physical/social environment
Links to other health-related programs in the organization
Screening programs and appropriate follow-up
Integration of the program into the administrative structure
(e.g. budget, staffing, etc.)

How many employers are offering a
“comprehensive” health promotion
program?
• And, are small employers different from other
employers in what they offer?

Use of a Health Risk Appraisal
50

750+ EES (n=111)

45
40

250-749 EES (n=211)

35
30
25

100-249 EES (n=229)
50-99 EES (n=179)

20
15
10
5
0

Linnan, Bowling et al. (2008). AJPH.

Total (n=730)

Differences
by worksite
size
statistically
significant
(p=0.0002)

Physical Activity and Nutrition
Programs by Worksite Size
70
60
50

750+ EES (n=111)

40

250-749 EES (n=211)

30

100-249 EES (n=229)

20

50-99 EES (n=179)

10

Total (n=730)

0
*Physical Activity

*Nutrition

* statistically significant
differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental
Programs by Worksite Size
100
90
80

750+ EES
(n=111)

70

250-749 EES
(n=211)

60
50

100-249 EES
(n=229)

40
30

50-99 EES
(n=179)

20
10
0

Total (n=730)

Onsite Fitness Fitness/Walking
Center
Trails

Cafeteria

Vending food/beverages

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling
Services by Worksite Size
100
90
80
70
60
50
40
30
20
10
0

750+ (n=111)
250-749 (n=211)
100-249 (n=229)
50-99 (n=179)
Total (n=730)

Can
cer
S

Dia
be

cree
n

ing

tes

HBP
Scr

Scr

een
ing

HBC
een
in

g

Sc r

Alco

een
in

Linnan, Bowling et al, 2008, AJPH

g

hol

or D
r

ug

Abu
se

Sup
por

t

Predictors of Comprehensive
Worksite Health Promotion Programs


Overall, 6.9% of employers offered a
comprehensive program – smaller worksites were
less likely to offer all elements/types of programs
 Controlling for all factors (e.g. model adjusted for
size, staff, experience, industry type), we found:
 Worksites with 750+ employees were 4.4 times
more likely to have a comprehensive program
(p=.06).
 Worksites with a dedicated staff person were
10.3 times more likely to have a comprehensive
program (p<.05).

Why Do Small Employers Offer
Fewer Programs?
• “Survival Mode” – HPP programs are costly
– Direct Costs – of offering programs/services
– Indirect Costs – time/resources – competing
demands

• Lack of personnel dedicated to wellness
• Small business culture/leadership
– “Leave it up to Workers” (Eakin)
– Managers concerned about employee privacy
(Linnan)

Barriers To Health Promotion Program Success
70
60
50
40
30
20
10
0
Lack of
Employee
Interest

Lack of Staff
Resources

Lack of Funding Lack of High-Risk
Employee
Participation

Lack of
Management
Support

No differences in barriers were reported based on industry type or worksite size except that worksites with 750+
employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

Linnan, Bowling et al. 2008. AJPH

“When business survival is the
focus, any other costs, including
those linked to employee health,
may be seen as prohibitive.”
Linnan & Birken (2007)
NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007
Employment-Based
Coverage
Sector

Individually
Purchased

Total
Own Name

Public

Uninsured

Dependent

Total

100.0

50.6

17.5

6.7

7.4

20.3

Self-employed

100.0

22.9

25.7

20.0

7.1

26.4

Wage-and-Salary Workers

100.0

54.1

16.5

5.1

7.5

19.5

Firm Employment Size
< 10 Employees

100.0

26.6

21.9

9.5

10.1

34.3

10-24 Employees

100.0

38.3

20.3

6.3

7.8

28.9

25-99 Employees

100.0

52.0

17.3

5.2

6.9

20.8

100-499 Employees

100.0

62.1

14.8

3.6

6.5

15.4

< 500 Employees

100.0

45.2

18.5

6.1

7.8

24.6

500+ Employees

100.0

65.7

13.8

3.7

7.0

12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the
president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths
• Often, there is a family focus
• Fewer organizational layers – less complexity
re: decision-making
• Less complexity re: implementation
• Understand that each individual employee
and his/her health is important
• Understand that health influences the
“bottom line” of the company

Multiple Level Intervention for
Small Employers
Level of Intervention

Strategy

Intrapersonal/
Interpersonal

-Briefings (print) and Web-based resources
-Leading by Example – employers
-CEO breakfast meetings
-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational

-Free or low-cost HPPs + TA to implement them from
community, hospitals, voluntary health organizations…
-TA from State Health Department and/or insurers

Community

-Business Groups on Health – leverage for purchasing power
-University partnerships to get student help, grant funding

Policy

-National or state-level tax credits for small employers who
adopt HPPs
-Purchasing agreements for health
-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US
Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*
Individual Level
- Periodic health assessments tied to personalized feedback and individual coaching and motivational
interviewing
- Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with
all employees and is available to discuss health concerns
-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and
meet monthly with participants to collect program activity points and measure progress (eg, changes in
weight and blood pressure) toward positive health outcomes
-Strong linkage of wellness program with worker safety, including group stretching to promote model of an
“industrial athlete”
-Health coaches who travel among a company’s worksites to meet with employees
Environmental Level
-Strong support from wellness committee for establishing culture of wellness
-Inclusion of healthy food in criteria for selecting cafeteria vendor
-Free access to onsite physical activity facilities
-Provision of bicycles for travel between buildings
Organizational Level
-Incentive of paid day of leave to encourage program participation
-Reallocation of existing benefits to provide incentives for participating in screening activities and attaining
wellness goals
-Strong financial disincentives for employees and spouses with health insurance through the company who
do not participate in wellness program
-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:
Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for
Small Businesses
The North Carolina General Assembly should direct the North Carolina Public Health
Foundation to establish the North Carolina Worksite Wellness Collaborative to
promote evidence-based strategies to support the optimal health and well-being of
North Carolina’s workforce. The collaborative should help businesses implement
healthy workplace policies and benefits, implement health risk appraisals, develop
comprehensive employee wellness programs, and implement data systems that
track outcomes and the organizational and employee level.
The North Carolina General Assembly should provide start-up funding of $800,000 in
SFY 2011, with a reduced amount over the next four years, to support this
collaborative.
In addition, the North Carolina General Assembly should provide a tax credit to
businesses with 50 or fewer employees that have implemented a comprehensive
worksite wellness program for their employees.

Key Considerations
•
•
•
•
•
•
•

Get employees involved! Get dedicated staff!
Management support is necessary but not sufficient
Offer a comprehensive program with all 5 elements
Offer incentives for participation/behavior change
Provide links to local health care systems/providers
Address social contextual factors influencing health
Support research that builds evidence base and then
offer evidence-based programs
• Special focused activities for small employers

Related Information
• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small manufacturing
worksites that employ multiethnic, low-wage workforces into a cancer
prevention research trial. Prev Chronic Dis. 2004;1(3):A04.
• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change
among working-class, multiethnic workers: results of the healthy
directions—small business study. Am J Public Health. 2005;95(8):13891395.
• Divine RL. Determinants of small business interest in offering a wellness
program to their employees. Health Mark Q. 2005;22(3):43-58.
• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of
healthy weight at small and medium-sized US worksites. Prev Chronic Dis
2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.
• Linnan L & Birken B. Small businesses, worksite wellness and public
health: A time for action. NC Med J. 2006;67(6):433-438.


Slide 4

Worksite Wellness – Working
with Small Businesses
17th Annual Healthy Carolinians &
NCIOM Prevention Summit
Laura A. Linnan, ScD, CHES
The UNC Gillings School of Global Public Health
Thursday, October 8, 2009

Objectives
• Offer a brief overview of the importance of worksite
health promotion and its prevalence among small
employers
• Provide a rationale for offering comprehensive HPPs
among small employers
• Identify strengths/assets of small employers for
promoting employee health
• Share some promising intervention strategies –
including those recommended by the NC IOM -- for
increasing the prevalence of small employers which
offer comprehensive HPPs

Why Worksite Health Promotion?
• More than 60% of US adults are employed
• Employees spend a considerable number of waking
hours working
• Health care for US adults is directly linked with
employer-provided health insurance; many working
adults are without health insurance
• Many leading causes of death (CVD, cancer, stroke)
are preventable through lifestyle behavior changes
(smoking, diet, PA)

Why Should Employers Be Interested in Worksite
Health Promotion?
• Preventable illness makes up 70% of the total burden
of disease and their associated costs; employers pay
for these costs
• 10 modifiable risk factors account for approximately
25% of all employer healthcare expenditures
(Anderson, 2000)
• Employer medical costs average $7910/employee
annually (O’Donnell, 2007)
• Effective worksite health promotion programs have
demonstrated a positive impact on employee morale,
employee health and risk behaviors, productivity, and
health care costs

What is a “small” business?
• US Small Business Administration defines
“small” business as an employer with 500
employees or less
• SBA estimates there are 25.8 million small
businesses in the US
– They employee nearly 50% of the working adults!
– Employed adults spend about ½ of their waking
hours at work

Not all “small” employers are
equal… but they are important!
• Among small employers, there is great
heterogeneity
• The smaller the employer, the less likely it is to
offer health insurance or any health
programming for employees..
• 98% of employers with at least 200 employees offer some
type of health insurance while only 59% of those under
200 employees do
• One serious health problem represents financial disaster
for an employee and his/her family

Healthy People 2010 – WorksiteRelated National Health Objective
• “75% of employers (of all sizes) should offer a
comprehensive worksite health promotion
program,” which includes 5 key elements:
•
•
•
•
•

Health education programming
Supportive physical/social environment
Links to other health-related programs in the organization
Screening programs and appropriate follow-up
Integration of the program into the administrative structure
(e.g. budget, staffing, etc.)

How many employers are offering a
“comprehensive” health promotion
program?
• And, are small employers different from other
employers in what they offer?

Use of a Health Risk Appraisal
50

750+ EES (n=111)

45
40

250-749 EES (n=211)

35
30
25

100-249 EES (n=229)
50-99 EES (n=179)

20
15
10
5
0

Linnan, Bowling et al. (2008). AJPH.

Total (n=730)

Differences
by worksite
size
statistically
significant
(p=0.0002)

Physical Activity and Nutrition
Programs by Worksite Size
70
60
50

750+ EES (n=111)

40

250-749 EES (n=211)

30

100-249 EES (n=229)

20

50-99 EES (n=179)

10

Total (n=730)

0
*Physical Activity

*Nutrition

* statistically significant
differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental
Programs by Worksite Size
100
90
80

750+ EES
(n=111)

70

250-749 EES
(n=211)

60
50

100-249 EES
(n=229)

40
30

50-99 EES
(n=179)

20
10
0

Total (n=730)

Onsite Fitness Fitness/Walking
Center
Trails

Cafeteria

Vending food/beverages

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling
Services by Worksite Size
100
90
80
70
60
50
40
30
20
10
0

750+ (n=111)
250-749 (n=211)
100-249 (n=229)
50-99 (n=179)
Total (n=730)

Can
cer
S

Dia
be

cree
n

ing

tes

HBP
Scr

Scr

een
ing

HBC
een
in

g

Sc r

Alco

een
in

Linnan, Bowling et al, 2008, AJPH

g

hol

or D
r

ug

Abu
se

Sup
por

t

Predictors of Comprehensive
Worksite Health Promotion Programs


Overall, 6.9% of employers offered a
comprehensive program – smaller worksites were
less likely to offer all elements/types of programs
 Controlling for all factors (e.g. model adjusted for
size, staff, experience, industry type), we found:
 Worksites with 750+ employees were 4.4 times
more likely to have a comprehensive program
(p=.06).
 Worksites with a dedicated staff person were
10.3 times more likely to have a comprehensive
program (p<.05).

Why Do Small Employers Offer
Fewer Programs?
• “Survival Mode” – HPP programs are costly
– Direct Costs – of offering programs/services
– Indirect Costs – time/resources – competing
demands

• Lack of personnel dedicated to wellness
• Small business culture/leadership
– “Leave it up to Workers” (Eakin)
– Managers concerned about employee privacy
(Linnan)

Barriers To Health Promotion Program Success
70
60
50
40
30
20
10
0
Lack of
Employee
Interest

Lack of Staff
Resources

Lack of Funding Lack of High-Risk
Employee
Participation

Lack of
Management
Support

No differences in barriers were reported based on industry type or worksite size except that worksites with 750+
employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

Linnan, Bowling et al. 2008. AJPH

“When business survival is the
focus, any other costs, including
those linked to employee health,
may be seen as prohibitive.”
Linnan & Birken (2007)
NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007
Employment-Based
Coverage
Sector

Individually
Purchased

Total
Own Name

Public

Uninsured

Dependent

Total

100.0

50.6

17.5

6.7

7.4

20.3

Self-employed

100.0

22.9

25.7

20.0

7.1

26.4

Wage-and-Salary Workers

100.0

54.1

16.5

5.1

7.5

19.5

Firm Employment Size
< 10 Employees

100.0

26.6

21.9

9.5

10.1

34.3

10-24 Employees

100.0

38.3

20.3

6.3

7.8

28.9

25-99 Employees

100.0

52.0

17.3

5.2

6.9

20.8

100-499 Employees

100.0

62.1

14.8

3.6

6.5

15.4

< 500 Employees

100.0

45.2

18.5

6.1

7.8

24.6

500+ Employees

100.0

65.7

13.8

3.7

7.0

12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the
president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths
• Often, there is a family focus
• Fewer organizational layers – less complexity
re: decision-making
• Less complexity re: implementation
• Understand that each individual employee
and his/her health is important
• Understand that health influences the
“bottom line” of the company

Multiple Level Intervention for
Small Employers
Level of Intervention

Strategy

Intrapersonal/
Interpersonal

-Briefings (print) and Web-based resources
-Leading by Example – employers
-CEO breakfast meetings
-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational

-Free or low-cost HPPs + TA to implement them from
community, hospitals, voluntary health organizations…
-TA from State Health Department and/or insurers

Community

-Business Groups on Health – leverage for purchasing power
-University partnerships to get student help, grant funding

Policy

-National or state-level tax credits for small employers who
adopt HPPs
-Purchasing agreements for health
-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US
Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*
Individual Level
- Periodic health assessments tied to personalized feedback and individual coaching and motivational
interviewing
- Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with
all employees and is available to discuss health concerns
-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and
meet monthly with participants to collect program activity points and measure progress (eg, changes in
weight and blood pressure) toward positive health outcomes
-Strong linkage of wellness program with worker safety, including group stretching to promote model of an
“industrial athlete”
-Health coaches who travel among a company’s worksites to meet with employees
Environmental Level
-Strong support from wellness committee for establishing culture of wellness
-Inclusion of healthy food in criteria for selecting cafeteria vendor
-Free access to onsite physical activity facilities
-Provision of bicycles for travel between buildings
Organizational Level
-Incentive of paid day of leave to encourage program participation
-Reallocation of existing benefits to provide incentives for participating in screening activities and attaining
wellness goals
-Strong financial disincentives for employees and spouses with health insurance through the company who
do not participate in wellness program
-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:
Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for
Small Businesses
The North Carolina General Assembly should direct the North Carolina Public Health
Foundation to establish the North Carolina Worksite Wellness Collaborative to
promote evidence-based strategies to support the optimal health and well-being of
North Carolina’s workforce. The collaborative should help businesses implement
healthy workplace policies and benefits, implement health risk appraisals, develop
comprehensive employee wellness programs, and implement data systems that
track outcomes and the organizational and employee level.
The North Carolina General Assembly should provide start-up funding of $800,000 in
SFY 2011, with a reduced amount over the next four years, to support this
collaborative.
In addition, the North Carolina General Assembly should provide a tax credit to
businesses with 50 or fewer employees that have implemented a comprehensive
worksite wellness program for their employees.

Key Considerations
•
•
•
•
•
•
•

Get employees involved! Get dedicated staff!
Management support is necessary but not sufficient
Offer a comprehensive program with all 5 elements
Offer incentives for participation/behavior change
Provide links to local health care systems/providers
Address social contextual factors influencing health
Support research that builds evidence base and then
offer evidence-based programs
• Special focused activities for small employers

Related Information
• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small manufacturing
worksites that employ multiethnic, low-wage workforces into a cancer
prevention research trial. Prev Chronic Dis. 2004;1(3):A04.
• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change
among working-class, multiethnic workers: results of the healthy
directions—small business study. Am J Public Health. 2005;95(8):13891395.
• Divine RL. Determinants of small business interest in offering a wellness
program to their employees. Health Mark Q. 2005;22(3):43-58.
• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of
healthy weight at small and medium-sized US worksites. Prev Chronic Dis
2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.
• Linnan L & Birken B. Small businesses, worksite wellness and public
health: A time for action. NC Med J. 2006;67(6):433-438.


Slide 5

Worksite Wellness – Working
with Small Businesses
17th Annual Healthy Carolinians &
NCIOM Prevention Summit
Laura A. Linnan, ScD, CHES
The UNC Gillings School of Global Public Health
Thursday, October 8, 2009

Objectives
• Offer a brief overview of the importance of worksite
health promotion and its prevalence among small
employers
• Provide a rationale for offering comprehensive HPPs
among small employers
• Identify strengths/assets of small employers for
promoting employee health
• Share some promising intervention strategies –
including those recommended by the NC IOM -- for
increasing the prevalence of small employers which
offer comprehensive HPPs

Why Worksite Health Promotion?
• More than 60% of US adults are employed
• Employees spend a considerable number of waking
hours working
• Health care for US adults is directly linked with
employer-provided health insurance; many working
adults are without health insurance
• Many leading causes of death (CVD, cancer, stroke)
are preventable through lifestyle behavior changes
(smoking, diet, PA)

Why Should Employers Be Interested in Worksite
Health Promotion?
• Preventable illness makes up 70% of the total burden
of disease and their associated costs; employers pay
for these costs
• 10 modifiable risk factors account for approximately
25% of all employer healthcare expenditures
(Anderson, 2000)
• Employer medical costs average $7910/employee
annually (O’Donnell, 2007)
• Effective worksite health promotion programs have
demonstrated a positive impact on employee morale,
employee health and risk behaviors, productivity, and
health care costs

What is a “small” business?
• US Small Business Administration defines
“small” business as an employer with 500
employees or less
• SBA estimates there are 25.8 million small
businesses in the US
– They employee nearly 50% of the working adults!
– Employed adults spend about ½ of their waking
hours at work

Not all “small” employers are
equal… but they are important!
• Among small employers, there is great
heterogeneity
• The smaller the employer, the less likely it is to
offer health insurance or any health
programming for employees..
• 98% of employers with at least 200 employees offer some
type of health insurance while only 59% of those under
200 employees do
• One serious health problem represents financial disaster
for an employee and his/her family

Healthy People 2010 – WorksiteRelated National Health Objective
• “75% of employers (of all sizes) should offer a
comprehensive worksite health promotion
program,” which includes 5 key elements:
•
•
•
•
•

Health education programming
Supportive physical/social environment
Links to other health-related programs in the organization
Screening programs and appropriate follow-up
Integration of the program into the administrative structure
(e.g. budget, staffing, etc.)

How many employers are offering a
“comprehensive” health promotion
program?
• And, are small employers different from other
employers in what they offer?

Use of a Health Risk Appraisal
50

750+ EES (n=111)

45
40

250-749 EES (n=211)

35
30
25

100-249 EES (n=229)
50-99 EES (n=179)

20
15
10
5
0

Linnan, Bowling et al. (2008). AJPH.

Total (n=730)

Differences
by worksite
size
statistically
significant
(p=0.0002)

Physical Activity and Nutrition
Programs by Worksite Size
70
60
50

750+ EES (n=111)

40

250-749 EES (n=211)

30

100-249 EES (n=229)

20

50-99 EES (n=179)

10

Total (n=730)

0
*Physical Activity

*Nutrition

* statistically significant
differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental
Programs by Worksite Size
100
90
80

750+ EES
(n=111)

70

250-749 EES
(n=211)

60
50

100-249 EES
(n=229)

40
30

50-99 EES
(n=179)

20
10
0

Total (n=730)

Onsite Fitness Fitness/Walking
Center
Trails

Cafeteria

Vending food/beverages

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling
Services by Worksite Size
100
90
80
70
60
50
40
30
20
10
0

750+ (n=111)
250-749 (n=211)
100-249 (n=229)
50-99 (n=179)
Total (n=730)

Can
cer
S

Dia
be

cree
n

ing

tes

HBP
Scr

Scr

een
ing

HBC
een
in

g

Sc r

Alco

een
in

Linnan, Bowling et al, 2008, AJPH

g

hol

or D
r

ug

Abu
se

Sup
por

t

Predictors of Comprehensive
Worksite Health Promotion Programs


Overall, 6.9% of employers offered a
comprehensive program – smaller worksites were
less likely to offer all elements/types of programs
 Controlling for all factors (e.g. model adjusted for
size, staff, experience, industry type), we found:
 Worksites with 750+ employees were 4.4 times
more likely to have a comprehensive program
(p=.06).
 Worksites with a dedicated staff person were
10.3 times more likely to have a comprehensive
program (p<.05).

Why Do Small Employers Offer
Fewer Programs?
• “Survival Mode” – HPP programs are costly
– Direct Costs – of offering programs/services
– Indirect Costs – time/resources – competing
demands

• Lack of personnel dedicated to wellness
• Small business culture/leadership
– “Leave it up to Workers” (Eakin)
– Managers concerned about employee privacy
(Linnan)

Barriers To Health Promotion Program Success
70
60
50
40
30
20
10
0
Lack of
Employee
Interest

Lack of Staff
Resources

Lack of Funding Lack of High-Risk
Employee
Participation

Lack of
Management
Support

No differences in barriers were reported based on industry type or worksite size except that worksites with 750+
employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

Linnan, Bowling et al. 2008. AJPH

“When business survival is the
focus, any other costs, including
those linked to employee health,
may be seen as prohibitive.”
Linnan & Birken (2007)
NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007
Employment-Based
Coverage
Sector

Individually
Purchased

Total
Own Name

Public

Uninsured

Dependent

Total

100.0

50.6

17.5

6.7

7.4

20.3

Self-employed

100.0

22.9

25.7

20.0

7.1

26.4

Wage-and-Salary Workers

100.0

54.1

16.5

5.1

7.5

19.5

Firm Employment Size
< 10 Employees

100.0

26.6

21.9

9.5

10.1

34.3

10-24 Employees

100.0

38.3

20.3

6.3

7.8

28.9

25-99 Employees

100.0

52.0

17.3

5.2

6.9

20.8

100-499 Employees

100.0

62.1

14.8

3.6

6.5

15.4

< 500 Employees

100.0

45.2

18.5

6.1

7.8

24.6

500+ Employees

100.0

65.7

13.8

3.7

7.0

12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the
president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths
• Often, there is a family focus
• Fewer organizational layers – less complexity
re: decision-making
• Less complexity re: implementation
• Understand that each individual employee
and his/her health is important
• Understand that health influences the
“bottom line” of the company

Multiple Level Intervention for
Small Employers
Level of Intervention

Strategy

Intrapersonal/
Interpersonal

-Briefings (print) and Web-based resources
-Leading by Example – employers
-CEO breakfast meetings
-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational

-Free or low-cost HPPs + TA to implement them from
community, hospitals, voluntary health organizations…
-TA from State Health Department and/or insurers

Community

-Business Groups on Health – leverage for purchasing power
-University partnerships to get student help, grant funding

Policy

-National or state-level tax credits for small employers who
adopt HPPs
-Purchasing agreements for health
-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US
Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*
Individual Level
- Periodic health assessments tied to personalized feedback and individual coaching and motivational
interviewing
- Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with
all employees and is available to discuss health concerns
-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and
meet monthly with participants to collect program activity points and measure progress (eg, changes in
weight and blood pressure) toward positive health outcomes
-Strong linkage of wellness program with worker safety, including group stretching to promote model of an
“industrial athlete”
-Health coaches who travel among a company’s worksites to meet with employees
Environmental Level
-Strong support from wellness committee for establishing culture of wellness
-Inclusion of healthy food in criteria for selecting cafeteria vendor
-Free access to onsite physical activity facilities
-Provision of bicycles for travel between buildings
Organizational Level
-Incentive of paid day of leave to encourage program participation
-Reallocation of existing benefits to provide incentives for participating in screening activities and attaining
wellness goals
-Strong financial disincentives for employees and spouses with health insurance through the company who
do not participate in wellness program
-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:
Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for
Small Businesses
The North Carolina General Assembly should direct the North Carolina Public Health
Foundation to establish the North Carolina Worksite Wellness Collaborative to
promote evidence-based strategies to support the optimal health and well-being of
North Carolina’s workforce. The collaborative should help businesses implement
healthy workplace policies and benefits, implement health risk appraisals, develop
comprehensive employee wellness programs, and implement data systems that
track outcomes and the organizational and employee level.
The North Carolina General Assembly should provide start-up funding of $800,000 in
SFY 2011, with a reduced amount over the next four years, to support this
collaborative.
In addition, the North Carolina General Assembly should provide a tax credit to
businesses with 50 or fewer employees that have implemented a comprehensive
worksite wellness program for their employees.

Key Considerations
•
•
•
•
•
•
•

Get employees involved! Get dedicated staff!
Management support is necessary but not sufficient
Offer a comprehensive program with all 5 elements
Offer incentives for participation/behavior change
Provide links to local health care systems/providers
Address social contextual factors influencing health
Support research that builds evidence base and then
offer evidence-based programs
• Special focused activities for small employers

Related Information
• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small manufacturing
worksites that employ multiethnic, low-wage workforces into a cancer
prevention research trial. Prev Chronic Dis. 2004;1(3):A04.
• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change
among working-class, multiethnic workers: results of the healthy
directions—small business study. Am J Public Health. 2005;95(8):13891395.
• Divine RL. Determinants of small business interest in offering a wellness
program to their employees. Health Mark Q. 2005;22(3):43-58.
• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of
healthy weight at small and medium-sized US worksites. Prev Chronic Dis
2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.
• Linnan L & Birken B. Small businesses, worksite wellness and public
health: A time for action. NC Med J. 2006;67(6):433-438.


Slide 6

Worksite Wellness – Working
with Small Businesses
17th Annual Healthy Carolinians &
NCIOM Prevention Summit
Laura A. Linnan, ScD, CHES
The UNC Gillings School of Global Public Health
Thursday, October 8, 2009

Objectives
• Offer a brief overview of the importance of worksite
health promotion and its prevalence among small
employers
• Provide a rationale for offering comprehensive HPPs
among small employers
• Identify strengths/assets of small employers for
promoting employee health
• Share some promising intervention strategies –
including those recommended by the NC IOM -- for
increasing the prevalence of small employers which
offer comprehensive HPPs

Why Worksite Health Promotion?
• More than 60% of US adults are employed
• Employees spend a considerable number of waking
hours working
• Health care for US adults is directly linked with
employer-provided health insurance; many working
adults are without health insurance
• Many leading causes of death (CVD, cancer, stroke)
are preventable through lifestyle behavior changes
(smoking, diet, PA)

Why Should Employers Be Interested in Worksite
Health Promotion?
• Preventable illness makes up 70% of the total burden
of disease and their associated costs; employers pay
for these costs
• 10 modifiable risk factors account for approximately
25% of all employer healthcare expenditures
(Anderson, 2000)
• Employer medical costs average $7910/employee
annually (O’Donnell, 2007)
• Effective worksite health promotion programs have
demonstrated a positive impact on employee morale,
employee health and risk behaviors, productivity, and
health care costs

What is a “small” business?
• US Small Business Administration defines
“small” business as an employer with 500
employees or less
• SBA estimates there are 25.8 million small
businesses in the US
– They employee nearly 50% of the working adults!
– Employed adults spend about ½ of their waking
hours at work

Not all “small” employers are
equal… but they are important!
• Among small employers, there is great
heterogeneity
• The smaller the employer, the less likely it is to
offer health insurance or any health
programming for employees..
• 98% of employers with at least 200 employees offer some
type of health insurance while only 59% of those under
200 employees do
• One serious health problem represents financial disaster
for an employee and his/her family

Healthy People 2010 – WorksiteRelated National Health Objective
• “75% of employers (of all sizes) should offer a
comprehensive worksite health promotion
program,” which includes 5 key elements:
•
•
•
•
•

Health education programming
Supportive physical/social environment
Links to other health-related programs in the organization
Screening programs and appropriate follow-up
Integration of the program into the administrative structure
(e.g. budget, staffing, etc.)

How many employers are offering a
“comprehensive” health promotion
program?
• And, are small employers different from other
employers in what they offer?

Use of a Health Risk Appraisal
50

750+ EES (n=111)

45
40

250-749 EES (n=211)

35
30
25

100-249 EES (n=229)
50-99 EES (n=179)

20
15
10
5
0

Linnan, Bowling et al. (2008). AJPH.

Total (n=730)

Differences
by worksite
size
statistically
significant
(p=0.0002)

Physical Activity and Nutrition
Programs by Worksite Size
70
60
50

750+ EES (n=111)

40

250-749 EES (n=211)

30

100-249 EES (n=229)

20

50-99 EES (n=179)

10

Total (n=730)

0
*Physical Activity

*Nutrition

* statistically significant
differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental
Programs by Worksite Size
100
90
80

750+ EES
(n=111)

70

250-749 EES
(n=211)

60
50

100-249 EES
(n=229)

40
30

50-99 EES
(n=179)

20
10
0

Total (n=730)

Onsite Fitness Fitness/Walking
Center
Trails

Cafeteria

Vending food/beverages

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling
Services by Worksite Size
100
90
80
70
60
50
40
30
20
10
0

750+ (n=111)
250-749 (n=211)
100-249 (n=229)
50-99 (n=179)
Total (n=730)

Can
cer
S

Dia
be

cree
n

ing

tes

HBP
Scr

Scr

een
ing

HBC
een
in

g

Sc r

Alco

een
in

Linnan, Bowling et al, 2008, AJPH

g

hol

or D
r

ug

Abu
se

Sup
por

t

Predictors of Comprehensive
Worksite Health Promotion Programs


Overall, 6.9% of employers offered a
comprehensive program – smaller worksites were
less likely to offer all elements/types of programs
 Controlling for all factors (e.g. model adjusted for
size, staff, experience, industry type), we found:
 Worksites with 750+ employees were 4.4 times
more likely to have a comprehensive program
(p=.06).
 Worksites with a dedicated staff person were
10.3 times more likely to have a comprehensive
program (p<.05).

Why Do Small Employers Offer
Fewer Programs?
• “Survival Mode” – HPP programs are costly
– Direct Costs – of offering programs/services
– Indirect Costs – time/resources – competing
demands

• Lack of personnel dedicated to wellness
• Small business culture/leadership
– “Leave it up to Workers” (Eakin)
– Managers concerned about employee privacy
(Linnan)

Barriers To Health Promotion Program Success
70
60
50
40
30
20
10
0
Lack of
Employee
Interest

Lack of Staff
Resources

Lack of Funding Lack of High-Risk
Employee
Participation

Lack of
Management
Support

No differences in barriers were reported based on industry type or worksite size except that worksites with 750+
employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

Linnan, Bowling et al. 2008. AJPH

“When business survival is the
focus, any other costs, including
those linked to employee health,
may be seen as prohibitive.”
Linnan & Birken (2007)
NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007
Employment-Based
Coverage
Sector

Individually
Purchased

Total
Own Name

Public

Uninsured

Dependent

Total

100.0

50.6

17.5

6.7

7.4

20.3

Self-employed

100.0

22.9

25.7

20.0

7.1

26.4

Wage-and-Salary Workers

100.0

54.1

16.5

5.1

7.5

19.5

Firm Employment Size
< 10 Employees

100.0

26.6

21.9

9.5

10.1

34.3

10-24 Employees

100.0

38.3

20.3

6.3

7.8

28.9

25-99 Employees

100.0

52.0

17.3

5.2

6.9

20.8

100-499 Employees

100.0

62.1

14.8

3.6

6.5

15.4

< 500 Employees

100.0

45.2

18.5

6.1

7.8

24.6

500+ Employees

100.0

65.7

13.8

3.7

7.0

12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the
president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths
• Often, there is a family focus
• Fewer organizational layers – less complexity
re: decision-making
• Less complexity re: implementation
• Understand that each individual employee
and his/her health is important
• Understand that health influences the
“bottom line” of the company

Multiple Level Intervention for
Small Employers
Level of Intervention

Strategy

Intrapersonal/
Interpersonal

-Briefings (print) and Web-based resources
-Leading by Example – employers
-CEO breakfast meetings
-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational

-Free or low-cost HPPs + TA to implement them from
community, hospitals, voluntary health organizations…
-TA from State Health Department and/or insurers

Community

-Business Groups on Health – leverage for purchasing power
-University partnerships to get student help, grant funding

Policy

-National or state-level tax credits for small employers who
adopt HPPs
-Purchasing agreements for health
-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US
Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*
Individual Level
- Periodic health assessments tied to personalized feedback and individual coaching and motivational
interviewing
- Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with
all employees and is available to discuss health concerns
-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and
meet monthly with participants to collect program activity points and measure progress (eg, changes in
weight and blood pressure) toward positive health outcomes
-Strong linkage of wellness program with worker safety, including group stretching to promote model of an
“industrial athlete”
-Health coaches who travel among a company’s worksites to meet with employees
Environmental Level
-Strong support from wellness committee for establishing culture of wellness
-Inclusion of healthy food in criteria for selecting cafeteria vendor
-Free access to onsite physical activity facilities
-Provision of bicycles for travel between buildings
Organizational Level
-Incentive of paid day of leave to encourage program participation
-Reallocation of existing benefits to provide incentives for participating in screening activities and attaining
wellness goals
-Strong financial disincentives for employees and spouses with health insurance through the company who
do not participate in wellness program
-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:
Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for
Small Businesses
The North Carolina General Assembly should direct the North Carolina Public Health
Foundation to establish the North Carolina Worksite Wellness Collaborative to
promote evidence-based strategies to support the optimal health and well-being of
North Carolina’s workforce. The collaborative should help businesses implement
healthy workplace policies and benefits, implement health risk appraisals, develop
comprehensive employee wellness programs, and implement data systems that
track outcomes and the organizational and employee level.
The North Carolina General Assembly should provide start-up funding of $800,000 in
SFY 2011, with a reduced amount over the next four years, to support this
collaborative.
In addition, the North Carolina General Assembly should provide a tax credit to
businesses with 50 or fewer employees that have implemented a comprehensive
worksite wellness program for their employees.

Key Considerations
•
•
•
•
•
•
•

Get employees involved! Get dedicated staff!
Management support is necessary but not sufficient
Offer a comprehensive program with all 5 elements
Offer incentives for participation/behavior change
Provide links to local health care systems/providers
Address social contextual factors influencing health
Support research that builds evidence base and then
offer evidence-based programs
• Special focused activities for small employers

Related Information
• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small manufacturing
worksites that employ multiethnic, low-wage workforces into a cancer
prevention research trial. Prev Chronic Dis. 2004;1(3):A04.
• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change
among working-class, multiethnic workers: results of the healthy
directions—small business study. Am J Public Health. 2005;95(8):13891395.
• Divine RL. Determinants of small business interest in offering a wellness
program to their employees. Health Mark Q. 2005;22(3):43-58.
• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of
healthy weight at small and medium-sized US worksites. Prev Chronic Dis
2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.
• Linnan L & Birken B. Small businesses, worksite wellness and public
health: A time for action. NC Med J. 2006;67(6):433-438.


Slide 7

Worksite Wellness – Working
with Small Businesses
17th Annual Healthy Carolinians &
NCIOM Prevention Summit
Laura A. Linnan, ScD, CHES
The UNC Gillings School of Global Public Health
Thursday, October 8, 2009

Objectives
• Offer a brief overview of the importance of worksite
health promotion and its prevalence among small
employers
• Provide a rationale for offering comprehensive HPPs
among small employers
• Identify strengths/assets of small employers for
promoting employee health
• Share some promising intervention strategies –
including those recommended by the NC IOM -- for
increasing the prevalence of small employers which
offer comprehensive HPPs

Why Worksite Health Promotion?
• More than 60% of US adults are employed
• Employees spend a considerable number of waking
hours working
• Health care for US adults is directly linked with
employer-provided health insurance; many working
adults are without health insurance
• Many leading causes of death (CVD, cancer, stroke)
are preventable through lifestyle behavior changes
(smoking, diet, PA)

Why Should Employers Be Interested in Worksite
Health Promotion?
• Preventable illness makes up 70% of the total burden
of disease and their associated costs; employers pay
for these costs
• 10 modifiable risk factors account for approximately
25% of all employer healthcare expenditures
(Anderson, 2000)
• Employer medical costs average $7910/employee
annually (O’Donnell, 2007)
• Effective worksite health promotion programs have
demonstrated a positive impact on employee morale,
employee health and risk behaviors, productivity, and
health care costs

What is a “small” business?
• US Small Business Administration defines
“small” business as an employer with 500
employees or less
• SBA estimates there are 25.8 million small
businesses in the US
– They employee nearly 50% of the working adults!
– Employed adults spend about ½ of their waking
hours at work

Not all “small” employers are
equal… but they are important!
• Among small employers, there is great
heterogeneity
• The smaller the employer, the less likely it is to
offer health insurance or any health
programming for employees..
• 98% of employers with at least 200 employees offer some
type of health insurance while only 59% of those under
200 employees do
• One serious health problem represents financial disaster
for an employee and his/her family

Healthy People 2010 – WorksiteRelated National Health Objective
• “75% of employers (of all sizes) should offer a
comprehensive worksite health promotion
program,” which includes 5 key elements:
•
•
•
•
•

Health education programming
Supportive physical/social environment
Links to other health-related programs in the organization
Screening programs and appropriate follow-up
Integration of the program into the administrative structure
(e.g. budget, staffing, etc.)

How many employers are offering a
“comprehensive” health promotion
program?
• And, are small employers different from other
employers in what they offer?

Use of a Health Risk Appraisal
50

750+ EES (n=111)

45
40

250-749 EES (n=211)

35
30
25

100-249 EES (n=229)
50-99 EES (n=179)

20
15
10
5
0

Linnan, Bowling et al. (2008). AJPH.

Total (n=730)

Differences
by worksite
size
statistically
significant
(p=0.0002)

Physical Activity and Nutrition
Programs by Worksite Size
70
60
50

750+ EES (n=111)

40

250-749 EES (n=211)

30

100-249 EES (n=229)

20

50-99 EES (n=179)

10

Total (n=730)

0
*Physical Activity

*Nutrition

* statistically significant
differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental
Programs by Worksite Size
100
90
80

750+ EES
(n=111)

70

250-749 EES
(n=211)

60
50

100-249 EES
(n=229)

40
30

50-99 EES
(n=179)

20
10
0

Total (n=730)

Onsite Fitness Fitness/Walking
Center
Trails

Cafeteria

Vending food/beverages

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling
Services by Worksite Size
100
90
80
70
60
50
40
30
20
10
0

750+ (n=111)
250-749 (n=211)
100-249 (n=229)
50-99 (n=179)
Total (n=730)

Can
cer
S

Dia
be

cree
n

ing

tes

HBP
Scr

Scr

een
ing

HBC
een
in

g

Sc r

Alco

een
in

Linnan, Bowling et al, 2008, AJPH

g

hol

or D
r

ug

Abu
se

Sup
por

t

Predictors of Comprehensive
Worksite Health Promotion Programs


Overall, 6.9% of employers offered a
comprehensive program – smaller worksites were
less likely to offer all elements/types of programs
 Controlling for all factors (e.g. model adjusted for
size, staff, experience, industry type), we found:
 Worksites with 750+ employees were 4.4 times
more likely to have a comprehensive program
(p=.06).
 Worksites with a dedicated staff person were
10.3 times more likely to have a comprehensive
program (p<.05).

Why Do Small Employers Offer
Fewer Programs?
• “Survival Mode” – HPP programs are costly
– Direct Costs – of offering programs/services
– Indirect Costs – time/resources – competing
demands

• Lack of personnel dedicated to wellness
• Small business culture/leadership
– “Leave it up to Workers” (Eakin)
– Managers concerned about employee privacy
(Linnan)

Barriers To Health Promotion Program Success
70
60
50
40
30
20
10
0
Lack of
Employee
Interest

Lack of Staff
Resources

Lack of Funding Lack of High-Risk
Employee
Participation

Lack of
Management
Support

No differences in barriers were reported based on industry type or worksite size except that worksites with 750+
employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

Linnan, Bowling et al. 2008. AJPH

“When business survival is the
focus, any other costs, including
those linked to employee health,
may be seen as prohibitive.”
Linnan & Birken (2007)
NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007
Employment-Based
Coverage
Sector

Individually
Purchased

Total
Own Name

Public

Uninsured

Dependent

Total

100.0

50.6

17.5

6.7

7.4

20.3

Self-employed

100.0

22.9

25.7

20.0

7.1

26.4

Wage-and-Salary Workers

100.0

54.1

16.5

5.1

7.5

19.5

Firm Employment Size
< 10 Employees

100.0

26.6

21.9

9.5

10.1

34.3

10-24 Employees

100.0

38.3

20.3

6.3

7.8

28.9

25-99 Employees

100.0

52.0

17.3

5.2

6.9

20.8

100-499 Employees

100.0

62.1

14.8

3.6

6.5

15.4

< 500 Employees

100.0

45.2

18.5

6.1

7.8

24.6

500+ Employees

100.0

65.7

13.8

3.7

7.0

12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the
president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths
• Often, there is a family focus
• Fewer organizational layers – less complexity
re: decision-making
• Less complexity re: implementation
• Understand that each individual employee
and his/her health is important
• Understand that health influences the
“bottom line” of the company

Multiple Level Intervention for
Small Employers
Level of Intervention

Strategy

Intrapersonal/
Interpersonal

-Briefings (print) and Web-based resources
-Leading by Example – employers
-CEO breakfast meetings
-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational

-Free or low-cost HPPs + TA to implement them from
community, hospitals, voluntary health organizations…
-TA from State Health Department and/or insurers

Community

-Business Groups on Health – leverage for purchasing power
-University partnerships to get student help, grant funding

Policy

-National or state-level tax credits for small employers who
adopt HPPs
-Purchasing agreements for health
-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US
Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*
Individual Level
- Periodic health assessments tied to personalized feedback and individual coaching and motivational
interviewing
- Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with
all employees and is available to discuss health concerns
-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and
meet monthly with participants to collect program activity points and measure progress (eg, changes in
weight and blood pressure) toward positive health outcomes
-Strong linkage of wellness program with worker safety, including group stretching to promote model of an
“industrial athlete”
-Health coaches who travel among a company’s worksites to meet with employees
Environmental Level
-Strong support from wellness committee for establishing culture of wellness
-Inclusion of healthy food in criteria for selecting cafeteria vendor
-Free access to onsite physical activity facilities
-Provision of bicycles for travel between buildings
Organizational Level
-Incentive of paid day of leave to encourage program participation
-Reallocation of existing benefits to provide incentives for participating in screening activities and attaining
wellness goals
-Strong financial disincentives for employees and spouses with health insurance through the company who
do not participate in wellness program
-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:
Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for
Small Businesses
The North Carolina General Assembly should direct the North Carolina Public Health
Foundation to establish the North Carolina Worksite Wellness Collaborative to
promote evidence-based strategies to support the optimal health and well-being of
North Carolina’s workforce. The collaborative should help businesses implement
healthy workplace policies and benefits, implement health risk appraisals, develop
comprehensive employee wellness programs, and implement data systems that
track outcomes and the organizational and employee level.
The North Carolina General Assembly should provide start-up funding of $800,000 in
SFY 2011, with a reduced amount over the next four years, to support this
collaborative.
In addition, the North Carolina General Assembly should provide a tax credit to
businesses with 50 or fewer employees that have implemented a comprehensive
worksite wellness program for their employees.

Key Considerations
•
•
•
•
•
•
•

Get employees involved! Get dedicated staff!
Management support is necessary but not sufficient
Offer a comprehensive program with all 5 elements
Offer incentives for participation/behavior change
Provide links to local health care systems/providers
Address social contextual factors influencing health
Support research that builds evidence base and then
offer evidence-based programs
• Special focused activities for small employers

Related Information
• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small manufacturing
worksites that employ multiethnic, low-wage workforces into a cancer
prevention research trial. Prev Chronic Dis. 2004;1(3):A04.
• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change
among working-class, multiethnic workers: results of the healthy
directions—small business study. Am J Public Health. 2005;95(8):13891395.
• Divine RL. Determinants of small business interest in offering a wellness
program to their employees. Health Mark Q. 2005;22(3):43-58.
• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of
healthy weight at small and medium-sized US worksites. Prev Chronic Dis
2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.
• Linnan L & Birken B. Small businesses, worksite wellness and public
health: A time for action. NC Med J. 2006;67(6):433-438.


Slide 8

Worksite Wellness – Working
with Small Businesses
17th Annual Healthy Carolinians &
NCIOM Prevention Summit
Laura A. Linnan, ScD, CHES
The UNC Gillings School of Global Public Health
Thursday, October 8, 2009

Objectives
• Offer a brief overview of the importance of worksite
health promotion and its prevalence among small
employers
• Provide a rationale for offering comprehensive HPPs
among small employers
• Identify strengths/assets of small employers for
promoting employee health
• Share some promising intervention strategies –
including those recommended by the NC IOM -- for
increasing the prevalence of small employers which
offer comprehensive HPPs

Why Worksite Health Promotion?
• More than 60% of US adults are employed
• Employees spend a considerable number of waking
hours working
• Health care for US adults is directly linked with
employer-provided health insurance; many working
adults are without health insurance
• Many leading causes of death (CVD, cancer, stroke)
are preventable through lifestyle behavior changes
(smoking, diet, PA)

Why Should Employers Be Interested in Worksite
Health Promotion?
• Preventable illness makes up 70% of the total burden
of disease and their associated costs; employers pay
for these costs
• 10 modifiable risk factors account for approximately
25% of all employer healthcare expenditures
(Anderson, 2000)
• Employer medical costs average $7910/employee
annually (O’Donnell, 2007)
• Effective worksite health promotion programs have
demonstrated a positive impact on employee morale,
employee health and risk behaviors, productivity, and
health care costs

What is a “small” business?
• US Small Business Administration defines
“small” business as an employer with 500
employees or less
• SBA estimates there are 25.8 million small
businesses in the US
– They employee nearly 50% of the working adults!
– Employed adults spend about ½ of their waking
hours at work

Not all “small” employers are
equal… but they are important!
• Among small employers, there is great
heterogeneity
• The smaller the employer, the less likely it is to
offer health insurance or any health
programming for employees..
• 98% of employers with at least 200 employees offer some
type of health insurance while only 59% of those under
200 employees do
• One serious health problem represents financial disaster
for an employee and his/her family

Healthy People 2010 – WorksiteRelated National Health Objective
• “75% of employers (of all sizes) should offer a
comprehensive worksite health promotion
program,” which includes 5 key elements:
•
•
•
•
•

Health education programming
Supportive physical/social environment
Links to other health-related programs in the organization
Screening programs and appropriate follow-up
Integration of the program into the administrative structure
(e.g. budget, staffing, etc.)

How many employers are offering a
“comprehensive” health promotion
program?
• And, are small employers different from other
employers in what they offer?

Use of a Health Risk Appraisal
50

750+ EES (n=111)

45
40

250-749 EES (n=211)

35
30
25

100-249 EES (n=229)
50-99 EES (n=179)

20
15
10
5
0

Linnan, Bowling et al. (2008). AJPH.

Total (n=730)

Differences
by worksite
size
statistically
significant
(p=0.0002)

Physical Activity and Nutrition
Programs by Worksite Size
70
60
50

750+ EES (n=111)

40

250-749 EES (n=211)

30

100-249 EES (n=229)

20

50-99 EES (n=179)

10

Total (n=730)

0
*Physical Activity

*Nutrition

* statistically significant
differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental
Programs by Worksite Size
100
90
80

750+ EES
(n=111)

70

250-749 EES
(n=211)

60
50

100-249 EES
(n=229)

40
30

50-99 EES
(n=179)

20
10
0

Total (n=730)

Onsite Fitness Fitness/Walking
Center
Trails

Cafeteria

Vending food/beverages

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling
Services by Worksite Size
100
90
80
70
60
50
40
30
20
10
0

750+ (n=111)
250-749 (n=211)
100-249 (n=229)
50-99 (n=179)
Total (n=730)

Can
cer
S

Dia
be

cree
n

ing

tes

HBP
Scr

Scr

een
ing

HBC
een
in

g

Sc r

Alco

een
in

Linnan, Bowling et al, 2008, AJPH

g

hol

or D
r

ug

Abu
se

Sup
por

t

Predictors of Comprehensive
Worksite Health Promotion Programs


Overall, 6.9% of employers offered a
comprehensive program – smaller worksites were
less likely to offer all elements/types of programs
 Controlling for all factors (e.g. model adjusted for
size, staff, experience, industry type), we found:
 Worksites with 750+ employees were 4.4 times
more likely to have a comprehensive program
(p=.06).
 Worksites with a dedicated staff person were
10.3 times more likely to have a comprehensive
program (p<.05).

Why Do Small Employers Offer
Fewer Programs?
• “Survival Mode” – HPP programs are costly
– Direct Costs – of offering programs/services
– Indirect Costs – time/resources – competing
demands

• Lack of personnel dedicated to wellness
• Small business culture/leadership
– “Leave it up to Workers” (Eakin)
– Managers concerned about employee privacy
(Linnan)

Barriers To Health Promotion Program Success
70
60
50
40
30
20
10
0
Lack of
Employee
Interest

Lack of Staff
Resources

Lack of Funding Lack of High-Risk
Employee
Participation

Lack of
Management
Support

No differences in barriers were reported based on industry type or worksite size except that worksites with 750+
employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

Linnan, Bowling et al. 2008. AJPH

“When business survival is the
focus, any other costs, including
those linked to employee health,
may be seen as prohibitive.”
Linnan & Birken (2007)
NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007
Employment-Based
Coverage
Sector

Individually
Purchased

Total
Own Name

Public

Uninsured

Dependent

Total

100.0

50.6

17.5

6.7

7.4

20.3

Self-employed

100.0

22.9

25.7

20.0

7.1

26.4

Wage-and-Salary Workers

100.0

54.1

16.5

5.1

7.5

19.5

Firm Employment Size
< 10 Employees

100.0

26.6

21.9

9.5

10.1

34.3

10-24 Employees

100.0

38.3

20.3

6.3

7.8

28.9

25-99 Employees

100.0

52.0

17.3

5.2

6.9

20.8

100-499 Employees

100.0

62.1

14.8

3.6

6.5

15.4

< 500 Employees

100.0

45.2

18.5

6.1

7.8

24.6

500+ Employees

100.0

65.7

13.8

3.7

7.0

12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the
president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths
• Often, there is a family focus
• Fewer organizational layers – less complexity
re: decision-making
• Less complexity re: implementation
• Understand that each individual employee
and his/her health is important
• Understand that health influences the
“bottom line” of the company

Multiple Level Intervention for
Small Employers
Level of Intervention

Strategy

Intrapersonal/
Interpersonal

-Briefings (print) and Web-based resources
-Leading by Example – employers
-CEO breakfast meetings
-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational

-Free or low-cost HPPs + TA to implement them from
community, hospitals, voluntary health organizations…
-TA from State Health Department and/or insurers

Community

-Business Groups on Health – leverage for purchasing power
-University partnerships to get student help, grant funding

Policy

-National or state-level tax credits for small employers who
adopt HPPs
-Purchasing agreements for health
-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US
Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*
Individual Level
- Periodic health assessments tied to personalized feedback and individual coaching and motivational
interviewing
- Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with
all employees and is available to discuss health concerns
-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and
meet monthly with participants to collect program activity points and measure progress (eg, changes in
weight and blood pressure) toward positive health outcomes
-Strong linkage of wellness program with worker safety, including group stretching to promote model of an
“industrial athlete”
-Health coaches who travel among a company’s worksites to meet with employees
Environmental Level
-Strong support from wellness committee for establishing culture of wellness
-Inclusion of healthy food in criteria for selecting cafeteria vendor
-Free access to onsite physical activity facilities
-Provision of bicycles for travel between buildings
Organizational Level
-Incentive of paid day of leave to encourage program participation
-Reallocation of existing benefits to provide incentives for participating in screening activities and attaining
wellness goals
-Strong financial disincentives for employees and spouses with health insurance through the company who
do not participate in wellness program
-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:
Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for
Small Businesses
The North Carolina General Assembly should direct the North Carolina Public Health
Foundation to establish the North Carolina Worksite Wellness Collaborative to
promote evidence-based strategies to support the optimal health and well-being of
North Carolina’s workforce. The collaborative should help businesses implement
healthy workplace policies and benefits, implement health risk appraisals, develop
comprehensive employee wellness programs, and implement data systems that
track outcomes and the organizational and employee level.
The North Carolina General Assembly should provide start-up funding of $800,000 in
SFY 2011, with a reduced amount over the next four years, to support this
collaborative.
In addition, the North Carolina General Assembly should provide a tax credit to
businesses with 50 or fewer employees that have implemented a comprehensive
worksite wellness program for their employees.

Key Considerations
•
•
•
•
•
•
•

Get employees involved! Get dedicated staff!
Management support is necessary but not sufficient
Offer a comprehensive program with all 5 elements
Offer incentives for participation/behavior change
Provide links to local health care systems/providers
Address social contextual factors influencing health
Support research that builds evidence base and then
offer evidence-based programs
• Special focused activities for small employers

Related Information
• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small manufacturing
worksites that employ multiethnic, low-wage workforces into a cancer
prevention research trial. Prev Chronic Dis. 2004;1(3):A04.
• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change
among working-class, multiethnic workers: results of the healthy
directions—small business study. Am J Public Health. 2005;95(8):13891395.
• Divine RL. Determinants of small business interest in offering a wellness
program to their employees. Health Mark Q. 2005;22(3):43-58.
• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of
healthy weight at small and medium-sized US worksites. Prev Chronic Dis
2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.
• Linnan L & Birken B. Small businesses, worksite wellness and public
health: A time for action. NC Med J. 2006;67(6):433-438.


Slide 9

Worksite Wellness – Working
with Small Businesses
17th Annual Healthy Carolinians &
NCIOM Prevention Summit
Laura A. Linnan, ScD, CHES
The UNC Gillings School of Global Public Health
Thursday, October 8, 2009

Objectives
• Offer a brief overview of the importance of worksite
health promotion and its prevalence among small
employers
• Provide a rationale for offering comprehensive HPPs
among small employers
• Identify strengths/assets of small employers for
promoting employee health
• Share some promising intervention strategies –
including those recommended by the NC IOM -- for
increasing the prevalence of small employers which
offer comprehensive HPPs

Why Worksite Health Promotion?
• More than 60% of US adults are employed
• Employees spend a considerable number of waking
hours working
• Health care for US adults is directly linked with
employer-provided health insurance; many working
adults are without health insurance
• Many leading causes of death (CVD, cancer, stroke)
are preventable through lifestyle behavior changes
(smoking, diet, PA)

Why Should Employers Be Interested in Worksite
Health Promotion?
• Preventable illness makes up 70% of the total burden
of disease and their associated costs; employers pay
for these costs
• 10 modifiable risk factors account for approximately
25% of all employer healthcare expenditures
(Anderson, 2000)
• Employer medical costs average $7910/employee
annually (O’Donnell, 2007)
• Effective worksite health promotion programs have
demonstrated a positive impact on employee morale,
employee health and risk behaviors, productivity, and
health care costs

What is a “small” business?
• US Small Business Administration defines
“small” business as an employer with 500
employees or less
• SBA estimates there are 25.8 million small
businesses in the US
– They employee nearly 50% of the working adults!
– Employed adults spend about ½ of their waking
hours at work

Not all “small” employers are
equal… but they are important!
• Among small employers, there is great
heterogeneity
• The smaller the employer, the less likely it is to
offer health insurance or any health
programming for employees..
• 98% of employers with at least 200 employees offer some
type of health insurance while only 59% of those under
200 employees do
• One serious health problem represents financial disaster
for an employee and his/her family

Healthy People 2010 – WorksiteRelated National Health Objective
• “75% of employers (of all sizes) should offer a
comprehensive worksite health promotion
program,” which includes 5 key elements:
•
•
•
•
•

Health education programming
Supportive physical/social environment
Links to other health-related programs in the organization
Screening programs and appropriate follow-up
Integration of the program into the administrative structure
(e.g. budget, staffing, etc.)

How many employers are offering a
“comprehensive” health promotion
program?
• And, are small employers different from other
employers in what they offer?

Use of a Health Risk Appraisal
50

750+ EES (n=111)

45
40

250-749 EES (n=211)

35
30
25

100-249 EES (n=229)
50-99 EES (n=179)

20
15
10
5
0

Linnan, Bowling et al. (2008). AJPH.

Total (n=730)

Differences
by worksite
size
statistically
significant
(p=0.0002)

Physical Activity and Nutrition
Programs by Worksite Size
70
60
50

750+ EES (n=111)

40

250-749 EES (n=211)

30

100-249 EES (n=229)

20

50-99 EES (n=179)

10

Total (n=730)

0
*Physical Activity

*Nutrition

* statistically significant
differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental
Programs by Worksite Size
100
90
80

750+ EES
(n=111)

70

250-749 EES
(n=211)

60
50

100-249 EES
(n=229)

40
30

50-99 EES
(n=179)

20
10
0

Total (n=730)

Onsite Fitness Fitness/Walking
Center
Trails

Cafeteria

Vending food/beverages

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling
Services by Worksite Size
100
90
80
70
60
50
40
30
20
10
0

750+ (n=111)
250-749 (n=211)
100-249 (n=229)
50-99 (n=179)
Total (n=730)

Can
cer
S

Dia
be

cree
n

ing

tes

HBP
Scr

Scr

een
ing

HBC
een
in

g

Sc r

Alco

een
in

Linnan, Bowling et al, 2008, AJPH

g

hol

or D
r

ug

Abu
se

Sup
por

t

Predictors of Comprehensive
Worksite Health Promotion Programs


Overall, 6.9% of employers offered a
comprehensive program – smaller worksites were
less likely to offer all elements/types of programs
 Controlling for all factors (e.g. model adjusted for
size, staff, experience, industry type), we found:
 Worksites with 750+ employees were 4.4 times
more likely to have a comprehensive program
(p=.06).
 Worksites with a dedicated staff person were
10.3 times more likely to have a comprehensive
program (p<.05).

Why Do Small Employers Offer
Fewer Programs?
• “Survival Mode” – HPP programs are costly
– Direct Costs – of offering programs/services
– Indirect Costs – time/resources – competing
demands

• Lack of personnel dedicated to wellness
• Small business culture/leadership
– “Leave it up to Workers” (Eakin)
– Managers concerned about employee privacy
(Linnan)

Barriers To Health Promotion Program Success
70
60
50
40
30
20
10
0
Lack of
Employee
Interest

Lack of Staff
Resources

Lack of Funding Lack of High-Risk
Employee
Participation

Lack of
Management
Support

No differences in barriers were reported based on industry type or worksite size except that worksites with 750+
employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

Linnan, Bowling et al. 2008. AJPH

“When business survival is the
focus, any other costs, including
those linked to employee health,
may be seen as prohibitive.”
Linnan & Birken (2007)
NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007
Employment-Based
Coverage
Sector

Individually
Purchased

Total
Own Name

Public

Uninsured

Dependent

Total

100.0

50.6

17.5

6.7

7.4

20.3

Self-employed

100.0

22.9

25.7

20.0

7.1

26.4

Wage-and-Salary Workers

100.0

54.1

16.5

5.1

7.5

19.5

Firm Employment Size
< 10 Employees

100.0

26.6

21.9

9.5

10.1

34.3

10-24 Employees

100.0

38.3

20.3

6.3

7.8

28.9

25-99 Employees

100.0

52.0

17.3

5.2

6.9

20.8

100-499 Employees

100.0

62.1

14.8

3.6

6.5

15.4

< 500 Employees

100.0

45.2

18.5

6.1

7.8

24.6

500+ Employees

100.0

65.7

13.8

3.7

7.0

12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the
president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths
• Often, there is a family focus
• Fewer organizational layers – less complexity
re: decision-making
• Less complexity re: implementation
• Understand that each individual employee
and his/her health is important
• Understand that health influences the
“bottom line” of the company

Multiple Level Intervention for
Small Employers
Level of Intervention

Strategy

Intrapersonal/
Interpersonal

-Briefings (print) and Web-based resources
-Leading by Example – employers
-CEO breakfast meetings
-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational

-Free or low-cost HPPs + TA to implement them from
community, hospitals, voluntary health organizations…
-TA from State Health Department and/or insurers

Community

-Business Groups on Health – leverage for purchasing power
-University partnerships to get student help, grant funding

Policy

-National or state-level tax credits for small employers who
adopt HPPs
-Purchasing agreements for health
-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US
Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*
Individual Level
- Periodic health assessments tied to personalized feedback and individual coaching and motivational
interviewing
- Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with
all employees and is available to discuss health concerns
-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and
meet monthly with participants to collect program activity points and measure progress (eg, changes in
weight and blood pressure) toward positive health outcomes
-Strong linkage of wellness program with worker safety, including group stretching to promote model of an
“industrial athlete”
-Health coaches who travel among a company’s worksites to meet with employees
Environmental Level
-Strong support from wellness committee for establishing culture of wellness
-Inclusion of healthy food in criteria for selecting cafeteria vendor
-Free access to onsite physical activity facilities
-Provision of bicycles for travel between buildings
Organizational Level
-Incentive of paid day of leave to encourage program participation
-Reallocation of existing benefits to provide incentives for participating in screening activities and attaining
wellness goals
-Strong financial disincentives for employees and spouses with health insurance through the company who
do not participate in wellness program
-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:
Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for
Small Businesses
The North Carolina General Assembly should direct the North Carolina Public Health
Foundation to establish the North Carolina Worksite Wellness Collaborative to
promote evidence-based strategies to support the optimal health and well-being of
North Carolina’s workforce. The collaborative should help businesses implement
healthy workplace policies and benefits, implement health risk appraisals, develop
comprehensive employee wellness programs, and implement data systems that
track outcomes and the organizational and employee level.
The North Carolina General Assembly should provide start-up funding of $800,000 in
SFY 2011, with a reduced amount over the next four years, to support this
collaborative.
In addition, the North Carolina General Assembly should provide a tax credit to
businesses with 50 or fewer employees that have implemented a comprehensive
worksite wellness program for their employees.

Key Considerations
•
•
•
•
•
•
•

Get employees involved! Get dedicated staff!
Management support is necessary but not sufficient
Offer a comprehensive program with all 5 elements
Offer incentives for participation/behavior change
Provide links to local health care systems/providers
Address social contextual factors influencing health
Support research that builds evidence base and then
offer evidence-based programs
• Special focused activities for small employers

Related Information
• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small manufacturing
worksites that employ multiethnic, low-wage workforces into a cancer
prevention research trial. Prev Chronic Dis. 2004;1(3):A04.
• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change
among working-class, multiethnic workers: results of the healthy
directions—small business study. Am J Public Health. 2005;95(8):13891395.
• Divine RL. Determinants of small business interest in offering a wellness
program to their employees. Health Mark Q. 2005;22(3):43-58.
• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of
healthy weight at small and medium-sized US worksites. Prev Chronic Dis
2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.
• Linnan L & Birken B. Small businesses, worksite wellness and public
health: A time for action. NC Med J. 2006;67(6):433-438.


Slide 10

Worksite Wellness – Working
with Small Businesses
17th Annual Healthy Carolinians &
NCIOM Prevention Summit
Laura A. Linnan, ScD, CHES
The UNC Gillings School of Global Public Health
Thursday, October 8, 2009

Objectives
• Offer a brief overview of the importance of worksite
health promotion and its prevalence among small
employers
• Provide a rationale for offering comprehensive HPPs
among small employers
• Identify strengths/assets of small employers for
promoting employee health
• Share some promising intervention strategies –
including those recommended by the NC IOM -- for
increasing the prevalence of small employers which
offer comprehensive HPPs

Why Worksite Health Promotion?
• More than 60% of US adults are employed
• Employees spend a considerable number of waking
hours working
• Health care for US adults is directly linked with
employer-provided health insurance; many working
adults are without health insurance
• Many leading causes of death (CVD, cancer, stroke)
are preventable through lifestyle behavior changes
(smoking, diet, PA)

Why Should Employers Be Interested in Worksite
Health Promotion?
• Preventable illness makes up 70% of the total burden
of disease and their associated costs; employers pay
for these costs
• 10 modifiable risk factors account for approximately
25% of all employer healthcare expenditures
(Anderson, 2000)
• Employer medical costs average $7910/employee
annually (O’Donnell, 2007)
• Effective worksite health promotion programs have
demonstrated a positive impact on employee morale,
employee health and risk behaviors, productivity, and
health care costs

What is a “small” business?
• US Small Business Administration defines
“small” business as an employer with 500
employees or less
• SBA estimates there are 25.8 million small
businesses in the US
– They employee nearly 50% of the working adults!
– Employed adults spend about ½ of their waking
hours at work

Not all “small” employers are
equal… but they are important!
• Among small employers, there is great
heterogeneity
• The smaller the employer, the less likely it is to
offer health insurance or any health
programming for employees..
• 98% of employers with at least 200 employees offer some
type of health insurance while only 59% of those under
200 employees do
• One serious health problem represents financial disaster
for an employee and his/her family

Healthy People 2010 – WorksiteRelated National Health Objective
• “75% of employers (of all sizes) should offer a
comprehensive worksite health promotion
program,” which includes 5 key elements:
•
•
•
•
•

Health education programming
Supportive physical/social environment
Links to other health-related programs in the organization
Screening programs and appropriate follow-up
Integration of the program into the administrative structure
(e.g. budget, staffing, etc.)

How many employers are offering a
“comprehensive” health promotion
program?
• And, are small employers different from other
employers in what they offer?

Use of a Health Risk Appraisal
50

750+ EES (n=111)

45
40

250-749 EES (n=211)

35
30
25

100-249 EES (n=229)
50-99 EES (n=179)

20
15
10
5
0

Linnan, Bowling et al. (2008). AJPH.

Total (n=730)

Differences
by worksite
size
statistically
significant
(p=0.0002)

Physical Activity and Nutrition
Programs by Worksite Size
70
60
50

750+ EES (n=111)

40

250-749 EES (n=211)

30

100-249 EES (n=229)

20

50-99 EES (n=179)

10

Total (n=730)

0
*Physical Activity

*Nutrition

* statistically significant
differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental
Programs by Worksite Size
100
90
80

750+ EES
(n=111)

70

250-749 EES
(n=211)

60
50

100-249 EES
(n=229)

40
30

50-99 EES
(n=179)

20
10
0

Total (n=730)

Onsite Fitness Fitness/Walking
Center
Trails

Cafeteria

Vending food/beverages

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling
Services by Worksite Size
100
90
80
70
60
50
40
30
20
10
0

750+ (n=111)
250-749 (n=211)
100-249 (n=229)
50-99 (n=179)
Total (n=730)

Can
cer
S

Dia
be

cree
n

ing

tes

HBP
Scr

Scr

een
ing

HBC
een
in

g

Sc r

Alco

een
in

Linnan, Bowling et al, 2008, AJPH

g

hol

or D
r

ug

Abu
se

Sup
por

t

Predictors of Comprehensive
Worksite Health Promotion Programs


Overall, 6.9% of employers offered a
comprehensive program – smaller worksites were
less likely to offer all elements/types of programs
 Controlling for all factors (e.g. model adjusted for
size, staff, experience, industry type), we found:
 Worksites with 750+ employees were 4.4 times
more likely to have a comprehensive program
(p=.06).
 Worksites with a dedicated staff person were
10.3 times more likely to have a comprehensive
program (p<.05).

Why Do Small Employers Offer
Fewer Programs?
• “Survival Mode” – HPP programs are costly
– Direct Costs – of offering programs/services
– Indirect Costs – time/resources – competing
demands

• Lack of personnel dedicated to wellness
• Small business culture/leadership
– “Leave it up to Workers” (Eakin)
– Managers concerned about employee privacy
(Linnan)

Barriers To Health Promotion Program Success
70
60
50
40
30
20
10
0
Lack of
Employee
Interest

Lack of Staff
Resources

Lack of Funding Lack of High-Risk
Employee
Participation

Lack of
Management
Support

No differences in barriers were reported based on industry type or worksite size except that worksites with 750+
employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

Linnan, Bowling et al. 2008. AJPH

“When business survival is the
focus, any other costs, including
those linked to employee health,
may be seen as prohibitive.”
Linnan & Birken (2007)
NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007
Employment-Based
Coverage
Sector

Individually
Purchased

Total
Own Name

Public

Uninsured

Dependent

Total

100.0

50.6

17.5

6.7

7.4

20.3

Self-employed

100.0

22.9

25.7

20.0

7.1

26.4

Wage-and-Salary Workers

100.0

54.1

16.5

5.1

7.5

19.5

Firm Employment Size
< 10 Employees

100.0

26.6

21.9

9.5

10.1

34.3

10-24 Employees

100.0

38.3

20.3

6.3

7.8

28.9

25-99 Employees

100.0

52.0

17.3

5.2

6.9

20.8

100-499 Employees

100.0

62.1

14.8

3.6

6.5

15.4

< 500 Employees

100.0

45.2

18.5

6.1

7.8

24.6

500+ Employees

100.0

65.7

13.8

3.7

7.0

12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the
president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths
• Often, there is a family focus
• Fewer organizational layers – less complexity
re: decision-making
• Less complexity re: implementation
• Understand that each individual employee
and his/her health is important
• Understand that health influences the
“bottom line” of the company

Multiple Level Intervention for
Small Employers
Level of Intervention

Strategy

Intrapersonal/
Interpersonal

-Briefings (print) and Web-based resources
-Leading by Example – employers
-CEO breakfast meetings
-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational

-Free or low-cost HPPs + TA to implement them from
community, hospitals, voluntary health organizations…
-TA from State Health Department and/or insurers

Community

-Business Groups on Health – leverage for purchasing power
-University partnerships to get student help, grant funding

Policy

-National or state-level tax credits for small employers who
adopt HPPs
-Purchasing agreements for health
-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US
Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*
Individual Level
- Periodic health assessments tied to personalized feedback and individual coaching and motivational
interviewing
- Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with
all employees and is available to discuss health concerns
-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and
meet monthly with participants to collect program activity points and measure progress (eg, changes in
weight and blood pressure) toward positive health outcomes
-Strong linkage of wellness program with worker safety, including group stretching to promote model of an
“industrial athlete”
-Health coaches who travel among a company’s worksites to meet with employees
Environmental Level
-Strong support from wellness committee for establishing culture of wellness
-Inclusion of healthy food in criteria for selecting cafeteria vendor
-Free access to onsite physical activity facilities
-Provision of bicycles for travel between buildings
Organizational Level
-Incentive of paid day of leave to encourage program participation
-Reallocation of existing benefits to provide incentives for participating in screening activities and attaining
wellness goals
-Strong financial disincentives for employees and spouses with health insurance through the company who
do not participate in wellness program
-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:
Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for
Small Businesses
The North Carolina General Assembly should direct the North Carolina Public Health
Foundation to establish the North Carolina Worksite Wellness Collaborative to
promote evidence-based strategies to support the optimal health and well-being of
North Carolina’s workforce. The collaborative should help businesses implement
healthy workplace policies and benefits, implement health risk appraisals, develop
comprehensive employee wellness programs, and implement data systems that
track outcomes and the organizational and employee level.
The North Carolina General Assembly should provide start-up funding of $800,000 in
SFY 2011, with a reduced amount over the next four years, to support this
collaborative.
In addition, the North Carolina General Assembly should provide a tax credit to
businesses with 50 or fewer employees that have implemented a comprehensive
worksite wellness program for their employees.

Key Considerations
•
•
•
•
•
•
•

Get employees involved! Get dedicated staff!
Management support is necessary but not sufficient
Offer a comprehensive program with all 5 elements
Offer incentives for participation/behavior change
Provide links to local health care systems/providers
Address social contextual factors influencing health
Support research that builds evidence base and then
offer evidence-based programs
• Special focused activities for small employers

Related Information
• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small manufacturing
worksites that employ multiethnic, low-wage workforces into a cancer
prevention research trial. Prev Chronic Dis. 2004;1(3):A04.
• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change
among working-class, multiethnic workers: results of the healthy
directions—small business study. Am J Public Health. 2005;95(8):13891395.
• Divine RL. Determinants of small business interest in offering a wellness
program to their employees. Health Mark Q. 2005;22(3):43-58.
• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of
healthy weight at small and medium-sized US worksites. Prev Chronic Dis
2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.
• Linnan L & Birken B. Small businesses, worksite wellness and public
health: A time for action. NC Med J. 2006;67(6):433-438.


Slide 11

Worksite Wellness – Working
with Small Businesses
17th Annual Healthy Carolinians &
NCIOM Prevention Summit
Laura A. Linnan, ScD, CHES
The UNC Gillings School of Global Public Health
Thursday, October 8, 2009

Objectives
• Offer a brief overview of the importance of worksite
health promotion and its prevalence among small
employers
• Provide a rationale for offering comprehensive HPPs
among small employers
• Identify strengths/assets of small employers for
promoting employee health
• Share some promising intervention strategies –
including those recommended by the NC IOM -- for
increasing the prevalence of small employers which
offer comprehensive HPPs

Why Worksite Health Promotion?
• More than 60% of US adults are employed
• Employees spend a considerable number of waking
hours working
• Health care for US adults is directly linked with
employer-provided health insurance; many working
adults are without health insurance
• Many leading causes of death (CVD, cancer, stroke)
are preventable through lifestyle behavior changes
(smoking, diet, PA)

Why Should Employers Be Interested in Worksite
Health Promotion?
• Preventable illness makes up 70% of the total burden
of disease and their associated costs; employers pay
for these costs
• 10 modifiable risk factors account for approximately
25% of all employer healthcare expenditures
(Anderson, 2000)
• Employer medical costs average $7910/employee
annually (O’Donnell, 2007)
• Effective worksite health promotion programs have
demonstrated a positive impact on employee morale,
employee health and risk behaviors, productivity, and
health care costs

What is a “small” business?
• US Small Business Administration defines
“small” business as an employer with 500
employees or less
• SBA estimates there are 25.8 million small
businesses in the US
– They employee nearly 50% of the working adults!
– Employed adults spend about ½ of their waking
hours at work

Not all “small” employers are
equal… but they are important!
• Among small employers, there is great
heterogeneity
• The smaller the employer, the less likely it is to
offer health insurance or any health
programming for employees..
• 98% of employers with at least 200 employees offer some
type of health insurance while only 59% of those under
200 employees do
• One serious health problem represents financial disaster
for an employee and his/her family

Healthy People 2010 – WorksiteRelated National Health Objective
• “75% of employers (of all sizes) should offer a
comprehensive worksite health promotion
program,” which includes 5 key elements:
•
•
•
•
•

Health education programming
Supportive physical/social environment
Links to other health-related programs in the organization
Screening programs and appropriate follow-up
Integration of the program into the administrative structure
(e.g. budget, staffing, etc.)

How many employers are offering a
“comprehensive” health promotion
program?
• And, are small employers different from other
employers in what they offer?

Use of a Health Risk Appraisal
50

750+ EES (n=111)

45
40

250-749 EES (n=211)

35
30
25

100-249 EES (n=229)
50-99 EES (n=179)

20
15
10
5
0

Linnan, Bowling et al. (2008). AJPH.

Total (n=730)

Differences
by worksite
size
statistically
significant
(p=0.0002)

Physical Activity and Nutrition
Programs by Worksite Size
70
60
50

750+ EES (n=111)

40

250-749 EES (n=211)

30

100-249 EES (n=229)

20

50-99 EES (n=179)

10

Total (n=730)

0
*Physical Activity

*Nutrition

* statistically significant
differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental
Programs by Worksite Size
100
90
80

750+ EES
(n=111)

70

250-749 EES
(n=211)

60
50

100-249 EES
(n=229)

40
30

50-99 EES
(n=179)

20
10
0

Total (n=730)

Onsite Fitness Fitness/Walking
Center
Trails

Cafeteria

Vending food/beverages

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling
Services by Worksite Size
100
90
80
70
60
50
40
30
20
10
0

750+ (n=111)
250-749 (n=211)
100-249 (n=229)
50-99 (n=179)
Total (n=730)

Can
cer
S

Dia
be

cree
n

ing

tes

HBP
Scr

Scr

een
ing

HBC
een
in

g

Sc r

Alco

een
in

Linnan, Bowling et al, 2008, AJPH

g

hol

or D
r

ug

Abu
se

Sup
por

t

Predictors of Comprehensive
Worksite Health Promotion Programs


Overall, 6.9% of employers offered a
comprehensive program – smaller worksites were
less likely to offer all elements/types of programs
 Controlling for all factors (e.g. model adjusted for
size, staff, experience, industry type), we found:
 Worksites with 750+ employees were 4.4 times
more likely to have a comprehensive program
(p=.06).
 Worksites with a dedicated staff person were
10.3 times more likely to have a comprehensive
program (p<.05).

Why Do Small Employers Offer
Fewer Programs?
• “Survival Mode” – HPP programs are costly
– Direct Costs – of offering programs/services
– Indirect Costs – time/resources – competing
demands

• Lack of personnel dedicated to wellness
• Small business culture/leadership
– “Leave it up to Workers” (Eakin)
– Managers concerned about employee privacy
(Linnan)

Barriers To Health Promotion Program Success
70
60
50
40
30
20
10
0
Lack of
Employee
Interest

Lack of Staff
Resources

Lack of Funding Lack of High-Risk
Employee
Participation

Lack of
Management
Support

No differences in barriers were reported based on industry type or worksite size except that worksites with 750+
employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

Linnan, Bowling et al. 2008. AJPH

“When business survival is the
focus, any other costs, including
those linked to employee health,
may be seen as prohibitive.”
Linnan & Birken (2007)
NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007
Employment-Based
Coverage
Sector

Individually
Purchased

Total
Own Name

Public

Uninsured

Dependent

Total

100.0

50.6

17.5

6.7

7.4

20.3

Self-employed

100.0

22.9

25.7

20.0

7.1

26.4

Wage-and-Salary Workers

100.0

54.1

16.5

5.1

7.5

19.5

Firm Employment Size
< 10 Employees

100.0

26.6

21.9

9.5

10.1

34.3

10-24 Employees

100.0

38.3

20.3

6.3

7.8

28.9

25-99 Employees

100.0

52.0

17.3

5.2

6.9

20.8

100-499 Employees

100.0

62.1

14.8

3.6

6.5

15.4

< 500 Employees

100.0

45.2

18.5

6.1

7.8

24.6

500+ Employees

100.0

65.7

13.8

3.7

7.0

12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the
president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths
• Often, there is a family focus
• Fewer organizational layers – less complexity
re: decision-making
• Less complexity re: implementation
• Understand that each individual employee
and his/her health is important
• Understand that health influences the
“bottom line” of the company

Multiple Level Intervention for
Small Employers
Level of Intervention

Strategy

Intrapersonal/
Interpersonal

-Briefings (print) and Web-based resources
-Leading by Example – employers
-CEO breakfast meetings
-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational

-Free or low-cost HPPs + TA to implement them from
community, hospitals, voluntary health organizations…
-TA from State Health Department and/or insurers

Community

-Business Groups on Health – leverage for purchasing power
-University partnerships to get student help, grant funding

Policy

-National or state-level tax credits for small employers who
adopt HPPs
-Purchasing agreements for health
-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US
Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*
Individual Level
- Periodic health assessments tied to personalized feedback and individual coaching and motivational
interviewing
- Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with
all employees and is available to discuss health concerns
-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and
meet monthly with participants to collect program activity points and measure progress (eg, changes in
weight and blood pressure) toward positive health outcomes
-Strong linkage of wellness program with worker safety, including group stretching to promote model of an
“industrial athlete”
-Health coaches who travel among a company’s worksites to meet with employees
Environmental Level
-Strong support from wellness committee for establishing culture of wellness
-Inclusion of healthy food in criteria for selecting cafeteria vendor
-Free access to onsite physical activity facilities
-Provision of bicycles for travel between buildings
Organizational Level
-Incentive of paid day of leave to encourage program participation
-Reallocation of existing benefits to provide incentives for participating in screening activities and attaining
wellness goals
-Strong financial disincentives for employees and spouses with health insurance through the company who
do not participate in wellness program
-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:
Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for
Small Businesses
The North Carolina General Assembly should direct the North Carolina Public Health
Foundation to establish the North Carolina Worksite Wellness Collaborative to
promote evidence-based strategies to support the optimal health and well-being of
North Carolina’s workforce. The collaborative should help businesses implement
healthy workplace policies and benefits, implement health risk appraisals, develop
comprehensive employee wellness programs, and implement data systems that
track outcomes and the organizational and employee level.
The North Carolina General Assembly should provide start-up funding of $800,000 in
SFY 2011, with a reduced amount over the next four years, to support this
collaborative.
In addition, the North Carolina General Assembly should provide a tax credit to
businesses with 50 or fewer employees that have implemented a comprehensive
worksite wellness program for their employees.

Key Considerations
•
•
•
•
•
•
•

Get employees involved! Get dedicated staff!
Management support is necessary but not sufficient
Offer a comprehensive program with all 5 elements
Offer incentives for participation/behavior change
Provide links to local health care systems/providers
Address social contextual factors influencing health
Support research that builds evidence base and then
offer evidence-based programs
• Special focused activities for small employers

Related Information
• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small manufacturing
worksites that employ multiethnic, low-wage workforces into a cancer
prevention research trial. Prev Chronic Dis. 2004;1(3):A04.
• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change
among working-class, multiethnic workers: results of the healthy
directions—small business study. Am J Public Health. 2005;95(8):13891395.
• Divine RL. Determinants of small business interest in offering a wellness
program to their employees. Health Mark Q. 2005;22(3):43-58.
• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of
healthy weight at small and medium-sized US worksites. Prev Chronic Dis
2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.
• Linnan L & Birken B. Small businesses, worksite wellness and public
health: A time for action. NC Med J. 2006;67(6):433-438.


Slide 12

Worksite Wellness – Working
with Small Businesses
17th Annual Healthy Carolinians &
NCIOM Prevention Summit
Laura A. Linnan, ScD, CHES
The UNC Gillings School of Global Public Health
Thursday, October 8, 2009

Objectives
• Offer a brief overview of the importance of worksite
health promotion and its prevalence among small
employers
• Provide a rationale for offering comprehensive HPPs
among small employers
• Identify strengths/assets of small employers for
promoting employee health
• Share some promising intervention strategies –
including those recommended by the NC IOM -- for
increasing the prevalence of small employers which
offer comprehensive HPPs

Why Worksite Health Promotion?
• More than 60% of US adults are employed
• Employees spend a considerable number of waking
hours working
• Health care for US adults is directly linked with
employer-provided health insurance; many working
adults are without health insurance
• Many leading causes of death (CVD, cancer, stroke)
are preventable through lifestyle behavior changes
(smoking, diet, PA)

Why Should Employers Be Interested in Worksite
Health Promotion?
• Preventable illness makes up 70% of the total burden
of disease and their associated costs; employers pay
for these costs
• 10 modifiable risk factors account for approximately
25% of all employer healthcare expenditures
(Anderson, 2000)
• Employer medical costs average $7910/employee
annually (O’Donnell, 2007)
• Effective worksite health promotion programs have
demonstrated a positive impact on employee morale,
employee health and risk behaviors, productivity, and
health care costs

What is a “small” business?
• US Small Business Administration defines
“small” business as an employer with 500
employees or less
• SBA estimates there are 25.8 million small
businesses in the US
– They employee nearly 50% of the working adults!
– Employed adults spend about ½ of their waking
hours at work

Not all “small” employers are
equal… but they are important!
• Among small employers, there is great
heterogeneity
• The smaller the employer, the less likely it is to
offer health insurance or any health
programming for employees..
• 98% of employers with at least 200 employees offer some
type of health insurance while only 59% of those under
200 employees do
• One serious health problem represents financial disaster
for an employee and his/her family

Healthy People 2010 – WorksiteRelated National Health Objective
• “75% of employers (of all sizes) should offer a
comprehensive worksite health promotion
program,” which includes 5 key elements:
•
•
•
•
•

Health education programming
Supportive physical/social environment
Links to other health-related programs in the organization
Screening programs and appropriate follow-up
Integration of the program into the administrative structure
(e.g. budget, staffing, etc.)

How many employers are offering a
“comprehensive” health promotion
program?
• And, are small employers different from other
employers in what they offer?

Use of a Health Risk Appraisal
50

750+ EES (n=111)

45
40

250-749 EES (n=211)

35
30
25

100-249 EES (n=229)
50-99 EES (n=179)

20
15
10
5
0

Linnan, Bowling et al. (2008). AJPH.

Total (n=730)

Differences
by worksite
size
statistically
significant
(p=0.0002)

Physical Activity and Nutrition
Programs by Worksite Size
70
60
50

750+ EES (n=111)

40

250-749 EES (n=211)

30

100-249 EES (n=229)

20

50-99 EES (n=179)

10

Total (n=730)

0
*Physical Activity

*Nutrition

* statistically significant
differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental
Programs by Worksite Size
100
90
80

750+ EES
(n=111)

70

250-749 EES
(n=211)

60
50

100-249 EES
(n=229)

40
30

50-99 EES
(n=179)

20
10
0

Total (n=730)

Onsite Fitness Fitness/Walking
Center
Trails

Cafeteria

Vending food/beverages

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling
Services by Worksite Size
100
90
80
70
60
50
40
30
20
10
0

750+ (n=111)
250-749 (n=211)
100-249 (n=229)
50-99 (n=179)
Total (n=730)

Can
cer
S

Dia
be

cree
n

ing

tes

HBP
Scr

Scr

een
ing

HBC
een
in

g

Sc r

Alco

een
in

Linnan, Bowling et al, 2008, AJPH

g

hol

or D
r

ug

Abu
se

Sup
por

t

Predictors of Comprehensive
Worksite Health Promotion Programs


Overall, 6.9% of employers offered a
comprehensive program – smaller worksites were
less likely to offer all elements/types of programs
 Controlling for all factors (e.g. model adjusted for
size, staff, experience, industry type), we found:
 Worksites with 750+ employees were 4.4 times
more likely to have a comprehensive program
(p=.06).
 Worksites with a dedicated staff person were
10.3 times more likely to have a comprehensive
program (p<.05).

Why Do Small Employers Offer
Fewer Programs?
• “Survival Mode” – HPP programs are costly
– Direct Costs – of offering programs/services
– Indirect Costs – time/resources – competing
demands

• Lack of personnel dedicated to wellness
• Small business culture/leadership
– “Leave it up to Workers” (Eakin)
– Managers concerned about employee privacy
(Linnan)

Barriers To Health Promotion Program Success
70
60
50
40
30
20
10
0
Lack of
Employee
Interest

Lack of Staff
Resources

Lack of Funding Lack of High-Risk
Employee
Participation

Lack of
Management
Support

No differences in barriers were reported based on industry type or worksite size except that worksites with 750+
employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

Linnan, Bowling et al. 2008. AJPH

“When business survival is the
focus, any other costs, including
those linked to employee health,
may be seen as prohibitive.”
Linnan & Birken (2007)
NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007
Employment-Based
Coverage
Sector

Individually
Purchased

Total
Own Name

Public

Uninsured

Dependent

Total

100.0

50.6

17.5

6.7

7.4

20.3

Self-employed

100.0

22.9

25.7

20.0

7.1

26.4

Wage-and-Salary Workers

100.0

54.1

16.5

5.1

7.5

19.5

Firm Employment Size
< 10 Employees

100.0

26.6

21.9

9.5

10.1

34.3

10-24 Employees

100.0

38.3

20.3

6.3

7.8

28.9

25-99 Employees

100.0

52.0

17.3

5.2

6.9

20.8

100-499 Employees

100.0

62.1

14.8

3.6

6.5

15.4

< 500 Employees

100.0

45.2

18.5

6.1

7.8

24.6

500+ Employees

100.0

65.7

13.8

3.7

7.0

12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the
president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths
• Often, there is a family focus
• Fewer organizational layers – less complexity
re: decision-making
• Less complexity re: implementation
• Understand that each individual employee
and his/her health is important
• Understand that health influences the
“bottom line” of the company

Multiple Level Intervention for
Small Employers
Level of Intervention

Strategy

Intrapersonal/
Interpersonal

-Briefings (print) and Web-based resources
-Leading by Example – employers
-CEO breakfast meetings
-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational

-Free or low-cost HPPs + TA to implement them from
community, hospitals, voluntary health organizations…
-TA from State Health Department and/or insurers

Community

-Business Groups on Health – leverage for purchasing power
-University partnerships to get student help, grant funding

Policy

-National or state-level tax credits for small employers who
adopt HPPs
-Purchasing agreements for health
-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US
Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*
Individual Level
- Periodic health assessments tied to personalized feedback and individual coaching and motivational
interviewing
- Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with
all employees and is available to discuss health concerns
-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and
meet monthly with participants to collect program activity points and measure progress (eg, changes in
weight and blood pressure) toward positive health outcomes
-Strong linkage of wellness program with worker safety, including group stretching to promote model of an
“industrial athlete”
-Health coaches who travel among a company’s worksites to meet with employees
Environmental Level
-Strong support from wellness committee for establishing culture of wellness
-Inclusion of healthy food in criteria for selecting cafeteria vendor
-Free access to onsite physical activity facilities
-Provision of bicycles for travel between buildings
Organizational Level
-Incentive of paid day of leave to encourage program participation
-Reallocation of existing benefits to provide incentives for participating in screening activities and attaining
wellness goals
-Strong financial disincentives for employees and spouses with health insurance through the company who
do not participate in wellness program
-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:
Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for
Small Businesses
The North Carolina General Assembly should direct the North Carolina Public Health
Foundation to establish the North Carolina Worksite Wellness Collaborative to
promote evidence-based strategies to support the optimal health and well-being of
North Carolina’s workforce. The collaborative should help businesses implement
healthy workplace policies and benefits, implement health risk appraisals, develop
comprehensive employee wellness programs, and implement data systems that
track outcomes and the organizational and employee level.
The North Carolina General Assembly should provide start-up funding of $800,000 in
SFY 2011, with a reduced amount over the next four years, to support this
collaborative.
In addition, the North Carolina General Assembly should provide a tax credit to
businesses with 50 or fewer employees that have implemented a comprehensive
worksite wellness program for their employees.

Key Considerations
•
•
•
•
•
•
•

Get employees involved! Get dedicated staff!
Management support is necessary but not sufficient
Offer a comprehensive program with all 5 elements
Offer incentives for participation/behavior change
Provide links to local health care systems/providers
Address social contextual factors influencing health
Support research that builds evidence base and then
offer evidence-based programs
• Special focused activities for small employers

Related Information
• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small manufacturing
worksites that employ multiethnic, low-wage workforces into a cancer
prevention research trial. Prev Chronic Dis. 2004;1(3):A04.
• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change
among working-class, multiethnic workers: results of the healthy
directions—small business study. Am J Public Health. 2005;95(8):13891395.
• Divine RL. Determinants of small business interest in offering a wellness
program to their employees. Health Mark Q. 2005;22(3):43-58.
• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of
healthy weight at small and medium-sized US worksites. Prev Chronic Dis
2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.
• Linnan L & Birken B. Small businesses, worksite wellness and public
health: A time for action. NC Med J. 2006;67(6):433-438.


Slide 13

Worksite Wellness – Working
with Small Businesses
17th Annual Healthy Carolinians &
NCIOM Prevention Summit
Laura A. Linnan, ScD, CHES
The UNC Gillings School of Global Public Health
Thursday, October 8, 2009

Objectives
• Offer a brief overview of the importance of worksite
health promotion and its prevalence among small
employers
• Provide a rationale for offering comprehensive HPPs
among small employers
• Identify strengths/assets of small employers for
promoting employee health
• Share some promising intervention strategies –
including those recommended by the NC IOM -- for
increasing the prevalence of small employers which
offer comprehensive HPPs

Why Worksite Health Promotion?
• More than 60% of US adults are employed
• Employees spend a considerable number of waking
hours working
• Health care for US adults is directly linked with
employer-provided health insurance; many working
adults are without health insurance
• Many leading causes of death (CVD, cancer, stroke)
are preventable through lifestyle behavior changes
(smoking, diet, PA)

Why Should Employers Be Interested in Worksite
Health Promotion?
• Preventable illness makes up 70% of the total burden
of disease and their associated costs; employers pay
for these costs
• 10 modifiable risk factors account for approximately
25% of all employer healthcare expenditures
(Anderson, 2000)
• Employer medical costs average $7910/employee
annually (O’Donnell, 2007)
• Effective worksite health promotion programs have
demonstrated a positive impact on employee morale,
employee health and risk behaviors, productivity, and
health care costs

What is a “small” business?
• US Small Business Administration defines
“small” business as an employer with 500
employees or less
• SBA estimates there are 25.8 million small
businesses in the US
– They employee nearly 50% of the working adults!
– Employed adults spend about ½ of their waking
hours at work

Not all “small” employers are
equal… but they are important!
• Among small employers, there is great
heterogeneity
• The smaller the employer, the less likely it is to
offer health insurance or any health
programming for employees..
• 98% of employers with at least 200 employees offer some
type of health insurance while only 59% of those under
200 employees do
• One serious health problem represents financial disaster
for an employee and his/her family

Healthy People 2010 – WorksiteRelated National Health Objective
• “75% of employers (of all sizes) should offer a
comprehensive worksite health promotion
program,” which includes 5 key elements:
•
•
•
•
•

Health education programming
Supportive physical/social environment
Links to other health-related programs in the organization
Screening programs and appropriate follow-up
Integration of the program into the administrative structure
(e.g. budget, staffing, etc.)

How many employers are offering a
“comprehensive” health promotion
program?
• And, are small employers different from other
employers in what they offer?

Use of a Health Risk Appraisal
50

750+ EES (n=111)

45
40

250-749 EES (n=211)

35
30
25

100-249 EES (n=229)
50-99 EES (n=179)

20
15
10
5
0

Linnan, Bowling et al. (2008). AJPH.

Total (n=730)

Differences
by worksite
size
statistically
significant
(p=0.0002)

Physical Activity and Nutrition
Programs by Worksite Size
70
60
50

750+ EES (n=111)

40

250-749 EES (n=211)

30

100-249 EES (n=229)

20

50-99 EES (n=179)

10

Total (n=730)

0
*Physical Activity

*Nutrition

* statistically significant
differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental
Programs by Worksite Size
100
90
80

750+ EES
(n=111)

70

250-749 EES
(n=211)

60
50

100-249 EES
(n=229)

40
30

50-99 EES
(n=179)

20
10
0

Total (n=730)

Onsite Fitness Fitness/Walking
Center
Trails

Cafeteria

Vending food/beverages

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling
Services by Worksite Size
100
90
80
70
60
50
40
30
20
10
0

750+ (n=111)
250-749 (n=211)
100-249 (n=229)
50-99 (n=179)
Total (n=730)

Can
cer
S

Dia
be

cree
n

ing

tes

HBP
Scr

Scr

een
ing

HBC
een
in

g

Sc r

Alco

een
in

Linnan, Bowling et al, 2008, AJPH

g

hol

or D
r

ug

Abu
se

Sup
por

t

Predictors of Comprehensive
Worksite Health Promotion Programs


Overall, 6.9% of employers offered a
comprehensive program – smaller worksites were
less likely to offer all elements/types of programs
 Controlling for all factors (e.g. model adjusted for
size, staff, experience, industry type), we found:
 Worksites with 750+ employees were 4.4 times
more likely to have a comprehensive program
(p=.06).
 Worksites with a dedicated staff person were
10.3 times more likely to have a comprehensive
program (p<.05).

Why Do Small Employers Offer
Fewer Programs?
• “Survival Mode” – HPP programs are costly
– Direct Costs – of offering programs/services
– Indirect Costs – time/resources – competing
demands

• Lack of personnel dedicated to wellness
• Small business culture/leadership
– “Leave it up to Workers” (Eakin)
– Managers concerned about employee privacy
(Linnan)

Barriers To Health Promotion Program Success
70
60
50
40
30
20
10
0
Lack of
Employee
Interest

Lack of Staff
Resources

Lack of Funding Lack of High-Risk
Employee
Participation

Lack of
Management
Support

No differences in barriers were reported based on industry type or worksite size except that worksites with 750+
employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

Linnan, Bowling et al. 2008. AJPH

“When business survival is the
focus, any other costs, including
those linked to employee health,
may be seen as prohibitive.”
Linnan & Birken (2007)
NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007
Employment-Based
Coverage
Sector

Individually
Purchased

Total
Own Name

Public

Uninsured

Dependent

Total

100.0

50.6

17.5

6.7

7.4

20.3

Self-employed

100.0

22.9

25.7

20.0

7.1

26.4

Wage-and-Salary Workers

100.0

54.1

16.5

5.1

7.5

19.5

Firm Employment Size
< 10 Employees

100.0

26.6

21.9

9.5

10.1

34.3

10-24 Employees

100.0

38.3

20.3

6.3

7.8

28.9

25-99 Employees

100.0

52.0

17.3

5.2

6.9

20.8

100-499 Employees

100.0

62.1

14.8

3.6

6.5

15.4

< 500 Employees

100.0

45.2

18.5

6.1

7.8

24.6

500+ Employees

100.0

65.7

13.8

3.7

7.0

12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the
president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths
• Often, there is a family focus
• Fewer organizational layers – less complexity
re: decision-making
• Less complexity re: implementation
• Understand that each individual employee
and his/her health is important
• Understand that health influences the
“bottom line” of the company

Multiple Level Intervention for
Small Employers
Level of Intervention

Strategy

Intrapersonal/
Interpersonal

-Briefings (print) and Web-based resources
-Leading by Example – employers
-CEO breakfast meetings
-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational

-Free or low-cost HPPs + TA to implement them from
community, hospitals, voluntary health organizations…
-TA from State Health Department and/or insurers

Community

-Business Groups on Health – leverage for purchasing power
-University partnerships to get student help, grant funding

Policy

-National or state-level tax credits for small employers who
adopt HPPs
-Purchasing agreements for health
-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US
Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*
Individual Level
- Periodic health assessments tied to personalized feedback and individual coaching and motivational
interviewing
- Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with
all employees and is available to discuss health concerns
-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and
meet monthly with participants to collect program activity points and measure progress (eg, changes in
weight and blood pressure) toward positive health outcomes
-Strong linkage of wellness program with worker safety, including group stretching to promote model of an
“industrial athlete”
-Health coaches who travel among a company’s worksites to meet with employees
Environmental Level
-Strong support from wellness committee for establishing culture of wellness
-Inclusion of healthy food in criteria for selecting cafeteria vendor
-Free access to onsite physical activity facilities
-Provision of bicycles for travel between buildings
Organizational Level
-Incentive of paid day of leave to encourage program participation
-Reallocation of existing benefits to provide incentives for participating in screening activities and attaining
wellness goals
-Strong financial disincentives for employees and spouses with health insurance through the company who
do not participate in wellness program
-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:
Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for
Small Businesses
The North Carolina General Assembly should direct the North Carolina Public Health
Foundation to establish the North Carolina Worksite Wellness Collaborative to
promote evidence-based strategies to support the optimal health and well-being of
North Carolina’s workforce. The collaborative should help businesses implement
healthy workplace policies and benefits, implement health risk appraisals, develop
comprehensive employee wellness programs, and implement data systems that
track outcomes and the organizational and employee level.
The North Carolina General Assembly should provide start-up funding of $800,000 in
SFY 2011, with a reduced amount over the next four years, to support this
collaborative.
In addition, the North Carolina General Assembly should provide a tax credit to
businesses with 50 or fewer employees that have implemented a comprehensive
worksite wellness program for their employees.

Key Considerations
•
•
•
•
•
•
•

Get employees involved! Get dedicated staff!
Management support is necessary but not sufficient
Offer a comprehensive program with all 5 elements
Offer incentives for participation/behavior change
Provide links to local health care systems/providers
Address social contextual factors influencing health
Support research that builds evidence base and then
offer evidence-based programs
• Special focused activities for small employers

Related Information
• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small manufacturing
worksites that employ multiethnic, low-wage workforces into a cancer
prevention research trial. Prev Chronic Dis. 2004;1(3):A04.
• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change
among working-class, multiethnic workers: results of the healthy
directions—small business study. Am J Public Health. 2005;95(8):13891395.
• Divine RL. Determinants of small business interest in offering a wellness
program to their employees. Health Mark Q. 2005;22(3):43-58.
• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of
healthy weight at small and medium-sized US worksites. Prev Chronic Dis
2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.
• Linnan L & Birken B. Small businesses, worksite wellness and public
health: A time for action. NC Med J. 2006;67(6):433-438.


Slide 14

Worksite Wellness – Working
with Small Businesses
17th Annual Healthy Carolinians &
NCIOM Prevention Summit
Laura A. Linnan, ScD, CHES
The UNC Gillings School of Global Public Health
Thursday, October 8, 2009

Objectives
• Offer a brief overview of the importance of worksite
health promotion and its prevalence among small
employers
• Provide a rationale for offering comprehensive HPPs
among small employers
• Identify strengths/assets of small employers for
promoting employee health
• Share some promising intervention strategies –
including those recommended by the NC IOM -- for
increasing the prevalence of small employers which
offer comprehensive HPPs

Why Worksite Health Promotion?
• More than 60% of US adults are employed
• Employees spend a considerable number of waking
hours working
• Health care for US adults is directly linked with
employer-provided health insurance; many working
adults are without health insurance
• Many leading causes of death (CVD, cancer, stroke)
are preventable through lifestyle behavior changes
(smoking, diet, PA)

Why Should Employers Be Interested in Worksite
Health Promotion?
• Preventable illness makes up 70% of the total burden
of disease and their associated costs; employers pay
for these costs
• 10 modifiable risk factors account for approximately
25% of all employer healthcare expenditures
(Anderson, 2000)
• Employer medical costs average $7910/employee
annually (O’Donnell, 2007)
• Effective worksite health promotion programs have
demonstrated a positive impact on employee morale,
employee health and risk behaviors, productivity, and
health care costs

What is a “small” business?
• US Small Business Administration defines
“small” business as an employer with 500
employees or less
• SBA estimates there are 25.8 million small
businesses in the US
– They employee nearly 50% of the working adults!
– Employed adults spend about ½ of their waking
hours at work

Not all “small” employers are
equal… but they are important!
• Among small employers, there is great
heterogeneity
• The smaller the employer, the less likely it is to
offer health insurance or any health
programming for employees..
• 98% of employers with at least 200 employees offer some
type of health insurance while only 59% of those under
200 employees do
• One serious health problem represents financial disaster
for an employee and his/her family

Healthy People 2010 – WorksiteRelated National Health Objective
• “75% of employers (of all sizes) should offer a
comprehensive worksite health promotion
program,” which includes 5 key elements:
•
•
•
•
•

Health education programming
Supportive physical/social environment
Links to other health-related programs in the organization
Screening programs and appropriate follow-up
Integration of the program into the administrative structure
(e.g. budget, staffing, etc.)

How many employers are offering a
“comprehensive” health promotion
program?
• And, are small employers different from other
employers in what they offer?

Use of a Health Risk Appraisal
50

750+ EES (n=111)

45
40

250-749 EES (n=211)

35
30
25

100-249 EES (n=229)
50-99 EES (n=179)

20
15
10
5
0

Linnan, Bowling et al. (2008). AJPH.

Total (n=730)

Differences
by worksite
size
statistically
significant
(p=0.0002)

Physical Activity and Nutrition
Programs by Worksite Size
70
60
50

750+ EES (n=111)

40

250-749 EES (n=211)

30

100-249 EES (n=229)

20

50-99 EES (n=179)

10

Total (n=730)

0
*Physical Activity

*Nutrition

* statistically significant
differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental
Programs by Worksite Size
100
90
80

750+ EES
(n=111)

70

250-749 EES
(n=211)

60
50

100-249 EES
(n=229)

40
30

50-99 EES
(n=179)

20
10
0

Total (n=730)

Onsite Fitness Fitness/Walking
Center
Trails

Cafeteria

Vending food/beverages

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling
Services by Worksite Size
100
90
80
70
60
50
40
30
20
10
0

750+ (n=111)
250-749 (n=211)
100-249 (n=229)
50-99 (n=179)
Total (n=730)

Can
cer
S

Dia
be

cree
n

ing

tes

HBP
Scr

Scr

een
ing

HBC
een
in

g

Sc r

Alco

een
in

Linnan, Bowling et al, 2008, AJPH

g

hol

or D
r

ug

Abu
se

Sup
por

t

Predictors of Comprehensive
Worksite Health Promotion Programs


Overall, 6.9% of employers offered a
comprehensive program – smaller worksites were
less likely to offer all elements/types of programs
 Controlling for all factors (e.g. model adjusted for
size, staff, experience, industry type), we found:
 Worksites with 750+ employees were 4.4 times
more likely to have a comprehensive program
(p=.06).
 Worksites with a dedicated staff person were
10.3 times more likely to have a comprehensive
program (p<.05).

Why Do Small Employers Offer
Fewer Programs?
• “Survival Mode” – HPP programs are costly
– Direct Costs – of offering programs/services
– Indirect Costs – time/resources – competing
demands

• Lack of personnel dedicated to wellness
• Small business culture/leadership
– “Leave it up to Workers” (Eakin)
– Managers concerned about employee privacy
(Linnan)

Barriers To Health Promotion Program Success
70
60
50
40
30
20
10
0
Lack of
Employee
Interest

Lack of Staff
Resources

Lack of Funding Lack of High-Risk
Employee
Participation

Lack of
Management
Support

No differences in barriers were reported based on industry type or worksite size except that worksites with 750+
employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

Linnan, Bowling et al. 2008. AJPH

“When business survival is the
focus, any other costs, including
those linked to employee health,
may be seen as prohibitive.”
Linnan & Birken (2007)
NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007
Employment-Based
Coverage
Sector

Individually
Purchased

Total
Own Name

Public

Uninsured

Dependent

Total

100.0

50.6

17.5

6.7

7.4

20.3

Self-employed

100.0

22.9

25.7

20.0

7.1

26.4

Wage-and-Salary Workers

100.0

54.1

16.5

5.1

7.5

19.5

Firm Employment Size
< 10 Employees

100.0

26.6

21.9

9.5

10.1

34.3

10-24 Employees

100.0

38.3

20.3

6.3

7.8

28.9

25-99 Employees

100.0

52.0

17.3

5.2

6.9

20.8

100-499 Employees

100.0

62.1

14.8

3.6

6.5

15.4

< 500 Employees

100.0

45.2

18.5

6.1

7.8

24.6

500+ Employees

100.0

65.7

13.8

3.7

7.0

12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the
president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths
• Often, there is a family focus
• Fewer organizational layers – less complexity
re: decision-making
• Less complexity re: implementation
• Understand that each individual employee
and his/her health is important
• Understand that health influences the
“bottom line” of the company

Multiple Level Intervention for
Small Employers
Level of Intervention

Strategy

Intrapersonal/
Interpersonal

-Briefings (print) and Web-based resources
-Leading by Example – employers
-CEO breakfast meetings
-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational

-Free or low-cost HPPs + TA to implement them from
community, hospitals, voluntary health organizations…
-TA from State Health Department and/or insurers

Community

-Business Groups on Health – leverage for purchasing power
-University partnerships to get student help, grant funding

Policy

-National or state-level tax credits for small employers who
adopt HPPs
-Purchasing agreements for health
-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US
Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*
Individual Level
- Periodic health assessments tied to personalized feedback and individual coaching and motivational
interviewing
- Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with
all employees and is available to discuss health concerns
-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and
meet monthly with participants to collect program activity points and measure progress (eg, changes in
weight and blood pressure) toward positive health outcomes
-Strong linkage of wellness program with worker safety, including group stretching to promote model of an
“industrial athlete”
-Health coaches who travel among a company’s worksites to meet with employees
Environmental Level
-Strong support from wellness committee for establishing culture of wellness
-Inclusion of healthy food in criteria for selecting cafeteria vendor
-Free access to onsite physical activity facilities
-Provision of bicycles for travel between buildings
Organizational Level
-Incentive of paid day of leave to encourage program participation
-Reallocation of existing benefits to provide incentives for participating in screening activities and attaining
wellness goals
-Strong financial disincentives for employees and spouses with health insurance through the company who
do not participate in wellness program
-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:
Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for
Small Businesses
The North Carolina General Assembly should direct the North Carolina Public Health
Foundation to establish the North Carolina Worksite Wellness Collaborative to
promote evidence-based strategies to support the optimal health and well-being of
North Carolina’s workforce. The collaborative should help businesses implement
healthy workplace policies and benefits, implement health risk appraisals, develop
comprehensive employee wellness programs, and implement data systems that
track outcomes and the organizational and employee level.
The North Carolina General Assembly should provide start-up funding of $800,000 in
SFY 2011, with a reduced amount over the next four years, to support this
collaborative.
In addition, the North Carolina General Assembly should provide a tax credit to
businesses with 50 or fewer employees that have implemented a comprehensive
worksite wellness program for their employees.

Key Considerations
•
•
•
•
•
•
•

Get employees involved! Get dedicated staff!
Management support is necessary but not sufficient
Offer a comprehensive program with all 5 elements
Offer incentives for participation/behavior change
Provide links to local health care systems/providers
Address social contextual factors influencing health
Support research that builds evidence base and then
offer evidence-based programs
• Special focused activities for small employers

Related Information
• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small manufacturing
worksites that employ multiethnic, low-wage workforces into a cancer
prevention research trial. Prev Chronic Dis. 2004;1(3):A04.
• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change
among working-class, multiethnic workers: results of the healthy
directions—small business study. Am J Public Health. 2005;95(8):13891395.
• Divine RL. Determinants of small business interest in offering a wellness
program to their employees. Health Mark Q. 2005;22(3):43-58.
• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of
healthy weight at small and medium-sized US worksites. Prev Chronic Dis
2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.
• Linnan L & Birken B. Small businesses, worksite wellness and public
health: A time for action. NC Med J. 2006;67(6):433-438.


Slide 15

Worksite Wellness – Working
with Small Businesses
17th Annual Healthy Carolinians &
NCIOM Prevention Summit
Laura A. Linnan, ScD, CHES
The UNC Gillings School of Global Public Health
Thursday, October 8, 2009

Objectives
• Offer a brief overview of the importance of worksite
health promotion and its prevalence among small
employers
• Provide a rationale for offering comprehensive HPPs
among small employers
• Identify strengths/assets of small employers for
promoting employee health
• Share some promising intervention strategies –
including those recommended by the NC IOM -- for
increasing the prevalence of small employers which
offer comprehensive HPPs

Why Worksite Health Promotion?
• More than 60% of US adults are employed
• Employees spend a considerable number of waking
hours working
• Health care for US adults is directly linked with
employer-provided health insurance; many working
adults are without health insurance
• Many leading causes of death (CVD, cancer, stroke)
are preventable through lifestyle behavior changes
(smoking, diet, PA)

Why Should Employers Be Interested in Worksite
Health Promotion?
• Preventable illness makes up 70% of the total burden
of disease and their associated costs; employers pay
for these costs
• 10 modifiable risk factors account for approximately
25% of all employer healthcare expenditures
(Anderson, 2000)
• Employer medical costs average $7910/employee
annually (O’Donnell, 2007)
• Effective worksite health promotion programs have
demonstrated a positive impact on employee morale,
employee health and risk behaviors, productivity, and
health care costs

What is a “small” business?
• US Small Business Administration defines
“small” business as an employer with 500
employees or less
• SBA estimates there are 25.8 million small
businesses in the US
– They employee nearly 50% of the working adults!
– Employed adults spend about ½ of their waking
hours at work

Not all “small” employers are
equal… but they are important!
• Among small employers, there is great
heterogeneity
• The smaller the employer, the less likely it is to
offer health insurance or any health
programming for employees..
• 98% of employers with at least 200 employees offer some
type of health insurance while only 59% of those under
200 employees do
• One serious health problem represents financial disaster
for an employee and his/her family

Healthy People 2010 – WorksiteRelated National Health Objective
• “75% of employers (of all sizes) should offer a
comprehensive worksite health promotion
program,” which includes 5 key elements:
•
•
•
•
•

Health education programming
Supportive physical/social environment
Links to other health-related programs in the organization
Screening programs and appropriate follow-up
Integration of the program into the administrative structure
(e.g. budget, staffing, etc.)

How many employers are offering a
“comprehensive” health promotion
program?
• And, are small employers different from other
employers in what they offer?

Use of a Health Risk Appraisal
50

750+ EES (n=111)

45
40

250-749 EES (n=211)

35
30
25

100-249 EES (n=229)
50-99 EES (n=179)

20
15
10
5
0

Linnan, Bowling et al. (2008). AJPH.

Total (n=730)

Differences
by worksite
size
statistically
significant
(p=0.0002)

Physical Activity and Nutrition
Programs by Worksite Size
70
60
50

750+ EES (n=111)

40

250-749 EES (n=211)

30

100-249 EES (n=229)

20

50-99 EES (n=179)

10

Total (n=730)

0
*Physical Activity

*Nutrition

* statistically significant
differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental
Programs by Worksite Size
100
90
80

750+ EES
(n=111)

70

250-749 EES
(n=211)

60
50

100-249 EES
(n=229)

40
30

50-99 EES
(n=179)

20
10
0

Total (n=730)

Onsite Fitness Fitness/Walking
Center
Trails

Cafeteria

Vending food/beverages

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling
Services by Worksite Size
100
90
80
70
60
50
40
30
20
10
0

750+ (n=111)
250-749 (n=211)
100-249 (n=229)
50-99 (n=179)
Total (n=730)

Can
cer
S

Dia
be

cree
n

ing

tes

HBP
Scr

Scr

een
ing

HBC
een
in

g

Sc r

Alco

een
in

Linnan, Bowling et al, 2008, AJPH

g

hol

or D
r

ug

Abu
se

Sup
por

t

Predictors of Comprehensive
Worksite Health Promotion Programs


Overall, 6.9% of employers offered a
comprehensive program – smaller worksites were
less likely to offer all elements/types of programs
 Controlling for all factors (e.g. model adjusted for
size, staff, experience, industry type), we found:
 Worksites with 750+ employees were 4.4 times
more likely to have a comprehensive program
(p=.06).
 Worksites with a dedicated staff person were
10.3 times more likely to have a comprehensive
program (p<.05).

Why Do Small Employers Offer
Fewer Programs?
• “Survival Mode” – HPP programs are costly
– Direct Costs – of offering programs/services
– Indirect Costs – time/resources – competing
demands

• Lack of personnel dedicated to wellness
• Small business culture/leadership
– “Leave it up to Workers” (Eakin)
– Managers concerned about employee privacy
(Linnan)

Barriers To Health Promotion Program Success
70
60
50
40
30
20
10
0
Lack of
Employee
Interest

Lack of Staff
Resources

Lack of Funding Lack of High-Risk
Employee
Participation

Lack of
Management
Support

No differences in barriers were reported based on industry type or worksite size except that worksites with 750+
employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

Linnan, Bowling et al. 2008. AJPH

“When business survival is the
focus, any other costs, including
those linked to employee health,
may be seen as prohibitive.”
Linnan & Birken (2007)
NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007
Employment-Based
Coverage
Sector

Individually
Purchased

Total
Own Name

Public

Uninsured

Dependent

Total

100.0

50.6

17.5

6.7

7.4

20.3

Self-employed

100.0

22.9

25.7

20.0

7.1

26.4

Wage-and-Salary Workers

100.0

54.1

16.5

5.1

7.5

19.5

Firm Employment Size
< 10 Employees

100.0

26.6

21.9

9.5

10.1

34.3

10-24 Employees

100.0

38.3

20.3

6.3

7.8

28.9

25-99 Employees

100.0

52.0

17.3

5.2

6.9

20.8

100-499 Employees

100.0

62.1

14.8

3.6

6.5

15.4

< 500 Employees

100.0

45.2

18.5

6.1

7.8

24.6

500+ Employees

100.0

65.7

13.8

3.7

7.0

12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the
president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths
• Often, there is a family focus
• Fewer organizational layers – less complexity
re: decision-making
• Less complexity re: implementation
• Understand that each individual employee
and his/her health is important
• Understand that health influences the
“bottom line” of the company

Multiple Level Intervention for
Small Employers
Level of Intervention

Strategy

Intrapersonal/
Interpersonal

-Briefings (print) and Web-based resources
-Leading by Example – employers
-CEO breakfast meetings
-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational

-Free or low-cost HPPs + TA to implement them from
community, hospitals, voluntary health organizations…
-TA from State Health Department and/or insurers

Community

-Business Groups on Health – leverage for purchasing power
-University partnerships to get student help, grant funding

Policy

-National or state-level tax credits for small employers who
adopt HPPs
-Purchasing agreements for health
-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US
Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*
Individual Level
- Periodic health assessments tied to personalized feedback and individual coaching and motivational
interviewing
- Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with
all employees and is available to discuss health concerns
-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and
meet monthly with participants to collect program activity points and measure progress (eg, changes in
weight and blood pressure) toward positive health outcomes
-Strong linkage of wellness program with worker safety, including group stretching to promote model of an
“industrial athlete”
-Health coaches who travel among a company’s worksites to meet with employees
Environmental Level
-Strong support from wellness committee for establishing culture of wellness
-Inclusion of healthy food in criteria for selecting cafeteria vendor
-Free access to onsite physical activity facilities
-Provision of bicycles for travel between buildings
Organizational Level
-Incentive of paid day of leave to encourage program participation
-Reallocation of existing benefits to provide incentives for participating in screening activities and attaining
wellness goals
-Strong financial disincentives for employees and spouses with health insurance through the company who
do not participate in wellness program
-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:
Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for
Small Businesses
The North Carolina General Assembly should direct the North Carolina Public Health
Foundation to establish the North Carolina Worksite Wellness Collaborative to
promote evidence-based strategies to support the optimal health and well-being of
North Carolina’s workforce. The collaborative should help businesses implement
healthy workplace policies and benefits, implement health risk appraisals, develop
comprehensive employee wellness programs, and implement data systems that
track outcomes and the organizational and employee level.
The North Carolina General Assembly should provide start-up funding of $800,000 in
SFY 2011, with a reduced amount over the next four years, to support this
collaborative.
In addition, the North Carolina General Assembly should provide a tax credit to
businesses with 50 or fewer employees that have implemented a comprehensive
worksite wellness program for their employees.

Key Considerations
•
•
•
•
•
•
•

Get employees involved! Get dedicated staff!
Management support is necessary but not sufficient
Offer a comprehensive program with all 5 elements
Offer incentives for participation/behavior change
Provide links to local health care systems/providers
Address social contextual factors influencing health
Support research that builds evidence base and then
offer evidence-based programs
• Special focused activities for small employers

Related Information
• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small manufacturing
worksites that employ multiethnic, low-wage workforces into a cancer
prevention research trial. Prev Chronic Dis. 2004;1(3):A04.
• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change
among working-class, multiethnic workers: results of the healthy
directions—small business study. Am J Public Health. 2005;95(8):13891395.
• Divine RL. Determinants of small business interest in offering a wellness
program to their employees. Health Mark Q. 2005;22(3):43-58.
• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of
healthy weight at small and medium-sized US worksites. Prev Chronic Dis
2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.
• Linnan L & Birken B. Small businesses, worksite wellness and public
health: A time for action. NC Med J. 2006;67(6):433-438.


Slide 16

Worksite Wellness – Working
with Small Businesses
17th Annual Healthy Carolinians &
NCIOM Prevention Summit
Laura A. Linnan, ScD, CHES
The UNC Gillings School of Global Public Health
Thursday, October 8, 2009

Objectives
• Offer a brief overview of the importance of worksite
health promotion and its prevalence among small
employers
• Provide a rationale for offering comprehensive HPPs
among small employers
• Identify strengths/assets of small employers for
promoting employee health
• Share some promising intervention strategies –
including those recommended by the NC IOM -- for
increasing the prevalence of small employers which
offer comprehensive HPPs

Why Worksite Health Promotion?
• More than 60% of US adults are employed
• Employees spend a considerable number of waking
hours working
• Health care for US adults is directly linked with
employer-provided health insurance; many working
adults are without health insurance
• Many leading causes of death (CVD, cancer, stroke)
are preventable through lifestyle behavior changes
(smoking, diet, PA)

Why Should Employers Be Interested in Worksite
Health Promotion?
• Preventable illness makes up 70% of the total burden
of disease and their associated costs; employers pay
for these costs
• 10 modifiable risk factors account for approximately
25% of all employer healthcare expenditures
(Anderson, 2000)
• Employer medical costs average $7910/employee
annually (O’Donnell, 2007)
• Effective worksite health promotion programs have
demonstrated a positive impact on employee morale,
employee health and risk behaviors, productivity, and
health care costs

What is a “small” business?
• US Small Business Administration defines
“small” business as an employer with 500
employees or less
• SBA estimates there are 25.8 million small
businesses in the US
– They employee nearly 50% of the working adults!
– Employed adults spend about ½ of their waking
hours at work

Not all “small” employers are
equal… but they are important!
• Among small employers, there is great
heterogeneity
• The smaller the employer, the less likely it is to
offer health insurance or any health
programming for employees..
• 98% of employers with at least 200 employees offer some
type of health insurance while only 59% of those under
200 employees do
• One serious health problem represents financial disaster
for an employee and his/her family

Healthy People 2010 – WorksiteRelated National Health Objective
• “75% of employers (of all sizes) should offer a
comprehensive worksite health promotion
program,” which includes 5 key elements:
•
•
•
•
•

Health education programming
Supportive physical/social environment
Links to other health-related programs in the organization
Screening programs and appropriate follow-up
Integration of the program into the administrative structure
(e.g. budget, staffing, etc.)

How many employers are offering a
“comprehensive” health promotion
program?
• And, are small employers different from other
employers in what they offer?

Use of a Health Risk Appraisal
50

750+ EES (n=111)

45
40

250-749 EES (n=211)

35
30
25

100-249 EES (n=229)
50-99 EES (n=179)

20
15
10
5
0

Linnan, Bowling et al. (2008). AJPH.

Total (n=730)

Differences
by worksite
size
statistically
significant
(p=0.0002)

Physical Activity and Nutrition
Programs by Worksite Size
70
60
50

750+ EES (n=111)

40

250-749 EES (n=211)

30

100-249 EES (n=229)

20

50-99 EES (n=179)

10

Total (n=730)

0
*Physical Activity

*Nutrition

* statistically significant
differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental
Programs by Worksite Size
100
90
80

750+ EES
(n=111)

70

250-749 EES
(n=211)

60
50

100-249 EES
(n=229)

40
30

50-99 EES
(n=179)

20
10
0

Total (n=730)

Onsite Fitness Fitness/Walking
Center
Trails

Cafeteria

Vending food/beverages

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling
Services by Worksite Size
100
90
80
70
60
50
40
30
20
10
0

750+ (n=111)
250-749 (n=211)
100-249 (n=229)
50-99 (n=179)
Total (n=730)

Can
cer
S

Dia
be

cree
n

ing

tes

HBP
Scr

Scr

een
ing

HBC
een
in

g

Sc r

Alco

een
in

Linnan, Bowling et al, 2008, AJPH

g

hol

or D
r

ug

Abu
se

Sup
por

t

Predictors of Comprehensive
Worksite Health Promotion Programs


Overall, 6.9% of employers offered a
comprehensive program – smaller worksites were
less likely to offer all elements/types of programs
 Controlling for all factors (e.g. model adjusted for
size, staff, experience, industry type), we found:
 Worksites with 750+ employees were 4.4 times
more likely to have a comprehensive program
(p=.06).
 Worksites with a dedicated staff person were
10.3 times more likely to have a comprehensive
program (p<.05).

Why Do Small Employers Offer
Fewer Programs?
• “Survival Mode” – HPP programs are costly
– Direct Costs – of offering programs/services
– Indirect Costs – time/resources – competing
demands

• Lack of personnel dedicated to wellness
• Small business culture/leadership
– “Leave it up to Workers” (Eakin)
– Managers concerned about employee privacy
(Linnan)

Barriers To Health Promotion Program Success
70
60
50
40
30
20
10
0
Lack of
Employee
Interest

Lack of Staff
Resources

Lack of Funding Lack of High-Risk
Employee
Participation

Lack of
Management
Support

No differences in barriers were reported based on industry type or worksite size except that worksites with 750+
employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

Linnan, Bowling et al. 2008. AJPH

“When business survival is the
focus, any other costs, including
those linked to employee health,
may be seen as prohibitive.”
Linnan & Birken (2007)
NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007
Employment-Based
Coverage
Sector

Individually
Purchased

Total
Own Name

Public

Uninsured

Dependent

Total

100.0

50.6

17.5

6.7

7.4

20.3

Self-employed

100.0

22.9

25.7

20.0

7.1

26.4

Wage-and-Salary Workers

100.0

54.1

16.5

5.1

7.5

19.5

Firm Employment Size
< 10 Employees

100.0

26.6

21.9

9.5

10.1

34.3

10-24 Employees

100.0

38.3

20.3

6.3

7.8

28.9

25-99 Employees

100.0

52.0

17.3

5.2

6.9

20.8

100-499 Employees

100.0

62.1

14.8

3.6

6.5

15.4

< 500 Employees

100.0

45.2

18.5

6.1

7.8

24.6

500+ Employees

100.0

65.7

13.8

3.7

7.0

12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the
president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths
• Often, there is a family focus
• Fewer organizational layers – less complexity
re: decision-making
• Less complexity re: implementation
• Understand that each individual employee
and his/her health is important
• Understand that health influences the
“bottom line” of the company

Multiple Level Intervention for
Small Employers
Level of Intervention

Strategy

Intrapersonal/
Interpersonal

-Briefings (print) and Web-based resources
-Leading by Example – employers
-CEO breakfast meetings
-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational

-Free or low-cost HPPs + TA to implement them from
community, hospitals, voluntary health organizations…
-TA from State Health Department and/or insurers

Community

-Business Groups on Health – leverage for purchasing power
-University partnerships to get student help, grant funding

Policy

-National or state-level tax credits for small employers who
adopt HPPs
-Purchasing agreements for health
-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US
Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*
Individual Level
- Periodic health assessments tied to personalized feedback and individual coaching and motivational
interviewing
- Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with
all employees and is available to discuss health concerns
-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and
meet monthly with participants to collect program activity points and measure progress (eg, changes in
weight and blood pressure) toward positive health outcomes
-Strong linkage of wellness program with worker safety, including group stretching to promote model of an
“industrial athlete”
-Health coaches who travel among a company’s worksites to meet with employees
Environmental Level
-Strong support from wellness committee for establishing culture of wellness
-Inclusion of healthy food in criteria for selecting cafeteria vendor
-Free access to onsite physical activity facilities
-Provision of bicycles for travel between buildings
Organizational Level
-Incentive of paid day of leave to encourage program participation
-Reallocation of existing benefits to provide incentives for participating in screening activities and attaining
wellness goals
-Strong financial disincentives for employees and spouses with health insurance through the company who
do not participate in wellness program
-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:
Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for
Small Businesses
The North Carolina General Assembly should direct the North Carolina Public Health
Foundation to establish the North Carolina Worksite Wellness Collaborative to
promote evidence-based strategies to support the optimal health and well-being of
North Carolina’s workforce. The collaborative should help businesses implement
healthy workplace policies and benefits, implement health risk appraisals, develop
comprehensive employee wellness programs, and implement data systems that
track outcomes and the organizational and employee level.
The North Carolina General Assembly should provide start-up funding of $800,000 in
SFY 2011, with a reduced amount over the next four years, to support this
collaborative.
In addition, the North Carolina General Assembly should provide a tax credit to
businesses with 50 or fewer employees that have implemented a comprehensive
worksite wellness program for their employees.

Key Considerations
•
•
•
•
•
•
•

Get employees involved! Get dedicated staff!
Management support is necessary but not sufficient
Offer a comprehensive program with all 5 elements
Offer incentives for participation/behavior change
Provide links to local health care systems/providers
Address social contextual factors influencing health
Support research that builds evidence base and then
offer evidence-based programs
• Special focused activities for small employers

Related Information
• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small manufacturing
worksites that employ multiethnic, low-wage workforces into a cancer
prevention research trial. Prev Chronic Dis. 2004;1(3):A04.
• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change
among working-class, multiethnic workers: results of the healthy
directions—small business study. Am J Public Health. 2005;95(8):13891395.
• Divine RL. Determinants of small business interest in offering a wellness
program to their employees. Health Mark Q. 2005;22(3):43-58.
• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of
healthy weight at small and medium-sized US worksites. Prev Chronic Dis
2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.
• Linnan L & Birken B. Small businesses, worksite wellness and public
health: A time for action. NC Med J. 2006;67(6):433-438.


Slide 17

Worksite Wellness – Working
with Small Businesses
17th Annual Healthy Carolinians &
NCIOM Prevention Summit
Laura A. Linnan, ScD, CHES
The UNC Gillings School of Global Public Health
Thursday, October 8, 2009

Objectives
• Offer a brief overview of the importance of worksite
health promotion and its prevalence among small
employers
• Provide a rationale for offering comprehensive HPPs
among small employers
• Identify strengths/assets of small employers for
promoting employee health
• Share some promising intervention strategies –
including those recommended by the NC IOM -- for
increasing the prevalence of small employers which
offer comprehensive HPPs

Why Worksite Health Promotion?
• More than 60% of US adults are employed
• Employees spend a considerable number of waking
hours working
• Health care for US adults is directly linked with
employer-provided health insurance; many working
adults are without health insurance
• Many leading causes of death (CVD, cancer, stroke)
are preventable through lifestyle behavior changes
(smoking, diet, PA)

Why Should Employers Be Interested in Worksite
Health Promotion?
• Preventable illness makes up 70% of the total burden
of disease and their associated costs; employers pay
for these costs
• 10 modifiable risk factors account for approximately
25% of all employer healthcare expenditures
(Anderson, 2000)
• Employer medical costs average $7910/employee
annually (O’Donnell, 2007)
• Effective worksite health promotion programs have
demonstrated a positive impact on employee morale,
employee health and risk behaviors, productivity, and
health care costs

What is a “small” business?
• US Small Business Administration defines
“small” business as an employer with 500
employees or less
• SBA estimates there are 25.8 million small
businesses in the US
– They employee nearly 50% of the working adults!
– Employed adults spend about ½ of their waking
hours at work

Not all “small” employers are
equal… but they are important!
• Among small employers, there is great
heterogeneity
• The smaller the employer, the less likely it is to
offer health insurance or any health
programming for employees..
• 98% of employers with at least 200 employees offer some
type of health insurance while only 59% of those under
200 employees do
• One serious health problem represents financial disaster
for an employee and his/her family

Healthy People 2010 – WorksiteRelated National Health Objective
• “75% of employers (of all sizes) should offer a
comprehensive worksite health promotion
program,” which includes 5 key elements:
•
•
•
•
•

Health education programming
Supportive physical/social environment
Links to other health-related programs in the organization
Screening programs and appropriate follow-up
Integration of the program into the administrative structure
(e.g. budget, staffing, etc.)

How many employers are offering a
“comprehensive” health promotion
program?
• And, are small employers different from other
employers in what they offer?

Use of a Health Risk Appraisal
50

750+ EES (n=111)

45
40

250-749 EES (n=211)

35
30
25

100-249 EES (n=229)
50-99 EES (n=179)

20
15
10
5
0

Linnan, Bowling et al. (2008). AJPH.

Total (n=730)

Differences
by worksite
size
statistically
significant
(p=0.0002)

Physical Activity and Nutrition
Programs by Worksite Size
70
60
50

750+ EES (n=111)

40

250-749 EES (n=211)

30

100-249 EES (n=229)

20

50-99 EES (n=179)

10

Total (n=730)

0
*Physical Activity

*Nutrition

* statistically significant
differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental
Programs by Worksite Size
100
90
80

750+ EES
(n=111)

70

250-749 EES
(n=211)

60
50

100-249 EES
(n=229)

40
30

50-99 EES
(n=179)

20
10
0

Total (n=730)

Onsite Fitness Fitness/Walking
Center
Trails

Cafeteria

Vending food/beverages

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling
Services by Worksite Size
100
90
80
70
60
50
40
30
20
10
0

750+ (n=111)
250-749 (n=211)
100-249 (n=229)
50-99 (n=179)
Total (n=730)

Can
cer
S

Dia
be

cree
n

ing

tes

HBP
Scr

Scr

een
ing

HBC
een
in

g

Sc r

Alco

een
in

Linnan, Bowling et al, 2008, AJPH

g

hol

or D
r

ug

Abu
se

Sup
por

t

Predictors of Comprehensive
Worksite Health Promotion Programs


Overall, 6.9% of employers offered a
comprehensive program – smaller worksites were
less likely to offer all elements/types of programs
 Controlling for all factors (e.g. model adjusted for
size, staff, experience, industry type), we found:
 Worksites with 750+ employees were 4.4 times
more likely to have a comprehensive program
(p=.06).
 Worksites with a dedicated staff person were
10.3 times more likely to have a comprehensive
program (p<.05).

Why Do Small Employers Offer
Fewer Programs?
• “Survival Mode” – HPP programs are costly
– Direct Costs – of offering programs/services
– Indirect Costs – time/resources – competing
demands

• Lack of personnel dedicated to wellness
• Small business culture/leadership
– “Leave it up to Workers” (Eakin)
– Managers concerned about employee privacy
(Linnan)

Barriers To Health Promotion Program Success
70
60
50
40
30
20
10
0
Lack of
Employee
Interest

Lack of Staff
Resources

Lack of Funding Lack of High-Risk
Employee
Participation

Lack of
Management
Support

No differences in barriers were reported based on industry type or worksite size except that worksites with 750+
employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

Linnan, Bowling et al. 2008. AJPH

“When business survival is the
focus, any other costs, including
those linked to employee health,
may be seen as prohibitive.”
Linnan & Birken (2007)
NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007
Employment-Based
Coverage
Sector

Individually
Purchased

Total
Own Name

Public

Uninsured

Dependent

Total

100.0

50.6

17.5

6.7

7.4

20.3

Self-employed

100.0

22.9

25.7

20.0

7.1

26.4

Wage-and-Salary Workers

100.0

54.1

16.5

5.1

7.5

19.5

Firm Employment Size
< 10 Employees

100.0

26.6

21.9

9.5

10.1

34.3

10-24 Employees

100.0

38.3

20.3

6.3

7.8

28.9

25-99 Employees

100.0

52.0

17.3

5.2

6.9

20.8

100-499 Employees

100.0

62.1

14.8

3.6

6.5

15.4

< 500 Employees

100.0

45.2

18.5

6.1

7.8

24.6

500+ Employees

100.0

65.7

13.8

3.7

7.0

12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the
president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths
• Often, there is a family focus
• Fewer organizational layers – less complexity
re: decision-making
• Less complexity re: implementation
• Understand that each individual employee
and his/her health is important
• Understand that health influences the
“bottom line” of the company

Multiple Level Intervention for
Small Employers
Level of Intervention

Strategy

Intrapersonal/
Interpersonal

-Briefings (print) and Web-based resources
-Leading by Example – employers
-CEO breakfast meetings
-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational

-Free or low-cost HPPs + TA to implement them from
community, hospitals, voluntary health organizations…
-TA from State Health Department and/or insurers

Community

-Business Groups on Health – leverage for purchasing power
-University partnerships to get student help, grant funding

Policy

-National or state-level tax credits for small employers who
adopt HPPs
-Purchasing agreements for health
-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US
Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*
Individual Level
- Periodic health assessments tied to personalized feedback and individual coaching and motivational
interviewing
- Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with
all employees and is available to discuss health concerns
-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and
meet monthly with participants to collect program activity points and measure progress (eg, changes in
weight and blood pressure) toward positive health outcomes
-Strong linkage of wellness program with worker safety, including group stretching to promote model of an
“industrial athlete”
-Health coaches who travel among a company’s worksites to meet with employees
Environmental Level
-Strong support from wellness committee for establishing culture of wellness
-Inclusion of healthy food in criteria for selecting cafeteria vendor
-Free access to onsite physical activity facilities
-Provision of bicycles for travel between buildings
Organizational Level
-Incentive of paid day of leave to encourage program participation
-Reallocation of existing benefits to provide incentives for participating in screening activities and attaining
wellness goals
-Strong financial disincentives for employees and spouses with health insurance through the company who
do not participate in wellness program
-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:
Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for
Small Businesses
The North Carolina General Assembly should direct the North Carolina Public Health
Foundation to establish the North Carolina Worksite Wellness Collaborative to
promote evidence-based strategies to support the optimal health and well-being of
North Carolina’s workforce. The collaborative should help businesses implement
healthy workplace policies and benefits, implement health risk appraisals, develop
comprehensive employee wellness programs, and implement data systems that
track outcomes and the organizational and employee level.
The North Carolina General Assembly should provide start-up funding of $800,000 in
SFY 2011, with a reduced amount over the next four years, to support this
collaborative.
In addition, the North Carolina General Assembly should provide a tax credit to
businesses with 50 or fewer employees that have implemented a comprehensive
worksite wellness program for their employees.

Key Considerations
•
•
•
•
•
•
•

Get employees involved! Get dedicated staff!
Management support is necessary but not sufficient
Offer a comprehensive program with all 5 elements
Offer incentives for participation/behavior change
Provide links to local health care systems/providers
Address social contextual factors influencing health
Support research that builds evidence base and then
offer evidence-based programs
• Special focused activities for small employers

Related Information
• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small manufacturing
worksites that employ multiethnic, low-wage workforces into a cancer
prevention research trial. Prev Chronic Dis. 2004;1(3):A04.
• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change
among working-class, multiethnic workers: results of the healthy
directions—small business study. Am J Public Health. 2005;95(8):13891395.
• Divine RL. Determinants of small business interest in offering a wellness
program to their employees. Health Mark Q. 2005;22(3):43-58.
• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of
healthy weight at small and medium-sized US worksites. Prev Chronic Dis
2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.
• Linnan L & Birken B. Small businesses, worksite wellness and public
health: A time for action. NC Med J. 2006;67(6):433-438.


Slide 18

Worksite Wellness – Working
with Small Businesses
17th Annual Healthy Carolinians &
NCIOM Prevention Summit
Laura A. Linnan, ScD, CHES
The UNC Gillings School of Global Public Health
Thursday, October 8, 2009

Objectives
• Offer a brief overview of the importance of worksite
health promotion and its prevalence among small
employers
• Provide a rationale for offering comprehensive HPPs
among small employers
• Identify strengths/assets of small employers for
promoting employee health
• Share some promising intervention strategies –
including those recommended by the NC IOM -- for
increasing the prevalence of small employers which
offer comprehensive HPPs

Why Worksite Health Promotion?
• More than 60% of US adults are employed
• Employees spend a considerable number of waking
hours working
• Health care for US adults is directly linked with
employer-provided health insurance; many working
adults are without health insurance
• Many leading causes of death (CVD, cancer, stroke)
are preventable through lifestyle behavior changes
(smoking, diet, PA)

Why Should Employers Be Interested in Worksite
Health Promotion?
• Preventable illness makes up 70% of the total burden
of disease and their associated costs; employers pay
for these costs
• 10 modifiable risk factors account for approximately
25% of all employer healthcare expenditures
(Anderson, 2000)
• Employer medical costs average $7910/employee
annually (O’Donnell, 2007)
• Effective worksite health promotion programs have
demonstrated a positive impact on employee morale,
employee health and risk behaviors, productivity, and
health care costs

What is a “small” business?
• US Small Business Administration defines
“small” business as an employer with 500
employees or less
• SBA estimates there are 25.8 million small
businesses in the US
– They employee nearly 50% of the working adults!
– Employed adults spend about ½ of their waking
hours at work

Not all “small” employers are
equal… but they are important!
• Among small employers, there is great
heterogeneity
• The smaller the employer, the less likely it is to
offer health insurance or any health
programming for employees..
• 98% of employers with at least 200 employees offer some
type of health insurance while only 59% of those under
200 employees do
• One serious health problem represents financial disaster
for an employee and his/her family

Healthy People 2010 – WorksiteRelated National Health Objective
• “75% of employers (of all sizes) should offer a
comprehensive worksite health promotion
program,” which includes 5 key elements:
•
•
•
•
•

Health education programming
Supportive physical/social environment
Links to other health-related programs in the organization
Screening programs and appropriate follow-up
Integration of the program into the administrative structure
(e.g. budget, staffing, etc.)

How many employers are offering a
“comprehensive” health promotion
program?
• And, are small employers different from other
employers in what they offer?

Use of a Health Risk Appraisal
50

750+ EES (n=111)

45
40

250-749 EES (n=211)

35
30
25

100-249 EES (n=229)
50-99 EES (n=179)

20
15
10
5
0

Linnan, Bowling et al. (2008). AJPH.

Total (n=730)

Differences
by worksite
size
statistically
significant
(p=0.0002)

Physical Activity and Nutrition
Programs by Worksite Size
70
60
50

750+ EES (n=111)

40

250-749 EES (n=211)

30

100-249 EES (n=229)

20

50-99 EES (n=179)

10

Total (n=730)

0
*Physical Activity

*Nutrition

* statistically significant
differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental
Programs by Worksite Size
100
90
80

750+ EES
(n=111)

70

250-749 EES
(n=211)

60
50

100-249 EES
(n=229)

40
30

50-99 EES
(n=179)

20
10
0

Total (n=730)

Onsite Fitness Fitness/Walking
Center
Trails

Cafeteria

Vending food/beverages

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling
Services by Worksite Size
100
90
80
70
60
50
40
30
20
10
0

750+ (n=111)
250-749 (n=211)
100-249 (n=229)
50-99 (n=179)
Total (n=730)

Can
cer
S

Dia
be

cree
n

ing

tes

HBP
Scr

Scr

een
ing

HBC
een
in

g

Sc r

Alco

een
in

Linnan, Bowling et al, 2008, AJPH

g

hol

or D
r

ug

Abu
se

Sup
por

t

Predictors of Comprehensive
Worksite Health Promotion Programs


Overall, 6.9% of employers offered a
comprehensive program – smaller worksites were
less likely to offer all elements/types of programs
 Controlling for all factors (e.g. model adjusted for
size, staff, experience, industry type), we found:
 Worksites with 750+ employees were 4.4 times
more likely to have a comprehensive program
(p=.06).
 Worksites with a dedicated staff person were
10.3 times more likely to have a comprehensive
program (p<.05).

Why Do Small Employers Offer
Fewer Programs?
• “Survival Mode” – HPP programs are costly
– Direct Costs – of offering programs/services
– Indirect Costs – time/resources – competing
demands

• Lack of personnel dedicated to wellness
• Small business culture/leadership
– “Leave it up to Workers” (Eakin)
– Managers concerned about employee privacy
(Linnan)

Barriers To Health Promotion Program Success
70
60
50
40
30
20
10
0
Lack of
Employee
Interest

Lack of Staff
Resources

Lack of Funding Lack of High-Risk
Employee
Participation

Lack of
Management
Support

No differences in barriers were reported based on industry type or worksite size except that worksites with 750+
employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

Linnan, Bowling et al. 2008. AJPH

“When business survival is the
focus, any other costs, including
those linked to employee health,
may be seen as prohibitive.”
Linnan & Birken (2007)
NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007
Employment-Based
Coverage
Sector

Individually
Purchased

Total
Own Name

Public

Uninsured

Dependent

Total

100.0

50.6

17.5

6.7

7.4

20.3

Self-employed

100.0

22.9

25.7

20.0

7.1

26.4

Wage-and-Salary Workers

100.0

54.1

16.5

5.1

7.5

19.5

Firm Employment Size
< 10 Employees

100.0

26.6

21.9

9.5

10.1

34.3

10-24 Employees

100.0

38.3

20.3

6.3

7.8

28.9

25-99 Employees

100.0

52.0

17.3

5.2

6.9

20.8

100-499 Employees

100.0

62.1

14.8

3.6

6.5

15.4

< 500 Employees

100.0

45.2

18.5

6.1

7.8

24.6

500+ Employees

100.0

65.7

13.8

3.7

7.0

12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the
president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths
• Often, there is a family focus
• Fewer organizational layers – less complexity
re: decision-making
• Less complexity re: implementation
• Understand that each individual employee
and his/her health is important
• Understand that health influences the
“bottom line” of the company

Multiple Level Intervention for
Small Employers
Level of Intervention

Strategy

Intrapersonal/
Interpersonal

-Briefings (print) and Web-based resources
-Leading by Example – employers
-CEO breakfast meetings
-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational

-Free or low-cost HPPs + TA to implement them from
community, hospitals, voluntary health organizations…
-TA from State Health Department and/or insurers

Community

-Business Groups on Health – leverage for purchasing power
-University partnerships to get student help, grant funding

Policy

-National or state-level tax credits for small employers who
adopt HPPs
-Purchasing agreements for health
-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US
Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*
Individual Level
- Periodic health assessments tied to personalized feedback and individual coaching and motivational
interviewing
- Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with
all employees and is available to discuss health concerns
-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and
meet monthly with participants to collect program activity points and measure progress (eg, changes in
weight and blood pressure) toward positive health outcomes
-Strong linkage of wellness program with worker safety, including group stretching to promote model of an
“industrial athlete”
-Health coaches who travel among a company’s worksites to meet with employees
Environmental Level
-Strong support from wellness committee for establishing culture of wellness
-Inclusion of healthy food in criteria for selecting cafeteria vendor
-Free access to onsite physical activity facilities
-Provision of bicycles for travel between buildings
Organizational Level
-Incentive of paid day of leave to encourage program participation
-Reallocation of existing benefits to provide incentives for participating in screening activities and attaining
wellness goals
-Strong financial disincentives for employees and spouses with health insurance through the company who
do not participate in wellness program
-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:
Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for
Small Businesses
The North Carolina General Assembly should direct the North Carolina Public Health
Foundation to establish the North Carolina Worksite Wellness Collaborative to
promote evidence-based strategies to support the optimal health and well-being of
North Carolina’s workforce. The collaborative should help businesses implement
healthy workplace policies and benefits, implement health risk appraisals, develop
comprehensive employee wellness programs, and implement data systems that
track outcomes and the organizational and employee level.
The North Carolina General Assembly should provide start-up funding of $800,000 in
SFY 2011, with a reduced amount over the next four years, to support this
collaborative.
In addition, the North Carolina General Assembly should provide a tax credit to
businesses with 50 or fewer employees that have implemented a comprehensive
worksite wellness program for their employees.

Key Considerations
•
•
•
•
•
•
•

Get employees involved! Get dedicated staff!
Management support is necessary but not sufficient
Offer a comprehensive program with all 5 elements
Offer incentives for participation/behavior change
Provide links to local health care systems/providers
Address social contextual factors influencing health
Support research that builds evidence base and then
offer evidence-based programs
• Special focused activities for small employers

Related Information
• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small manufacturing
worksites that employ multiethnic, low-wage workforces into a cancer
prevention research trial. Prev Chronic Dis. 2004;1(3):A04.
• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change
among working-class, multiethnic workers: results of the healthy
directions—small business study. Am J Public Health. 2005;95(8):13891395.
• Divine RL. Determinants of small business interest in offering a wellness
program to their employees. Health Mark Q. 2005;22(3):43-58.
• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of
healthy weight at small and medium-sized US worksites. Prev Chronic Dis
2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.
• Linnan L & Birken B. Small businesses, worksite wellness and public
health: A time for action. NC Med J. 2006;67(6):433-438.


Slide 19

Worksite Wellness – Working
with Small Businesses
17th Annual Healthy Carolinians &
NCIOM Prevention Summit
Laura A. Linnan, ScD, CHES
The UNC Gillings School of Global Public Health
Thursday, October 8, 2009

Objectives
• Offer a brief overview of the importance of worksite
health promotion and its prevalence among small
employers
• Provide a rationale for offering comprehensive HPPs
among small employers
• Identify strengths/assets of small employers for
promoting employee health
• Share some promising intervention strategies –
including those recommended by the NC IOM -- for
increasing the prevalence of small employers which
offer comprehensive HPPs

Why Worksite Health Promotion?
• More than 60% of US adults are employed
• Employees spend a considerable number of waking
hours working
• Health care for US adults is directly linked with
employer-provided health insurance; many working
adults are without health insurance
• Many leading causes of death (CVD, cancer, stroke)
are preventable through lifestyle behavior changes
(smoking, diet, PA)

Why Should Employers Be Interested in Worksite
Health Promotion?
• Preventable illness makes up 70% of the total burden
of disease and their associated costs; employers pay
for these costs
• 10 modifiable risk factors account for approximately
25% of all employer healthcare expenditures
(Anderson, 2000)
• Employer medical costs average $7910/employee
annually (O’Donnell, 2007)
• Effective worksite health promotion programs have
demonstrated a positive impact on employee morale,
employee health and risk behaviors, productivity, and
health care costs

What is a “small” business?
• US Small Business Administration defines
“small” business as an employer with 500
employees or less
• SBA estimates there are 25.8 million small
businesses in the US
– They employee nearly 50% of the working adults!
– Employed adults spend about ½ of their waking
hours at work

Not all “small” employers are
equal… but they are important!
• Among small employers, there is great
heterogeneity
• The smaller the employer, the less likely it is to
offer health insurance or any health
programming for employees..
• 98% of employers with at least 200 employees offer some
type of health insurance while only 59% of those under
200 employees do
• One serious health problem represents financial disaster
for an employee and his/her family

Healthy People 2010 – WorksiteRelated National Health Objective
• “75% of employers (of all sizes) should offer a
comprehensive worksite health promotion
program,” which includes 5 key elements:
•
•
•
•
•

Health education programming
Supportive physical/social environment
Links to other health-related programs in the organization
Screening programs and appropriate follow-up
Integration of the program into the administrative structure
(e.g. budget, staffing, etc.)

How many employers are offering a
“comprehensive” health promotion
program?
• And, are small employers different from other
employers in what they offer?

Use of a Health Risk Appraisal
50

750+ EES (n=111)

45
40

250-749 EES (n=211)

35
30
25

100-249 EES (n=229)
50-99 EES (n=179)

20
15
10
5
0

Linnan, Bowling et al. (2008). AJPH.

Total (n=730)

Differences
by worksite
size
statistically
significant
(p=0.0002)

Physical Activity and Nutrition
Programs by Worksite Size
70
60
50

750+ EES (n=111)

40

250-749 EES (n=211)

30

100-249 EES (n=229)

20

50-99 EES (n=179)

10

Total (n=730)

0
*Physical Activity

*Nutrition

* statistically significant
differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental
Programs by Worksite Size
100
90
80

750+ EES
(n=111)

70

250-749 EES
(n=211)

60
50

100-249 EES
(n=229)

40
30

50-99 EES
(n=179)

20
10
0

Total (n=730)

Onsite Fitness Fitness/Walking
Center
Trails

Cafeteria

Vending food/beverages

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling
Services by Worksite Size
100
90
80
70
60
50
40
30
20
10
0

750+ (n=111)
250-749 (n=211)
100-249 (n=229)
50-99 (n=179)
Total (n=730)

Can
cer
S

Dia
be

cree
n

ing

tes

HBP
Scr

Scr

een
ing

HBC
een
in

g

Sc r

Alco

een
in

Linnan, Bowling et al, 2008, AJPH

g

hol

or D
r

ug

Abu
se

Sup
por

t

Predictors of Comprehensive
Worksite Health Promotion Programs


Overall, 6.9% of employers offered a
comprehensive program – smaller worksites were
less likely to offer all elements/types of programs
 Controlling for all factors (e.g. model adjusted for
size, staff, experience, industry type), we found:
 Worksites with 750+ employees were 4.4 times
more likely to have a comprehensive program
(p=.06).
 Worksites with a dedicated staff person were
10.3 times more likely to have a comprehensive
program (p<.05).

Why Do Small Employers Offer
Fewer Programs?
• “Survival Mode” – HPP programs are costly
– Direct Costs – of offering programs/services
– Indirect Costs – time/resources – competing
demands

• Lack of personnel dedicated to wellness
• Small business culture/leadership
– “Leave it up to Workers” (Eakin)
– Managers concerned about employee privacy
(Linnan)

Barriers To Health Promotion Program Success
70
60
50
40
30
20
10
0
Lack of
Employee
Interest

Lack of Staff
Resources

Lack of Funding Lack of High-Risk
Employee
Participation

Lack of
Management
Support

No differences in barriers were reported based on industry type or worksite size except that worksites with 750+
employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

Linnan, Bowling et al. 2008. AJPH

“When business survival is the
focus, any other costs, including
those linked to employee health,
may be seen as prohibitive.”
Linnan & Birken (2007)
NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007
Employment-Based
Coverage
Sector

Individually
Purchased

Total
Own Name

Public

Uninsured

Dependent

Total

100.0

50.6

17.5

6.7

7.4

20.3

Self-employed

100.0

22.9

25.7

20.0

7.1

26.4

Wage-and-Salary Workers

100.0

54.1

16.5

5.1

7.5

19.5

Firm Employment Size
< 10 Employees

100.0

26.6

21.9

9.5

10.1

34.3

10-24 Employees

100.0

38.3

20.3

6.3

7.8

28.9

25-99 Employees

100.0

52.0

17.3

5.2

6.9

20.8

100-499 Employees

100.0

62.1

14.8

3.6

6.5

15.4

< 500 Employees

100.0

45.2

18.5

6.1

7.8

24.6

500+ Employees

100.0

65.7

13.8

3.7

7.0

12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the
president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths
• Often, there is a family focus
• Fewer organizational layers – less complexity
re: decision-making
• Less complexity re: implementation
• Understand that each individual employee
and his/her health is important
• Understand that health influences the
“bottom line” of the company

Multiple Level Intervention for
Small Employers
Level of Intervention

Strategy

Intrapersonal/
Interpersonal

-Briefings (print) and Web-based resources
-Leading by Example – employers
-CEO breakfast meetings
-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational

-Free or low-cost HPPs + TA to implement them from
community, hospitals, voluntary health organizations…
-TA from State Health Department and/or insurers

Community

-Business Groups on Health – leverage for purchasing power
-University partnerships to get student help, grant funding

Policy

-National or state-level tax credits for small employers who
adopt HPPs
-Purchasing agreements for health
-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US
Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*
Individual Level
- Periodic health assessments tied to personalized feedback and individual coaching and motivational
interviewing
- Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with
all employees and is available to discuss health concerns
-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and
meet monthly with participants to collect program activity points and measure progress (eg, changes in
weight and blood pressure) toward positive health outcomes
-Strong linkage of wellness program with worker safety, including group stretching to promote model of an
“industrial athlete”
-Health coaches who travel among a company’s worksites to meet with employees
Environmental Level
-Strong support from wellness committee for establishing culture of wellness
-Inclusion of healthy food in criteria for selecting cafeteria vendor
-Free access to onsite physical activity facilities
-Provision of bicycles for travel between buildings
Organizational Level
-Incentive of paid day of leave to encourage program participation
-Reallocation of existing benefits to provide incentives for participating in screening activities and attaining
wellness goals
-Strong financial disincentives for employees and spouses with health insurance through the company who
do not participate in wellness program
-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:
Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for
Small Businesses
The North Carolina General Assembly should direct the North Carolina Public Health
Foundation to establish the North Carolina Worksite Wellness Collaborative to
promote evidence-based strategies to support the optimal health and well-being of
North Carolina’s workforce. The collaborative should help businesses implement
healthy workplace policies and benefits, implement health risk appraisals, develop
comprehensive employee wellness programs, and implement data systems that
track outcomes and the organizational and employee level.
The North Carolina General Assembly should provide start-up funding of $800,000 in
SFY 2011, with a reduced amount over the next four years, to support this
collaborative.
In addition, the North Carolina General Assembly should provide a tax credit to
businesses with 50 or fewer employees that have implemented a comprehensive
worksite wellness program for their employees.

Key Considerations
•
•
•
•
•
•
•

Get employees involved! Get dedicated staff!
Management support is necessary but not sufficient
Offer a comprehensive program with all 5 elements
Offer incentives for participation/behavior change
Provide links to local health care systems/providers
Address social contextual factors influencing health
Support research that builds evidence base and then
offer evidence-based programs
• Special focused activities for small employers

Related Information
• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small manufacturing
worksites that employ multiethnic, low-wage workforces into a cancer
prevention research trial. Prev Chronic Dis. 2004;1(3):A04.
• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change
among working-class, multiethnic workers: results of the healthy
directions—small business study. Am J Public Health. 2005;95(8):13891395.
• Divine RL. Determinants of small business interest in offering a wellness
program to their employees. Health Mark Q. 2005;22(3):43-58.
• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of
healthy weight at small and medium-sized US worksites. Prev Chronic Dis
2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.
• Linnan L & Birken B. Small businesses, worksite wellness and public
health: A time for action. NC Med J. 2006;67(6):433-438.


Slide 20

Worksite Wellness – Working
with Small Businesses
17th Annual Healthy Carolinians &
NCIOM Prevention Summit
Laura A. Linnan, ScD, CHES
The UNC Gillings School of Global Public Health
Thursday, October 8, 2009

Objectives
• Offer a brief overview of the importance of worksite
health promotion and its prevalence among small
employers
• Provide a rationale for offering comprehensive HPPs
among small employers
• Identify strengths/assets of small employers for
promoting employee health
• Share some promising intervention strategies –
including those recommended by the NC IOM -- for
increasing the prevalence of small employers which
offer comprehensive HPPs

Why Worksite Health Promotion?
• More than 60% of US adults are employed
• Employees spend a considerable number of waking
hours working
• Health care for US adults is directly linked with
employer-provided health insurance; many working
adults are without health insurance
• Many leading causes of death (CVD, cancer, stroke)
are preventable through lifestyle behavior changes
(smoking, diet, PA)

Why Should Employers Be Interested in Worksite
Health Promotion?
• Preventable illness makes up 70% of the total burden
of disease and their associated costs; employers pay
for these costs
• 10 modifiable risk factors account for approximately
25% of all employer healthcare expenditures
(Anderson, 2000)
• Employer medical costs average $7910/employee
annually (O’Donnell, 2007)
• Effective worksite health promotion programs have
demonstrated a positive impact on employee morale,
employee health and risk behaviors, productivity, and
health care costs

What is a “small” business?
• US Small Business Administration defines
“small” business as an employer with 500
employees or less
• SBA estimates there are 25.8 million small
businesses in the US
– They employee nearly 50% of the working adults!
– Employed adults spend about ½ of their waking
hours at work

Not all “small” employers are
equal… but they are important!
• Among small employers, there is great
heterogeneity
• The smaller the employer, the less likely it is to
offer health insurance or any health
programming for employees..
• 98% of employers with at least 200 employees offer some
type of health insurance while only 59% of those under
200 employees do
• One serious health problem represents financial disaster
for an employee and his/her family

Healthy People 2010 – WorksiteRelated National Health Objective
• “75% of employers (of all sizes) should offer a
comprehensive worksite health promotion
program,” which includes 5 key elements:
•
•
•
•
•

Health education programming
Supportive physical/social environment
Links to other health-related programs in the organization
Screening programs and appropriate follow-up
Integration of the program into the administrative structure
(e.g. budget, staffing, etc.)

How many employers are offering a
“comprehensive” health promotion
program?
• And, are small employers different from other
employers in what they offer?

Use of a Health Risk Appraisal
50

750+ EES (n=111)

45
40

250-749 EES (n=211)

35
30
25

100-249 EES (n=229)
50-99 EES (n=179)

20
15
10
5
0

Linnan, Bowling et al. (2008). AJPH.

Total (n=730)

Differences
by worksite
size
statistically
significant
(p=0.0002)

Physical Activity and Nutrition
Programs by Worksite Size
70
60
50

750+ EES (n=111)

40

250-749 EES (n=211)

30

100-249 EES (n=229)

20

50-99 EES (n=179)

10

Total (n=730)

0
*Physical Activity

*Nutrition

* statistically significant
differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental
Programs by Worksite Size
100
90
80

750+ EES
(n=111)

70

250-749 EES
(n=211)

60
50

100-249 EES
(n=229)

40
30

50-99 EES
(n=179)

20
10
0

Total (n=730)

Onsite Fitness Fitness/Walking
Center
Trails

Cafeteria

Vending food/beverages

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling
Services by Worksite Size
100
90
80
70
60
50
40
30
20
10
0

750+ (n=111)
250-749 (n=211)
100-249 (n=229)
50-99 (n=179)
Total (n=730)

Can
cer
S

Dia
be

cree
n

ing

tes

HBP
Scr

Scr

een
ing

HBC
een
in

g

Sc r

Alco

een
in

Linnan, Bowling et al, 2008, AJPH

g

hol

or D
r

ug

Abu
se

Sup
por

t

Predictors of Comprehensive
Worksite Health Promotion Programs


Overall, 6.9% of employers offered a
comprehensive program – smaller worksites were
less likely to offer all elements/types of programs
 Controlling for all factors (e.g. model adjusted for
size, staff, experience, industry type), we found:
 Worksites with 750+ employees were 4.4 times
more likely to have a comprehensive program
(p=.06).
 Worksites with a dedicated staff person were
10.3 times more likely to have a comprehensive
program (p<.05).

Why Do Small Employers Offer
Fewer Programs?
• “Survival Mode” – HPP programs are costly
– Direct Costs – of offering programs/services
– Indirect Costs – time/resources – competing
demands

• Lack of personnel dedicated to wellness
• Small business culture/leadership
– “Leave it up to Workers” (Eakin)
– Managers concerned about employee privacy
(Linnan)

Barriers To Health Promotion Program Success
70
60
50
40
30
20
10
0
Lack of
Employee
Interest

Lack of Staff
Resources

Lack of Funding Lack of High-Risk
Employee
Participation

Lack of
Management
Support

No differences in barriers were reported based on industry type or worksite size except that worksites with 750+
employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

Linnan, Bowling et al. 2008. AJPH

“When business survival is the
focus, any other costs, including
those linked to employee health,
may be seen as prohibitive.”
Linnan & Birken (2007)
NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007
Employment-Based
Coverage
Sector

Individually
Purchased

Total
Own Name

Public

Uninsured

Dependent

Total

100.0

50.6

17.5

6.7

7.4

20.3

Self-employed

100.0

22.9

25.7

20.0

7.1

26.4

Wage-and-Salary Workers

100.0

54.1

16.5

5.1

7.5

19.5

Firm Employment Size
< 10 Employees

100.0

26.6

21.9

9.5

10.1

34.3

10-24 Employees

100.0

38.3

20.3

6.3

7.8

28.9

25-99 Employees

100.0

52.0

17.3

5.2

6.9

20.8

100-499 Employees

100.0

62.1

14.8

3.6

6.5

15.4

< 500 Employees

100.0

45.2

18.5

6.1

7.8

24.6

500+ Employees

100.0

65.7

13.8

3.7

7.0

12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the
president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths
• Often, there is a family focus
• Fewer organizational layers – less complexity
re: decision-making
• Less complexity re: implementation
• Understand that each individual employee
and his/her health is important
• Understand that health influences the
“bottom line” of the company

Multiple Level Intervention for
Small Employers
Level of Intervention

Strategy

Intrapersonal/
Interpersonal

-Briefings (print) and Web-based resources
-Leading by Example – employers
-CEO breakfast meetings
-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational

-Free or low-cost HPPs + TA to implement them from
community, hospitals, voluntary health organizations…
-TA from State Health Department and/or insurers

Community

-Business Groups on Health – leverage for purchasing power
-University partnerships to get student help, grant funding

Policy

-National or state-level tax credits for small employers who
adopt HPPs
-Purchasing agreements for health
-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US
Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*
Individual Level
- Periodic health assessments tied to personalized feedback and individual coaching and motivational
interviewing
- Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with
all employees and is available to discuss health concerns
-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and
meet monthly with participants to collect program activity points and measure progress (eg, changes in
weight and blood pressure) toward positive health outcomes
-Strong linkage of wellness program with worker safety, including group stretching to promote model of an
“industrial athlete”
-Health coaches who travel among a company’s worksites to meet with employees
Environmental Level
-Strong support from wellness committee for establishing culture of wellness
-Inclusion of healthy food in criteria for selecting cafeteria vendor
-Free access to onsite physical activity facilities
-Provision of bicycles for travel between buildings
Organizational Level
-Incentive of paid day of leave to encourage program participation
-Reallocation of existing benefits to provide incentives for participating in screening activities and attaining
wellness goals
-Strong financial disincentives for employees and spouses with health insurance through the company who
do not participate in wellness program
-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:
Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for
Small Businesses
The North Carolina General Assembly should direct the North Carolina Public Health
Foundation to establish the North Carolina Worksite Wellness Collaborative to
promote evidence-based strategies to support the optimal health and well-being of
North Carolina’s workforce. The collaborative should help businesses implement
healthy workplace policies and benefits, implement health risk appraisals, develop
comprehensive employee wellness programs, and implement data systems that
track outcomes and the organizational and employee level.
The North Carolina General Assembly should provide start-up funding of $800,000 in
SFY 2011, with a reduced amount over the next four years, to support this
collaborative.
In addition, the North Carolina General Assembly should provide a tax credit to
businesses with 50 or fewer employees that have implemented a comprehensive
worksite wellness program for their employees.

Key Considerations
•
•
•
•
•
•
•

Get employees involved! Get dedicated staff!
Management support is necessary but not sufficient
Offer a comprehensive program with all 5 elements
Offer incentives for participation/behavior change
Provide links to local health care systems/providers
Address social contextual factors influencing health
Support research that builds evidence base and then
offer evidence-based programs
• Special focused activities for small employers

Related Information
• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small manufacturing
worksites that employ multiethnic, low-wage workforces into a cancer
prevention research trial. Prev Chronic Dis. 2004;1(3):A04.
• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change
among working-class, multiethnic workers: results of the healthy
directions—small business study. Am J Public Health. 2005;95(8):13891395.
• Divine RL. Determinants of small business interest in offering a wellness
program to their employees. Health Mark Q. 2005;22(3):43-58.
• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of
healthy weight at small and medium-sized US worksites. Prev Chronic Dis
2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.
• Linnan L & Birken B. Small businesses, worksite wellness and public
health: A time for action. NC Med J. 2006;67(6):433-438.


Slide 21

Worksite Wellness – Working
with Small Businesses
17th Annual Healthy Carolinians &
NCIOM Prevention Summit
Laura A. Linnan, ScD, CHES
The UNC Gillings School of Global Public Health
Thursday, October 8, 2009

Objectives
• Offer a brief overview of the importance of worksite
health promotion and its prevalence among small
employers
• Provide a rationale for offering comprehensive HPPs
among small employers
• Identify strengths/assets of small employers for
promoting employee health
• Share some promising intervention strategies –
including those recommended by the NC IOM -- for
increasing the prevalence of small employers which
offer comprehensive HPPs

Why Worksite Health Promotion?
• More than 60% of US adults are employed
• Employees spend a considerable number of waking
hours working
• Health care for US adults is directly linked with
employer-provided health insurance; many working
adults are without health insurance
• Many leading causes of death (CVD, cancer, stroke)
are preventable through lifestyle behavior changes
(smoking, diet, PA)

Why Should Employers Be Interested in Worksite
Health Promotion?
• Preventable illness makes up 70% of the total burden
of disease and their associated costs; employers pay
for these costs
• 10 modifiable risk factors account for approximately
25% of all employer healthcare expenditures
(Anderson, 2000)
• Employer medical costs average $7910/employee
annually (O’Donnell, 2007)
• Effective worksite health promotion programs have
demonstrated a positive impact on employee morale,
employee health and risk behaviors, productivity, and
health care costs

What is a “small” business?
• US Small Business Administration defines
“small” business as an employer with 500
employees or less
• SBA estimates there are 25.8 million small
businesses in the US
– They employee nearly 50% of the working adults!
– Employed adults spend about ½ of their waking
hours at work

Not all “small” employers are
equal… but they are important!
• Among small employers, there is great
heterogeneity
• The smaller the employer, the less likely it is to
offer health insurance or any health
programming for employees..
• 98% of employers with at least 200 employees offer some
type of health insurance while only 59% of those under
200 employees do
• One serious health problem represents financial disaster
for an employee and his/her family

Healthy People 2010 – WorksiteRelated National Health Objective
• “75% of employers (of all sizes) should offer a
comprehensive worksite health promotion
program,” which includes 5 key elements:
•
•
•
•
•

Health education programming
Supportive physical/social environment
Links to other health-related programs in the organization
Screening programs and appropriate follow-up
Integration of the program into the administrative structure
(e.g. budget, staffing, etc.)

How many employers are offering a
“comprehensive” health promotion
program?
• And, are small employers different from other
employers in what they offer?

Use of a Health Risk Appraisal
50

750+ EES (n=111)

45
40

250-749 EES (n=211)

35
30
25

100-249 EES (n=229)
50-99 EES (n=179)

20
15
10
5
0

Linnan, Bowling et al. (2008). AJPH.

Total (n=730)

Differences
by worksite
size
statistically
significant
(p=0.0002)

Physical Activity and Nutrition
Programs by Worksite Size
70
60
50

750+ EES (n=111)

40

250-749 EES (n=211)

30

100-249 EES (n=229)

20

50-99 EES (n=179)

10

Total (n=730)

0
*Physical Activity

*Nutrition

* statistically significant
differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental
Programs by Worksite Size
100
90
80

750+ EES
(n=111)

70

250-749 EES
(n=211)

60
50

100-249 EES
(n=229)

40
30

50-99 EES
(n=179)

20
10
0

Total (n=730)

Onsite Fitness Fitness/Walking
Center
Trails

Cafeteria

Vending food/beverages

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling
Services by Worksite Size
100
90
80
70
60
50
40
30
20
10
0

750+ (n=111)
250-749 (n=211)
100-249 (n=229)
50-99 (n=179)
Total (n=730)

Can
cer
S

Dia
be

cree
n

ing

tes

HBP
Scr

Scr

een
ing

HBC
een
in

g

Sc r

Alco

een
in

Linnan, Bowling et al, 2008, AJPH

g

hol

or D
r

ug

Abu
se

Sup
por

t

Predictors of Comprehensive
Worksite Health Promotion Programs


Overall, 6.9% of employers offered a
comprehensive program – smaller worksites were
less likely to offer all elements/types of programs
 Controlling for all factors (e.g. model adjusted for
size, staff, experience, industry type), we found:
 Worksites with 750+ employees were 4.4 times
more likely to have a comprehensive program
(p=.06).
 Worksites with a dedicated staff person were
10.3 times more likely to have a comprehensive
program (p<.05).

Why Do Small Employers Offer
Fewer Programs?
• “Survival Mode” – HPP programs are costly
– Direct Costs – of offering programs/services
– Indirect Costs – time/resources – competing
demands

• Lack of personnel dedicated to wellness
• Small business culture/leadership
– “Leave it up to Workers” (Eakin)
– Managers concerned about employee privacy
(Linnan)

Barriers To Health Promotion Program Success
70
60
50
40
30
20
10
0
Lack of
Employee
Interest

Lack of Staff
Resources

Lack of Funding Lack of High-Risk
Employee
Participation

Lack of
Management
Support

No differences in barriers were reported based on industry type or worksite size except that worksites with 750+
employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

Linnan, Bowling et al. 2008. AJPH

“When business survival is the
focus, any other costs, including
those linked to employee health,
may be seen as prohibitive.”
Linnan & Birken (2007)
NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007
Employment-Based
Coverage
Sector

Individually
Purchased

Total
Own Name

Public

Uninsured

Dependent

Total

100.0

50.6

17.5

6.7

7.4

20.3

Self-employed

100.0

22.9

25.7

20.0

7.1

26.4

Wage-and-Salary Workers

100.0

54.1

16.5

5.1

7.5

19.5

Firm Employment Size
< 10 Employees

100.0

26.6

21.9

9.5

10.1

34.3

10-24 Employees

100.0

38.3

20.3

6.3

7.8

28.9

25-99 Employees

100.0

52.0

17.3

5.2

6.9

20.8

100-499 Employees

100.0

62.1

14.8

3.6

6.5

15.4

< 500 Employees

100.0

45.2

18.5

6.1

7.8

24.6

500+ Employees

100.0

65.7

13.8

3.7

7.0

12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the
president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths
• Often, there is a family focus
• Fewer organizational layers – less complexity
re: decision-making
• Less complexity re: implementation
• Understand that each individual employee
and his/her health is important
• Understand that health influences the
“bottom line” of the company

Multiple Level Intervention for
Small Employers
Level of Intervention

Strategy

Intrapersonal/
Interpersonal

-Briefings (print) and Web-based resources
-Leading by Example – employers
-CEO breakfast meetings
-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational

-Free or low-cost HPPs + TA to implement them from
community, hospitals, voluntary health organizations…
-TA from State Health Department and/or insurers

Community

-Business Groups on Health – leverage for purchasing power
-University partnerships to get student help, grant funding

Policy

-National or state-level tax credits for small employers who
adopt HPPs
-Purchasing agreements for health
-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US
Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*
Individual Level
- Periodic health assessments tied to personalized feedback and individual coaching and motivational
interviewing
- Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with
all employees and is available to discuss health concerns
-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and
meet monthly with participants to collect program activity points and measure progress (eg, changes in
weight and blood pressure) toward positive health outcomes
-Strong linkage of wellness program with worker safety, including group stretching to promote model of an
“industrial athlete”
-Health coaches who travel among a company’s worksites to meet with employees
Environmental Level
-Strong support from wellness committee for establishing culture of wellness
-Inclusion of healthy food in criteria for selecting cafeteria vendor
-Free access to onsite physical activity facilities
-Provision of bicycles for travel between buildings
Organizational Level
-Incentive of paid day of leave to encourage program participation
-Reallocation of existing benefits to provide incentives for participating in screening activities and attaining
wellness goals
-Strong financial disincentives for employees and spouses with health insurance through the company who
do not participate in wellness program
-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:
Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for
Small Businesses
The North Carolina General Assembly should direct the North Carolina Public Health
Foundation to establish the North Carolina Worksite Wellness Collaborative to
promote evidence-based strategies to support the optimal health and well-being of
North Carolina’s workforce. The collaborative should help businesses implement
healthy workplace policies and benefits, implement health risk appraisals, develop
comprehensive employee wellness programs, and implement data systems that
track outcomes and the organizational and employee level.
The North Carolina General Assembly should provide start-up funding of $800,000 in
SFY 2011, with a reduced amount over the next four years, to support this
collaborative.
In addition, the North Carolina General Assembly should provide a tax credit to
businesses with 50 or fewer employees that have implemented a comprehensive
worksite wellness program for their employees.

Key Considerations
•
•
•
•
•
•
•

Get employees involved! Get dedicated staff!
Management support is necessary but not sufficient
Offer a comprehensive program with all 5 elements
Offer incentives for participation/behavior change
Provide links to local health care systems/providers
Address social contextual factors influencing health
Support research that builds evidence base and then
offer evidence-based programs
• Special focused activities for small employers

Related Information
• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small manufacturing
worksites that employ multiethnic, low-wage workforces into a cancer
prevention research trial. Prev Chronic Dis. 2004;1(3):A04.
• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change
among working-class, multiethnic workers: results of the healthy
directions—small business study. Am J Public Health. 2005;95(8):13891395.
• Divine RL. Determinants of small business interest in offering a wellness
program to their employees. Health Mark Q. 2005;22(3):43-58.
• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of
healthy weight at small and medium-sized US worksites. Prev Chronic Dis
2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.
• Linnan L & Birken B. Small businesses, worksite wellness and public
health: A time for action. NC Med J. 2006;67(6):433-438.


Slide 22

Worksite Wellness – Working
with Small Businesses
17th Annual Healthy Carolinians &
NCIOM Prevention Summit
Laura A. Linnan, ScD, CHES
The UNC Gillings School of Global Public Health
Thursday, October 8, 2009

Objectives
• Offer a brief overview of the importance of worksite
health promotion and its prevalence among small
employers
• Provide a rationale for offering comprehensive HPPs
among small employers
• Identify strengths/assets of small employers for
promoting employee health
• Share some promising intervention strategies –
including those recommended by the NC IOM -- for
increasing the prevalence of small employers which
offer comprehensive HPPs

Why Worksite Health Promotion?
• More than 60% of US adults are employed
• Employees spend a considerable number of waking
hours working
• Health care for US adults is directly linked with
employer-provided health insurance; many working
adults are without health insurance
• Many leading causes of death (CVD, cancer, stroke)
are preventable through lifestyle behavior changes
(smoking, diet, PA)

Why Should Employers Be Interested in Worksite
Health Promotion?
• Preventable illness makes up 70% of the total burden
of disease and their associated costs; employers pay
for these costs
• 10 modifiable risk factors account for approximately
25% of all employer healthcare expenditures
(Anderson, 2000)
• Employer medical costs average $7910/employee
annually (O’Donnell, 2007)
• Effective worksite health promotion programs have
demonstrated a positive impact on employee morale,
employee health and risk behaviors, productivity, and
health care costs

What is a “small” business?
• US Small Business Administration defines
“small” business as an employer with 500
employees or less
• SBA estimates there are 25.8 million small
businesses in the US
– They employee nearly 50% of the working adults!
– Employed adults spend about ½ of their waking
hours at work

Not all “small” employers are
equal… but they are important!
• Among small employers, there is great
heterogeneity
• The smaller the employer, the less likely it is to
offer health insurance or any health
programming for employees..
• 98% of employers with at least 200 employees offer some
type of health insurance while only 59% of those under
200 employees do
• One serious health problem represents financial disaster
for an employee and his/her family

Healthy People 2010 – WorksiteRelated National Health Objective
• “75% of employers (of all sizes) should offer a
comprehensive worksite health promotion
program,” which includes 5 key elements:
•
•
•
•
•

Health education programming
Supportive physical/social environment
Links to other health-related programs in the organization
Screening programs and appropriate follow-up
Integration of the program into the administrative structure
(e.g. budget, staffing, etc.)

How many employers are offering a
“comprehensive” health promotion
program?
• And, are small employers different from other
employers in what they offer?

Use of a Health Risk Appraisal
50

750+ EES (n=111)

45
40

250-749 EES (n=211)

35
30
25

100-249 EES (n=229)
50-99 EES (n=179)

20
15
10
5
0

Linnan, Bowling et al. (2008). AJPH.

Total (n=730)

Differences
by worksite
size
statistically
significant
(p=0.0002)

Physical Activity and Nutrition
Programs by Worksite Size
70
60
50

750+ EES (n=111)

40

250-749 EES (n=211)

30

100-249 EES (n=229)

20

50-99 EES (n=179)

10

Total (n=730)

0
*Physical Activity

*Nutrition

* statistically significant
differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental
Programs by Worksite Size
100
90
80

750+ EES
(n=111)

70

250-749 EES
(n=211)

60
50

100-249 EES
(n=229)

40
30

50-99 EES
(n=179)

20
10
0

Total (n=730)

Onsite Fitness Fitness/Walking
Center
Trails

Cafeteria

Vending food/beverages

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling
Services by Worksite Size
100
90
80
70
60
50
40
30
20
10
0

750+ (n=111)
250-749 (n=211)
100-249 (n=229)
50-99 (n=179)
Total (n=730)

Can
cer
S

Dia
be

cree
n

ing

tes

HBP
Scr

Scr

een
ing

HBC
een
in

g

Sc r

Alco

een
in

Linnan, Bowling et al, 2008, AJPH

g

hol

or D
r

ug

Abu
se

Sup
por

t

Predictors of Comprehensive
Worksite Health Promotion Programs


Overall, 6.9% of employers offered a
comprehensive program – smaller worksites were
less likely to offer all elements/types of programs
 Controlling for all factors (e.g. model adjusted for
size, staff, experience, industry type), we found:
 Worksites with 750+ employees were 4.4 times
more likely to have a comprehensive program
(p=.06).
 Worksites with a dedicated staff person were
10.3 times more likely to have a comprehensive
program (p<.05).

Why Do Small Employers Offer
Fewer Programs?
• “Survival Mode” – HPP programs are costly
– Direct Costs – of offering programs/services
– Indirect Costs – time/resources – competing
demands

• Lack of personnel dedicated to wellness
• Small business culture/leadership
– “Leave it up to Workers” (Eakin)
– Managers concerned about employee privacy
(Linnan)

Barriers To Health Promotion Program Success
70
60
50
40
30
20
10
0
Lack of
Employee
Interest

Lack of Staff
Resources

Lack of Funding Lack of High-Risk
Employee
Participation

Lack of
Management
Support

No differences in barriers were reported based on industry type or worksite size except that worksites with 750+
employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

Linnan, Bowling et al. 2008. AJPH

“When business survival is the
focus, any other costs, including
those linked to employee health,
may be seen as prohibitive.”
Linnan & Birken (2007)
NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007
Employment-Based
Coverage
Sector

Individually
Purchased

Total
Own Name

Public

Uninsured

Dependent

Total

100.0

50.6

17.5

6.7

7.4

20.3

Self-employed

100.0

22.9

25.7

20.0

7.1

26.4

Wage-and-Salary Workers

100.0

54.1

16.5

5.1

7.5

19.5

Firm Employment Size
< 10 Employees

100.0

26.6

21.9

9.5

10.1

34.3

10-24 Employees

100.0

38.3

20.3

6.3

7.8

28.9

25-99 Employees

100.0

52.0

17.3

5.2

6.9

20.8

100-499 Employees

100.0

62.1

14.8

3.6

6.5

15.4

< 500 Employees

100.0

45.2

18.5

6.1

7.8

24.6

500+ Employees

100.0

65.7

13.8

3.7

7.0

12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the
president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths
• Often, there is a family focus
• Fewer organizational layers – less complexity
re: decision-making
• Less complexity re: implementation
• Understand that each individual employee
and his/her health is important
• Understand that health influences the
“bottom line” of the company

Multiple Level Intervention for
Small Employers
Level of Intervention

Strategy

Intrapersonal/
Interpersonal

-Briefings (print) and Web-based resources
-Leading by Example – employers
-CEO breakfast meetings
-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational

-Free or low-cost HPPs + TA to implement them from
community, hospitals, voluntary health organizations…
-TA from State Health Department and/or insurers

Community

-Business Groups on Health – leverage for purchasing power
-University partnerships to get student help, grant funding

Policy

-National or state-level tax credits for small employers who
adopt HPPs
-Purchasing agreements for health
-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US
Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*
Individual Level
- Periodic health assessments tied to personalized feedback and individual coaching and motivational
interviewing
- Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with
all employees and is available to discuss health concerns
-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and
meet monthly with participants to collect program activity points and measure progress (eg, changes in
weight and blood pressure) toward positive health outcomes
-Strong linkage of wellness program with worker safety, including group stretching to promote model of an
“industrial athlete”
-Health coaches who travel among a company’s worksites to meet with employees
Environmental Level
-Strong support from wellness committee for establishing culture of wellness
-Inclusion of healthy food in criteria for selecting cafeteria vendor
-Free access to onsite physical activity facilities
-Provision of bicycles for travel between buildings
Organizational Level
-Incentive of paid day of leave to encourage program participation
-Reallocation of existing benefits to provide incentives for participating in screening activities and attaining
wellness goals
-Strong financial disincentives for employees and spouses with health insurance through the company who
do not participate in wellness program
-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:
Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for
Small Businesses
The North Carolina General Assembly should direct the North Carolina Public Health
Foundation to establish the North Carolina Worksite Wellness Collaborative to
promote evidence-based strategies to support the optimal health and well-being of
North Carolina’s workforce. The collaborative should help businesses implement
healthy workplace policies and benefits, implement health risk appraisals, develop
comprehensive employee wellness programs, and implement data systems that
track outcomes and the organizational and employee level.
The North Carolina General Assembly should provide start-up funding of $800,000 in
SFY 2011, with a reduced amount over the next four years, to support this
collaborative.
In addition, the North Carolina General Assembly should provide a tax credit to
businesses with 50 or fewer employees that have implemented a comprehensive
worksite wellness program for their employees.

Key Considerations
•
•
•
•
•
•
•

Get employees involved! Get dedicated staff!
Management support is necessary but not sufficient
Offer a comprehensive program with all 5 elements
Offer incentives for participation/behavior change
Provide links to local health care systems/providers
Address social contextual factors influencing health
Support research that builds evidence base and then
offer evidence-based programs
• Special focused activities for small employers

Related Information
• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small manufacturing
worksites that employ multiethnic, low-wage workforces into a cancer
prevention research trial. Prev Chronic Dis. 2004;1(3):A04.
• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change
among working-class, multiethnic workers: results of the healthy
directions—small business study. Am J Public Health. 2005;95(8):13891395.
• Divine RL. Determinants of small business interest in offering a wellness
program to their employees. Health Mark Q. 2005;22(3):43-58.
• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of
healthy weight at small and medium-sized US worksites. Prev Chronic Dis
2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.
• Linnan L & Birken B. Small businesses, worksite wellness and public
health: A time for action. NC Med J. 2006;67(6):433-438.


Slide 23

Worksite Wellness – Working
with Small Businesses
17th Annual Healthy Carolinians &
NCIOM Prevention Summit
Laura A. Linnan, ScD, CHES
The UNC Gillings School of Global Public Health
Thursday, October 8, 2009

Objectives
• Offer a brief overview of the importance of worksite
health promotion and its prevalence among small
employers
• Provide a rationale for offering comprehensive HPPs
among small employers
• Identify strengths/assets of small employers for
promoting employee health
• Share some promising intervention strategies –
including those recommended by the NC IOM -- for
increasing the prevalence of small employers which
offer comprehensive HPPs

Why Worksite Health Promotion?
• More than 60% of US adults are employed
• Employees spend a considerable number of waking
hours working
• Health care for US adults is directly linked with
employer-provided health insurance; many working
adults are without health insurance
• Many leading causes of death (CVD, cancer, stroke)
are preventable through lifestyle behavior changes
(smoking, diet, PA)

Why Should Employers Be Interested in Worksite
Health Promotion?
• Preventable illness makes up 70% of the total burden
of disease and their associated costs; employers pay
for these costs
• 10 modifiable risk factors account for approximately
25% of all employer healthcare expenditures
(Anderson, 2000)
• Employer medical costs average $7910/employee
annually (O’Donnell, 2007)
• Effective worksite health promotion programs have
demonstrated a positive impact on employee morale,
employee health and risk behaviors, productivity, and
health care costs

What is a “small” business?
• US Small Business Administration defines
“small” business as an employer with 500
employees or less
• SBA estimates there are 25.8 million small
businesses in the US
– They employee nearly 50% of the working adults!
– Employed adults spend about ½ of their waking
hours at work

Not all “small” employers are
equal… but they are important!
• Among small employers, there is great
heterogeneity
• The smaller the employer, the less likely it is to
offer health insurance or any health
programming for employees..
• 98% of employers with at least 200 employees offer some
type of health insurance while only 59% of those under
200 employees do
• One serious health problem represents financial disaster
for an employee and his/her family

Healthy People 2010 – WorksiteRelated National Health Objective
• “75% of employers (of all sizes) should offer a
comprehensive worksite health promotion
program,” which includes 5 key elements:
•
•
•
•
•

Health education programming
Supportive physical/social environment
Links to other health-related programs in the organization
Screening programs and appropriate follow-up
Integration of the program into the administrative structure
(e.g. budget, staffing, etc.)

How many employers are offering a
“comprehensive” health promotion
program?
• And, are small employers different from other
employers in what they offer?

Use of a Health Risk Appraisal
50

750+ EES (n=111)

45
40

250-749 EES (n=211)

35
30
25

100-249 EES (n=229)
50-99 EES (n=179)

20
15
10
5
0

Linnan, Bowling et al. (2008). AJPH.

Total (n=730)

Differences
by worksite
size
statistically
significant
(p=0.0002)

Physical Activity and Nutrition
Programs by Worksite Size
70
60
50

750+ EES (n=111)

40

250-749 EES (n=211)

30

100-249 EES (n=229)

20

50-99 EES (n=179)

10

Total (n=730)

0
*Physical Activity

*Nutrition

* statistically significant
differences by worksite size

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Select Environmental
Programs by Worksite Size
100
90
80

750+ EES
(n=111)

70

250-749 EES
(n=211)

60
50

100-249 EES
(n=229)

40
30

50-99 EES
(n=179)

20
10
0

Total (n=730)

Onsite Fitness Fitness/Walking
Center
Trails

Cafeteria

Vending food/beverages

DO NOT CITE WITHOUT PERMISSION –PENDING PUBLICATION BY AJPH

Screenings/Counseling
Services by Worksite Size
100
90
80
70
60
50
40
30
20
10
0

750+ (n=111)
250-749 (n=211)
100-249 (n=229)
50-99 (n=179)
Total (n=730)

Can
cer
S

Dia
be

cree
n

ing

tes

HBP
Scr

Scr

een
ing

HBC
een
in

g

Sc r

Alco

een
in

Linnan, Bowling et al, 2008, AJPH

g

hol

or D
r

ug

Abu
se

Sup
por

t

Predictors of Comprehensive
Worksite Health Promotion Programs


Overall, 6.9% of employers offered a
comprehensive program – smaller worksites were
less likely to offer all elements/types of programs
 Controlling for all factors (e.g. model adjusted for
size, staff, experience, industry type), we found:
 Worksites with 750+ employees were 4.4 times
more likely to have a comprehensive program
(p=.06).
 Worksites with a dedicated staff person were
10.3 times more likely to have a comprehensive
program (p<.05).

Why Do Small Employers Offer
Fewer Programs?
• “Survival Mode” – HPP programs are costly
– Direct Costs – of offering programs/services
– Indirect Costs – time/resources – competing
demands

• Lack of personnel dedicated to wellness
• Small business culture/leadership
– “Leave it up to Workers” (Eakin)
– Managers concerned about employee privacy
(Linnan)

Barriers To Health Promotion Program Success
70
60
50
40
30
20
10
0
Lack of
Employee
Interest

Lack of Staff
Resources

Lack of Funding Lack of High-Risk
Employee
Participation

Lack of
Management
Support

No differences in barriers were reported based on industry type or worksite size except that worksites with 750+
employees were sig more likely to report lack of participation by high-risk employees (p=0.002).

Linnan, Bowling et al. 2008. AJPH

“When business survival is the
focus, any other costs, including
those linked to employee health,
may be seen as prohibitive.”
Linnan & Birken (2007)
NC Med J

Private Sector Workers with Selected Sources of Health Insurance, ages 18-64, 2007
Employment-Based
Coverage
Sector

Individually
Purchased

Total
Own Name

Public

Uninsured

Dependent

Total

100.0

50.6

17.5

6.7

7.4

20.3

Self-employed

100.0

22.9

25.7

20.0

7.1

26.4

Wage-and-Salary Workers

100.0

54.1

16.5

5.1

7.5

19.5

Firm Employment Size
< 10 Employees

100.0

26.6

21.9

9.5

10.1

34.3

10-24 Employees

100.0

38.3

20.3

6.3

7.8

28.9

25-99 Employees

100.0

52.0

17.3

5.2

6.9

20.8

100-499 Employees

100.0

62.1

14.8

3.6

6.5

15.4

< 500 Employees

100.0

45.2

18.5

6.1

7.8

24.6

500+ Employees

100.0

65.7

13.8

3.7

7.0

12.6

Source: U.S. Small Business Administration, Office of Advocacy. The small business economy: a report to the
president. Washington: United States Government Printing Office 2009.

Small Business Assets & Strengths
• Often, there is a family focus
• Fewer organizational layers – less complexity
re: decision-making
• Less complexity re: implementation
• Understand that each individual employee
and his/her health is important
• Understand that health influences the
“bottom line” of the company

Multiple Level Intervention for
Small Employers
Level of Intervention

Strategy

Intrapersonal/
Interpersonal

-Briefings (print) and Web-based resources
-Leading by Example – employers
-CEO breakfast meetings
-Chamber of Commerce/SBA -- Peer leaders/champions

Organizational

-Free or low-cost HPPs + TA to implement them from
community, hospitals, voluntary health organizations…
-TA from State Health Department and/or insurers

Community

-Business Groups on Health – leverage for purchasing power
-University partnerships to get student help, grant funding

Policy

-National or state-level tax credits for small employers who
adopt HPPs
-Purchasing agreements for health
-Health care reform

Promising Strategies to Promote Healthy Weight Among Employees in Small and Medium-Sized US
Worksites Evaluated With the Swift Worksite Assessment and Translation Method, 2005-2006*
Individual Level
- Periodic health assessments tied to personalized feedback and individual coaching and motivational
interviewing
- Monthly walk-through of entire worksite by occupational health nurse (vendor) during which she visits with
all employees and is available to discuss health concerns
-The use of peer coaching to deliver the program, whereby employees are trained as health coaches and
meet monthly with participants to collect program activity points and measure progress (eg, changes in
weight and blood pressure) toward positive health outcomes
-Strong linkage of wellness program with worker safety, including group stretching to promote model of an
“industrial athlete”
-Health coaches who travel among a company’s worksites to meet with employees
Environmental Level
-Strong support from wellness committee for establishing culture of wellness
-Inclusion of healthy food in criteria for selecting cafeteria vendor
-Free access to onsite physical activity facilities
-Provision of bicycles for travel between buildings
Organizational Level
-Incentive of paid day of leave to encourage program participation
-Reallocation of existing benefits to provide incentives for participating in screening activities and attaining
wellness goals
-Strong financial disincentives for employees and spouses with health insurance through the company who
do not participate in wellness program
-Integration of wellness goals into work performance expectations

*Hersey et al. (2008). Preventing Chronic Disease

Recommendation 12.3:
Create the North Carolina Worksite Wellness Collaborative and Tax Incentives for
Small Businesses
The North Carolina General Assembly should direct the North Carolina Public Health
Foundation to establish the North Carolina Worksite Wellness Collaborative to
promote evidence-based strategies to support the optimal health and well-being of
North Carolina’s workforce. The collaborative should help businesses implement
healthy workplace policies and benefits, implement health risk appraisals, develop
comprehensive employee wellness programs, and implement data systems that
track outcomes and the organizational and employee level.
The North Carolina General Assembly should provide start-up funding of $800,000 in
SFY 2011, with a reduced amount over the next four years, to support this
collaborative.
In addition, the North Carolina General Assembly should provide a tax credit to
businesses with 50 or fewer employees that have implemented a comprehensive
worksite wellness program for their employees.

Key Considerations
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Get employees involved! Get dedicated staff!
Management support is necessary but not sufficient
Offer a comprehensive program with all 5 elements
Offer incentives for participation/behavior change
Provide links to local health care systems/providers
Address social contextual factors influencing health
Support research that builds evidence base and then
offer evidence-based programs
• Special focused activities for small employers

Related Information
• Barbeau EM, Wallace L, Lederman R, et al. Recruiting small manufacturing
worksites that employ multiethnic, low-wage workforces into a cancer
prevention research trial. Prev Chronic Dis. 2004;1(3):A04.
• Sorensen G, Barbeau E, Stoddard AM, et al. Promoting behavior change
among working-class, multiethnic workers: results of the healthy
directions—small business study. Am J Public Health. 2005;95(8):13891395.
• Divine RL. Determinants of small business interest in offering a wellness
program to their employees. Health Mark Q. 2005;22(3):43-58.
• Hersey J, Hill MD, Isenberg KB, et al. Promising practices in promotion of
healthy weight at small and medium-sized US worksites. Prev Chronic Dis
2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0172.htm.
• Linnan L & Birken B. Small businesses, worksite wellness and public
health: A time for action. NC Med J. 2006;67(6):433-438.