What Is A Comprehensive Wellness Program?

A comprehensive wellness program involves all employees, deals with all major health risks, offers choices, and targets both the employees and the worksite environment; provides periodic evaluation of its results. A comprehensive program emphasizes follow-up and offers support for the employee as long as he/she is employed. Studies have shown this approach to be highly successful. Key components are planning, implementation, and evaluation.

Planning involves performing a needs assessment, appointing a wellness committee, selecting providers, setting goals/objectives, marketing/promoting the program, and establishing procedures to ensure confidentiality.

Implementation consists of five major tasks:

• Health screening and referral
• Follow-up and counseling employees
• Follow-up with physicians
• Health improvement programs
• Organizing worksite-wide activities.

All of these tasks will be explained in this manual.

Evaluation involves monitoring your program to find out if it is working and to help you refine it. Measuring success shows what you have achieved, helps justify costs, and provides information for management to support continued programming.

Needs Assessment

An initial health screening can include a survey of employees' interests as part of the assessment. Successful wellness programs are designed to meet the needs and interests of the employees. The information you need to get from a survey depends on the scope of your program. A sample survey can be obtained in the HOPE Publications Web site. If you plan to adapt this sample survey or develop your own survey, keep the following hints in mind:

• Ask mostly closed-choice questions, especially if you will be sending the survey to a large number of employees. Closed-choice questions provide specific choices and are easy to tabulate. You may want to use a computer for data entry and analysis.
• Invite comments, suggestions and recommendations, or ask open-ended questions at the end of the survey. Open-ended items are more difficult to summarize.
• Include a brief explanatory cover letter with the survey with the signature of the company president. Make sure to include a statement about confidentiality and anonymity.
• Ask a group of representative employees to review the survey before it is distributed. Find out if the questions will be understood by employees and won't be objected to.
• Include demographic information at the beginning or end of the survey. Consider various ways that you might analyze the responses by demographic characteristics (gender, age, shift, site, department, etc.).

When considering who should get the survey, a simple rule is if you have under 500 employees, everyone should receive one. The public relations benefit of everyone receiving a survey can be significant. Over 500 employees, a sample of the work population will suffice. A sample saves on costs and time. You may want to consider consulting with a statistician to determine an appropriate sample size for your worksite.

Needs surveys are confidential and anonymous; they do not request information that may identify a person.

Getting support from management is crucial to the success of the program.

One way to do this is to survey managers (see forms) and conduct interviews with decision-makers in the organization. You can use the surveys here or make up your own. If you decide to do your own, keep the survey short. It shouldn't take more than ten minutes to complete.

The interview process can also serve as a means of educating management. Provide concise fact sheets on the benefits of wellness programs for management. When surveys and interviews are completed, tally the surveys and write brief summaries of the interviews. Provide these reports to management.

Once completed present a brief executive summary to management. Highlight a few interesting findings that can be used immediately to make decisions about the program.

Utilize charts and graphs to make your points. Prepare a detailed report for wellness committee members itemizing each response. Provide a short article about the survey in the company newsletter.

The higher the response the more valid and reliable the results. A minimum response of 40% to 50% is acceptable.

Work Environment

Effective wellness programs attempt to create healthy workplace climates. A healthy workplace climate is one which encourages teamwork, cooperation, and empowerment of the individual.

People have a sense of community, a shared vision, and a positive outlook. Policies promote and support wellness efforts within the workplace.

• Effective programs identify ways that company policies and organizational traditions encourage wellness.
• Effective programs work at the group and organizational level to build support for healthy lifestyle choices.
• Effective programs set clear target goals and objectives for the health improvement of the worksite.

Corporate Culture

Effective wellness programs recognize the importance of building a supportive cultural environment. The workplace culture includes shared values/heartfelt beliefs about what is important. It includes social standards of expected and accepted behavior called "cultural norms."

It includes peer support from family, friends, and co-workers. This support can help one adopt healthy lifestyles. Tools are available to audit a company.

The long-term success of any wellness program is dependent on the corporate culture.

Some healthy culture signs in a company are:

• Employees communicate openly
• Leaders support diversity and opinion
• Employees have fun
• Policies support wellness
• Employees are encouraged to grow
• Employees work together as a team
• Employees' skills and talents are matched to their jobs.
• Flexible work schedules are available
• Employers consider employees as their most valuable asset

Wellness Committee

Wellness committees are important in that they create a sense of ownership in the program, and facilitate various tasks involved in wellness programming at the workplace. The committee should be composed of a cross-section of employees representing various occupations, levels, and subgroups with the organization.

A common mistake is filling the committee with the most health/fitness-conscious people in the company. Don't rely solely on volunteers to fill a committee. Make sure that your committee members have enough power in the company to run an effective wellness program.

The wellness committee is made up of employees from the workplace. It oversees the wellness program and helps carry it out. The committee should meet about once a month to review the previous month's activities and plan future ones. When the program is just starting, the committee may meet on a weekly basis until things get going.

Committee members do not carry out medical procedures, counsel clients, or handle confidential health information. Wellness professionals perform these tasks.

In general, the committee's duties fall into three areas: planning, promoting, and helping to run programs.

Planning the programs can include:

• Finding space for activities
• Planning and organizing worksite-wide events such as contests
• Reviewing reports prepared by the program staff and making recommendations

Promoting the program can include:

• Recruiting workers to take part in screening and health improvement programs
• Encouraging workers to take part in follow-up counseling
• Organizing promotional strategies using newsletters, signs, bulletin boards, computers, and other media available within the workplace

Helping to run the program can include:

• Setting up equipment for various activities
• Helping to conduct worksite-wide activities
• Monitoring all activities and reviewing the performance of the professional staff
• Acting as wellness mentors to fellow employees

The size of the wellness committee will be dependent on the size of the organization. Pick members by asking day management to nominate or appoint employees.

Make an announcement through flyers, memos, and meetings to recruit potential members. Explain the purpose of the committee, duties and responsibilities, and the time commitment.

Recognize your wellness committee volunteers. Allow them to participate in programs at a reduced cost. Hold appreciation breakfasts/lunches/dinners. Print names of committee members on company communications about the wellness program.

Purchase special T-shirts, caps, and buttons for them. Write letters to supervisors saying that you appreciate the member's service. Create awards certificates for members.

The following can be used as a guide for committee size:

Goals and Objectives

Goals are broad-based statements about what the program is expected to do. The goal of the wellness program is to enhance the health of the individual and the organization. Goals like mission statements provide direction in a program.

Objectives are specific and provide a means of measurement of the program to determine effectiveness. There are two types of objectives, process and outcome. Process objectives state the activities that need to occur to achieve a desired outcome.

Examples of process objectives are:

• Number of participants screened
• Number of participants in and completing health improvement programs
• Satisfaction of program participants
• Number of participants who were medically referred and saw their physician
• Number of promotional activities
• Number of participants seen in follow-up

Example of outcome objectives are:

• Number of participants who improved fitness level
• Number of participants who lowered cholesterol level
• Number of participants who lost weight, body fat
• Number of participants who quit smoking
• Number of participants with high blood pressure who lowered their blood pressure
• Number of participants whose initial level of alcohol consumption put them at-risk who are no longer at-risk
• Number of participants with risk factors who saw their physician and are being treated for high blood pressure or cholesterol years later

Health Screening

The backbone of wellness programming at the worksite is health screening. It is the first major activity a company should do when first starting a wellness program. Health screening is often used in conjunction with the administration of a Health Risk Appraisal (HRA).

The most effective way to screen is to utilize a health professional trained in wellness screening techniques and counseling to privately and individually assess participants. This wellness professional takes a brief health history and measures blood pressure and cholesterol. With computerized cholesterol desktop analyzers, results are obtained in about four minutes.

Immediate feedback, consultation, and educational materials are provided. For those identified at-risk, follow-up appointments can be scheduled at this time. The whole process takes about twenty minutes per individual. The screening also provides an immediate opportunity to register participants in various health improvement programs based on their interests and identified health risks.

Health screening can be done on an annual basis and used as a means of monitoring health risks within the worksite.

A health screening program needs to provide multiple opportunities for participation. The service should be provided for all the various shifts of a company. The screening program should be conducted in highly visible areas so the process can be observed.

Reluctant employees often like to be able to see what the program is about before they participate. When wellness screeners are not busy, they should perform outreach going to areas where employees gather and attempt to recruit employees.

When well-planned and promoted, health screening can attract participation rates of 60% to 100%. These high participation rates have a positive impact on management producing support for further programming.

Heart Health

The most common screening performed in worksite wellness programs is heart health assessment.

The screening can include a written heart health test, blood pressure measurement, cholesterol/HDL-cholesterol test, glucose (blood sugar), weight, educational materials specific to diet, nutrition, exercise, cholesterol, smoking, and weight.

The health professional conducting the screening then provides a consultation and helps set goals with the participant.

Health Risk Appraisal

A Health Risk Appraisal (HRA) is sometimes used in conjunction with a health screening. An HRA is a computerized assessment tool which looks at an individual's family history, health status, and lifestyle. An HRA seeks to identify precursors associated with premature death or serious illness and quantifies the probable impact for each individual.

An HRA instrument is derived from an understanding of the course of a disease. Based on this understanding, useful prediction instruments can be constructed to assess the health risks of an individual. Individuals with a higher number of health risks tend to have more serious health problems over time.

Drawing attention to their health risks can help clients reduce risk factors which lead to the onset of unnecessary disease and subsequent premature death. The questionnaire covers lifestyle habits (such as smoking, seat belt use, and exercise) and physical measures (such as cholesterol, blood pressure levels, height, and weight).

For accuracy, it is crucial to obtain direct measures of blood pressure, cholesterol and HDL-cholesterol. The HRA also provides recommendations and indicates what risks are modifiable. Types of measures to assess health risks are discussed under Screening Programs.

The impact of a health risk appraisal is much greater when it is given in-person, with immediate feedback to the client. This also provides an opportunity to invite the client's participation in continuing health counseling and to gain their written consent to do pro-active outreach to them.

A health age can be computed based on the individual answers to the questionnaire and physiologic factors. The health age may indicate the individual to be younger or older than their chronological age.

HRA programs are one the most prolific types of wellness activities utilized by organizations. Continuing research on HRAs is examining the efficacy of this tool. One of the big benefits of this tool is that it can provide an aggregate group report of a company and can be utilized as an evaluation tool.

Detailed information is available from the Society of Prospective Medicine (www.spm.org/desc.html) who publishes a handbook on HRAs.

Planning

An annual plan for the major wellness programs and activities is a useful management tool. This is an excellent wellness committee task. Often an activity and wellness theme per month is offered to employees.

Some organizations choose to follow a National Health Observances calendar which offers advantages. The materials developed by these various national health organizations are very credible. The materials are usually high quality and available free or at a nominal cost.

The company benefits from additional publicity that occurs in various media throughout the community related to the national observance. For planning suggestions you may want to utilize the HOPE Publications Wellness Resource Planning Guide available for free at this Web site.

Selecting a Provider

When staffing your wellness program you need to consider whether to hire a wellness staff or contract with wellness professionals from outside your organization.

Small and medium size worksites do not usually have a wellness professional on staff. If your worksite is in this category, you will need to contract with providers outside your company.

Large companies have several options. They can hire a staff solely for the wellness program, they can contract with outside wellness providers, or they can use a combination of internal staff and outside providers.

When selecting a provider some key questions in the areas of staff, program structure, process, and effectiveness need to be addressed. Each of these key questions is discussed in the following sections.

Staff

Health professionals become wellness professionals when they are trained in the full range of wellness activities. Wellness professionals are generalists who come from a wide variety of backgrounds and schooling. They may be nurses, dietitians, health educators, counselors, exercise physiologists, or have other backgrounds. But in addition to their primary training, they know something about all wellness topics, including smoking, stress, exercise, and nutrition. They also know how to engage and support people in making and sustaining health improvements and have good people skills.

Generally, wellness professionals at worksites fall into three broad categories, wellness screeners, wellness counselors, and wellness instructors.

• Wellness screeners introduce employees to the program, take health measurements, collect health-related information, provide initial counseling, and help employees define for themselves what they need and want in a wellness program.
• Wellness counselors work with employees after the screening to help them create and carry out a plan to reduce their risks and improve their health.
• Wellness instructors teach classes and minigroups on different health topics.

A wellness program in a small business can be staffed by a single staff person who fills all three roles. Larger worksites will use different people to fill these roles.

When choosing staff or choosing among vendors, ask the following questions:

• Do prospective staff members have a range of health backgrounds that will provide appropriate expertise in the topics to be addressed?
• Have prospective staff members functioned well as wellness screeners, wellness counselors, and/or wellness instructors?
• Will this staff include people from the racial and ethnic backgrounds found in your employee population?
• Is each staff member comfortable with the range of backgrounds found in your employee population, and able to communicate effectively with the various social and educational levels of your employees?
• Do staff members have a warm, but professional, counseling style when interacting with employees?

Program Structure

When selecting a program from a vendor you should ask the following questions:

• How many worksites have done the program?
• What types of employee population was the program offered?
• What educational materials are used?
• Will the program meet the needs of employees?
• What are the techniques used to help change behaviors?
• Does the program help people move through stages of readiness to make health behavior changes?
• How do you market the program to employees?
• What follow-up do you provide?
• How do you make referrals for medical care or other supportive services employees may need?
• How do you know the program works?
• How do you measure participant satisfaction?

Marketing

A major concern in wellness programming is attracting employees to participate and maximizing participation. When introducing a program, a letter briefly explaining the program signed by the president or CEO is a great endorsement.

Utilizing posters, newsletter articles, and flyers are good means of promoting the program. Other promotional methods to consider are e-mail and announcements at staff meetings. Ask wellness committee members to recruit participants.

Once the program is kicked off you may want to provide an incentive for any employee who recruits another employee to any of the program offerings.

Incentives

Incentives can be used to increase participation rates, help with completion or attendance at programs, and to help individuals change or adhere to healthy behaviors. The purpose of the incentive is to encourage employees to adopt positive behaviors or maintain an existing positive behavior. Everyone who achieves a goal or maintains a behavior should receive something. Many organizations also provide incentives merely for participating in events.

Stay away from being the "best" or doing the "most." Encouraging people to be the best or doing the most promotes excessive behavior, discourages others, and creates elitism. The best designed incentive programs are ones which are based on achieving goals that are attainable by most individuals. Recognition, acknowledgment by top management, or special privileges are examples of excellent intangible incentives.

Incentive ideas:

• Free or Low-Cost:
  • Certificates
  • Movie passes
  • Recognition in employee newsletter
  • Mugs
  • Water bottles
  • Commendation from management
  • T-shirts
  • Hats
• Moderate Cost:
  • Entertainment tickets
  • Sweatshirts
  • Waist packs
  • Subscriptions to health magazines
  • Health and fitness books
  • Videos
• High Cost:
  • Week-end getaways
  • Dinner for two
  • Clocks
  • Watches
• Others:
  • Cash
  • Gift certificates

Effective Programming/General Recommendations

Program directors or providers should have a background in wellness programming and a professional health-related degree or certification. They should have expertise in content areas, planning, promotion, administration, evaluation, and ability to grow a program and tailor the program to the workplace.

Program providers should have a quality assurance program for evaluating the effectiveness of service personnel, to assess satisfaction of participants, and for personnel training and continuing education.

An overall policy statement should be available from directors and program vendors addressing the following issues: assurance of confidentiality of health data, referral to health and medical care for at-risk participants, follow-up with referred participants and those at-risk, program evaluation on process and outcomes, organization of the worksite for promotion of wellness and changes in corporate culture. A clear contract or letter of agreement for services should be provided.

Screening Programs

Health risk screening programs should be carried out on a one-on-one basis by trained health care professionals. Health risk measures should include the following:

• Blood pressure measurements - at least two blood pressure measurements taken during the screening episode, using a mercury sphygmomanometers or regularly calibrated aneroids.
• Blood pressure treatment status - ascertain whether the participant is under a doctor's care, on any medication, on a prescribed diet, or any other type of treatment for hypertension.
• Blood cholesterol measurement - total cholesterol and HDL-cholesterol taken either using a properly tested and maintained table top blood analyzer providing immediate feedback to the client, or sending blood to a laboratory providing feedback using a method that is as effective as immediate feedback.
• Cholesterol treatment status - ascertain whether the client is under a doctor's care, on any medication, on a prescribed diet, or any other type of treatment for high cholesterol.
• Obesity - utilize an accepted method for estimating obesity. For example assess participants height and weight and use the 1959 Metropolitan Life Height/Weight charts or use Body Mass Index.
• Identify people 20% or more above their ideal weight.
• Smoking status - assess whether the participant currently smokes cigarettes, whether the client has quit or never smoked, and the number of cigarettes smoked/day.
• Exercise habits - screening questions may be limited to frequency and duration exercise. Do participants exercise in a moderately vigorous fashion at least three times per week for 30 minutes or more.
• Diabetes - whether the client has diabetes, and whether or not it is currently under control. A blood glucose may be also done via finger stick and desk top analyzer. Several manufactures make available cassettes which include cholesterol and glucose measurements.
• Cerebrovascular disease or occlusive PVD - ascertain if the client has had a stroke or other kind of blood vessel disease.
• Family history of cardiovascular disease - ascertain whether any of the participants' parents or siblings had a heart attack or sudden death due to heart disease before age 55.
• Coronary heart disease - ascertain if the client has had a heart attack or other type of coronary heart disease.
• Stress - participant's assessment of stress in work and/or personal life. A series of well-tested and validated questions assessing levels of stress are available from the Worker Health Program.
• Participant release form (see forms) - A release form is required in which the participant authorizes the program to draw blood for testing to send information to the participant's medical care provider if medical risks are identified, and to obtain information from the provider about diagnosis and prescribed treatment.
• Participant interest survey - if an assessment of interest has not been collected previously, the screening activity must assess levels of interest in programs such as: weight control, smoking cessation, fitness or exercise, stress management, nutrition, self-care, cholesterol control.
• Health education messages - the screener must review with the participant his/her identified health risks and what they mean to the participant's overall health, and give the participant a written record of the blood pressure, total cholesterol, and any other physiological measures taken.
• Referral of participants for treatment - participants with elevated risks must be referred to appropriate sources of diagnosis and possible treatment following nationally or locally recognized guidelines for such referral.

Demographic information should include location of the screening, worksite, client's name, address, social security number, home and work phone numbers, sex, race, birthdate, relevant job information (e.g., hourly or salaried), department number, and work shift.

Blood Pressure Measurement and Education

Appropriate medical or allied health professional trained in measurement of blood pressure, referral protocols, and delivering educational messages to participant conducting blood pressure programs. These programs are required to follow national guidelines.

• National guidelines for blood pressure protocols:
• Calibration of blood pressure measuring equipment should be done at least annually.
• Two or more measurements of participant's blood pressure should be taken.
• Referral of participants with high blood pressure readings to personal physician for further evaluation.
• Systolic/Diastolic Follow-Up:
• Normal:   <130 / <85
  Action: Recheck in 2 years
• High Normal:   130-139 / 85-90
  Action: Recheck in 1 year
• Hypertension:
• Stage 1 (Mild):   140-159 / 90-99
  Action: Confirm within 2 Months.
• Stage 2 (Moderate):   160-179 / 100-109
  Action: Refer to source of care within 1 month.
• Stage 3 (Severe):   180-209 / 110-119
  Action: Refer to source of care within 1 week.
• Stage 4 (Very Severe):   >210 / >120
  Action: Refer to source of care immediately.
• Appropriate educational messages:
• Normal:   <130 systolic and <85 diastolic
  Action: No referral. If on treatment, then inform participant that blood pressure is under good control today and should continue seeing and following treatment program.
• High Normal:   130-139 systolic and/or 85-89 diastolic
  Action: Recommend that participant have blood pressure rechecked within 1 year unless under treatment. Advise participant that the readings are in a high normal range that needs rechecking. In the interim, suggest that one of the most effective means to lower blood pressure is to bring weight into normal range and to exercise.
• High:   >140 systolic and/or >90 diastolic
  Action: Refer to physician for further evaluation within 2 months unless the level is within urgent, emergency, or isolated systolic hypertension levels. If already on treatment, advise participant of readings and need to get blood pressure to a goal of 140/90 or less.
• Isolated Systolic Hypertension:   140-159 systolic and < 90 diastolic in a participant 65 years of age or older.
  Action: Advise participant to inform physician of readings at next visit and consider advice regarding weight loss and exercise if appropriate.
• Urgent:   180-209 systolic and/or 110-119 diastolic
  Action: Recommend obtaining medical evaluation within 1 week.
• Emergency:   >210 systolic and/or >120 diastolic
  Action: Obtain immediate medical attention.
• Provides the following:
• Written results, referral instructions, and an explanation of blood pressure levels given to each participant with individualized counseling, including advice about the interval of time recommended when the participant should be checked again.
• Utilizes the recommendations in The Fifth Report Of The Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure, March 1994.
• Written and audiovisual materials that are informative, easy to understand, and useful while containing scientifically accurate information.
• Relationship of high blood pressure and other risk factors, such as family history, smoking, high fat and unhealthy diet, lack of exercise, in the development of cardiovascular disease, including stroke, kidney disease, heart attack, and other diseases.
• Definition and causes of high blood pressure.
• Importance of following prescribed treatment.

Cholesterol Measurement and Education

Program is required to provide appropriate interpretation of cholesterol screening results, including a caution that a single measurement neither excludes nor establishes a diagnosis of their blood cholesterol.

Follow national guidelines:

Total Cholesterol

HDL

Refer cholesterol screening participants to medical care as follows:

Total Cholesterol

HDL

Provide the following:

• The relationship of blood cholesterol, high blood pressure, and other risk factors.
• Risk factors include: high blood pressure 140/90 or higher or on hypertension medication; current cigarette smoking; family history of premature CHD; diabetes mellitus; age - male > 45 years, female > 55 years or premature menopause without estrogen replacement therapy.
• Negative risk factor: high HDL 60 mg/dl or greater (subtract one risk factor).
• Risk factors such as family history, smoking, high fat or other unhealthy diet, and lack of exercise lead to the development of cardiovascular disease (CVD).
• Definitions and causes of high blood cholesterol and HDL, desirable levels, the meaning and limitations of a single measurement, the cause of variability, and the need for multiple measurements prior to diagnosis.
• Wide range of treatment options, including diet (e.g., importance of controlling fat intake less than 30% of total calories from fat, less 10% saturated fats), less than 300 mg. of cholesterol per day, well-balanced diet, weight maintenance or reduction, exercise, and medication.
• Importance of following prescribed treatment and professional advice.

Weight Control

Program offered is consistent with scientific and medical recommendations for weight loss, reflects a multi-disciplinary approach which offers four components: behavioral, exercise, nutrition, and maintenance, and is in accordance with the document Guidance For Treatment Of Adult Obesity. It includes:

• Screening to verify that the participant has no medical or psychological conditions which would make weight loss inappropriate, and to identify the participant's level of health risk, classifying participants not only on excess body weight, but also on the basis of associated medical conditions and overall heath risk.
• Referral for participants who are morbidly obese who would require medical guidance for weight loss.
• Informed consent, explanation of potential physical and psychological risk from weight loss and regain, likely long-term success of program, full cost of the program, credentials of the staff.
• Identification of contributing factors to participant's weight status, serving as the basis for an individualized weight loss plan which includes the weight goal and plans for nutrition, exercise, and behavioral components.
• Weight goal of participant is reasonable based on personal and family weight history not solely on height and weight charts; initial weight loss goal does not exceed loss of 10% of body weight, 1-2 pounds per week.
• Explanation of unsafe weight loss methods.
• Daily calorie level is adjusted to meet each participant's recommended rate of weight loss.
• Daily caloric intake is not less than 1,000 calories; if less, physician monitoring is required.
• Food plan designed so participants can select foods which meet 100% of all the Recommended Daily Allowance (RDA) except for calories. Nutritional supplementation can be used to achieve RDAs, however should not greatly exceed RDAs.
• Nutrition education encouraging permanent healthful eating habits based on The Food Guide Pyramid.
• Participant involved in meal planning and food selection.

The protein, fat, carbohydrate, and fluid content of the food plan meet safety recommendations:

Protein	Between 0.8 and 1.5 grams of protein per kilogram of goal body weight, but no more than 100 grams of protein a day.
Fat	10 - 30% calories as fat.
Carbohydrate	At least 100 grams per day.
Fluid	At least one liter of water daily.



• Exercise component should be a significant portion of the program and be both didactic and experiential.
• Participant is appropriately screened for exercise using a screening questionnaire such as the Par-Q Readiness Assessment (see forms). Instruction on recognizing untoward responses to exercise.
• Participants work towards 30-60 minutes of exercise 5-7 days per week.
• No appetite suppressant drugs.
• Maintenance plan offered for continued support.
• Weight control programs should be conducted by a registered dietitian or by degreed health professionals with training in nutrition with consultation by a registered dietitian.
• Trained lay leaders may assist if supervised by nutrition professional.

Note: There's an interactive version of Guidance for the Treatment of Adult Obesity at e-Guidance for the Treatment of Adult Obesity.

Exercise Programs

Participatory exercise programs should include education on benefits of regular exercise and risks of a sedentary lifestyle, its impact on cardiovascular health and diseases, its relationship with weight control and stress management, and aerobic exercise options. Discussion and practice of safe principles of exercise - warm up, cool down, frequency, intensity, duration, flexibility and strength components. The program follows guidelines by the American College Of Sports Medicine.

Safety precautions should include the following:

• Informed consent prior to starting exercise with clear and complete written and verbal instructions of possible risk, purpose of exercise, exercise format to be followed, opportunity for questions, and a signed informed consent with date.
• A screening/evaluation of participants to determine if medical evaluation is necessary for exercise such as the Physical Activity Readiness Questionnaire (PAR-Q, see forms).
• Measurements of blood pressure and resting heart rate are useful screening information to determine exercise readiness.
• Participants who fail screening are medically referred and should obtain a written clearance from their physician to exercise.
• The basic content of an aerobic exercise program should include:

Exercise instructors should have education and training in exercise physiology, physical education, physical therapy or comparable discipline, or possess a current certification by a nationally recognized sports medicine or exercise association, and be CPR certified.

Smoking Cessation

It is recommended that smoking cessation programs subscribe to the Code Of Practice for Smoking Cessation Programs.

Smoking cessation programs should be multi-component with a focus on skills to build positive voluntary behavior change practices. Useful techniques include establishing reasons for quitting, understanding the smoking habit, various techniques for stopping and remaining a non-smoker, overcoming the problems of quitting, short-term goal setting, weight control, stress management, importance of exercise, relationship of alcohol consumption to urges to smoke. Use no aversive or scare tactics.

In programs that use aids such as the "patch" or medications such as "Zyban" appropriate consultation should be available on the usage of these aids.

The instructor should have formal training in smoking cessation from a nationally recognized organization such as American Heart Association, American Cancer Society, American Lung Association, or a nationally recognized commercial program such as Smoke Enders.

Evaluation of success is sometimes very dubious in smoking cessation programs. Measurement of success should include participation rate, including the number starting the program, the number completing the program, and the average number per session. Also included, number and percent who stopped smoking at the end of the program, and the number and percent who had not resumed smoking by the end of one year.

Nutrition Education

A nutrition education program should include a nutritional needs assessment, education counseling, and referral as necessary.

Educational sessions and materials should include the following information:

• The relationship of nutrition and chronic diseases
• Improving eating patterns
• Relationship of nutrition and proper weight maintenance
• Exercise
• Stress
• Blood pressure
• Cholesterol
• Diabetes and other chronic diseases.
• Nutritionally accurate information regarding the relationship of health to diet, including cholesterol, fats, fiber, alcohol, carbohydrates, salt, sugar, and vitamin/mineral supplementation.

Methods for identifying healthier foods and incorporating low-calorie, high nutrient foods into eating habits. Guidelines for improving eating habits should be based on or consistent with national recommendations such as The Food Guide Pyramid.

Instructor should be a registered dietitian, registered nurse, or have a baccalaureate degree or higher in health education with training in nutrition. If an allied health professional instructs the program, a consultation and review of the program design by a registered dietitian is recommended.

Stress Management

The educational program should include approaches to stress awareness/reduction at the environmental level and at the individual level.

Social, physical, and organizational stressors should be explained and methods to ease or elevate stressors should be presented. At the individual level how changes in attitudes and behaviors help one to cope with stressors; learning techniques to minimize stress response, such as meditation, relaxation response, and exercise.

Content of the program should provide the following:

• Identifying sources of stress
• Relationship of stress to health
• How the individual experiences stress, personal, family, work
• Solutions for coping and managing stress
• Techniques for reducing stress
• Value of stress, both negative and positive
• Practical steps of incorporating stress reduction into lifestyle

Personnel conducting stress management programs should have training in psychology, behavioral sciences, or related disciplines such as mental health professionals, counselors, health educators, psychologists, and psychiatrists. Training in a reputable program on how to teach the stress management course including group process skills is a must.

Menu Approach of Services

The menu approach offers employees a range of options to support lifestyle changes. It allows people to choose the kind of help that suits their schedules and preferences.

The four basic types of programs include:

• Classes
• Minigroups
• Guided self help
• Individual counseling

Classes

Classes (8 or more) can be an effective means of providing education and social support for behavior change. The length of a class can vary depending on topic requirements. It is not sufficient to offer only classes at a worksite.

Many employees are under time constraints with after work commitments and although they may be interested they simply cannot participate because of their schedules.

Employees may be very eager to start a program but because of lack of participants to meet class quotas, the program is canceled. Many national organizations such as the American Heart Association, American Cancer Society, Weight Watchers, etc. offer classes; you should have little trouble in identifying a provider for class type programs.

You may want to contact your local hospital, health department, or YMCA for possible options. For selecting a vendor to provide a program you may want to review the section on program structure.

Minigroups

When there is not enough interest to create a class, those who are interested in a given health topic can be formed into a minigroup (2 to 7).

The minigroup can cover the same content as a class but do so in a less formal manner. Presentation of information and discussion is the major format of the minigroup.

Guided Self-Help

Most employees do not want formal help in making health changes; they prefer to do it on their own. In guided self-help, the wellness counselors provide support, materials, and encouragement.

Meeting times can be arranged and contact can be made either in person, by phone, or computer. Materials can be made available at the worksite, or mailed to the individual. Some worksites now make information available via intranets or the Internet.

Individual Counseling

One of the most successful ways to help individuals change and improve their health status is counseling (or coaching) on a one-on-one basis.

In published studies, wellness programs which incorporated individual counseling as part of the program process achieved significantly higher participation rates and achieved greater risk reduction/risk elimination than standard group programs. Studies have demonstrated that individual counseling is both cost effective and cost beneficial.

A wellness counselor should be trained in screening techniques, for in certain situations, they may be required to both screen individuals and counsel them. They should know how to do the following:

• Review employee health risks
• Contact employees who have health risks.
• Counsel employees on a one-on-one basis, helping them set goals, solve problems, and get expert help when they need it.
• Help employees follow their treatment recommendations and make lifestyle and health behavior changes.
• Recruit employees into health improvement programs, such as weight loss and smoking cessation.
• Work with employees on a one-on-one basis using guided self-help.
• Conduct classes and minigroups if necessary.
• Work with wellness committee members to plan and conduct worksite-wide wellness activities.

Wellness counselors are health generalists; they must have basic knowledge about a wide range of health topics and health risks.

Counselors must be able to talk with employees about their medical problems and the treatments prescribed by their doctors. They should have a good overview of nutrition, exercise physiology, pathophysiology of disease, pharmacology, psychology, and behavior change skills.

Follow-Up

The keys to a successful wellness program are persistent one-on-one outreach and follow-up counseling to encourage health improvement, adherence to treatment regimens, changes in lifestyle behaviors, and to prevent relapse. Periodic outreach and follow-up procedures provide employees with a safety net which keeps them involved in the program and prevents treatment dropout and relapse.

Counselors should follow up on employees at least every 6 months throughout the career of the employee at the worksite. The goals of follow-up are to:

• Involve employees who have health risks in treatment and risk reduction programs.
• Involve all employees in health improvement programs and worksite-wide wellness activities.
• Support employees in carrying out the risk reduction or health improvement activities they have chosen.
• Help employees comply with their treatment regimens.
• Prevent relapse.
• Prevent employees from dropping out.
• Help employees maintain behavior changes.

Follow-up can be conducted in person, by phone, mail, and via computer if the technology is available. Most preferable is an in-person contact. Computer programs which can do case load management are available to help counselors track information and perform follow-up.

Priorities for Follow-Up

People with multiple health risks should be at the top of the list. People in key positions such as union leaders or department heads with health risks should also be contacted early so that they learn what the program is about and can share the information with others.

People who need a medical evaluation for high blood pressure or cholesterol should also be targeted early. Many employees will have seen their doctors as a result of the screening, but some will need more encouragement to do so. Those with no health risks can be followed up annually.

A follow-up counseling session can take 20 to 45 minutes. At minimum, follow-up must include those who were told to seek medical evaluation for high blood pressure readings, high cholesterol readings, or borderline high blood cholesterol readings with 2 or more other risk factors.

It may include those who were identified as at-risk for one or more of the other major risk factors: at-risk levels of alcohol consumption, being overweight, and having low HDL.

Follow-Up With Physicians

A letter (see forms) should be sent to the physician or clinic of each employee who has high blood pressure, high cholesterol, or is under a physician's care.

The letter should explain the program and should include the employee's relevant, current health measurements.

Along with the letter, send a self-addressed return envelope. Follow-up with the physician should be repeated every 6 months until it is determined that the employee is under satisfactory control.

Contacting the physician is important for three reasons:

• The doctors receive employees' health measurements taken at the worksite.
• You receive the blood pressure and cholesterol readings the doctor takes and information on the treatment the doctor prescribes. Many times the employee does not have this information or does not remember it. The information can be used when counseling the employee.
• Follow-up encourages physicians to pay closer attention to heart disease risk factors among their patients.

Measuring Program Results

Information to evaluate your program comes from routinely collected screening and follow-up data of your program that look at process and outcomes of your program.

The Worker Health Program has available a computerized case-management system which includes queries that allow easy assessment of process and outcome results at any point in time.

Process Evaluation

Process evaluation looks at the program's impact as seen at various points in time.

Information that is gathered from the various forms that wellness employees fill out should supply you with the following:

• How many employees were screened?
• How many employees who were referred to a doctor went?
• How many employees who expressed interest in health improvement programs went?
• How many employees who were referred to health improvement programs went?
• How many employees who went to health improvement programs completed them?
• How many employees are in follow-up caseload?

You can use this type of process evaluation to evaluate and learn about the health of your program.

Outcome Evaluation

A central objective of the program is to improve the health of employees. Information on how to judge how well your program is meeting this objective is called "outcome evaluation" because you are evaluating the end results or outcome of your program.

In wellness programs, objectives are measured by specific (outcomes) behavior changes and reductions in health risk levels. Have employees lowered their blood pressure? Have they lost weight? Are they exercising more? Is alcohol consumption at a safe level? For example these are the types of questions you can ask to find out if you are reaching your objectives:

• For employees with high blood pressure (140 / 90 or higher or on medication) at screening, what percentage have it under control (below 140 / 90) a year later?
• What is the change in average blood pressure levels among all employees with high blood pressure 1 year after screening? Two years later?
• For employees with high blood cholesterol levels (above 240) at screening, what percentage has reduced their cholesterol to borderline-high levels (200-239)?
• For employees with borderline-high blood cholesterol levels, what percentages have reduced their cholesterol to the desirable range (below 200)?
• What is the change in average cholesterol levels among all employees with high and borderline-high blood cholesterol levels 1 year after screening? Two years later?
• For employees who were overweight at screening, what percentage have lost 20 pounds or more a year later? Ten pounds or more? What is the average weight loss?
• For employees who were smokers at screening, what percentages have quit smoking? For at least a year?
• For employees whose level of alcohol consumption put them at-risk at screening, what percentage have quit drinking alcohol? Are consuming alcohol at levels considered safe by CDC guidelines? Have reduced their drinking, but are still at-risk?
• For employees, what percentages are exercising at least three times a week for at least 20 minutes?
• If fitness levels were measured, what percentages have improved fitness?

Set a regular time such as every 6 months to look at which employees your program is reaching and how effective it is at helping them reduce their health risks. Use this information to make new decisions about how to direct your program efforts. Then make the change you need to improve your program.

Some may feel that evaluation is a frill; it is not. Evaluation is a necessary part of a wellness program. You will need to know what is working and what is not. Decision-makers who fund the program need to be updated on the performance of the program. Evaluation will provide you with necessary data to maintain and expand the program and convince management to continue to support the program.

Worksite-Wide Organization to Support Wellness Activities

A comprehensive program empowers its wellness committee to develop and implement a plan to address organizational wellness. This may include such things as worksite-wide wellness activities (contests, health fairs, walking clubs, smoke outs) or establishing "mentoring systems" to get workers to support each other in making healthy lifestyle changes. They might also recommend changes in company policies that will encourage health improvement (e.g., smoking policies, vending machines and cafeteria nutrition, etc.)

Wellness at the worksite works best when it is fun.

In addition, worksite-wide organizing activities may include working with ergonomics and safety departments to insure that the employees' work environment promotes health and well-being.

Additional suggestions can be found under Work Environment and Corporate Culture.