An increasing number of employers have introduced health promotion activities for their employees in recent years. These programs are not obligatory activities of an occupational health service but are proving themselves as useful and popular optional activities that can be introduced by phases in almost any size of organization.

Health promotion programs typically blend three approaches to employee health: health education, preventive medicine, and physical fitness. Table 27.1 presents the typical components of such programs. Health promotion programs usually incorporate several health-related activities. They may be based on company grounds or at a community facility. Some are run directly by the employer but many of the most successful programs are sponsored through employee recreation associations. Management of such programs has become highly specialized and professional, but small-scale programs can begin on an inexpensive basis.

The health education component is concerned with teaching employees the essentials of a healthy lifestyle, such as good health habits, sound nutrition, and the consequences of smoking, alcohol, and drug misuse. Beyond the informative aspect of health education, attention must be given to the psychological principles which motivate people to comply with sound health practices or to take unnecessary risks which jeopardize their health. Simple information transfer is not enough. Lectures on health seldom change behavior and approaches appropriate to patient education are not always helpful in health education for well employees. A health education component within a workplace health promotion program must be designed with attention to the characteristics of the population of workers to be reached (age, sex, class, education, health status, language, etc.), the most important health problems in the community as perceived by the workers, the most important health problems actually present in the community and the goals to be attained in changing health-related ineffective.

Health Education

Cancer prevention

Common minor illnesses

Heart disease

Cardiopulmonary resuscitation

Mental health

Diabetes

Nutrition

Allergies

Stress

Family health

Substance abuse

Automotive safety

Smoking

Occupational hazards

Back care (prophylactic)

Health fairs

Preventive Medicine

Screening Activities

Intervention Activities

Hypertension screening

Smoking cessation

Diabetes screening

Dietary interventions

Cardiovascular risk factors

Back care (rehabilitation)

Pulmonary function testing

Weight control

Weight monitoring

Stress reduction

Breast cancer

Prescriptive exercise regimes

Stool occult blood

Referral to physician

Physical Conditioning

Aerobic activity

Fitness centre

Strength and stretch

Sports medicine

The preventive medicine component is typically limited to screening for common disorders and risk factors and intervention activities which supplement but do not substitute for personal health care. There is usually a strong emphasis on reducing cholesterol levels and cardiovascular fitness training. The emphasis in health promotion programs is on primary prevention to reduce disease incidence in the working population and secondary prevention, the early detection of disease and referral for care. Reducing risk factors for later health problems is more easily accomplished in an integrated health promotion program. In such programs the group spirit, constant encouragement and feedback, and support network make compliance easier to achieve than on an individual basis.

Physical fitness is an important part of most health promotion programs for several reasons. Participation in fitness activities and sports programs provides a regularly scheduled opportunity for conditioning with encouragement and the sense of belonging to a group, both of which make compliance more likely. Workplace fitness programs are not oriented to athletes and persons of normal strength and coordination should be able to set reasonable goals and attain them. Fitness programs are fun and build morale among employees.

Health promotion programs, as distinct from fitness to work or health surveillance programs, focus on lifestyle and wellness strategies. They are voluntary and do not directly influence employability.

The appropriate health promotion activities to offer in a program varies with the employee population and company settings. Most programs begin with a fitness component, screening for cardiovascular risk factors, and a health education activity emphasizing cigarette smoking cessation and common health problems. Training in how to lift in ways that avoid back injury may sound mundane but it is very practical and such program have become increasingly popular.

Many employers sponsor voluntary health evaluations for employees. Some aspects of such evaluations are discussed in Chapter 19. These examinations should not be confused with fitness-to-work evaluations (see Chapter 18) and any clinical opinion formed by the examining physician must not affect the employment status of the participating worker. Indeed, these examinations do not have to be performed in the occupational health service or by an occupational health professional. They are best performed by physicians who are experienced in preventive medicine. The outcome of this examination is strictly confidential. No fitness-to-work judgment is made. The content of the examination should be based on the age, lifestyle, present and past health status, family history as well as the working conditions and requirements of the job. The frequency of the examination is based on a clinical judgment relating to the age, outcome and desire of the employee. Company policy sets the maximum frequency and the cost of the examination.

Evaluation of the impact of worksite health promotion programs is an essential part of their management. Programs that are unpopular or poorly attended should be phased out and employee needs and interests should always be taken into consideration before introducing new activities. Even small employers can develop health promotion programs by sharing or by subsidizing the participation of employees in local health clubs.

The benefits of a well-managed worksite health promotion programs are many. They appear to succeed in encouraging good health habits and improving fitness among employees. Whether they actually reduce illness rates and increase productivity is not certain, although likely. They certainly improve employee morale and promote positive attitudes. Sponsorship of such programs is a tangible gesture of interest in the well-being of the employee by the employer; participation by the employee creates a bond with fellow employees and the employer.

Even with these benefits, health promotion programs are not universally accepted. Employees are often cautious about participating in such programs, while employers wonder whether supporting them is an effective use of company resources. Occupational health professionals understand their importance for an individual's health, but are reluctant to see support for them getting in the way of programs to ensure worker health and safety.

Unions often view such programs as a diversion to gain the support of workers without making concessions on fundamental issues such as wages, hours, working conditions, and autonomy on the job. Even so, where such programs have been successfully implemented, employees and employers alike believe that they are very useful and appropriate.

Underlying the successful programs has been adherence to eight critical principles on the part of sponsoring employers.

1. Employees must want and trust the program.
2. Employees must participate in its creation and be able to influence its evolution.
3. Employers must believe that the program is making a measurable contribution to the well being of its workforce and to the economics of the organization.
4. The program is effectively integrated with the employee health assistance program (alcohol and drug abuse and stress-related problems).
5. The program is effectively integrated with and makes use of available community resources.
6. The program focuses on self-responsibility.
7. The program must be suitable for the employee population (age, sex, class, education, health, language) and the type of industry (size, type, location).
8. The program must be reevaluated on a regular basis with new ideas and concepts being introduced frequently and old or unpopular ideas as quickly discarded.

Health promotion programs in industry can be extremely rewarding for both employees and employers. Studies are now confirming what has up until now been only believed presumptively. That is, employees who do take charge of their health by eating well, exercising regularly, learning to cope with life stresses, eliminating smoking and drug use, who use alcohol in moderation and who use common sense in the everyday activities, live longer and better. They have fewer days of illness and fewer injuries. In short, they lead more productive lives. Employers support such programs because they are satisfied that they have not only contributed to their employees' well being, but are reaping solid economic rewards as well.

Before a program is launched, the employees must be polled to determine their level of knowledge and attitude towards wellness and their current level of action. It is essential to open this line of communication at the beginning because it will indicate which programs have a likelihood to succeed and provides a baseline against which results can be measured.

At this time if the employer expects some measure of economic impact then absenteeism rates, turnover rates, health insurance costs, accident rates, and other measures of employee productivity should be chosen and documented before the program begins. If the program budget allows, it is advantageous to contract an outside research agency to conduct an independent objective analysis of the program's impact. Many private research firms and universities are prepared to do this. The general strategy of evaluation is outlined in Chapter 32.

The aim of a health promotion program is to influence the health attitudes of individual employees such that they will make personal choices in their everyday decisions which will lead to more positive and healthy lifestyle. Specific objectives should be clearly stated and made known to all potential participants. These objectives may include the following:

1. To influence employees to adopt and maintain a more physically active personal lifestyle.
2. To influence employees to adopt and maintain proper eating habits that optimize nutritional status and weight.
3. To influence employees to stop smoking.
4. To influence employees to eliminate or dramatically decrease alcohol and drug abuse.
5. To help employees cope better with ordinary and unexpected life stresses.
6. To teach employees cardiopulmonary resuscitation (CPR) and first aid skills.
7. To teach employees about common diseases and how to prevent or minimize their impact.
8. To provide comprehensive medical assessments.

This element focuses on aerobic exercise, muscle power and endurance and joint flexibility. Strategies include individual and group programs that are modified for sex and various age groups. All programs should be supervised either directly or indirectly by qualified fitness counsellors and every participant should have a medical clearance before entry. The medical screen can be as simple as a fitness counsellor administered questionnaire or as elaborate as a full and detailed review by a medical specialist. The program should be adaptable to accommodate the physically handicapped. Successful physical fitness programs range from state-of-the-art company owned fitness facilities through providing fees for membership in private or public clubs in the community. All fitness activities should incorporate regular tests for measuring progress and to provide encouragement.

This element may provide individual nutrition or weight counselling or classes presenting current knowledge and information on sound nutrition and weight control. Special attention is usually placed on dietary cardiovascular risk factors, diabetes and obesity. It is generally preferrable to have a qualified nutritionist to provide the counselling and teaching. Lacking this resource, the program should provide as much advice as possible and supplement this with readily available pamphlets and bulletins from recognized nutritional authorities.

This element focuses on providing support for employees to cope with ordinary day-to-day stress and occasional unusual stressful events. It should not attempt to provide individual counselling or psychotherapy in depth, as this is more appropriately dealt with by an employee assistance program. Care must be exercised in choosing qualified resource persons in this area. Certified psychologists tend to be the best qualified and most credible. All too often, however, persons with questionable credentials present themselves as experts. Short one-or-two-hour group sessions can be very effective. These sessions should be cheerful and informative. They can be enhanced by distribution of individual questionnaires to determine the levels of stress the participant is experiencing. Longer sessions of one to three days duration are useful but require considerable commitment of time and resources and must be organized and lead by a properly qualified professional.

This element may apply various techniques to the problem of helping workers stop smoking, ranging from individual counselling to group sessions and special aversion methods. Frequently this element is so successful that it achieves a shift in the organization from a majority of smokers to a majority of non-smokers. This often leads to a non-smoking policy in the company.

This element is the preventive link the employee assistance program. As alcohol and drug consumption progresses from casual use, through misuse, to abuse, so do the type and intensity of the intervention strategies needed to deal with the problem. The health promotion component provides information to enhance self-awareness, using various approaches. These may include films, demonstrations, and printed material. Frequently community resources agencies are brought into the program to give demonstrations. The purpose is to inform employees about the nature of alcohol and drugs so that casual use is under control and misuse or abuse never comes about.

This element is often surprisingly popular. Here employees learn about common medical problems and how to keep themselves and their families healthy. Information provided covers how the health problems are detected, basic pathophysiology and how conditions can be prevented or at least controlled. Some of the topics of most consistent interest are cancer (in all its forms), heart disease, back and other musculoskeletal problems, sports medicine, diabetes, AIDS, and mental disorders. Different topics will appeal to different groups. At the time of the information session, or later as a special event such as a health fair, it is often useful and even fun to demonstrate and actually to conduct screening tests for hypertension, diabetes, and other conditions easily detectable in a clinic setting.

This element dovetails nicely with an employee safety training program. Many health authorities believe everyone should know CPR and at least basic first aid in order to create a "first line" of defense in the community. The workplace is an excellent place to help realize this goal. If all employees had these skills, benefit to the employees and employer is obvious. Most large workplaces have over the years had employees who sustained heart attacks while at work and other workers are usually highly motivated to learn CPR after such an incident.

 Chenoweth D. Fitness program evaluation: Results with muscle. Occ Health Safety 1983;52:14-17, 40-42. 

Chen MS, Jones RM. Establishing priorities in the wellness program. Occ Health Safety 1982;51:6-7, 36. 

Nast PF, McDonald L. Planning the employee fitness program. Occ Health Safety 1981;50:27-29. 

Chenoweth D. Health promotion: Benefits vs. costs. Occ Health Safety 1983; 52:37-41. 

Dedmon RE, et al. Employees as health educators: A reality at Kimberly-Clark. Occ Health Safety 1980; 49:18-24. 

O'Donnell MP, Ainsworth TH. Health Promotion in the Workplace. New York, John Wiley and Sons,1984. 

Parkinson RS et al. Managing Health Promotion in the Workplace: Guidelines for Implementation and Evaluation. Palo Alto, California, Maryfield Publishing, 1982.