Workplace Health Needs More Rigorous Evaluation of Comprehensive Programs

Dual photo of Eduardo Sanchez, M.D., M.P.H. and Chris Calitz, M.P.P.Eduardo Sanchez, M.D., M.P.H., Chief, Center for Health Metrics and Evaluation
Chris Calitz, M.P.P, Director, Center for Workplace Health

A worksite wellness study published in the Journal of the American Medical Association (JAMA) on April 16, 2019, and a corresponding New York Times article headlined “Employee Wellness Programs Yield Little Benefit, Study Shows” appeared to question the effectiveness of workplace health promotion programs.

A more accurate headline may have been “One Employee Wellness Program from One Employer Yields Limited Benefits.” In this rigorously evaluated study, 4,037 employees from 20 worksites of a large U.S. retail warehouse were randomized to receive a “comprehensive” wellness program, and 4,106 employees at 20 different worksites received no program. Over 18 months, researchers found statistically significant improvements in the number of employees self-reporting regular physical activity and active weight management. However, there was no significant improvement in clinical measures of health, health care spending and utilization, and employee outcomes (absenteeism, tenure and job performance).

The wellness program was implemented by an established wellness vendor and had 8 health education modules (physical activity, nutrition, stress reduction, etc.) delivered by registered dietitians over 4 to 8 weeks. No financial incentives were offered to complete an online health assessment or participate in onsite biometric screenings. Participants received small financial incentives ($25 per module), compared with national averages, for program participation.

These design choices could explain why program participation and completion was relatively modest: 34% to 45% of eligible employees participated in health assessment surveys and health screenings. Employees completed an average of 1.3 of the 8 modules, with roughly 1 in 5 completing at least 3 modules. Given these low engagement data, it’s no surprise that the study didn’t find more significant program effects.

The researchers describe the wellness program as being “comprehensive,” yet the program did not appear to incorporate science-based structure and process elements included in the AHA’s Workplace Health Achievement Index (WHAI), such as leadership support, health enhancing policies and environmental supports. The potential lack of these best practices may be another reason why this study found limited effectiveness.

A comprehensive approach to worksite wellness

The American Heart Association supports comprehensive health promotion and well-being initiatives delivered in worksites. Such an approach includes:
  1. An assessment of individual risk with tailored feedback
  2. Health-enhancing worksite policies (e.g., tobacco cessation)
  3. Leadership commitment and visible support for well-being
  4. Environmental supports (e.g., enhancing the built environment to empower people to move more and sit less)

Comprehensive programs must have adequate resources for implementation and undergo rigorous evaluation. This involves documenting the structure, process and performance metrics associated with employee outcomes such as health status, healthcare costs, productivity and engagement. All three aspects—structure, process and performance outcomes—are necessary for a company to fully engage in continuous performance improvement.

The future workplace health research agenda could include:
  1. Evaluating other single wellness programs across different employers
  2. Comparing different types of wellness programs across multiple worksites of the same employer
  3. Rigorous assessment the association between culture of health measures (structure and process metrics) and employee health outcomes (performance metrics) using instruments such as the WHAI
  4. Better description of program elements and implementation characteristics such as engagement, participation, completion and drop-out that are associated with outcomes
  5. Investigating targeted programs that are tailored to the needs of individuals that could most benefit
  6. Rigorous assessment of quality and performance, i.e., trends over time

The bottom line

The JAMA study by Dr. Song and colleagues is high-quality and worthy of emulation by others doing workplace wellness research. But perhaps the conclusion should be that workplace health research deserves more rigorous evaluation, and that we need better–defined, science-based components of comprehensive wellness programs, including the optimal dose of program modules, to move the needle on workplace health.

Employers, vendors and researchers should assess their current offerings and identify opportunities to improve, innovate and evaluate. Wellness initiatives must evolve to ensure the greatest possible health improvements in our rapidly changing workforce.

The AHA Center for Workplace Health is happy to discuss further questions about this study.