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Integrating Employee Health: A Model Program for NASA (2005)

Chapter: 5 Implementing Integrated Health Programs

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Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
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5
Implementing Integrated Health Programs

Integration of worksite health promotion and occupational health and safety provides a means for improving worker health behavior (Sorensen et al., 1996b, 1998; Sorensen and Barbeau, 2004). Following the management systems approach described previously, this chapter provides an overview of the characteristics of effective integrated health programs and approaches to setting program priorities; examines strategies for program implementation and evaluation; and explores implications for NASA. The chapter also reviews integrated workplace health programs and the implications for NASA occupational health programs.

Many organizations in both the private and public sectors are faced with similar challenges, that is, they are expected to do more with less and do it faster, better, and cheaper. Such expectations require a highly motivated and productive workforce. This, in turn, is dependent on a workforce that is mentally and physically healthy and a work environment that promotes learning, collaborative work, and enables the workforce to embrace frequent change. Occupational health strategies for advancing these workplace and workforce challenges require planning and implementation approaches that go well beyond traditional workplace health and safety constructs which employ isolated, segregated programs in a non-coordinated fashion. The latter is inadequate as a means to advance optimal health status and workforce productivity.

The integrated health approach is one which links programs into a single process emphasizing outcome, coordination, synergy, and measurement (Goetzel et al., 2002). In its most comprehensive form it ties together health promotion initiatives, medical benefits design and incen-

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
×

tives, short- and long-term disability, including programs for worker compensation, lifestyle, disease management and care, with additional evaluation of the effects of presenteeism on health status. A growing body of evidence shows that factors related to worker well-being—other than those addressed by traditional occupational health programs—have a quantifiable affect on workplace productivity, underscoring the value of extending programs beyond traditional health, safety, and health promotion, and into the realm of health-related behavioral change (Goetzel et al., 1998a; Burton et al., 1999; Sorensen et al., 2004).

WORKSITE MODELS FOR HEALTH BEHAVIOR CHANGE

The health behavior change approach is based on a strong theoretical foundation. Theoretical models developed by the behavioral and social sciences have guided research on health behavior change. Various theoretical frameworks suggest that worker health is the result of a complex interplay of factors involving the individual worker, the immediate work environment, and factors within the larger contexts in which both the individual worker and the worksite are embedded (Robins and Klitzman, 1988; Sorensen et al., 1995; Baker et al., 1996; Stokols et al., 1996).

The social-contextual model (Sorensen et al., 2003, 2004) integrates multiple social and behavioral theories to describe factors influencing social disparities in health behaviors. Structural forces may influence the social context of workers’ lives, reflected, for example, in their material circumstances or experiences of discrimination, and ultimately may shape health behavior outcomes. In their research, this team of investigators has applied this model to the design interventions for working class and multi-ethnic populations, aimed at health behavior changes such as tobacco control, diet, and physical activity. By applying this model in behavior change strategies, it may be possible to change some elements of the workers’ social context, and also to enhance the quality and relevance of interventions through an understanding of the social realities of workers’ lives.

The social-ecological model (see Chapter 3 and Table 3-1) provides a structure for incorporating theories that operate at various levels of influence, including at the individual, interpersonal, organizational, community, and public policy levels. This approach builds on an array of social and behavioral theories including the Health Belief Model (Rosenstock, 1982; Rosenstock et al., 1988), Theory of Planned Behavior (Expectancy X Model) (Ajzen, 1991; Montano et al., 1997), Social Cognitive Theory (Bandura and Walters, 1963; Baranowski et al., 1997), the Transtheoretical Model (Prochaska and DiClemente, 1994; Prochaska et al., 1997), and the Community Organization Model (Minkler and Wallerstein, 1997).

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
×

In following the social-ecological model, it is important that integrated health programs include efforts both to create healthy work environments and support individual workers to change health-related behaviors. Accordingly, the effectiveness of occupational health and worksite health promotion programs can be enhanced when coordinated interventions aim to promote worker health through direct education for individuals and their families by building social support and establishing social norms that encourage healthy behaviors, by assuring that policies and management actions provide a healthy workplace, and through linking worksite efforts to broader community and public policy initiatives that promote worker health (Linnan et al., 2001) (see also Figures 3-2 and 4-2).

This model also provides a framework for moving beyond the individual as the locus of intervention and responsibility for health, in recognition of management’s central role in worker health (Sorensen, 2000). Thus, effective programs need to be aimed at and coordinated across multiple levels of influence. The following discussion provides a structure for the specific program information presented below.

Environmental and Organizational Systems

Environmental- and organizational-level systems include the organizational context, management, and policy structures that support worker health by providing a healthy and safe work environment. Reducing the potential for hazardous work exposures within the work environment is the first line of defense for ensuring occupational health and safety. These environmental systems can also present both barriers and facilitators to individual worker health choices in the worksite. For example, social norms, availability, and accessibility are strongly influenced by environmental-level systems (Schmid et al., 1995). Management commitment to an integrated worker health program provides a key foundation for success (DeJoy and Southern, 1993; Sorensen, 2000).

Programs for Individual Employees

Management participation in individual-level programs is essential to their success. Leaders can become role models, uniting the organizational vision for health with its mission, as well as providing support and encouragement for employee participation. Programs at the individual or interpersonal level focus particularly on educating individual workers and building social norms supportive of worker health, through mechanisms such as educational classes or one-on-one training programs (Refer to Chapter 2 for a description of NASA’s preventive health programs, the NASA Occupational Health website, and the NASA Health Promotion

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
×

and Wellness Team). Such efforts require solid support from management in order to reduce structural barriers influencing workers’ participation. Particular efforts may be needed to address disparities in access to programs. For example, blue-collar and service workers are less likely than white-collar workers to participate in health promotion programs (Gebhardt and Crump, 1990; Glasgow et al., 1993; Sorensen et al., 1996a; Morris et al., 1999). Supervisors may serve as gatekeepers and may need clear guidance to provide workers with access to health promotion activities—for example, by allowing employees to attend events on work time (Morris et al. 1999).

For maximum reach, interventions must target workers at varying stages of readiness to make changes, including, for example, programs that require minimal contact for those not yet ready to make health-related changes (such as health fairs); incentives and competitions; and group programs aimed at building skills to make health behavior changes (Prochaska et al., 1997). Recent advances in tailoring messages to individual workers provide promise for increasing the efficacy of these interventions (Willemsen et al., 1998).

NEEDS ASSESSMENT

As noted previously, a critical requirement for integrating traditional health and safety with occupational and nonoccupational disability and health benefits is collaboration with health benefits program administrators and access to health benefits utilization data. This concept of integration is illustrated in Chapter 4, Figure 4-2, and examples are provided in the figure legend. In the private sector, leading employers have made their health plan contracts conditional upon specific requirements for the creation of integrated databases from all health plan suppliers. NASA’s health benefits are provided under the Federal Employee Health Benefits Program, which, in 2004, included over 350 different plans covering more than 9 million employees, retirees, former employees, family members, and former spouses (Tingwald, 2004). Currently, the administration of this government-wide health benefits program does not provide for agency-specific utilization data. Such a deficiency thwarts efforts to improve occupational health care through agency-specific approaches to health care consumption behavior of NASA employees.

Assessment Tools

A variety of resources and tools are available to assess the health and wellness needs of the workforce population. In choosing and evaluating health and wellness assessment instruments, it is important that NASA

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
×

follow standard guidance on measurement instrument reliability and validity. The instruments used should be periodically reviewed to ensure reliability and validity within the NASA system (Gulliksen and Messick, 1960; Gulliksen, 1987). The basic tool for needs assessment is the Health Risk Appraisal (HRA). Included in the HRA are the tools used to address issues of mental wellness and productivity. Health care services assessments are discussed in Chapter 4.

Health Risk Appraisals

The HRA comprises a questionnaire, risk estimation, and educational information. This instrument is commonly used in worksite preventive healthcare to identify the likelihood that an individual will develop a preventable or chronic disease based on personal, medical, and lifestyle indicators. It is also used as a health promotion technique to assess health status and the need for health intervention in employee and other populations (Foxman and Edington, 1987). More often, however, the HRA serves as a component of needs assessment, health education, and behavior change (incentive or motivation) programs.

Application of the HRA has changed over time. For example, early worksite health promotion programs often consisted solely of HRAs combined with screening, apparently under the assumption that medical or risk information as such would motivate large numbers of participants to reduce their health risks. Subsequent experience showed that effectively supporting risk reduction required integration of the HRA into a comprehensive health promotion process that would include follow-up education and behavior-change components (Schoenbach et al., 1987; Terry, 1987; Anderson and Staufacker, 1996; Edington et al., 1999).

The HRA not only allows employees to identify their own health risks and behaviors and make modifications to improve their health, but accounts for malleable risk factors affecting the health status of a population. This is an important resource of information to support baseline data for organization-wide as well as site-specific prioritization of employee health needs, and to enable development of appropriate intervention programs. As an awareness and education tool, the HRA has been shown to be useful. However, when used as a predictor of risk or cost, as a program management or evaluation tool, or as a stand-alone behavior change program, its validity has not been clearly demonstrated (Edington et al., 1999).

In choosing the most appropriate HRA, it is important to evaluate which instrument will best meet an organization’s objectives. More comprehensive tools with lifestyle and medical indicators are recommended for health education and gatekeeping/incentives (see below for discussion of incentives) (Hyner et al., 1999). Common considerations when de-

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
×

ciding on an HRA package are the inclusion of aggregate data reports, additional preventive health programming or materials, and retesting capabilities (Donnelly, 1993; Turner, 1995). To increase its impact, an HRA can be integrated into the medical benefits plan so that data obtained from it can be used by medical plan providers to recruit participation in disease management and other care coordination efforts.

Tools for Assessing Mental Wellness

As a part of the HRA, an assessment of stress experienced by employees may be of value. Ideally, the impact of stress would also be assessed via stress-related risk factors for chronic disease, such as high blood pressure, as well as the influence on performance of acute stress. Brief instruments for the assessment of perceived stress include the Perceived Stress Scale and the Hassles Scale (Cohen et al., 1983; Cohen, 1986; DeLongis et al., 1988). These, or related instruments, focus on individual stress regardless of its source. Stress imposed in part by the worksite should also be assessed with an instrument such as the Job Content Questionnaire (Karasek et al., 1998). As with all items of the HRA, the utility of these instruments should be periodically evaluated. An important assessment of stress unrelated to the HRA is manager and co-worker subjective evaluations of productivity and non-adaptive changes in work style, such as over-narrowing of a solution set or increased irritability with co-workers. Manager training could be designed to involve managers in the early identification and amelioration of worksite stress.

Assessing Productivity-Presenteeism

Incorporated into many contemporary HRAs are questions aimed at defining presenteeism in the workplace. Presenteeism is health-related productivity loss while at paid work and may include: time not on task (i.e., in the workplace, but not working); decreased quality of work (e.g., increased injury rates, product waste, product defects); decreased quantity of work; unsatisfactory employee interpersonal factors (e.g., personality disorders); and unsatisfactory work culture (Loeppke et al., 2003; Chapman, 2005).

Such measurement is in its infancy and currently consists of self-reported questionnaires that address an individual’s ability to perform effectively on the job. In a study by the American College of Occupational and Environmental Medicine (ACOEM) Expert Panel, Loeppke et al. (2003) discussed and identified the core characteristics that an instrument should have to adequately assess workplace productivity loss. The core characteristics were grouped into four categories: supporting scientific

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
×

evidence, applicability to a variety of occupations and disease states, ability to support business decision-making (i.e., ability for data to be translated into a monetary unit), and practicality.

THE PROGRAM IMPLEMENTATION PROCESS

The program implementation process relies on careful planning, beginning with the needs assessment. Employee involvement in planning and priority setting can help to assure that workers participate fully in the program. This section outlines key components of successful implementation.

Employee Involvement

Employee participation in program planning can assure that programs respond to worker needs, readiness, cultural requirements, and priorities; and are situated within the overall context of the work organization, thereby enhancing program effectiveness. Typically, worker input may be provided through health and safety committees, health and wellness committees, or through joint coordination across committees. Health and safety committees provide an integral framework for engaging workers and management in joint efforts to promote a healthy workplace; the roles of this committee could logically be expanded to include health improvement efforts aimed at promoting healthy behaviors. Alternatively, health and wellness committees may take the lead in planning health promotion programming, and may coordinate with occupational health and safety committees to design integrated health efforts.

In considering the composition of these committees, it is important to provide equal representation and voice to workers from diverse groups. For example, participation of line workers in committees may be constrained by concerns about workers’ time away from their jobs, or, because of obvious power differentials in joint worker-management committees, workers may hesitate to express their concerns in the presence of management (Sorensen, 2000).

Alternate methods may be employed to gain worker input in program planning; for example, through focus group interviews or informal conversations with diverse groups of workers. Worker participation has additional benefits for worker health. Participation in program planning and learner-centered educational methods may contribute to the development of skills that may be applied across health issues, such as problem identification, problem solving, and communication skills (Luskin et al., 1992; Wallerstein and Weinger, 1992; Blewett and Shaw, 1995; Baker et al., 1996).

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
×

As noted above and on the agency’s occupational health website (http://ohp.nasa.gov/), NASA has established a multidisciplinary health and wellness committee to help guide planning for worker health initiatives, with representation from multiple NASA centers. This committee meets quarterly to review relevant reports such as Healthy People 2010, and develops campaign topics to be distributed throughout the agency. This committee aims to standardize outreach efforts to employees; communicate health and wellness information to employees; identify resources; and coordinate and plan programs, including identifying quarterly campaign topics and identifying and evaluating educational materials. An important component of employee involvement is representation by both civil servants and contract workers on the planning committee. Improving participation, however, is not enough. Population health management programs focus on the overall health goal, managing participation to reduce the most costly risks in the population. This means reaching the right individual with the right programs when they are ready to benefit from them (Serxner et al., 2004).

Incentives

Along with managing participation in programs (see above), successful implementation of integrated workplace programs depends on achieving a significant participation rate among eligible employees. Across these varying programs, it is important to provide incentives for workers to participate. Consumer- and patient-focused financial incentives, even if modest, have been shown to be effective in the short run for simple preventive care and distinct, well-defined behavioral goals. A comprehensive meta-analysis demonstrated that, for preventive interventions such as obtaining clinical preventive services (e.g., immunizations and screening tests) and initiating health improvement behaviors (such as tobacco cessation, weight loss and increased physical activity), incentives are effective and important (Isaac and Flynn, 2001; Ozminkowski et al., 2002).

Terry et al. (1999) and Wang et al. (2002) showed that HRA response rates increase as a function of the intensity of recruitment efforts and financial incentives. Kane et al. (2004) found that economic incentives worked as a behavioral change incentive approximately 73 percent of the time. Cash incentives (as opposed to coupons, vouchers, gifts, “in-kind” awards, etc.) produced the greatest behavioral effect and demonstrated a dose-response relationship (Kane et al., 2004). All incentives, of various forms including spending account credits, gift cards, cash, or lower premiums on medical plans, tend to increase participation in the HRA. There is less evidence that incentives directed at individuals alone can sustain long-term improvement in behaviors and health outcomes. System-level

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
×

cultural expectations and aligned incentives at multiple levels are most likely to produce sustained behavioral change (Kane et al., 2004). Once incentives are in place, however, they are difficult to eliminate (Serxner et al., 2004).

Barriers

Health Disparities

Health risks are not evenly distributed among workers, and for this reason, it is important that integrated health programs consider the particular needs and concerns of diverse groups of workers. Disparities may exist between occupational groups, different racial or ethnic groups, and regular versus contractual workers. As noted in Chapter 2, approximately 75 percent of NASA workers are contractual employees. Exposures on the job as well as high-risk-related behaviors are concentrated among those in working-class occupations, meaning those employed in blue-collar or service occupations (Giovino et al., 2000; Barbeau et al., 2004) or in low supervisory, technical, semi-routine or routine occupations (National Statistics, 2004). These workers have higher work-related injury and illness rates than do professional employees (NIOSH, 2000). Blue-collar occupation and lower educational levels are also associated with negative health behaviors such as tobacco use (Giovino et al., 2000; Barbeau et al., 2004; CDC, 2004), overweight status (Galobardes et al., 2000; Everson et al., 2002; Mokdad et al., 2003; Sarlio-Lahteenkorva et al., 2004), poor nutrition (USDHHS, 2000a), and low levels of physical activity (USDHHS, 1996). These workers are also less likely to participate in health promotion programs.

It is also important to attend to disparities in worker health outcomes by race and ethnicity. Risk-related behaviors are disproportionately concentrated among some racial and ethnic minorities (USDHHS, 1996; USDHHS, 2000a; USDA/USDHHS, 2005). There is also evidence indicating that workers of color are more likely than other workers to be exposed to workplace hazards (Frumkin et al., 1999). Programs must be designed to attend to the cultural norms and priorities of ethnically diverse populations (IOM, 2002), the implications of acculturation, the potential for discrimination, and related social contextual issues (Sorensen et al., 2004).

It may be necessary to take special steps to engage diverse employees in integrated health programs—including male and female workers across multiple occupational groups, racial and ethnic groups, and from the ranks of both regular employees as well as contractual workers. Supervisors may serve as gatekeepers controlling access to programs (Morris et al., 1999)—for instance, to keep production lines moving, supervisors may

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
×

refuse to permit employees to participate in programs during the workday. These workers may face other barriers to participating, such as overtime, shift work, a second job, car-pooling to work, long distances between the plant and the employee’s home, and responsibilities at home (Alexy, 1990). Worksites also need to consider family-responsive policies as a crucial component of the organizational culture supportive of worker health (Glass and Fujimoto, 1994).

Other Barriers

Belza et al. (2004) examined barriers and facilitators to physical activity perceived by underserved, ethnically diverse older adults in a community. In this study, health was reported as both a facilitator and a barrier to exercise. Other reported barrier issues were weather, transportation, and personal safety. Another study by John and Ziebland (2004) examined barriers to increasing consumption of fruits and vegetables among participants in a randomized controlled trial in primary care. This study found a variety of barriers among different groups in the population. Women reported that their partners and children were barriers to their efforts to eat more fruits and vegetables. Individuals on limited incomes reported the cost of fruits and vegetables as barriers. Some members of the population reported unexpected changes in their daily routines as unanticipated barriers to fruit and vegetable consumption. Participation in a cardiac rehabilitation program was reported by men and women to be hindered by concomitant illness, lack of transportation, and inconvenient timing of the program (Lieberman et al., 1998).

Minimizing Barriers

Management support can help to minimize barriers to participation by placing high priority on a comprehensive program supporting worker health, with the same levels of support communicated for different groups of workers. It is also important to examine ways to structure programs around the schedules of line workers, bringing programs to their work areas, or scheduling programs during break times (refer to Chapter 2 for discussion of workforce composition).

Health Education and Awareness Activities

Health education and awareness activities take many forms, ranging from hard-copy literature dissemination to web-based resources and tools; and labor-intensive activities such as “brown-bag” or “lunch and learn” seminars or health fairs. These are useful means for increasing awareness,

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
×

are low in cost, and are popular with employers as starting points for dialogue with employees about health issues. However, these are not particularly effective as isolated activities in promoting any meaningful health behavior change (Robbins et al., 1987; Erfurt et al., 1991; Heaney and Goetzel, 1997). If on-site medical personnel are available, referral for additional support or case management can be made. Provision for privacy protection and the safeguard of protected health information are essential in these intervention activities. Increasingly, prevention efforts are being linked to medical benefits and health plans as either components of the coverage or incentives for willing participants (Stein et al., 2000; Lewis et al., 1996).

Health education programs include both worksite-wide initiatives, and efforts designed for helping individual workers make health behavior changes (Moher et al., 2003; Sorensen, 2000). The impact of a particular program is a product of both its efficacy in changing behavior and its reach, that is, the proportion of workers affected either through their direct participation, or indirectly through diffusion of health messages throughout the worksite (Abrams et al., 1996; Glasgow et al., 1999). Programs targeting individual workers have been found to be more efficacious in changing workers’ health behaviors (Moher et al., 2003). The overall impact of comprehensive worksite-wide programs may actually be greater, however, given that these programs aim to reach a broad audience within the worksite, and may have an impact on social norms and social support, thus creating an overall climate supportive of worker health (Hunt et al., 2005; Hunt et al., forthcoming). Regardless of whether programs are delivered one-on-one to individual workers or to groups of employees, it is important that programs are employee-centric, and are designed accordingly, to respond to worker priorities, concerns and readiness to make health behavior changes.

Opportunities for Integration

As described in Chapter 3, to create and support a healthy and productive workforce, integrated health programs must move toward programs that are integrated across multiple functions in the work organization rather than segregated within “silos,” and that are employee-centric rather than driven by employer priorities. Figure 4-2 illustrates the functions within the organization that can be integrated in order to promote and sustain worker health, ranging from health risk appraisals to behavioral health programs, disease case management, and occupational safety efforts; examples are given in the figure legend. Thus, an integrated approach to improving the health of employees involves going beyond traditional medical or occupational health to include a variety of fitness and

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
×

wellness programs, not as add-ons, but as integral components to a comprehensive approach.

As described in Chapter 4, an increasing number of companies within the United States are adopting integrated strategies to promote worker health. A growing body of research is systematically assessing the effectiveness of these approaches (Sorensen et al., 2004). For example, the WellWorks-2 study, a randomized, controlled study comparing the effectiveness of an integrated health promotion/occupational health program with a standard intervention, asked the question, “Does the integration of worksite health promotion and occupational health and safety programs increase program effectiveness over and above health promotion alone?” (Sorensen et al., 2002). The study design included 15 mid- to large-size manufacturing worksites, randomly assigned to receive either Worksite Health Promotion (HP) only or Worksite Health Promotion plus Occupational Safety and Health (OSH/WHP). The study hypothesized a priori that the integrated intervention would have the most relevance to workers in hourly positions where exposures to hazards on the job were more common than among salaried jobs. Smoking cessation rates among hourly workers in the OSH/WHP condition more than doubled relative to those in the HP condition (11.8 percent compared to 5.9 percent; p=0.04), and were comparable to cessation rates of salaried workers. This study also found that worksites in the integrated intervention group made statistically significant improvements in their health and safety programs compared to HP only sites (LaMontagne et al., 2004). Worker participation in intervention programs was also significantly higher in the integrated intervention condition than in the traditional health promotion condition (Hunt et al., forthcoming). This intervention targeted both the individual worker and the organizational level, through managers.

This total health strategy can be targeted on multiple levels. The social-ecological approach to worksite-integrated health provides a framework for thinking about health decisions as being influenced by multiple systems, including environmental and behavioral (see Figure 3-2). Integration of these functions thus occurs across the multiple levels.

At the organizational level, staff members working to promote worker health across these multiple domains can be effectively located in a single office to encourage coordination across content areas and functions. Additional staff training may be needed to effectively coordinate and integrate the diverse worksite functions influencing worker health. For example, the separate training programs for health educators and occupational health and safety professionals share little in terms of curricula and intervention methodology (Israel et al., 1996). Health promotion providers may not be trained to recognize and understand workplace health and safety hazards, for example, while occupational health

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
×

and safety professionals may have little training on worker health behavior. An expanded vision for worker health might be offered through joint training across worksite personnel responsible for worker health.

At the individual level, prevention programs such as those described below may also be enhanced through integration of content areas. As discussed above, for example, the WellWorks-2 intervention included educational messages to workers about the importance of smoking cessation in the context of hazardous job exposures, which together could increase risk for adverse health events. Such approaches build on opportunities for synergism across risk areas.

PREVENTION PROGRAMS

Prevention efforts include those aimed at health behaviors (such as nutrition, physical activity, tobacco use, and stress and mental wellness); prevention through medical surveillance, and preventive care services. It is important that these efforts be based on assessments of employee health, as through HRAs, and that programs aim not only to improve health outcomes among high-risk employees, but also to maintain and support health among low-risk workers.

Health Behavior

Once an employee’s health risks are identified and their willingness to change determined, these programs provide the means for employees to take action and modify their health behavior. Lifestyle risk management programs can be offered in several formats, and often a combination of approaches is more effective in helping individuals make changes. Provision for privacy protection and the safeguard of protected health information are essential in these intervention activities. Increasingly, lifestyle modifications pertinent to health are being linked to medical benefits and health plans as either components of the coverage or incentives for willing participants.

Nutrition

Trends in Dietary Intake. Nutrition concerns in the American population have shifted away from adequacy of intake and toward over-consumption of food as well as choices with an impact on the nutritional quality of diets. Current trends in food consumption patterns mirror the rise in health status issues. For example, nutrition-related health concerns include obesity and related chronic disease such as diabetes (Fried et al., 2003). Thus, trends in U.S. food consumption patterns are important de-

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
×

terminants of employee food selection in the workplace that may contribute to the health status of the workforce.

To illustrate, during the 30-year period from 1970 to 2000, mean energy intake increased among adults and was matched by steady increases in the prevalence of overweight. Factors contributing to this increase in intake included a greater percentage of meals eaten away from home (especially at fast-food restaurants), larger portion sizes of foods and beverages, increased consumption of sweetened beverages, and changes in snacking habits (Briefel and Johnson, 2004).

Food availability in the workplace can have an impact on food choices and thus the overall health of individuals. Among food selection patterns that fall short of the U.S. Dietary Guidelines are intakes of fruits, vegetables, and dairy products. By the Dietary Guidelines standard, only one in ten people in the United States has a “good” diet (Briefel and Johnson, 2004). Cafeteria choices as well as availability of “healthy” foods in vending machines for snacking and late afternoon or evening meals can contribute to the choices made by individuals at work.

Individual-Level Programs. The Next Step intervention trial assessed nutrition interventions to increase low-fat, high-fiber eating patterns among high-risk automotive industry employees (Tilley et al., 1999). This study showed small but statistically significant intervention outcomes for fat, fiber, and fruit and vegetable intake at 1 year; however, at 2 years, intervention outcomes were significant for fiber only, and were greater in younger compared to older employees. Similarly, interventions to improve fruit and vegetable consumption among callers to the National Cancer Institute’s Cancer Information Service showed significant results at 4 weeks, 4 months, and 12 months post-intervention, although the number of servings consumed daily was smaller at 4 and 12 months compared to 4 weeks (Marcus et al., 2001).

Several studies of worksite nutrition interventions have been offered across multiple levels of influence. One such example is the Treatwell 5-a-Day, which tested an intervention designed to increase fruit and vegetable consumption (Sorensen et al., 1998; Sorensen et al., 1999). Worksites were randomly assigned to the following interventions: minimal, worksite, or worksite-plus-family. Workers in the worksite-plus-family intervention increased their intake of fruits and vegetables by 18 percent on average, compared to a 7 percent increase in workers enrolled in the worksite-only intervention, and no change in the control condition (Sorensen et al., 1999). Change in the worksite-plus-family intervention represented a significant increase of one-half serving per day more than the minimal intervention group.

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
×

The Working Well Trial addressed nutrition within the context of a comprehensive cancer prevention intervention that addressed multiple health behaviors across multiple levels of influence (Sorensen et al., 1996b). The intervention programs tested included a kick-off event, interactive activities, posters and brochures, self assessments, self-help materials, campaigns and contests, and direct education.

A follow-up study was conducted to examine whether the nutrition interventions from the Working Well Trial were maintained (Patterson et al., 1998). The results of the study indicated a significant increase in nutrition activity scores at the end of the initial trial; however, at two years after the initial trial there was no significant increase in the nutrition activity scores of trial subjects and no significant difference between trial subjects and controls. The nutrition activity scores were indicators of change at the worksite, or organizational level; that is, organizational changes sustained over time. There were no measures in this study of whether or not health behaviors were sustained over time.

Environmental-Level Programs. Opportunities exist at the environmental level to facilitate healthful nutritional choices at the worksite. Environmental strategies to promote healthy eating are an important part of improving health behaviors. These strategies are valuable because they create opportunities for action to improve food selection and remove barriers to following a healthy diet. These strategies can be used in conjunction with individually-directed educational programs or they can serve as stand-alone interventions.

Glanz and Mullis (1988) reviewed environmental approaches to dietary behavior change. They identified four strategies for public health practitioners and researchers to consider in designing, implementing and evaluating nutrition behavior change programs:

  1. Health professionals must work collaboratively with the food marketing chain to promote healthy products.

  2. Appropriate scientific data must be gathered to support decisions about identifying desirable foods and food products and to identify the criteria upon which such decisions are based.

  3. Program plans need to take into consideration the time needed on the part of participants to accept and realize behavior change.

  4. Nutrition programs to improve health can contribute to long-term social change by exerting pressure for cultural change, and through stimulating and supporting private sector health promotion initiatives.

Five intervention programs were also described by Glanz and Mullis (1988). They include:

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
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  1. Changes in the food supply;

  2. Point-of-choice nutrition information;

  3. Collaboration with private-sector food vendors;

  4. Worksite nutrition policies and incentives; and

  5. Changes in the structure of health and medical care related to nutrition.

For example, more healthy food choices can be offered for sale in the cafeteria as well as provided for meetings, and in the variety of selections offered through vending services (French et al., 1997, 2001). In addition, opportunities to restructure the environment in which food is consumed include modifying the timing of cafeteria hours of operation, lunch periods and breaks. Healthful foods can be made available in convenient locations (Sorensen et al., 2004), at appropriate times and at an equal or lower cost than less healthful foods (Perlmutter et al., 1997; Buscher at al., 2001; Glanz and Hoelscher, 2004).

Decision-making in worksite food selection can also be influenced by signage that identifies healthful food choices (Sorensen et al., 2004). These decisions can be further supported by coordinating programs to support individually-oriented interventions with policies such as catering policies that encourage healthful choices or policies encouraging availability together with access to fitness programs. Marketing campaigns to promote healthy food choices can include promotions and campaigns that offer subsidies or other incentives to encourage healthful choices (Resnick et al., 1999).

Nutrition intervention strategies can further serve as a model for other types of health promotion activities in large populations such as the NASA workforce. For example, the Seattle 5-a-Day Work-Site Project utilized the approach of influencing policies related to food availability in a worksite cafeteria to achieve dietary behavior change (Beresford et al., 2000). The combined environmental and individual intervention reduced barriers for change through increased availability of fruits and vegetables in the worksite, and included informational and organizational support. The program outcome was a significant increase in fruit and vegetable intake and increased use of informational materials, compared to control sites, at a 2-year follow-up.

Physical Fitness Programs

Trends in Physical Activity. Over the past century, as the workforce has changed from agrarian to industrial to technological, the energy expended at work has declined drastically for most employee groups. Physical activities have not been added to most leisure routines to make up for the

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
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decrease in physical activity at work, and interest in physical activity to maintain good health seems to have peaked in the 1980s (Shephard, 1996).

The concomitant rise in the level of obesity in the last decade has been alarming, and obesity-related diseases may pose a threat to the health care system (Mokdad et al., 2003). In 2000, only 26 percent of U.S. adults engaged in moderate intensity physical activity for 30 minutes a day on most days of the week (CDC, 2003). Males, and those of higher socioeconomic status, are generally reported to have greater access to fitness facilities and neighborhood environments friendly to physical activity (Brownson et al., 2001).

Individual-Level Programs. Individual-level approaches include both informational and educational strategies, as well as behavioral and social activities that are targeted to promote increases in physical activity. Also included is the use of “mass media” which, in the case of worksites, would include newsletters, Internet sites, bulletin boards, and other dissemination channels to provide messages to encourage and promote health and physical activity. An additional strategy is the “point-of-decision” prompt, such as signs near elevators to encourage stair use. Incentives, contests, and other promotions targeted to individual behavior have also been found to be effective in worksite settings (Sorensen et al., 1998, 2004). Worksite social support systems can also be set up to facilitate activity groups to form, such as walking and sports clubs that promote physical activity.

An emerging consumer-friendly program for physical activity involves walking programs that include a pedometer. A pedometer is a step-counting device that objectively measures daily physical activity by step counts. Since it displays the number of steps taken at any time throughout the day, it provides a visible cue to obtain more physical activity as a continuous feedback mechanism. Hence, it is also considered a strong motivational tool for physical activity promotion, as well as being easy to use and inexpensive. Several programs have become widely available throughout the United States, many of which include websites that allow participants to track their progress (Lindberg, 2000; Pronk, 2003a; Wyatt et al., 2004). Box 5-1 provides a sampling of popular pedometer programs.

Research shows that the pedometer is an accurate tool to monitor physical activity when walking at normal to fast walking speeds (2.0 mph and up) (Melanson et al., 2004). In addition, the number of daily steps is related to health outcomes. First, there appears to be an inverse, although not causal, relationship between the number of daily steps and body mass index. This relationship has been noted among middle-aged women (Thompson et al., 2004), people with type 2 diabetes (Tudor-Locke et al., 2002), and older adults (Yamakawa et al., 2004). Secondly, an inverse rela-

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
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tionship has been noted between the number of daily steps and components of the metabolic syndrome i.e., blood pressure, blood lipids, and glucose tolerance, among adults (Chan et al., 2003).

Environmental-Level Programs. Environmental approaches include those that alter the worksite to facilitate movement and physical activity at work (this would include facilities such as fitness centers and shower facilities that encourage activity), as well as outreach for these programs.

Reported barriers to physical activity are lack of time, motivation, and access to fitness facilities (Brownson et al., 2001), thus worksite fitness programs provide a logical solution to increasing activity levels in the daily lives of the working public. Fitness facilities at the worksite are an important component of Occupational Health programs. However, published data on workplace fitness center utilization shows that overall utilization rates tend to be low relative to total worksite populations (Shephard, 1992; Lewis et al., 1996; Crump et al., 2001), and this appears to be true at NASA as well (see Chapter 2).

There are many reasons why on-site facilities attract certain users and not others, including dependent care and other worklife time conflicts; concern about supervisor perceptions of use during working hours despite flextime programs; the physical design, equipment, and programming of a center; self-consciousness and other socio-psychological issues related to fitness center clientele (Alexy, 1991; Bowles et al., 2002). Providing incentives to employees to increase their level of physical activity requires multiple interventions to meet the convenience, social, and personal preferences of individuals.

Following the framework of the social ecological model, the worksite offers opportunities to employees that encourage physical activity at individual and environmental levels. Interventions targeted to the environmental level have been defined as those that address availability, accessibility or social norms (Schmid et al., 1995). A supportive environment includes management encouragement for all employees to participate in

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
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corporate, and other, health and fitness facilities; and programming and other corporate policies that support health.

An emerging area of interest is in the relationship between the built environment and health. Research is ongoing to determine ways to design communities, which includes worksites, that promote health and fitness (Brownson et al., 2001; Frank et al., 2004). Concepts in community design to promote walking and activity, such as connectivity and proximity, may be applicable in work settings as well. Connectivity and proximity are related to the ability to walk to a destination such as a worksite. Workplaces that are located within walking distance of neighboring communities, and have no major barriers such as turnpikes separating the site from neighborhoods, promote walking to and from work, therefore increasing activity levels of workers. Worksites that are located in safe areas near neighborhoods, with sidewalks, walking trails or bike paths, or near mass transit routes such as bus and train stops also facilitate worker physical fitness. Workers who must drive to work lose these opportunities for physical activity. Healthy worksites include multiple opportunities for physical activity, including fitness centers, safe walking distance to neighborhoods, and proximity to open areas and parks that facilitate safe, pleasant physical activity during the work shift (Frank et al., 2003).

NASA work sites offer a remarkable array of open areas on the grounds, with miles of walking and jogging trails—in some cases, through wildlife preserves. Additional programming to encourage utilization of this valuable NASA resource could increase employee physical activity. The Task Force on Community Preventive Services has found a multilevel approach for increasing physical activity to be supported, for the most part, by research (http://www.thecommunityguide.org/). Research generally suggests positive benefits can be obtained from fitness facilities and programs (Shephard, 1996; Brownson et al., 2001). Findings include that participants in worksite fitness programs show evidence of decreased obesity and overall benefits in health and fitness measures, reduced illness and injury, and cost savings from medical claims (Shephard, 1996). However, these reports remain inconclusive and difficult to interpret because of the lack of common measures and methodological problems.

Tobacco Use

Trends in Tobacco Use. The overall prevalence of tobacco has been in decline in the United States (CDC, 2002). Of concern, however, are persistent disparities in use and cessation. Tobacco use differs markedly by occupation. In 1997, 37 percent of men employed in blue-collar occupations reported using tobacco, compared to 21 percent for men in white-collar positions; for women, the rates were 33 percent and 20 percent, respectively

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
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(Giovino et al., 2000). Barbeau et al. (2004) found that occupation, education, and income were independent correlates of tobacco use rates; other indicators of socioeconomic position were not found to explain these occupational disparities. Smoking rates are also declining more slowly among blue-collar compared to white-collar workers (Nelson et al., 1994). Although there does not appear to be a socio-economic gradient in quiting attempts, success with quitting is highest among those with the greatest socio-economic resources (Barbeau et al., 2004).

Individual-Level Programs. At the individual level, worksite smoking cessation initiatives aim to help smokers quit smoking. Smoking cessation programs include a range of strategies, ranging from smoking cessation clinics or classes, medical interventions, minimal intervention programs, incentives and competitions, and social and environmental supports. The full range of programs is important to a worksite-wide tobacco control program, because the combination of strategies increases the chances of influencing smokers at varying stages of readiness to quit smoking (Eriksen and Gottlieb, 1998; Sorensen, 2000; Hopkins et al., 2001).

Worksite smoking cessation interventions directed toward individual smokers, including advice from a health professional, individual or group counseling, and pharmacological treatment, can contribute to increases in smoking cessation (Moher et al., 2003). The Public Health Service’s Treating Tobacco Use and Dependence guidelines (USDHHS, 2000b) provide a standard of care for all tobacco control interventions, and recommend brief counseling with pharmacological treatment. Many worksites offer the same types of smoking cessation programs originally developed and offered in clinical settings, or, in some cases, provide referrals to clinic- or community-based programs, such as those of the American Cancer Society or the American Lung Association; for-profit programs (e.g., Smoke Enders); or health care organizations (Fielding, 1991).

Minimal-contact interventions often are used to promote smoking cessation among those not yet ready to quit, or to provide help with quitting for those not willing to invest time and energy in a group cessation program. Minimal-contact interventions may include promotion of a telephone help line or the Great American Smoke-out, self-help interventions such as written materials and short videos, and assessments with feedback, such as carbon monoxide assessments.

Within the context of a worksite-wide tobacco control program, minimal-contact intervention strategies may serve to engage smokers in thinking about quitting, increase participation in group programs, and support worksite norms encouraging non-smoking (Eriksen and Gottleib, 1998). Such efforts may include incentives to promote smoking cessation, whether monetary or non-monetary. For example, employers have often

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
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provided monetary incentives for quitting and maintenance of tobacco abstinence, including reduction in the cost of participation in a smoking cessation program; bonuses or payments for smoking cessation; or differential premiums for health or life insurance benefits (Fielding, 1991). There is limited evidence about the extent to which competitions and incentives increase employee participation in programs (Moher et al., 2003). As noted above, studies by Sorensen and colleagues have found that programs which integrate occupational health and safety and tobacco control are able to increase smoking quit rates for blue-collar workers (Sorensen et al., 1998, 2002).

Environmental-Level Programs. Tobacco control policies are designed both to protect non-smokers from the hazardous effects of second-hand smoke and to promote an environment supportive of non-smoking. Tobacco policies are a key component of an overall workplace tobacco control effort, and are central to supporting smoking cessation among workers. Worksite policies on tobacco have been shown to decrease worker exposure to environmental tobacco smoke (Stillman et al., 1990; Marcus et al., 1992; Hammond et al., 1995) and contribute to worker reductions in smoking, including quitting (Paulozzi et al., 1992; Kinne et al. 1993; Woodruff et al., 1993; Brigham et al., 1994; Pierce et al., 1994; Eriksen and Gottlieb, 1998). A recent review concluded that tobacco policies and bans are able to reduce workers’ tobacco consumption and non-smokers’ exposure to second-hand smoke during the workday, but found conflicting evidence about the impact of the policies on overall tobacco use prevalence (Moher et al., 2003). Employer efforts to promote compliance with smoking policies can contribute to an overall climate supportive of non-smoking (Sorensen et al., 1991). The effectiveness of worksite tobacco control policies are clearly enhanced when smoking cessation programs are offered as supporting measures.

Alcohol and drug abuse are also frequent problems among workers, and awareness of this in the workplace is important. Information campaigns based on the risks of alcohol and drug abuse can help keep employees informed (Saitz, 2005). Management education in recognizing potential problems and making appropriate referrals can be a useful approach for reducing workplace substance abuse.

Stress, Mental Wellness, and Performance

Trends in Stress, Mental Wellness, and Performance. The scientific definition of stress must include the stressor, the perception of it by the individual, and the individual’s subsequent mental and physiological reactions. These different facets of what we popularly combine and consider as “stressful”

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
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must all be taken into account when evaluating the impact of stress on an individual or organization. In evaluating the impact of stress at NASA two forms of stress, chronic and acute, should be considered. Chronic and acute stress may have different causes, may induce different reactions, and may have different implications for health and disease.

Chronic stress occurs over the time frame of years and is thought to contribute significantly to mental disease (e.g., Zuckerman, 1999) as well as chronic physical diseases, most particularly cardiovascular disease (Henry and Stephens, 1977; Sharpley and Gardner, 2001; see also brief review from workplace perspective, Rosenman, 1996). Situational factors, such as living or working in overcrowded settings, may impose chronic stress on an individual. Episodic but repeating incidents can also create chronic stress, e.g., day-by-day hassles or on-going conflict with co-workers or supervisors (Lazarus, 1991a,b). Individuals vary in their affective and physiological responses to such stressors, such that only some individuals may be placed at risk for disease from comparable exposures. Factors such as poor communication and interpersonal difficulties at the workplace can foster a chronic exposure to acute stress.

The pattern of physiological reactions induced by these chronic stressors has been conceptually related to cardiovascular disease by Krantz and Manuck (1984), and Treiber et al. (2003) reviewed supporting evidence. Most recently, prospective evidence has related blood pressure reactivity to transient challenges to both hypertension (Matthews et al., 2004) and coronary heart disease (Jennings et al., 2004). These demonstrations of the importance of stress to development of disease, however, neither identify specific psychophysiological mechanisms contributing to disease nor identify the bulk of the contribution of stress generally associated with disease.

Acute stressors are episodic threats to a person’s or organization’s achievement of goals. In the workplace context, these could be unpleasant exchanges with a colleague or a challenging deadline for task completion. The person typically feels stressed and will adjust to the stress through psychological processes altering the threat rationally or irrationally, through coping processes, or through behavior that may resolve the stress (Lazarus, 1991a). The physiological changes accompanying such stress can be energizing despite the potential for harm (Sapolsky, 1994). Acute stress can lead to both distress and poor performance, and excitement and energized performance. Energized performance can be useful but it can also be misdirected and not sufficiently guided by thought (Broadbent, 1971; Hamilton and Warburton, 1979; Eysenck, 1997).

Acute stressors pose a challenge to the organization, as productivity and employee morale may suffer. Acute stressors are, however, unavoidable, and not necessarily injurious to long-term health. Moreover, enhanc-

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
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ing general health and improving coping skills can yield an individual that is resilient and thus less affected by stressors. Preventing acute reactions to stress in employees and appropriately channeling responses to stress has short-term benefits that are readily realized in appropriately guided performance, and staff morale.

Addressing stress factors is appropriately done at a programmatic level through restructuring of the environment and training of individuals and groups, using a top-down process designed to create a work environment that eliminates unnecessary workplace stress and improves productivity. A current emphasis is to integrate health programs to yield a healthy individual that is resilient and ready to face the challenges of everyday, and more significant, mission stress. Rather than reacting to the stressed employee, individual and organizational prevention is advocated. The role of managers and supervisors is to take responsibility for effective communication, for balancing job demands and job control as well as effort and reward, and for recognizing workers who may require assistance in communication skills, social relations, affect control, or treatment of serious mental disorder. The role of the Employee Assistance Program (EAP) professional is to provide triage and train managers in the recognition of symptoms suggesting that an individual is experiencing significant problems. Training programs should focus on integrating both health practices and job productivity with health promotion. Group programs have been designed to induce positive mental health or focus on emotions in the workplace; unfortunately, such programs have not been proven to improve productivity (Slaski and Cartwright, 2003), and employees’ seeking emotional support on the job may be perceived as less productive (Bhanthumnavin, 2003).

Individual-Level Programs. Standardized stress-relief programs have a place in training the individual to cope with stress. Such programs, in conjunction with maintenance of overall health, create the resilient employee. For employees in their daily work lives, skills for increasing resilience can be taught. Some individuals seem naturally resilient (Kobasa and Puccetti, 1983), others work on resilience by enhancing general and emotional health. Much of our short- and long-term planning is directed at anticipating threats and providing ourselves with the capabilities to deal with them. Activities as diverse as buying a dead bolt lock and taking a course on time management could be considered as enhancing resilience. The typical stress program aims to reduce the physiological impact of stress (e.g., relaxation, meditation) or how to cope with stress (e.g., cognitive reframing, time management). Such training can often successfully reduce the impact of the stress on the individual’s physiology and psychological affect (McCraty et al., 2003). Even though these skills have been shown to

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
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be effective they require practice to maintain their efficacy, substantial initial investment in learning these skills, and a willingness to do both. Additionally, many individuals attempt to learn these skills only during or immediately after experiencing major stress rather than as long-term stress management skills. In short, programs in these areas can be helpful, but their impact may be limited. However, such programs may have greater effectiveness when made available as components of larger programs targeted at clusters of individuals, addressing stress concerns in conjunction with other risk factors.

Environmental-Level Programs. Acute stressors cannot be eliminated. Any individual or organization must face competitive challenges that can be defined as stressful, but which must be faced for the good of the organization or individual. Needless acute stress should obviously be eliminated, but stress is an aspect of life, and priority must be given to building resilience to stress, both individually and organizationally. Leadership and management can often increase resilience by considering a stressor as a challenge that a unit is prepared to meet. A basic resilience within organizations is conferred by positive affect/morale related to the organization.

George (1989) and George and Jones (1996), for example, found that high morale (positive affect) in an organization was an effective deterrent to absenteeism related to high levels of distress (negative affect). Cotton and Hart (2003) state that “…the simultaneous focus on employee health-related productivity (well-being) and performance recognizes the practical reality that having happy and satisfied staff is of little value to an organization unless staff are also performing efficiently and productively.”

The most relevant form of chronic stress is worksite stress created by a perceived imbalance between the demands of a position and the control over the work (Karasek, 1979; Bond and Bunce, 2001; Polanyi and Tompa, 2004), particularly with the added factor of Effort-Reward Imbalance (Bosma et al., 1998). Such stress seems consistently related to psychological and psychosomatic complaints as well as injurious health behaviors such as alcohol abuse (Terry and Jimmieson, 1999). Moreover, a number of studies have observed that job strain (high demands and low control) is associated with high risk for hypertension and cardiovascular disease (Landsbergis et al., 1999; Tsutsumi, 2001; Markovitz et al., 2004). As Terry and Jimmieson (1999) show in their review, however, job control has many dimensions, and these may buffer in different ways the influence of high work demands and may influence outcomes differently, e.g., absenteeism may be influenced differently than reported morale. They further note that third factors such as social support and personality differences may influence how job control and work demands alter worksite outcomes.

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
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Management training focusing on techniques to optimize communication, equitable workflow, and employee skills—thus balancing demands and control—should be a major focus of an integrated health and performance program. The organizational focus makes the manager responsible for facilitating communication, recognizing dysfunctional responses to stress, and generally minimizing acute stress that is due to organizational factors under his/her control. Occupational medicine and EAP then become partners with managers in the integrated health and performance focus. The primary role for occupational medicine is to develop, in conjunction with other NASA staff, the training program for managers (i.e., a program developed by and for NASA is advocated rather than use of contractors; see Chapter 4). Occupational medicine and EAP provide the professional backup for the manager and manage the resources for personal resilience. Occupational medicine and EAP professionals have the background training and knowledge that is appropriate to NASA, which should allow them to be the best trainers; however, they may require additional training to optimize their effectiveness in certain areas. This model adds productivity as a goal for EAP and occupational medicine personnel and brings them out to the workplace as part of their responsibility.

Prior programs have yielded positive results. Cotton and Hart (2003) review the success of such approaches. In addition, Bond and Bunce (2001) suggest that organizational resilience results from restructuring organizational command, control, and communication so employees have greater control of their jobs. Performance on the job has not been well evaluated as a function of such programs, however, and evaluating performance should be part of any new integrated health and performance program. The exact means for achieving the goals of such a program must be specific to both NASA as an organization as well as to individual work groups going through the program development process described in Chapter 4. NASA is composed of a truly strong and creative workforce that has the capacity for reorganizing itself to optimize both performance and human mental and physical health (see Box 5-2).

Preventive Services

Medical Surveillance Exams

Medical screening or surveillance is the periodic assessment of individual worker(s) in terms of occupational history, medical history, and symptoms and signs related to hazardous substance(s)/condition(s) exposure. Biologic screening is the periodic assessment of individual workers in terms of special investigations, e.g., blood or urine tests, related to

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
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BOX 5-2
Integrated Prevention Programs

NASA may effectively utilize the Health Risk Appraisal (HRA) along with additional assessment tools in the Total Health Management System (HMS) (see Figure 4-2) to design prevention programs tailored to meet both individual and group needs. All health promotion/prevention programs in the HMS would have an integrated core that emphasizes how health at home and work must include safety, good nutrition, stress reduction, exercise, and maintenance of positive social relationships. Analyses of integrated health management data obtained through the HMS could be used to identify risk profiles, e.g., exposure to safety hazards, alcohol and tobacco use, or nutrition and exercise patterns that place workers at increased risk for disease or disability. Prevention programs could then be designed to address, in a group setting, the needs of those workers with high risk profiles. Another outcome from the HMS assessment may be an individually tailored report, transmitted through a health advocate, that recommends one or more individualized programs to address the specific needs of a worker.

exposure to hazardous substance(s) or condition(s) (Zenz et al., 1994). The purpose of these examinations is to determine potentially harmful effects, both acute and chronic, from exposure to specific substances or environmental conditions. The periodic evaluation of people potentially exposed to certain hazards is required by some Occupational Safety and Health Administration (OSHA) standards; it is also considered standard practice for some job duties, according to professional guidelines and the OSHA general duty clause (McCunney, 2001).

Employees at NASA undergo a variety of surveillance exams, depending on their exposure. In industry, engineering controls are being put in place that may mitigate the need for surveillance exams, as exposures in the workplace are lowered. When non-mandated examinations are performed, these are frequently initiated by an employer’s occupational health and safety staff based upon local practice or “expert opinion.” Unfortunately, many such discretionary periodic examinations are initiated based on good risk assessments, but are rarely re-evaluated, resulting in an ever-expanding set of examinations, at least some of which may no longer be warranted. One of the tasks for NASA is to reassess its current screening program and look at the environmental hazards in the workplace to determine which exams need to stay in place and which can be eliminated. Health screening for the employees can be otherwise per-

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
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formed through the health risk appraisal, with appropriate referrals to a physician for identified conditions.

Periodic Health Examinations

There are two broad categories of examinations frequently offered to employees at the worksite: general periodic health examinations and occupational health examinations. While in some cases these two examinations are specifically designed to be complementary and synergistic, for most employers these are designed and managed separately and toward very different objectives. Employers who offer periodic health examinations in the context of a broad health and wellness program must insure that the results of the examinations are linked to the employee’s ongoing source of primary care for follow-up of findings. Helping employees understand the usefulness of periodic health examinations is the first step. With the employee’s approval, available personal health information can then be communicated to the physician.

Periodic health examinations consist of evidence-based clinical preventive services, defined as screening tests, counseling interventions, immunizations, and chemoprophylaxis. The U.S. Preventive Services Task Force (USPSTF), sponsored by the Agency for Healthcare Research and Quality, is the leading independent expert panel in prevention and primary care (http://www.ahrq.gov/clinic/uspstfix.htm). The USPSTF conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of various clinical preventive services. The panel, consisting of private-sector experts, regularly reviews and grades the evidence of effectiveness for clinical preventive services based upon age, gender, and risk status and uses a consistent and rigorous hierarchy of evidence in deriving its recommendations.

Periodic health examinations represent “teachable moments” to not only identify risk factors for morbidity and premature mortality but also to educate and promote primary preventive behaviors. Specialty organizations (e.g., American Academy of Pediatrics, American College of Physicians) and public (e.g., Advisory Committee on Immunization Practices [ACIP]) and private voluntary organizations (e.g., American Heart Association, American Cancer Association) provide patient and professional information about health examinations.

Immunizations

Offering annual “flu” immunization programs has been the mainstay of many worksite wellness programs. Influenza can have a considerable effect on the health of working adults and thus a significant impact on

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
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employers, resulting in millions of lost workdays and health-care-provider visits each year (Nichol, 2001). Lynch et al. (2004) focused on health activities and found that 90 percent of employers surveyed were offering flu shots to reduce absenteeism.

Numerous studies have been done that demonstrate the cost effectiveness of worksite flu immunization programs. Nichol et al. (1995) showed that immunization decreased the frequency of upper respiratory illness by 25 percent; absenteeism from work due to upper respiratory illness by 43 percent and due to all illnesses by 36 percent; and visits to physicians’ offices for upper respiratory illness by 44 percent. The results of this study demonstrated a cost savings of $46.85 per person vaccinated. Many NASA sites offer immunization programs and the continuation of these is certainly supported by the literature.

DISEASE, DISABILITY, AND INJURY MANAGEMENT PROGRAMS

On-Site Medical Clinics

Acute Care

Acute care onsite occupational health clinics traditionally provide treatment for injuries or illnesses occurring due to a work experience or exposure. Most onsite clinics also provide basic treatment for minor nonoccupational illnesses, such as headaches, gastrointestinal distress, and blood pressure monitoring. One occupational health clinic, though, has taken on the primary care treatment of employees, therefore offering an opportunity for them to seek care but not have to leave the workplace and take time away from work. This approach has proven effective in circumstances where the workplace is remote from usual providers of care, where even short periods of absence from a workstation can cause significant production shortages, or where occupational health is part of the health plan for workers and dependents with on-site facilities.

Disaster Preparedness and Emergency Response

The terrorist attacks of September 11, 2001, anthrax attacks of 2001, the threat of pandemic SARS and avian influenza, and natural disasters including Florida hurricanes in 2004 that damaged the Kennedy Space Center, have heightened awareness regarding the need for disaster preparedness and emergency response. Because of the heightened visibility and national security aspects of the NASA mission, NASA facilities must be prepared for any natural or man-made disaster and be self-sufficient in

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
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response to any emergency. The last five years have seen the development of the Department of Homeland Security; a major expansion of funding for federal, state and local preparedness programs; the development of the Strategic National Stockpile (SNS); the Health Alert Network (HAN); and the Cities Readiness Initiative (CRI). The Department of Health and Human Services, through its Office of Public Health Emergency Preparedness (OPHER) and through the Centers for Disease Control, has provided direction and funding for public health preparedness through state and local health departments (Hupert et al., 2004).

Other federal agencies have been charged with the development of their own disaster preparedness and emergency response programs consistent with their mission, location potential for population center impact, and coordination with local and state authorities. State health departments and departments of homeland security, assisted by CDC-funded university-based centers for public health preparedness, have provided preparedness information, training and exercises. Emphasis has been placed on collaboration between public safety, public health and health-care facilities and providers within communities; preparedness training for all sectors; scenario execution for man-made and natural disasters; and prospective evaluation of programs at all levels.

Integrated Disease Management, Counseling, and Monitoring

Disease management programs are typically part of health benefits plans, either as components of health plan coverage or as stand-alone programs provided by a separate vendor. These programs are intended to identify individuals with specific diagnoses to whom special services are offered to improve self-care, treatment plans, care coordination among providers, and medical and cost-of-care outcomes. Common target diseases for these programs include cardiovascular disease (coronary artery disease and congestive heart failure), diabetes, asthma and chronic obstructive pulmonary disease, depression, chronic low back pain syndromes, and some cancers. Although clinical and functional benefits have been demonstrated for many of these condition management programs, few organizations have capitalized on this vast opportunity. Adverse morbidity and productivity impacts of prescription drug utilization such as antihistamines or migraine medications have been shown to be substantially reduced by aggressive workplace health initiatives that integrate health benefits utilization experiences into their worksite health processes.

Evidence for reduced medical claims costs attributable to these programs also exist for some programs (Musich et al., 2004). Goetzel et al. (1998b) used the Health Enhancement Research Organization (HERO) database to analyze relationships between the status of ten modifiable

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
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health risk behaviors and medical expenditures. The results indicate important relationships between most of the risk factors analyzed and health care costs.

Mental Health and Substance Abuse Treatment

Occupational medicine and its Employee Assistance Program (EAP) component at NASA provide professional services for individuals suffering from stress and substance abuse, as well as providing stress-reduction education. At the workplace, a number of individuals will experience mental illness and acute episodes of psychologically-driven incapacity. Cotton and Hart (2003) suggest that these cases are best treated (through EAP and professionals accessed through employee medical plans) with state-of-the-art individualized treatments, as opposed to standardized stress relief programs (e.g., relaxation, meditation). The latter can be effective as a preventive program (e.g., McCraty et al., 2003), but are likely ineffective with a severely stressed person or someone suffering from mental disease.

Individuals reporting significant stress may also suffer from significant mental disease. Individuals with substance abuse problems may similarly present themselves as severely stressed. Severe cases and those showing significant symptoms of mental disorders or substance abuse (DSM IV) should be identified by managers or co-workers, if they are not self-identified, and referred to professional EAP staff. Individualized treatment plans administered by EAP and/or health plan providers should then be initiated as appropriate. Although the Committee did not find evidence that drug and alcohol abuse were a specific problem at NASA, their incidence is likely similar to that in other comparable workforces. Alcohol continues to be a major drug of abuse, although use in moderation may confer limited health benefits (Saitz, 2005).

Basic health education should ensure that employees understand when substance abuse becomes a problem. These signs are self-evident—e.g., lost work time, marital difficulties—but require reinforcement so the employee can recognize and ideally admit to having a substance abuse problem. As part of an integrated health program, maintenance of a healthy social environment at work should remove some of the incentives for abuse, e.g., drinking to alleviate experiences of stress and anxiety. In situations where drug and/or alcohol abuse become apparent at the worksite, EAP staff should work with managers to identify and educate individuals who may benefit from professional services, and to facilitate referral to the appropriate level of care if treatment is deemed appropriate.

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
×

Prevention of alcohol and drug abuse must focus as much or more on maintaining abstinence in persons with a history of abuse. Many effective programs and therapies are available for individuals with substance use disorders. In addition to referral for professional treatment, employees with alcohol or drug abuse issues can be provided information about mutual support groups such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) and encouraged to attend these programs. AA or NA is often used in conjunction with professional therapy, and after completion of therapy as an ongoing form of support. Employees with drug abuse or dependence problems also benefit from a comprehensive program that includes treatment, self-help such as NA, and urine monitoring.

Disability Management Programs

Disability Management

Another component of employee integrated health programs is disability management across both occupational and nonoccupational settings. Disability management (also referred to as return-to-work-programs) can be defined as a proactive, employer-based approach to prevent and limit disability; provide early intervention for health and disability risk factors; and foster coordinated disability management administrative and rehabilitative strategies to promote cost-effective functional restoration and return to work (Habeck et al., 1991; National Institute of Disability Management Research, 2000; Williams and Westmorland, 2002). Disability management is a collaborative approach involving labor-management support to implement programs to reduce the impact of disability on the workplace (Westmorland et al., 2002). Best practice in disability management includes the integration of fitness-for-duty and return-to-work programs, Federal workers’ compensation, long- and short-term nonoccupational disability programs, sick leave/ incidental absence, Family and Medical Leave Act (FMLA) and Americans with Disabilities Act (ADA)-related workplace accommodations and Employee Assistance Programs.

Linking these programs with health risk assessments, lifestyle risk management, and disease management programs has the potential to help return employees to full functionality in a much more timely manner. When determining how to manage absenteeism, employers should carefully consider the impact that health promotion programs can have on rates of absenteeism and other employee-related expenses. Aldana (2001) found that the majority of studies tend to support the hypothesis that employees who participate in worksite health promotion programs have lower subsequent levels of absenteeism than non-participating employ-

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
×

ees. Reductions were found to be approximately 3 percent to 16 percent and were found towards the end of the evaluation periods (Aldana, 2001). This points to the fact that health promotion programs may take some time to demonstrate effects on disability, and to be successful, they will need to continue to be reinforced over time. Serxner et al. (2001) found that participation in a worksite health promotion program for a large telecommunications company had a significant impact on short-term disability (StD) use. Employees receiving StD who were participants in the health promotion program used an average of 6 fewer net days than similar employees receiving StD who were not participants in the program. At this point, NASA has not undertaken an organization-wide disability management program; opportunity exists to more proactively return employees to full functionality and work, if designed cooperatively with health improvement programs.

Measuring productivity is more complex than counting absent and disability days. The complexity comes with the realization that not all absent employees are automatically unproductive, and not all present employees are automatically 100 percent productive. Isolating the components of absenteeism, disability, workers’ compensation, and presenteeism has facilitated a closer examination of the impact of health risks on overall productivity (Edington, 2001).

PROGRAM EVALUATION

As programs are implemented, the “checking and corrective action” step in the Cycle of Continuous Improvement (see Figure 4-1) ensures that evaluation is a core component of all programs and services provided to NASA employees. This checking and corrective action step would include a model, such as that described by Ozminkowski et al. (2004), for ensuring NASA a return on its investment in the programs that can be tailored to the full cost accounting effort already in place. Considering evaluation an integral part of every program will support a data-driven approach to programming and is consistent with the continuous quality improvement methodology (Langley et al., 1996; Ozminkowski and Goetzel, 2001).

Overall program impact may be evaluated using data collection tools that are not necessarily program specific, e.g., HRA data collection and analyses. This type of evaluation will indicate, for example, that the numbers of risk factors present in the population have improved over the course of the year due to the integrated health program, or that physical activity levels have increased in response to all programming that was made available throughout the course of the year. However, these data are not specific to individual program effectiveness. Hence, integration of

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
×

an evaluation step for each single program is needed to make sure that the programs themselves generate the anticipated improvement in health status for the intended audience. This approach to evaluation has to be efficient, low-cost, and above all, meaningful to the program staff. The measures should be embedded in the program implementation processes so that data collection is ongoing, and allow for as close to real-time feedback and analysis as possible. The measures should be few, simple, easy to collect, and inclusive of process and outcome variables. A more indepth description of this type of measurement approach is outlined in Table 6-1 under the Improvement column.

Important features of program evaluation to consider include a clear definition of the intended audience of the program, the degree to which the intended audience was reached, whether or not the program was implemented according to plan, and the assessment of desired outcomes. Specific variables to be collected are directly dependent upon the goals and objective for each unique program but should certainly include program reach, participation, and satisfaction. Ideally, reach and participation should be reported as a rate, i.e., an appropriate denominator needs to be identified for every program implementation effort. Absolute numbers are less informative than rates, especially considering issues such as program scalability and sustainability that underscore the importance of implementation efficiency and resource utilization on a program-by-program basis.

The process to conduct program evaluations is in itself an important consideration as well. The evaluation approach should be consciously planned, data to be collected need to be carefully considered, the analysis methods need to be appropriate to the evaluation approach, results need to be reported to the appropriate stakeholders, and the implications of the results need to be used for ongoing program improvement. All this needs to be considered in the context of appropriate use of resources available (McKenzie and Smeltzer, 2001).

Pronk (2003b) outlined an approach to program evaluation based on a set of simple rules. This approach represents a multi-level cascading model that systematically monitors program Penetration, Implementation, Participation, and Effectiveness (PIPE), and assigns a coefficient to each of these four steps. The product of the four coefficients describes the overall program impact and is referred to as the PIPE Impact Metric (see Table 5-1). To illustrate the PIPE Impact Metric using an example, consider a physical activity program designed to increase walking behavior among all NASA employees being announced and communicated to all employees. Subsequently, all employees would be invited to participate in the program, all program-related tools and support components necessary for employees to succeed would be made available, and a monitor-

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
×

TABLE 5-1 The PIPE Impact Metric

 

Variable

Variable Definition

Rate Calculation

Coefficient

P

Penetration

The proportion of the target population that is reached with invitations to engage in the walking program

10,000 of 10,000 employees reached = 10,000/10,000

1.0 (100%)

I

Implementation

The degree to which the program has been implemented according to the design specifications and the associated work plan

Following review, program staff concludes that 80% of the work plan was implemented

0.8 (80%)

P

Participation

The proportion of invited employees who enroll in the program according to program protocol (e.g., signed up via a website specifically created for this program or enrolled via a mail-based method)

2,000 employees enrolled = 2,000/10,000

0.2 (20%)

E

Effectiveness

The rate of successful participants. The criterion for success is set prior to program rollout and should be directly related to the program goals and objectives. For example, all participants who achieved 10,000 steps of walking per day at the end of week 8 of the program, a level of physical activity that is considered sufficient to achieve health benefits (USDHHS, 1996)

1,500 participants achieved 10,000 steps per day at the end of week 8 = 1,500/2,000

0.75 (75%)

PIPE

PIPE Impact Metric

Overall impact score of the program

1.0×0.8×0.2×0.75

0.12 (12%) improvement

 

SOURCE: Pronk, 2003b.

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
×

ing and evaluation system would be in place to provide ongoing feedback to both participants and program staff, related to effectiveness and success rates. The PIPE Impact Metric would be a useful and simple-to-implement tool to support the program evaluation efforts. The table above presents the individual components and the overall impact score using the example discussed above—for purposes of this example, assume that data reflects a single NASA center with 10,000 employees.

The process to calculate the PIPE Impact Metric score has been described and reported using actual program implementation data (Pronk, 2003b). However, no normative data are currently available against which others can compare their relative performance. For NASA this approach may be very practical in that implementation of this simple approach to evaluation can be implemented across centers and thereby immediately generate comparative scores that have high relevance for NASA administrators. This example provides several data-driven opportunities for improvement. The limiting factor in program success based on the PIPE coefficients is the participation rate. Program design changes can be implemented to facilitate a higher participation rate; for example, through the use of incentives. Also, PIPE Impact Scores can be compared between centers and an exchange of ideas for implementation can support outcomes successes.

FINDINGS

Many of the programs and interventions addressed in this chapter can be found on the NASA Occupational Health website. However, a common finding among large, decentralized organizations that also appears to be true at NASA is the development of communication gaps between the centers and Headquarters, as well as between managers and employees, which has an impact on the effectiveness of these programs. The Committee’s specific findings, based on observation of NASA programs and characteristics of established integrated health programs, encompass four general areas as follows:

  1. Variability in support for occupational health-related programs and resources weakens their effectiveness. Further, there is a need to connect the goals and objectives of occupational health programs with the NASA mission. Before initiating a large, systematic approach to employee health and medical record-keeping, NASA should define its mission-related data requirements so that they are in alignment with the vision of an integrated health program.

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
×
  1. Variability in access to health programs between civil servants and contract workers may have an impact on disparities in health outcomes among the NASA workforce.

  2. The current system of collecting health metrics lacks consistency among centers. Without uniform metrics to inform program planners of the needs of participants, it is difficult to design and implement preventive health care programs that optimize health outcomes for participants.

  3. There is a lack of integration among programs designed to optimize health, safety, and productivity at NASA (refer to Chapter 2, site visit observations). Furthermore, the current use of a segregated approach to program administration without integration across functions among large organizations such as NASA results in a less effective health care system. The Committee also found a need for effective policy development among upper-level managers and occupational health leaders in order to establish more effective health care program strategies for the centers.

RECOMMENDATIONS

The overarching recommendation (see Chapter 3) from this report is that NASA adopt a mission-driven vision for an integrated health program for all employees. The foundation for such a program is acquisition of evidence-based knowledge of the current health status of health program participants and appropriate metrics to define and predict participant needs. In order to establish a system whereby health data is collected in a consistent and useful way that will contribute to the design and implementation of health and safety programs that meet the NASA vision for a healthy workforce, the Committee recommends that:

(1) NASA should obtain health care cost and utilization data for its civil service employees enrolled in the Federal Employee Health Benefit Program (FEHBP) to inform, target, and optimize agency benefits, policies, and workplace interventions as private-sector employers do. Ideally, these data could be analyzed and reviewed at the directorate level to further inform and optimize local programmatic efforts.

(2) A basic health assessment tool such as a Health Risk Appraisal (HRA) should be selected from those available in the marketplace and offered to all NASA workers. For contract employees, NASA occupational health leaders should identify ways to channel HRA information back to the contracting company for its use in designing and implementing uniform health care programs, and prioritiz-

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
×

ing and monitoring longitudinal health and performance status that is consistent with the NASA vision.

The HRA can be used as a basic component to build an agency-wide database of aggregate health data that will inform the design, development, implementation, and evaluation of health programs to meet the needs of NASA employees. The subsequent recommendations flow from this vision for a uniform database.

(3) NASA should offer coordinated and integrated individual- and environmental-level health promotion policies and programs that promote worker health across content areas including diet, exercise, job stress, tobacco use, alcohol and substance abuse, and worksite hazardous exposure to meet the health needs of a diverse workforce. All programs should include program promotion strategies as well as financial and benefit-designed incentives to foster program participation across the diverse NASA workforce. Examples of policies and programs include:

  • Developing policies for making healthy food options available throughout the workplace, for all shifts, through a combination of cafeteria and vending options, and offering a variety of nutrition education programs targeting both healthy workers and those with nutrition-related diseases;

  • Ensuring a physical-activity-friendly atmosphere and environment that is supportive of employees’ efforts to achieve physical activity guidelines for health benefits as outlined by national policy, including Healthy People 2010 and the Dietary Guidelines for Americans;

  • Providing support for non-smoking employees by uniform adoption and enforcement of tobacco control policies, and through a broad spectrum of tobacco use cessation programs for tobacco users at varying stages of readiness for change. Further, review the medical benefit screen for tobacco cessation counseling and pharmacological support;

  • Implementing an approach to reducing stress and building resilience that focuses on enhancing output through enhancing organizational health-focused productivity. Perceived stress and job control and strain should be screened as part of the Health Risk Appraisal and further assessed, if needed, through referral to appropriate follow-up programs. For employees with stress concerns, individual programs should be made available that address both resilience, through integrated health promotion, and reduction of individual stress reactions. At the organizational level, managerial training should be organized within NASA and across contractors and civil servants. This training should address communication and job control issues that

Suggested Citation:"5 Implementing Integrated Health Programs." Institute of Medicine. 2005. Integrating Employee Health: A Model Program for NASA. Washington, DC: The National Academies Press. doi: 10.17226/11290.
×

impact both stress and productivity. Training should also include how to recognize and handle the stressed or mentally ill individual, in conjunction with EAP personnel;

  • Developing financial- and benefit-designed incentives to encourage employee participation in health promotion and disease management programs.

(4) NASA should reexamine the allocation of resources at the center level for periodic health examinations, in consideration of an integrated risk factor reduction program, and evaluate the data requirements, periodicity, and effectiveness of existing occupationally-related medical screening examinations. To achieve this goal requires a clear rationale, policy, and practice that drive accomplishment and resource allocation at the center level. The Committee recommends the following strategy:

  • Establish appropriate databases to provide health metrics to inform the evaluation process;

  • Define desired goals for periodic health examination programs and medical surveillance data requirements;

  • Stratify health and safety requirements into occupationally mandated standards;

  • Link health promotion and disease prevention examinations, if and when uniformly performed, through a standardized process, to the employee’s primary health provider and the Health Risk Appraisal.

(5) NASA should conduct program-specific evaluations to ensure the effectiveness and appropriate use of available resources. Ideally, each program should include some level of evaluation integrated into the program implementation process that will inform program staff about reach, acceptability, participation, and effectiveness.

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The American workforce is changing, creating new challenges for employers to provide occupational health services to meet the needs of employees. The National Aeronautics and Space Administration (NASA) workforce is highly skilled and competitive and employees frequently work under intense pressure to ensure mission success. The Office of the Chief Health and Medical Officer at NASA requested that the Institute of Medicine review its occupational health programs, assess employee awareness of and attitude toward those programs, recommend options for future worksite preventive health programs, and ways to evaluate their effectiveness. The committee’s findings show that although NASA has a history of being forward-looking in designing and improving health and wellness programs, there is a need to move from a traditional occupational health model to an integrated, employee-centered program that could serve as a national model for both public and private employers to emulate and improve the health and performance of their workforces.

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