Workplace Health and Workplace Wellness: Synergistic or Disconnected?

Abstract

Workplace health and wellness is paramount in many businesses and industries, for economic and social reasons. Workplace wellness programs have emerged to meet this need. This paper pursues a deeper understanding of the relationship between workplace health and workplace wellness initiatives in Australia. Based on a survey of published literature, Bayesian networks are developed to describe and quantify factors that contribute to each of these components of workplace efficiency. Workplace health was found to be a complex system of acute and chronic occupational medical conditions, as well as lifestyle factors. Successful wellness programs were found to be those that have a high level of participation and positive financial impacts, and are integrated into business strategy and company culture. It was observed that many workplace wellness programs tend to target non-occupational health risks and that there is an opportunity to address other critical components of worker health risk factors. The outputs of the Bayesian networks can provide an interrogative monitor of workplace health and the potential impact of corresponding wellness initiatives, facilitating the development of more targeted and cost-effective programs.

Appendices

Appendix 1

1.1 Healthy Worker Literature Survey

The following table summarises selected literature that identifies occupational associations with health outcomes among workers.

Health outcome	Occupational associations
Obesity • Around 2/3 of Australians are overweight or obese, and the proportion is growing [5]. • The economic costs of being overweight in the workplace have been shown to be higher than those of smoking, drinking, and poverty [26, 67, 68].	• Increases risk of hypertension, cardiovascular diseases, asthma, musculoskeletal disorders, some cancers [21, 62]. • Modifies response to occupational stress, immune response to chemical exposures, and risk of disease from occupational neurotoxins [62]. • Modifies intensity of response to various occupational hazards including heat exhaustion, pesticide exposure, accidents with equipment operators, and respiratory and physiological strain during hard physical work [31]. • Reduces effectiveness of personal respirator tests, protective equipment and clothing, particularly in hot and humid conditions [62]. • Increases absenteeism [49, 62, 73]. • Increases incidence of sick leave [13, 61] • Increases presenteeism [26]. • Occupational stress and fatigue increases behaviours associated with weight gain [77]. • Augments endocrine factors related to weight gain caused by psychological strain [77].
Musculoskeletal Disorders • Encompasses a variety of inflammatory and degenerative conditions involving muscles, tendons, ligaments, joints, peripheral nerves and supporting blood vessels • Can be caused by one acute traumatic event, or by chronic stress over a period of time due to repetitive use [58].	• Muscular stress due to lifting, carrying, lowering, and handling of objects as well as from other strenuous physical movements [58]. • Repetitive movements, excessive loading, muscle overuse and vibration are specific activities often associated with a heightened risk of musculoskeletal diseases [62]. • Exacerbated by jobs that demand excessive workloads and high responsibilities, time pressures, insufficient rest breaks, and inadequate resources and workplace support and resulting in increased injury risk from fatigue, poor posture, and stress [42].

Health outcome	Occupational associations
Cardiovascular Disease • Encompasses a range of disorders including heart disease and circulatory conditions. • A major cause of death globally [65].	• Air pollution, including short and long term exposure to gases, chemicals and particulate matter, can potentially increase the risk of heart disease. This is exacerbated by the well-established relationship between smoking, both active and passive, and heart disease and stroke [12, 30, 71]. • Occupational stress can increase the risk of cardiovascular disease [29, 35, 47]. • Impact of occupational cardiovascular disease on absenteeism and presenteeism, but this is not trivial [41]. Altering risk factors such as diet, exercise and smoking can aid in preventing the onset of various cardiovascular diseases [4, 28, 43].
Noise-induced hearing loss • Noise exposure has a range of undesirable effects including elevated blood pressure, reduced performance, sleeping difficulties, annoyance and stress, temporary shift in the hearing threshold, tinnitus and noise-induced hearing loss (NIHL) [55].	• Exposure to excessive noise at the workplace can cause NIHL, also known as industrial deafness [58]. • The extent of hearing loss can be affected by the level of noise and the length of exposure [52, 55] and by the type of exposure [46]. • NIHL impedes spoken communication and can cause social isolation and stress [55, 60]. • Hearing loss is the second most self reported occupational disease [52].
Respiratory Diseases • Various respiratory diseases have been associated with workplaces, including bronchitis, asthma, upper and lower respiratory illness, chronic obstructive pulmonary disease, lung cancer, pneumoconiosis [10, 20].	• Agents in the workplace that can exacerbate or cause several respiratory diseases include pesticides, herbicides, dust, lead, fumes, chemicals, gases, faulty air conditioners, particulates and gases emitted from fire and other activities, emissions from furnishings, and so on [10, 20]. • Occupational dust is a significant contributor to the development of bronchitis, asthma and other respiratory illnesses [20, 53]. • Exposure to dust in the workplace is also associated with chronic obstructive pulmonary disease with potential for continued development of the disease many years after exposure [10]. • There are also numerous respiratory carcinogens including asbestos, arsenic, radon, silica, chromium, cadmium, nickel and beryllium [10]. • Asbestos-related disorders and industrial bronchitis and asthma are respiratory diseases that have been amongst the most common occupational diseases, and silicosis and pneumoconiosis have been reported in US coal workers [20].

Health outcome	Occupational associations
Cancers • A variety of cancers are reportedly associated with occupational carcinogens, including lung, bone, liver, thyroid, bladder, skin and leukaemia [33].	• Well recognised carcinogenic agents include asbestos, silica, nickel, chromium, arsenicals, vinyl chloride, and halo ethers as well as ionising and solar radiation [33].
Mental Health Disorders • Poor mental health among workers is pervasive [14]. • It can lead to work impairment [37, 40], reduced job commitment and satisfaction [38]. • Anxiety disorders can be more costly than alcohol-related disorders due to their higher frequency rate [64].	• Occupational factors that can lead to poor mental health include long hours [32, 70], shift work [17, 25], low job control and high work demand [70]. • Traumatic events associated with work related incidents, harassment, bullying and exposure to violence have also been linked to mental disorders [58]. • Occupational stress can lead to absenteeism, loss of productivity, unemployment, social impairment and a high use rate of health care [16].
Alcohol-related Disorders • Alcohol affects hepatic and pancreatic systems [23, 34] and is also related to increased blood pressure, an increased risk of developing certain cancers, and cerebral dysfunction [23].	• Excessive alcohol consumption is related to poor health, resulting in absenteeism and presenteeism. It has also been linked with late arrival at work and reduced promotion success [34].

Appendix 2

1.1 Workplace Wellness Literature Survey

1.1.1 Definition of Wellness

Wellness is a balance of positive mental, physical and social health. It is variously defined, for example by the World Health organization as a “state of complete physical, mental and social-wellbeing and not merely the absence of disease or infirmity” [75], or “the process and state of a quest for maximum human functioning that involves the body, mind, and spirit” [51]. Models for wellness also exist, such as the Indivisible Self Model [50] which comprises five components, namely The Essential Self, The Creative Self, The Coping Self, The Social Self and The Physical Self.

1.1.2 Wellness Programs: Case Studies

The following table provides a summary of the wellness programs surveyed for the purposes of developing the Workplace Wellness BN. Numbers in brackets refer to number of programs.

Country	Aims	Methods	Outcomes
Australia: No. programs surveyed (9). No. programs that detailed:  - purpose (7)  - methods (9)  - outcomes (7)	• Improved physical health and wellbeing of employees (5) • Reduced risk of lifestyle disease (3) • Save money, improve productivity, improve staff relationships, reduce stress, reduce absenteeism, provide information to employees on benefit of a healthy lifestyle, improve quality of life, ensure employees are fit to work (≥ 2)	• Comprehensive health assessment of each employee (7) • Needs assessment and information sessions on healthy lifestyle (5) • Exercise programs, financial support to participate in community events (3) • Marketing of events outside the program, workplace audit, meditation classes, health challenges (2).	• Reduced sedentary category (4) • Improved blood pressure, energy, eating habits and staff morale, decreased stress levels (3) • Increase in employees in healthy weight range, increase in employees in ideal category for total cardiac risk, increased health knowledge, improved physical health, enhanced motivation, improved mental health, better staff relationships, increased job satisfaction (2)
USA: No. programs surveyed (8). No. programs that detailed:  - purpose (5)  - methods (6)  - outcomes (7)	• Reduction of tobacco intake (4) • Reduction of stress (3) • Improve exercise, improve diet, manage employee weight, improve employee fitness, reduce business costs (2)	• Tobacco cessation program (6) • Nutrition classes (4) • On-site exercise facilities, weight control programs, health services, free health screenings (3) • Educational material on health, stress management programs, fitness and activity programs, vaccinations, wellness magazines or newsletters, incentive programs, fitness classes (2)	• Saved money (7) • Reduced absenteeism (4) • Reduced weight, cholesterol, smoking and blood pressure (2) • Increased productivity, improvements in nutrition and emotional health, increased exercise, decreased alcohol use (≥ 1)
UK: No. programs surveyed (7). No. programs that detailed:  - purpose (0)  - methods (7)  - outcomes (7)	N/A	• Smoking cessation classes and stress interventions (4) • Massage sessions, healthy eating options at work, fitness classes, weight management courses, discounts at local gyms, blood pressure testing, counselling services (3) • Pedometer use (2)	• Decrease in staff absence (5) • Decrease in staff turnover, increase in corporate image, decrease in risky behaviour including smoking cessation, increased physical activity (3) • Increased employee engagement (2)

1.1.3 Types of Wellness Initiatives

Wellness initiatives have been categorised in many ways over many years. For example, Gebhardt and Crump [27] separated workplace wellness programs into three functional levels. Level one involves awareness programs such as newsletters, health fairs, screening sessions, posters, flyers and educational classes. These are not solely aimed at improving participants’ health or instantiating long term behavioural change, but are aimed at raising awareness of the consequences of unhealthy behaviours. Level two programs aim for behaviour and lifestyle modification and include self-administered fitness programs, memberships at local fitness facilities, classes related to proper performance of physically demanding work tasks, etc. Level three programs aim to create an environment that supports the sustainability of new healthy behaviours, for example via the provision of equipment, space or locker facilities at the worksite, availability of healthy foods and the removal of unhealthy temptations.

This historic categorisation generally conforms to more recent classifications of wellness initiatives. For example, Mattke et al. [45] performed a cluster analysis of a large dataset and identified five common configurations of workplace wellness programs that offered different levels of service for health risk screening, lifestyle management to reduce health risks and encourage healthy lifestyles, and chronic disease management.

Of the Australian case studies examined, a large proportion were level one programs, with the most popular being health and needs assessments. Information sessions on healthy lifestyle were also very popular, followed by marketing of the program audits of the workplace, health risk screening and marketing of events outside the program. Level two programs in Australia most commonly included: exercise programs; financial support to participate in community events; challenges and meditation sessions. None of the Australian case studies examined included any level three wellness programs.

In the United States wellness programs run were evenly distributed between level one and two programs, with the most popular level one programs: nutrition classes, free health screenings, educational materials on health and wellness newsletters or magazines. Level two programs included tobacco cessation programs; weight control programs, fitness classes and fitness and activity programs. The only level three program was the provision of onsite exercise facilities.

In the United Kingdom studies there was a greater proportion of level two programs, with only one level one and level three program offered by more than one company. The level one program was blood pressure testing. The most common level two programs included smoking cessation classes, fitness classes, discounted bicycle purchase, weight management courses, discounts at local gym, counselling services and the provision of pedometers. The level three option included was healthy eating options at work.

1.1.4 Characteristics of Successful Wellness Initiatives

In order to evaluate the success of a work-based wellness programme, it is necessary to establish what is used to define a program as either a success or a failure. Success can be defined in terms of financial, health and social benefits, and within different timeframes. For example, results from the 2004 National Worksite Health Promotion (NWHP) Survey revealed that the most commonly used definition of success was employee feedback, followed by employee participation, workers’ compensation costs, health care claims costs and reduced absenteeism, whereas the most common barriers to success were lack of employee interest, lack of staff resources and funding, lack of participation of high-risk employees and lack of support from upper level management.

These findings have been echoed in later surveys, for example, in the comprehensive studies of U.S. employers [45] and in U.K businesses [24]. The latter study reported reduced sickness absence (in 82% of programs surveyed), reduced staff turnover (33%), reduced accidents and injuries (29%), increased employee satisfaction (25%), reduced resource allocation (16%), increased company profile (15%), increased productivity (15%), and increased health and welfare (15%). Each of these was linked to positive economic contributions.

Similar benefits were observed among the successful wellness programs surveyed in the present paper. These included integration of the program into business strategy and company culture, the inclusion of a full time or part time program co-ordinator, support from upper level management, social support, the use of incentives to increase participation in the program and the convenience and accessibility of the program.

The following table provides a selection of references to literature supporting these findings.

Factors that increase the likelihood of success of a workplace wellness initiative: • The program is woven into the business strategy and culture of the company; a program is more vulnerable if it is considered to be a luxury rather than a necessity [11] • Strong management support for the program; the more an individual perceives support from their supervisor, the higher their participation [63]. • Employee involvement in the program design and implementation [69] • A full time or part time coordinator with the ability to motivate participation [27] • Use of incentives to increase employee participation [69]. Incentives work positively because employees prefer to feel that they are acting of their own volition rather than being forced to act by management policies [11]. • Accessibility and convenience of a program. In order to ensure maximum accessibility making a program either free or low cost to participants must be a priority [11]. • Onsite integration of wellness programs, making participation more straightforward and convenient for employees [11]. Factors that have contentious influence: • Co-worker support is reported in some studies to be an important influential factor on participation in health-related and fitness activities for all employee subgroups [19] but not in other studies [2, 63]. • Mattke et al. [45] found little evidence of the benefit of employee participation in the management aspects of wellness programs.

A final method of determining success is to examine the purpose of the program as set out by the company and then examining the achievements that were reported by the company. To be considered successful the company must as a minimum achieve the majority of the points set out in its “purpose of program statement”. For the Australian case studies, five of the nine companies detailed their purpose of program as well as the achievements. Based upon the criteria of a successful program, two of the five Australian programs that listed both their purpose of program as well as the achievements of their program can be labelled as successful. Four of the eight case studies examined from the United States detailed both their purpose of program and achievements. Three of these four programs can be classed as successful programs based on the criteria of a successful program. Three companies reportedly achieved everything they set out to achieve, saved money and improved productivity, although only one of these provided data on specific outcomes to support their claims. Success of the United Kingdom programs could not be evaluated due to the lack of recorded information on their purpose of program.

Appendix 3

1.1 Quantification of the Bayesian Networks

The Healthy Worker and Workplace Wellness BNs were quantified as follows. The quantification is intended for exposition purposes only. The resultant probabilities should not be interpreted medically, socially or economically, nor with respect to particular workplaces or wellness programs. However, the structure of the Healthy Worker network and its quantification could be targeted to a particular workplace cohort if data about the associated personal and lifestyle factors, health outcomes and workplace risks were made available. Similarly, the Workplace Wellness network could be structured and quantified using program-specific information, resulting in interpretable probabilities of success.

For the Healthy Worker model, each node was categorised as ‘yes’ or ‘no’. All exposures and factors at the top of the network were set to equal probabilities for each category and each health outcome was assigned equal weight. Thus the probability of a health outcome was determined by the number of detrimental factors affecting the node (depicted as directed arrows to the node) divided by the total number of factors affecting the node. Exceptions to this rule were made for respiratory diseases and acute & chronic diseases. Since the survey indicated that exercise heightens the inhalation of unwanted air pollution, exercise was included as a factor when combined with poor quality air, but was ignored for good quality air. However, since exercise was reportedly not as influential a risk factor as smoking, a weight of 0.2 of developing a respiratory disease was assigned to exercise alone, 0.4 to both smoking and poor air quality, 0.6 to performing strenuous activity and poor air quality, and 1.0 if the worker also smoked. For the node representing acute & chronic diseases, it was determined that if a worker had three or more diseases then they were deemed to have a higher chronic disease rate. Having two diseases was given a 2/3 weighting; having 1 disease was given a 1/3 weighting and no disease was given a 0 weighting. While this approach simplified the quantification of the network, the many nodes linking to the chronic and acute nodes meant that it was relatively easy to obtain a poor score on the chronic, acute, and overall worker health nodes.

The systems model for the workplace wellness programs was quantified in a similar manner. Probabilities were then assigned to each node, based on these information sources and on the other nodes in the model. For each of the nodes such as participation in program, physical, behavioural, and return on investment, the probability of a positive outcome was directly proportional to the number of positive outcomes in the parent nodes, with the maximum value set to 0.95 if all parent nodes were positive and the minimum value set to 0.05 if all parent nodes were ‘negative’. For those with two parent nodes, such as increase in wellness and accessibility of program, the probability of a positive outcome was set to 0.80 if both parent nodes were positive and to 0.2 if both parent nodes were negative.