The definition and core practices of wellness: wellness is a growing player in the integration movement, and EA professionals need to understand the principles around which it is organized.

For much of the last 20 years, the Employee Assistance Professionals Association has been examining the integration of employee assistance with other services. In the late 1980s, an EAPA task force focused on child care and its relationship to EAP services; the task force later attained committee status and began studying the juncture between EAPs and the work-family field.

In 2000, EAPA joined with the Alliance for Work/Life Progress (AWLP) and the Employee Assistance Society of North America (EASNA) to conduct a three-phase research project to examine various aspects of the "dance" between the employee assistance and work-family fields. A national survey of EA and work-life professionals found that a "significant level" of collaboration/integration was taking place and that a "new breed" of professional had emerged, one with expertise in both fields.

The second stage of the research project, an international survey of EAP and work-life vendors, made clear that wellness is another player in the integration movement. More than 80 percent of survey respondents reported they provide health and wellness services, and a similar percentage said they anticipate more demand for wellness services in the next five years. As a result of this finding, EAPA approached Michael Mulvihill from Leade Health, Inc., a vendor of wellness services, to discuss the history of the wellness field and its definitions and core concepts.

--Patricia Herlihy Ph.D., R. N.

Aquestion frequently asked by allied professionals outside the health promotion and wellness field is, What is wellness? It turns out to be a good question. Before we can begin to discuss the core practices of wellness and future considerations, we must get a clearer understanding of it.

Many people have what I call the "brown bag" view of wellness, meaning they see it as a series of "warm and fuzzy" activities like lunch-and-learn meetings, health fairs, and so on. While these activities may indeed be included in a health and wellness program, this view of the field is decidedly limited.

Michael O'Donnell, publisher of the American Journal of Health Promotion, has defined health promotion as "the science and art of helping people change their lifestyle to move toward a state of optimal health" (1989). While this definition has stood the test of time, it doesn't capture the many emerging developments within the wellness field today Health and wellness programs are becoming more sophisticated, more specialized, and more targeted to specific populations.

I would propose a more current definition of wellness, health promotion, and disease prevention, as follows:

"A set of organized activities and systematic interventions, offered through corporations/worksites, managed care organizations, and governmental/community agencies, whose primary purposes are to provide health education, identify modifiable health risks, and influence health behavior changes."

BRIEF HISTORY

Just as early EAPs focused on occupational alcoholism, wellness programs began in the 1970s as worksite-based programs essentially centered upon fitness centers and activities. One of the first fitness-oriented books, Kenneth Cooper's Aerobics, was a major influence on the fitness movement. The body of exercise science literature was growing during this time, and exercise physiologists began prescribing daily doses of exercise.

The fitness focus led to the spread of corporate fitness centers and then to modern, state-of-the-art corporate fitness facilities, which may now include occupational and physical therapy along with other rehabilitative and alternative services. It is important to note, however, that for the most part this trend remains confined to Fortune 500 companies that are able to commit the significant capital resources needed for these centers.

Another major development occurred when Erfurt and Foote (1983) began conducting cardiovascular-oriented blood pressure screenings in the auto industry They were also among the first to coordinate wellness programs and EAPs and illustrate the potential to save on health care costs, especially when effective follow-up programs are put in place.

The U.S. government, through the Department of Health and Human Services, also has played a major role in the spread of wellness and health promotion programs through it series of "Healthy People" reports. Current program objectives (for 2010) include increasing the proportion of worksites that offer comprehensive programs to encourage employees to participate in employer-sponsored health promotion activities.

Together, these developments and influences set the stage for today's cadre of comprehensive health management services, including fitness centers, health screenings, health risk appraisals, educational activities, behavior change programs, and high-risk interventions. The future is evolving into a sharper focus on improving employee productivity, containing health care costs, and integrating and coordinating with other key employee benefits programs and initiatives.

CORE PRACTICES

At this point I would like to delineate five core practices within the health and wellness field, but first I would like to make a couple of important caveats. As with my definition of wellness, these core practices represent my own (and solely my own) attempt to segregate the many practices of the wellness field--a field that is very broad indeed--into distinct and comprehensible areas. Next, while I periodically shall allude to the concept of "best practices," I am not in any way attempting to identify distinct best practices, which O'Donnell (2000) and others have done elsewhere.

In rough terms, my five core practices would be comparable to the EAP Core Technology as defined by Roman and Blum (1988). Erfurt, Foote, and Heirich later used the core technology concept in a manuscript, "The Core Technology of 'Megabrush'--Employee Assistance and Wellness Program Combined." But "megabrush" never became popular with wellness professionals, nor does the health promotion field use the "core technology" nomenclature, preferring instead to focus on best practices, benchmarks, and successful program characteristics. I prefer the term "core practices," which I find to be more relevant and applicable to the wellness field.

Core Practice Area I: Program mission and management/employee support

For any health and wellness program to be successful, there must be a strong sense of a prevention-oriented mission at the top and bottom of the organization. Wellness vendors or service providers that lack support from either the top or the bottom (or both) will find themselves swimming upstream, and ultimately will fail. Vendors will discover that the organization will expect them to "do it all" and will hold them accountable for the program's failure, when in fact the organization lacked a strong sense of purpose and mission. This is not uncommon, especially where there is an organizational champion who secured initial funding but did not have adequate organizational support.

The most successful companies and organizations not only establish a strong mission as a first order of business, they also operationalize it through management and employee involvement and accountability. In companies of all sizes, I've found that representational wellness committees and key leadership can he very effective in carrying the mission and energy of a program. Ford Motor Company, through its partnership with the United Auto Workers, was one of the early leaders in understanding the importance of this strategy Through the Ford-UAW partnership, management and labor have set up a strong support system for the organization's health and wellness program.

Core Practice Area II: Strategic planning 

In one sense, you could describe this practice area as the "road map" to fulfilling the organizational mission and developing a wellness-oriented culture. I have found that an annual plan that delineates programs to be offered, timelines, responsibilities, participation expectations, and evaluation strategies paves the way for a successful program. Too often, unsuccessful wellness efforts begin with the lack of a good plan.

For example, it's fairly easy to set up a plan that outlines the budget, the programs to be offered in the coming year, the promotional strategy, and timelines. What I frequently find missing, however, are more specific goals regarding participation targets, incentives to promote participation, target audiences, and evaluation criteria. When all these items are put in place, it is much easier to measure program effectiveness and provide upper management (or the purchaser) with levels and channels of accountability necessary to sustain the program.

When developing a strategic plan, pay special attention to setting expectations for management and employee/ member program participation (both spoken and unspoken). Just as high utilization is a major barometer of success in the EAP and work-life fields, widespread program participation is the Holy Grail of achievement in health and wellness.

Core Practice Area III: Health screening and risk stratification 

Without question, cardiovascular health screenings and, specifically, health risk appraisals have long been the bedrock of wellness and health promotion programs. A health screening is a preventive procedure for the identification of risk factors and early detection of chronic conditions, including high blood pressure, high cholesterol, diabetes, and prostate cancer. A health risk appraisal (HRA) is a diagnostic tool and is used to calculate an individual's overall likelihood of future health problems.

HRAs were developed in the early 1970s, evolving from a prospective medicine approach to promoting individual health and disease prevention. An HRA may incorporate many of the results of the health screening into a methodology for assessing and stratifying an individual's risk. Once that risk is stratified, behavioral health interventions can be recommended and tailored to the individual.

Used correctly, the HRA can not only help plan individual interventions but also serve as a powerful tool for conducting program and population planning based on the aggregate results of employee or health plan groups. Without careful planning, appropriate counseling and follow-up, and targeted interventions, an HRA will have little impact on health and wellness.

Core Practice Area IV: Risk-related health management interventions

It is generally accepted that a model wellness and health promotion program stratifies a given population into high and low risks, then offers appropriate interventions. Research directed by Dee Edington (1996) at the University of Michigan Health Management Center has shown the importance of addressing the health risks of individuals. Lowering the risk of high-risk individuals has consistently demonstrated a decrease in medical costs, while maintaining a low risk status has obvious disease prevention results.

Interventions for low-risk individuals include a variety of "demand management" strategies like newsletters, educational seminars, Web resources, and 24-hour telephonic nurse lines. Examples of high-risk interventions include smoking cessation, weight management and stress management programs, fitness prescriptions, and exercise programs. Further along the health continuum, disease management (DM) programs focus on high-risk individuals who have already entered the disease process and need assistance managing conditions such as diabetes, depression, cardiovascular disease, congestive heart failure, asthma, arthritis, and so on.

Clearly, the field of health and wellness is very broad in scope. I have only touched on examples of programs and interventions, but there is also the growing field of alternative medicine and the many different delivery methodologies, such as face-to-lace or group meetings, telephone services, mailings and printed materials, and a variety of Web-based applications.

Core Practice Area V: Evaluation and metrics

As indicated earlier, a solid strategic plan includes a carefully developed evaluation strategy incorporating specific metrics. This is particularly necessary in today's economic environment, when very few sponsors, funders, or purchasers will continue supporting a program that does not document outcomes and results.

Many wellness program managers are intimidated by the prospect of developing an evaluation strategy, thinking it implies conducting studies with control groups and so on. I have found there are a variety of simple measurements one can take to document results:

* Program participation. Set realistic participation targets and then see how well you've done. If people are not participating, your program will have no impact.

* Participant satisfaction. Measure pre- and post-program satisfaction on a five-point scale and summarize positive and negative comments. Every sponsor of a health and wellness program wants to know how highly users and participants regard it.

* Perceived health status. Using a five-point scale, measure an individual's perception of his/her health stares before and after program participation. Research has shown that an individual's assessment of his/her own health status is a reliable predictor of future health.

* Specific health outcomes. If you're providing behavior change programs like smoking cessation or weight management, measure the impact of the program specific to its focus (e.g., smoking quit rates or weight loss).

To maintain confidentiality, aggregate all of these measurements into an outcomes report for groups of participating individuals. Finally, while I have indicated that evaluation should not necessarily be viewed as a strictly scientific task, it's extremely important to maintain what I call "data integrity," meaning you should make clear what metric you're using and how your measurements are calculated.

THE FUTURE OF WELLNESS

If nothing else, the process of defining wellness and delineating its core practices should illustrate the complexity and variety of approaches within the health and wellness field. Most observers generally agree that the primary objectives of an effective wellness program are to prevent disease, decrease health risks, and contain rising health care costs. More importantly, health promotion and wellness programs, when conducted properly, represent a set of powerful tools and interventions for individuals, employers, and health care organizations.

Perhaps one of the most exciting developments in the health and wellness field is the migration toward integration and coordination with other employee benefit venues. From the wellness perspective, several national organizations are leading the way in these efforts, including the Institute for Health and Productivity Management (IHPM) and the Health Enhancement Research Organization (HERO). In the early going, there is agreement that in order to be successful in our integrative efforts, much work remains in understanding the richness of each field (employee assistance, work-life, and wellness) along with the many challenges associated with true integration.

Michael Mulvihill is president of Leade Health, Inc,, a vender of wellness services in Ann Arbor, Michigan,