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Wellness that works.

Employers are increasingly relying on workplace wellness programs to address employees' unhealthy behaviors and their adverse effects on health, health care costs, productivity, attendance, workplace injuries, and bottom lines.

However, recent research has cast doubt on the effectiveness of conventional wellness programs. As a result, there is a significant gap between the demand for and availability of effective workplace preventive services, and those who can address this shortcoming.

Wellness Programs lack Evidence of Effectiveness

Researchers at the Rand Corporation have reviewed studies on 33 conventional wellness programs since 2000. They only examined studies that compared outcomes for employees who did ... and did not ... participate in the programs. This was important because such studies can indicate whether any positive changes are attributable to wellness programs as opposed to other factors, such as community wellness campaigns or increases in tobacco taxes.

Most of the programs studied involved education, coaching, biometrics or some combination. Researchers found that most programs were ineffective, and the rest were only slightly effective--clearly not sufficient enough to generate any return on investment (ROI). Programs focusing on diet, fitness and weight loss were especially ineffective (Osilla, 2012).

A study of Pepsico's comprehensive, conventional wellness program, published in early 2014, followed over 20,000 employees over seven years. The study found that the wellness program was associated with only slight reductions in health care costs and absenteeism. For each dollar spent, the program reduced costs by only 48 cents (Caloyeras, 2014).

A similar, three-year study of more than 6,000 employees of the University of Minnesota obtained comparable findings. Thus, the most rigorous available research suggests that conventional wellness programs are, at best, slightly effective and fail to deliver ROI. Clearly a new approach to workplace wellness is needed.

BSI--A New Alternative

Behavioral screening and intervention (BSI) is a new alternative approach to workplace wellness that offers strong evidence of effectiveness and cost savings (Brown, 2011 ; Brown, 2014). BSI is delivered by specially trained coaches who may or may not have a background in mental health or employee assistance. Coaches meet one-on-one with employees annually, assure them of confidentiality, and ask roughly one dozen screening questions on various behavioral risks and disorders.

Coaches follow up on positive screens with further assessment questions to determine the severity of risks or disorders. Coaches offer feedback on possible areas of risk, collaborate with employees in selecting issues for discussion, and conduct motivational interviewing to promote readiness to change unhealthy behaviors.

More than 1,200 studies have documented the effectiveness of motivational interviewing in promoting a wide variety of healthy behaviors. Comparison studies have demonstrated the superiority of motivational interviewing over other methods in addressing smoking and unhealthy drinking.

Coaches assist employees committed to change in constructing plans for behavioral change. These plans include setting behavioral limits or targets, as well as behavioral triggers, alternate behaviors, medications, follow-up coaching appointments, and others. Plans may also include participation in a variety of wellness and treatment resources offered by workplaces, healthcare providers, health insurance companies, and community-based organizations.

At subsequent sessions, which can be delivered by phone for convenience and confidentiality, coaches review progress, guide employees in refining their plans to meet their goals, and refer struggling employees to additional resources. Thus health coaches administering BSI can serve as the hub of wellness services for each employee and enhance utilization of these services.

BSI is especially effective for unhealthy drinking and smoking. Straightforward screening questions on smoking and amounts of drinking and lengthier alcohol assessment questionnaires elicit accurate information when respondents do not fear adverse consequences (Del Boca, 2003). Consider that BSI for alcohol elicits reductions of:

* 20% in emergency room visits;

* 33% in serious injuries;

* 37% in hospital admissions;

* 46% in arrests; and

* 50% in vehicular crashes (National Business Group on Health, 2011 ).

BSI can also target depression, which goes undiagnosed in 30% to 50% of affected individuals. Employees with positive responses to a brief screen, such as the PHQ-2, complete a lengthier assessment, such as the PHQ-9. For employees with likely major depression, coaches initially provide education about depression, instill optimism for treatment, and make referrals for medication and/or counseling. They also deliver behavioral activation, promoting behaviors such as exercising and socializing to lift depressive symptoms.

In regular follow-up contacts, coaches support full engagement in treatment, re-administer the assessment, and request that other treatment professionals reconsider the treatment plan if results do not improve as expected. This set of services, called collaborative care, increases the odds of remission at 6 and 12 months by 75% (Thota, 2012). Behavioral activation alone may be effective for minor depression and prevent progression to major depression (Cuijpers, 2007).

Effectiveness and Cost Savings of BSI

Several studies demonstrate that using BSI for unhealthy drinking, smoking and depression elicits substantial reductions in healthcare and other costs. Drawing on findings from prior research, U.S. employers can expect cost savings of $820 for each employee in the year after screening. Although several studies suggest that BSI is effective for drug use, economic impacts have not been studied.

Because of the well-documented effectiveness of BSI, its services are recommended by the Centers for Disease Control and Prevention, National Business Group on Health, U.S. Preventive Services Task Force, White House Office of national Drug Control Policy, and others.

Behavioral screening and intervention can also target cardiovascular risks, although less effectively. One year after a highly structured intervention, only 1 in 12 healthy, sedentary individuals sustained recommended levels of physical activity. Brief advice can increase fruit and vegetable intake.

A typical obese individual who participates for 6 to 12 months in a structured, intensive weight-loss program loses 9 to 15 pounds and demonstrates small declines in blood pressure, blood glucose and lipids (Appel, 2011).

Unfortunately, none of these services are known to prevent cardiovascular disease nor to generate ROI. In fact, ROI may not be possible for obesity interventions (Trogdon, 2009). The difficulty in modifying diet, exercise, and weight may be one reason why conventional wellness programs lack effectiveness and ROI. Perhaps a combination of BSI and various efforts to modify workplace and community culture deserves study.


As stated, research has shown that most current workplace wellness offerings are, at best, slightly effective and are not economical. This leaves employers without options for addressing the root causes of high healthcare costs, loss of productivity, absenteeism, and workplace injuries.

Conversely, ample research has demonstrated that BSI for unhealthy drinking, drug use, smoking and depression is effective and generates substantial cost savings for employers. The second article in this series will discuss how EAPs could deliver BSI.

Richard L. Brown, MD, MPH, is professor of family medicine and director of the Wisconsin Initiative to Promote Healthy Lifestyles at the University of Wisconsin School of Medicine and Public Health. Maria Lund, MA, is president and CEO of First Sun EAP in Columbia, S.C. Stan Granberry, PhD, is the executive director of the National Behavioral Consortium in Baton Rouge, La.


Appel LJ, Clark JM, Hsin-Chieh Y, et al. Comparative effectiveness of weight-loss interventions in clinical practice. New England Journal of Medicine 2011; 365:1959-1968.

Brown RL. Configuring health care for systematic behavioral screening and intervention. Population Health Management 2011; 14:299-305.

Brown RL, Moberg DP, Allen J, et al. A team approach to systematic behavioral screening and intervention. American Journal of Managed Care 2014; 20:e113-e121.

Cuijpers P, van Straten A, Warmerdam L. Behavioral activation treatments of depression: a meta-analysis. Clinical Psychology Review 2007; 27:318-326.

Del Boca FK, Darkes J. The validity of self-reports of alcohol consumption: state of the science and challenges for research. Addiction. 2003; 98 (suppl. 2): 1 -12.

Flore MC, Jaen CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: Public Health Service. May 2008.

National Business Group on Health. Moving science into coverage: an employer's guide to preventive services. Alcohol misuse (screening and counseling), updated Sept. 23, 2011. Retrieved from:

Osilla KC, Van Busum K, Schnyer C, Larkin JW, Eibner C, Mattke S. Systematic review of the impact of worksite wellness programs. American Journal of Managed Care 2012; 18(2):e68-81.

Thota AB, Sipe TA, Byard GJ, et al. Collaborative care to improve the management of depressive disorders: a community guide systematic review and meta-analysis. American Journal of Preventive Medicine 2012; 42:525-538.

Trogdon J, Finkelstein EA, Reyes M, Dietz WH. A return-on-investment simulation model of workplace obesity interventions. Journal of Occupational and Environmental Medicine 2009; 51:751-758.

Note: Many additional references were omitted from space constraints and are available from Dr. Brown,
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Article Details
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Author:Brown, Richard L.; Lund, Maria; Granberry, Stanford W.
Publication:The Journal of Employee Assistance
Geographic Code:1USA
Date:Jan 1, 2015
Previous Article:Improving utilization reports.
Next Article:Imagining the EAP of the future.

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