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A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:
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A Workshop Looking At The Evidence on Workplace Health Wellness Programmes:

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Dr John Wren …

Dr John Wren
Principal Researcher Advisor
New Zealand Accident Compensation Corporation
PO Box 242, Wellington, New Zealand
john.wren@acc.co.nz

(P23, Thursday 27, Civic Room 3, 1.30)

Published in: Health & Medicine
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  • Feb 2011
  • Feb 2011
  • The effect of a pre-existing health co-morbidity on increased health service utilisation has been well-documented in recent World Health Organisation (WHO) reports (Cameron, Purdie, Kliewer, McClure, & Wajda, 2007; Cameron, Kliewer, Purdie, & McClure, 2006; Cameron, Prudie, Kliewer, & McClure, 2005) . The findings of these reports were based upon analysis of a population-based matched cohort of injured and non-injured people between 18 and 65 years of age who had been treated for injury between 1988-1991 in Manitoba, Canada. The authors of these reports have concluded that: injured people are different from the non-injured population in terms of pre-existing morbidity; the existence of a wide range of health co-morbidities results in significant additional risk of injury-related primary care and hospital treatment utilisation that includes increased use of services including length of stay in hospital; patients with mental health and behavioural disorders and those with previous injuries respectively, result in rates of utilisation which are at least double compared to those without a co-morbidity, and compared to other co-morbidities; patients with higher numbers of co-morbidities utilise injury services more than patients with lower co-morbidities; existing population attributable estimates of injury that extrapolate from samples of the injured population may over-estimate the size of the injury problem (Cameron, Prudie, Kliewer et al., 2005) .
  • Those with a prior history of an injury or poisoning have hospital admission claim rates 3.68 times higher than those without that co-morbidity. Other studies of a range of other health co-morbidities report excess health service utilisation and costs of approximately double, compared to the population with no health co-morbidity (Edington, 2001; Musich, Hook, Barnett et al., 2003; Yen, Edington, & Witting, 1991; Yen, Schultz, Schnueringer et al., 2006) In a recent briefing report for the Australian Institute of Health and Welfare, Cripps & Harrison (2008) have concluded “there appears to an aetiological link between mental health conditions and injury, particularly in relation to risk-taking behaviours, alcohol misuse, and psychological traits such as impulsivity, sensation-seeking, and risk-perception.”
  • The epidemiologic work of the Health Management Research Centre has consistently documented a positive association between increased health service utilisation (including pharmaceutical services) and workers compensation costs among working people in a variety of settings and a variety of health co-morbidities (Edington, 2001; Forrester, Weaver, Brown, Phillips, & Hilyer, 1996; Goetzel, Anderson, Whitmer, & al., 1998; Mills, Kessler, Cooper, & Sullivan, 2007; Milzman, Boulanger, Rodriguez, Soderstrom, Mitchell, & Magnant, 1992; Morris, MacKenzie, Damiano, & Bass, 1990; Morris, MacKenzie, & Edelstein, 1990; Musich, Hook, Barnett et al., 2003; Musich, Napier, & Edington, 2001; Ostbye, Dement, & Krause, 2007; Pronk, Goodman, O'Conner, & Martinson, 1999; Rochon, Katz, Morrow, McGlinchey-Berroth, Ahlquist, Sarkarati et al., 1996; Schultz, Chen, & Edington, 2009; Truls, Dement, & Krause, 2007; Wardle, 1999; Wright, Adams, Beard et al., 2004; Wright, Beard, & Edington, 2002; Yen, Edington, & Witting, 1991, 1994; Yen, Schultz, Schnueringer et al., 2006) . In addition to increased injury risks, higher medical treatment costs, workers compensation costs, and poor work performance (presenteeism) have also consistently been associated with specific lifestyle risk factors such as tobacco use (current and previous), obesity, stress, and lack of regular physical activity (Cripps & Harrison, 2008; Mills, Kessler, Cooper et al., 2007). There is considerable confidence that the excess risk from health co-morbidities accounts for at least 25% to 30% of medical costs per year across a wide variety of companies, regardless of industry or demographics; the biggest cost factors are the cost of extra treatment utilisation, and medical costs associated with the complications of a co-morbidity;
  • Table 5 (next page) focuses upon ACC Consultations, and compares the mean number of consultations between those with and those without the presence of a health co-morbidity. 95% confidence levels are presented, to show the statistically significant differences between the two groups. Multivariate analysis showed that the observed differences persist after controlling for age, sex and ethnicity (CBG Health Research Ltd, 2009).
  • Table 5 (next page) focuses upon ACC Consultations, and compares the mean number of consultations between those with and those without the presence of a health co-morbidity. 95% confidence levels are presented, to show the statistically significant differences between the two groups. Multivariate analysis showed that the observed differences persist after controlling for age, sex and ethnicity (CBG Health Research Ltd, 2009).
  • Focuses upon ACC Consultations, and compares the mean number of consultations between those with and those without the presence of a health co-morbidity. 95% confidence levels are presented, to show the statistically significant differences between the two groups. Multivariate analysis showed that the observed differences persist after controlling for age, sex and ethnicity (CBG Health Research Ltd, 2009).
  • Prevalent in the New Zealand population Availability of validated indicators Age, sex and ethnicity are all complicating factors.
  • Pellietier, K. (2001)
  • Pellietier, K. (2001)
  • A substantive body of over 500 published health promotion articles has been identified that focuses on the effectiveness of worksite-based programmes to deliver general lifestyle health promotion and injury prevention to employees (Chapman, 2003, 2005; Mills, Kessler, Cooper et al., 2007; Pelletier, 2001) . Meta evaluations have been undertaken by Chapman (2003, 2005) and Pelletier (2001) on the effectiveness of such programmes. In spite of methodological differences between evaluation studies, meta-analysis has shown a high degree of “congruence” with worksite-based programmes showing “average reductions in sick leave, health plan costs, and workers’ compensation and disability costs of slightly more than 25%” (Chapman, 2005) . Chapman (2005) also found that more recent intervention studies have shown cost/benefit ratio returns of 1:6.3. Pelletier (2001:115) has concluded that: “ the most salient issue for insurers and corporations to address is not whether worksite health promotion and disease management programmes should be implemented…to reduce risks…, but rather how such programmes should be designed, implemented and evaluated in order to achieve optimal clinical effectiveness and cost-effectiveness.”
  • Pelleter, K. (2001) A review and analysis of the clinical and cost-effectiveness studies of comprehensive health promotion and disease management programs at the worksite:1998-200 Update . Am J Health Promotion 16, 2. Goetzel RZ, Ozminkowski RJ. The health and cost benefits of work site health-promotion programs. Annu Rev Public Health 2008;29:303-23.
  • Pelleter, K. (2001) A review and analysis of the clinical and cost-effectiveness studies of comprehensive health promotion and disease management programs at the worksite:1998-200 Update . Am J Health Promotion 16, 2. Goetzel RZ, Ozminkowski RJ. The health and cost benefits of work site health-promotion programs. Annu Rev Public Health 2008;29:303-23.
  • Pelleter, K. (2001) A review and analysis of the clinical and cost-effectiveness studies of comprehensive health promotion and disease management programs at the worksite:1998-200 Update . Am J Health Promotion 16, 2. Goetzel RZ, Ozminkowski RJ. The health and cost benefits of work site health-promotion programs. Annu Rev Public Health 2008;29:303-23.
  • Chris Polaczuk and Maddy Schafer ACC DPI Programme Manager and Administrator
  • Transcript

    • 1. A Workshop Looking At The Evidence on Workplace Health Wellness Programmes: Presenter: Dr John Wren, Principal Research Advisor, ACC OHSIG Conference, Wellington, 26-28 October 2011
      • Workshop covers
        • Why should I care?
        • What are they?
        • Do they work?
        • What makes a successful programme?
    • 2. Wellness Programmes The challenge for OHS professionals Safeguard, March 2011
    • 3. Why Should I Care? Health Co-morbidity Effects on ACC Claims Utilisation and Costs: Results of a Suite of Pilot Studies: 1) Brief literature review 2) GP Practice data 3) ACC-MOH Linked data pilot
    • 4. The question…
      • What effect does the existence of a health co-morbidity have upon ACC clients:
        • injury treatment claim rates (utilisation)
        • duration of claim
        • costs over time?
      • What is the international research evidence base for such effects?
    • 5. What did we do?
      • Brief review of the published literature
      • Examined treatment service provision in GP Practices using GP Practice data
        • CBG HealthStat Study
      • Used linked ACC-MOH data to examine ACC Claims Utilisation and Costs
        • Focus upon Diabetes and Coronary Heart Diseases (CHD)
    • 6. Headline Results:
      • Health Literature
      • Pre-existing health co-morbidity effects on increased health service utilisation well-documented in recent World Health Organisation (WHO) reports
        • Injured people are different from the non-injured population in terms of pre-existing morbidity
        • Patients with higher numbers of co-morbidities utilise injury services more than patients with lower co-morbidities
        • (Cameron, Prudie, Kliewer et al., 2005)
    • 7. 1.21 1.70 Circulatory diseases 1.38 1.98 Respiratory diseases 1.42 2.35 Nervous system diseases 1.76 2.61 Musculoskeletal disorders 1.38 2.79 Endocrine and metabolic 1.53 3.36 Blood diseases 2.72 3.68 Injury and poisonings 3.50 9.31 Mental Health disorders Claims per 1000 person years Physician Hospital Admissions Source: Adapted from Cameron et al, 2005. Tables 4 and 5 respectively. Rate Ratios* Injured/ Non-Injured *Adjusted for age, sex and place of residence * Health co-morbidity (ICD-9-CM Chapter)
    • 8.
      • “ There appears to an aetiological link between mental health conditions and injury, particularly in relation to risk-taking behaviours, alcohol misuse, and psychological traits such as impulsivity, sensation-seeking, and risk-perception.”
      • (Cripps & Harrison, 2008. Briefing report for the Australian Institute of Health and Welfare)
      Role of Mental Health, Alcohol and Psychological Traits
    • 9. Literature Review:
      • Workers Compensation
      • Increased injury risks, higher medical treatment costs (including pharmaceutical services), workers compensation costs, and poor work performance (presenteeism) have consistently been associated with specific lifestyle risk factors such as tobacco use (current and previous), obesity, stress, and lack of regular physical activity among working people in a variety of settings
      • (Studies published by Health Management Research Centre, and Others)
    • 10. Literature Review
      • Workers Compensation
      • Considerable confidence the excess risk from health co-morbidities accounts for at least 25% to 30% of medical costs per year across a wide variety of companies, regardless of industry or demographics
      • The biggest cost factors are the cost of extra treatment utilisation, and medical costs associated with the complications of a co-morbidity
      • (Studies published by Health Management Research Centre)
    • 11. New Zealand Treasury Working Papers, November 2010
    • 12. New Zealand Treasury Estimates “The Cost of Ill-Health” to Work (Working Paper 10/04. Heather Holt.)
    • 13. ACC Pilot Study: GP Practice (CBG HealthStat Study)
      • Asthma
      • Chronic obstructive pulmonary diseases
      • Ischemic heart disease
      • Hypertension
      • Heart Failure
      • Diabetes
      • Mental Health diagnosis
      • Cancer
      • 32% of the GP patient population recorded as having at least one health co-morbidity
        • (in 12 month period April 2008 to March 2009)
      ACC Consultations represented 8.1% of all GP consultations in Health Stat sample
    • 14. ACC Pilot Study: GP Practice – Key Results (CBG Study)
      • Consultation rates approx double for those with a co-morbidity
        • irrespective of age, sex, and ethnicity
        • for both GP Consults and ACC Injury Treatment Consults
      • $12,620,800 (excl GST) estimated extra cost to ACC
        • extra 340,000 consultations nationally
        • at an average cost of $37.12 per consultation in the 12 month period
    • 15. 2.78 8.88 3.19 1.88 0.49 0.26 Total 2.92 8.30 2.84 1.43 0.30 0.21 Pacific 2.74 9.18 3.35 2.00 0.54 0.27 Other 2.78 8.06 2.90 1.64 0.41 0.25 Mãori 2.94 7.96 2.71 1.66 0.53 0.32 Male 2.63 9.65 3.67 2.35 0.47 0.20 Female 2.32 13.71 5.92 1.76 0.65 0.37 65+ 2.56 9.55 3.73 1.56 0.56 0.36 45-64 2.46 6.93 2.82 1.63 0.44 0.27 25-44 2.21 5.60 2.53 1.44 0.36 0.25 18-24 2.15 4.19 1.95 1.48 0.31 0.21 6-17 1.46 7.49 5.12 1.53 0.23 0.15 0-5 Ratio Chronic / No Chronic Chronic Condition No Chronic Condition Ratio Chronic / No Chronic Chronic Condition No Chronic Condition Age group All GP Consults ACC Consults Mean Number GP Consultation Rates by Demographic Group and Existence of Co-morbidity: Effects persist after controlling for age, sex and ethnicity
    • 16. 0.49 – 0.50 0.49 0.26 – 0.26 0.26 Total 0.27 – 0.32 0.30 0.20 – 0.21 0.21 Pacific 0.53 – 0.55 0.54 0.27 – 0.28 0.27 Other 0.40 – 0.43 0.41 0.25 – 0.26 0.25 Mãori 0.51 – 0.54 0.53 0.32 – 0.33 0.32 Male 0.46 – 0.48 0.47 0.19 – 0.20 0.20 Female 0.63 – 0.67 0.65 0.34 – 0.39 0.37 65+ 0.54 – 0.57 0.56 0.35 – 0.37 0.36 45-64 0.42 – 0.45 0.44 0.27 – 0.28 0.27 25-44 0.34 – 0.38 0.36 0.24 – 0.26 0.25 18-24 0.29 – 0.32 0.31 0.20 – 0.21 0.21 6-17 0.21 – 0.25 0.23 0.14 – 0.15 0.15 0-5 95% Confidence Interval Mean consults 95% Confidence Interval Mean Consults Age group With Health Co-morbidity No Health Co-morbidity Patient Mean Number (and 95% Confidence Intervals) of GP ACC Consultations by Patients With No Co-Morbidity Compared to Patients With Co-morbidity
    • 17. 2 nd Pilot Study: ACC-MOH Linked Data
      • Headline Results
      • Extra ACC injury treatment and rehabilitation costs of approximately $100 million in a 12 month period have been associated with the presence of diabetes and coronary heart disease.
      • There are marked differences between life-cycle age groups and gender in extra claim utilisation and cost where a co-morbidity is present.
    • 18. Why Diabetes and CHD?
      • Complicates injury treatment and rehabilitation
        • patients with diabetes can suffer from neuropathies that reduce heat and pain sensation so burn, cutting and piercing injuries are more likely
        • treatment is complicated and recovery prolonged for diabetes and CHD because poor tissue perfusion
        • obese patients have reduced opportunities for physical activity based rehabilitation
    • 19. * % based upon: Utilisation Ratio Claims per 1000 people CHD / No CHD Yes, those working age - particularly Males approx. 30 - 40 payments Yes, those working age - particularly Males approx. 20 - 30 payments 23% $27,567,687 $27,859,014 Entitlement Claims n/a Yes, particularly 25-44 age group 20% $66,635,192 $62,670,614 All Claims 12 months 6 months Duration: Paydays Duration: Medical Payments Percent Extra Claims Utilisation associated with co-morbidity* Extra Costs (Incl. PHAS) Excess associated with Coronary Heart Disease Claims made in July / June 2008/09 Year, for whom ACC has an NHI number
    • 20. * % based upon: Utilisation Ratio Claims per 1000 people Diabetes / No Diabetes Yes Males Working Age - approx. 10 - 18 payments, varies by age Yes, Males Working Age - approx. 6 - 16 payments increasing with age 14% $14,189,812 $13,168,872 Entitlement Claims n/a None 16% $ 40,964,302 $36,396,050 All Claims 12 months 6 months Duration: Paydays Duration: Medical Payments Percent Extra Claims Utilisation associated with co-morbidity Extra Costs (Incl. PHAS) Excess associated with Diabetes Claims made in July / June 2008/09 Year, for whom ACC has an NHI number
    • 21. Implications for ACC Scheme
      • Clear evidence that there is an extra cost to ACC for treating injuries where health co-morbidities are present
      • Given marked age effects it is expected that as the New Zealand population gets older Scheme liability will increase due to increased prevalence of co-morbidities such as CHD and Diabetes
      • Cost estimates presented are “tip of the iceberg”
    • 22. Implications for ACC Scheme
      • Well designed work place based health promotion interventions shown to be cost-effective in reducing Weekly Comp costs
      • Theoretically possible to develop experience rating models for population groups that includes a health co-morbidity function
      • Substantive research value to be derived from using linked ACC-MOH administrative data
    • 23. Conclusions
      • Evidence for the existence of health co-morbidity effects on increased injury treatment utilisation and costs is well supported in the literature. There are marked differences between life-cycle age groups and gender
      • This is the first paper to produce quantified estimates of the effects of health comorbidities on ACC – the indicative costs are significant
      • Demonstrates the utility and efficacy of using linked administrative data sets to add value to agency research initiatives
    • 24. Health and Wellness Programmes
      • What are they?
    • 25.
      • Health and Wellness
      • programmes:
      • are workplace based health promotion and disease management programmes
      • evolved significantly over the last 25 years
      • originated in US, now present in UK and Australia – New Zealand professional group established
      • prevalent in large companies who are self-managing their medical / workers comp costs
      • a priority for the World Health Organisation (WHO – health promoting workplaces)
    • 26.
      • Health and Wellness
      • programmes:
      • Focus on clinical effectiveness and cost effectiveness
      • Increasingly involve a greater focus :
        • on disease management
        • target high risk lifestyles
        • changing behaviour
        • use internet / telephone support services as delivery mechanism
    • 27. Health Promotion is…
      • "the science and art of helping people change their lifestyle to move toward a state of optimal health“ (American Journal of Health Promotion)
      • “ the process of enabling people to increase control over, and to improve their health” (WHO)
      • “ the promotion of healthy ideas and concepts to motivate individuals to adopt healthy behaviours” (Dictionary of Wellness)
    • 28. Worksite health promotion
      • "the combined efforts of employers, employees and society to improve the health and well-being of people at work" (WHO, and European Network for Workplace Health Promotion)
      • The workplace influences "physical, mental, economic and social well-being" and "offers an ideal setting and infrastructure to support the promotion of health of a large audience“ (WHO)
    • 29. Disease Management: A process that…
      • focuses upon chronic disease conditions
      • aims to reduce health care costs
      • intends to improve the quality of life enjoyed by individuals, and
      • minimise the symptoms of the disease (Dictionary of Wellness)
    • 30. Health and Wellness Programmes
      • Do they work?
    • 31. Substantive body of literature
      • Comprehensive workplace-based health promotion programmes shown to be:
      • Cost-effective (typical cost-benefit ratio 1:6.3)
      • Reduce economic losses including Workers Compensation costs associated with workers with a risky life style, health co-morbidity or injury experience
      • (Chapman, 2003, 2005; Mills, Kessler, Cooper et al., 2007; Pelletier, 2001)
      • See end slides for other substantive references
    • 32. The salient issue…
      • “ for insurers and corporations…is not whether worksite health promotion and disease management programs should be implemented…
      • but rather how such programs should be designed, implemented and evaluated in order to achieve optimal clinical…and cost-effectiveness.”
      • (Pelleter, K. (2001) A review and analysis of the clinical and cost-effectiveness studies of comprehensive health promotion and disease management programs at the worksite:1998-200 Update . Am J Health Promotion 16, 2.)
    • 33. Effective programs
      • Have a multi-factorial approach
        • targeting multiple risk factors are much more likely to reduce risk of chronic disease
      • Focus on behaviour change , with medical oversight for intensive interventions
      • Involve periodic, intensive, sustained, personal support for employees at high risk
    • 34. Effective programs…
      • Can include a ‘dose-response’ model of increasing intervention with higher levels of risk
      • Recognise that education programs for the whole workforce, may be cheap, BUT are not sufficient on their own
        • such programs though are good for building participation and a supportive environment
    • 35. Effective industry based programs, typically
      • Very focussed on disease management in areas of specific importance to industry / employer
        • Approach outlined is effective to single risk factors such as
          • smoking, obesity, musculoskeletal, hypertension / stress, arthritis, repetitive strain, motion trauma and disabilities, back injuries or pain, cancer
    • 36. Good Programs
      • Start with individual health risk assessments / corporate health profiles
      Free, Validated, Corporate Health Wellness Assessment Questionnaire http://www.biomedcentral.com/content/supplementary/1476-069X-4-1-S1.doc Article Source:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC548523/?tool=pmcentrez#S1
    • 37. The ACC DPI Programme: A Robust Building Block for a Health and Wellness Programme for New Zealand workplaces: Preventing and Managing Discomfort, Pain and Injury: http://www.accdpi.org.nz/
    • 38.
      • Thank You!
      • Questions?
    • 39.
      • Some References: Evidence for Effectiveness
      • of Workplace based Wellness Programmes
      • Kuoppala J, Lamminpää A, Husman P. Work health promotion, job well-being, and sickness absences - a systematic review and meta-analysis. J Occup Environ Med 2008 Nov;50(11):1216-27.
      • Martin A, Sanderson K, Cocker F. Meta-analysis of the effects of health promotion intervention in the workplace on depression and anxiety symptoms. Scand J Work Environ Health 2008 Dec 9.
      • Goetzel RZ, Ozminkowski RJ. The health and cost benefits of work site health-promotion programs. Annu Rev Public Health 2008;29:303-23.
      • Engbers LH, van Poppel MN, Chin A Paw MJ, van Mechelen W. Worksite health promotion programs with environmental changes: a systematic review. Am J Prev Med 2005 Jul;29(1):61-70.
      • Pelletier KR . A review and analysis of the clinical and cost-effectiveness studies of comprehensive health promotion and disease management programs at the worksite: update VI 2000-2004. J Occup Environ Med 2005 Oct;47(10):1051-8.
      • Chapman LS. Meta-evaluation of worksite health promotion economic return studies: 2005 update. Am J Health Promot 2005 Jul-Aug;19(6):1-11.
    • 40.
      • Some References: Employee Health and
      • Work Productivity
      • Mills PR, Kessler RC, Cooper J, et al. Impact of a health promotion program on employee health risks and work productivity. Am J Health Promot. 2007;22(1):45–53
      • Financial costs due to excess health risks among employees of a utility company. J. Occup Environ Med. 2006; 48: 896 -905
      • Comparing excess costs across multiple corporate populations. Wright D, Adams L, Beard MJ, Burton WN, Hirschland D, McDonald T et al. J Occup Environ Med. 2004; 46: 937-945
      • The Health and Productivity Advantage; 2009/2010 North American Staying@work Report. Watson Wyatt Worldwide and National Business Group on Health.
      • Boles M, Pelletier B, Lynch W. The relationship between health risks and work productivity. J Occup Environ Med 2004: vol 46(7); pages 737-745.
      • Mills, P.R., Kessler, R.C., Cooper, J., & Sullivan, S. Impact of a health promotion program on employee health risks and work productivity. Am J of Health Promot 2007: vol 22 (1): pages 45-53.
      • Association of health risks with the cost of time away from work. J Occup Environ Med. 2002; 44: 1126 - 1134
      • Market and Business Development 2008, ‘UK OCCUPATIONAL HEALTH MARKET RESEARCH REPORT’, September, viewed 21st April 2009 http://www.mbdltd.co.uk/Press-Release/Occupational-Health.htm
    • 41. Other resources
      • http://www.cdc.gov/workplacehealthpromotion/references/index.html#Implementation

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