Posts from — May 2009

The most common evaluation performed in Worksite Wellness Programs is heart health assessment.

The assessment can include a written heart health test, Blood Pressure (BP) measurement, cholesterol/HDL-cholesterol test, glucose (blood glucose), weight, educational materials specific to diet, nutrition, exercise, cholesterol, smoking, and weight.

The health professional conducting the evaluation then provides a consultation and helps set goals with the colleague.

The backbone of wellness programming at the workplace is health screening. It is the first primary activity a company ought to do when first starting a wellness program. Health screening is often used in conjunction with the administration of a Health Risk Appraisal (HRA).

The most effective way to screen is to utilize a health professional trained in wellness evaluation techniques and counseling to privately and individually assess participants. This wellness professional takes a brief health history and measures Blood Pressure (BP) and cholesterol. With computerized cholesterol desktop analyzers, results are obtained in about four minutes.

Immediate feedback, consultation, and educational materials are provided. For those identified at-risk, follow-up appointments can be scheduled at this time. The whole process takes about twenty minutes per individual. The screening also provides an immediate opportunity to register participants in various health improvement programs based on their interests and identified health risks.

Health evaluation can be done on an yearly basis and used as a means of monitoring health risks within the workplace.

A health screening program needs to offer multiple opportunities for participation. The service should be provided for all the various shifts of a employer. The screening program should be conducted in highly visible areas so the process can be observed.

Reluctant staff members frequently like to be able to see what the program is about before they participate. When wellness screeners are not busy, they ought to perform outreach going to areas where staff members gather and attempt to recruit staff members.

When well-planned and promoted, health evaluation can attract participation rates of 60% to 100%. These high participation rates have a beneficial impact on management producing support for further programming.

Goals are broad-based statements about what the program is expected to do. The goal of the wellness program is to enhance the health of the individual and the organization. Goals like mission statements offer direction in a program.

Objectives are specific and provide a means of measurement of the program to determine success. There are two types of objectives, process and outcome. Process objectives state the activities that need to occur to achieve a desired outcome.

Examples of process objectives are:
• Number of participants screened
• Number of participants in and completing health improvement programs
• Satisfaction of program participants
• Number of participants who were medically referred and saw their physician
• Number of promotional activities
• Number of participants seen in follow-up

Example of outcome objectives are:
• Number of participants who improved fitness level
• Number of participants who lowered cholesterol level
• Number of participants who lost weight, body fat
• Number of participants who quit smoking
• Number of participants with high Blood Pressure (BP) who lowered their Blood Pressure (BP)
• Number of participants whose initial level of alcohol consumption put them at-risk who are no longer at-risk
• Number of participants with risk factors who saw their physician and are being treated for elevated Blood Pressure (BP) or cholesterol years later

Wellness committees are important in that they create a sense of ownership in the program, and facilitate various tasks involved in wellness programming at the worksite. The Employee Wellness Program Committee should be composed of a cross-section of workers representing various occupations, levels, and subgroups with the employer.

A common mistake is filling the Workplace Health Promotion Program Committee with the most health/fitness-conscious people in the employer. Don’t rely solely on volunteers to fill a Workplace Health Promotion Program Committee. Make sure that your Workplace Health Promotion Program Committee participants have enough power in the employer to run an effective wellness program.

The Workplace Health Promotion Program Committee is made up of staff members from the workplace. It oversees the wellness program and helps carry it out. The Workplace Health Promotion Program Committee should meet about once a month to review the previous month’s activities and plan future ones. When the program is just starting, the Workplace Health Promotion Program Committee may meet on a weekly basis until things get going.

Committee participants do not carry out medical care procedures, counsel clients, or handle confidential health information. Wellness professionals perform these tasks.

In general, the Company Health Promotion Program Committee’s duties fall into three areas: planning, promoting, and assisting to run programs.

Developing the programs can include:

• Finding space for activities
• Planning and organizing worksite-wide events such as contests
• Analyzing reports prepared by the program employee and making recommendations

Promoting the program can include:
• Recruiting staff members to take part in evaluation and health improvement programs
• Encouraging staff members to take part in follow-up counseling
• Organizing promotional strategies using newsletters, signs, bulletin boards, computers, and other media available within the worksite

Helping to run the program can include:
• Setting up equipment for various activities
• Helping to conduct workplace-wide activities
• Monitoring all activities and reviewing the performance of the professional employee
• Acting as wellness mentors to fellow employees

The size of the Corporate Wellness Program Committee will be dependent on the size of the organization. Pick participants by asking day management to nominate or appoint employees.

Make an announcement through handouts, memos, and gatherings to recruit potential participants. Explain the purpose of the Company Health Promotion Program Committee, duties and responsibilities, and the time commitment.

Recognize your Corporate Health Promotion Program Committee volunteers. Allow them to take part in programs at a reduced cost. Have appreciation breakfasts/lunches/dinners. Print names of Corporate Health Promotion Program Committee members on business communications about the wellness program.

Purchase special T-shirts, caps, and buttons for them. Write letters to supervisors saying that you appreciate the member’s service. Organize awards certificates for members.

The following can be used as a guide for Corporate Wellness Program Committee size:

• Less than 300 workers   2 to 4
• 300 to 1,000 staff members   4 to 6
• 1,000 workers or more   6 to 12

Effective wellness programs recognize the importance of building a supportive cultural environment. The worksite culture includes shared values/heartfelt beliefs about what is valuable. It includes social standards of expected and accepted behavior called “cultural norms.”

It includes peer reinforcement from family, friends, and co-workers. This reinforcement can help one adopt healthy lifestyles. Tools are available to audit a employer.

The long-term success of any wellness program is dependent on the corporate culture.

Some healthy culture signs in a organization are:

• employees communicate openly
• Leaders support diversity and opinion
• workers have fun
• Policies support wellness
• employees are encouraged to grow
• staff members work together as a team
• staff members’ skills and talents are matched to their jobs.
• Flexible work schedules are available
• Employers consider workers as their most valuable asset

Effective wellness programs attempt to set up healthy workplace climates. A healthy workplace climate is one which encourages teamwork, cooperation, and empowerment of the individual.

People have a sense of community, a shared vision, and a positive outlook. Policies promote and support wellness efforts within the workplace.

• Effective programs identify ways that company policies and company traditions encourage wellness.
• Effective programs work at the group and corporation level to build support for healthy lifestyle choices.
• Effective programs set clear target goals and objectives for the health improvement of the worksite.

An initial health evaluation can include a survey of staff members’ interests as part of the assessment. Effective wellness programs are designed to meet the needs and interests of the staff members. The information you need to get from a survey is dependent upon the scope of your program. A sample survey can be obtained in the HOPE Publications Web site. If you plan to adjust this sample survey or develop your own survey, keep the following hints in mind:

• Ask mostly closed-choice questions, especially if you will be sending the survey to a big number of employees. Closed-choice questions support specific choices and are easy to tabulate. You may want to use a computer for data entry and analysis.
• Invite comments, opinions and recommendations, or ask open-ended questions at the end of the survey. Open-ended items are more difficult to summarize.
• Include a brief explanatory cover letter with the survey with the signature of the business president. Make sure to include a statement about confidentiality and anonymity.
• Ask a group of representative workers to review the survey before it is distributed. Find out if the questions will be understood by workers and will not be objected to.
• Include demographic information at the beginning or end of the survey. Consider various ways that you might analyze the responses by demographic characteristics (gender, age, shift, site, department, etc.).

When thinking of who ought to get the survey, a simple rule is if you have under 500 staff members, everyone ought to receive one. The public relations benefit of everyone receiving a survey can be valuable. Over 500 staff members, a sample of the work population will suffice. A sample saves on expenditures and time. You may want to consider hiring a statistician to determine a suitable sample size for your worksite.

Needs surveys are confidential and anonymous; they do not request information that may identify a person.

Getting reinforcement from management is crucial to the success of the program.

One way to do this is to survey managers (see forms) and conduct interviews with decision-makers in the organization. You can use the surveys here or make up your own. If you decide to do your own, keep the survey short. It shouldn’t take more than ten minutes to complete.

The interview process can also serve as a means of educating management. Give concise fact sheets on the benefits of wellness programs for management. When surveys and interviews are completed, tally the surveys and write brief summaries of the interviews. Give these reports to management.

Once completed present a brief executive summary to management. Highlight a few interesting findings that can be used immediately to make decisions about the program.

Utilize charts and graphs to make your points. Prepare a detailed report for Workplace Wellness Program Committee members itemizing each response. Provide a short article about the survey in the company newsletter.

The higher the response the more valid and reliable the results. A minimum response of 40 percent to 50 percent is acceptable.

Complete Workplace Health Promotion Programs involve all workers, deal with all primary health risks, offers choices, and target both the workers and the workplace environment; support periodic assessment of its results.  Complete Workplace Health Promotion Programs emphasize follow-up and offers reinforcement for the employee as long as he/she is employed. Studies have demonstrated this approach to be highly successful. Key components are planning, implementation, and assessment.

Beginning all-inclusive Employee Health Promotion Programs involve performing a needs and interest assessment, appointing a Employee Health Promotion Program Committee, selecting wellness providers, setting goals for the corporate wellness program, marketing/promoting the program, and establishing procedures to ensure confidentiality.

Implementation of all-inclusive Worksite Health Promotion Programs consist of five major tasks:

1.   Health assessment and referral
2.   Follow-up and counseling workers
3.   Follow-up with physicians
4.   Health improvement programs
5.   Organizing workplace-wide activities.

Evaluation involves monitoring Corporate Wellness Programs to learn if it is working and to help you refine it. Measuring success shows what you have achieved, helps justify expenditures, and supports information for management to support continued programming.

Initially introduced by Halbert Dunn in the 1950’s, wellness became a popular buzzword during the late 1970’s and received considerable academic attention in the 1980’s.  Company Health Promotion Programs for employees became more widespread during the following decade, and credible evidence for their economic viability began to be published.  There have now been over 100 published research studies on this topic and a number of systematic reviews.

Health risks inflate costs.  Health Care Insurance costs escalate with both age and number of risks present.8,10   The number of risks is also strongly related to sick time absenteeism, Worker’s Compensation costs, STD, and reduced productivity (”presenteeism”).

Early Company Health Promotion Programs were relatively basic and typically produced a return on investment (ROI) of less than one dollar for every dollar spent operating the program (ROI = <1:1).8 Such programs might be characterized as "fun-oriented".  Participation is entirely voluntary, and there is no particular focus on the reduction of specifically identified elevated risks.  Interventions and activities are not customized, and there is no emphasis on the management of health costs.  These programs are typically site-based only, lack options to address all of the major behaviorally-related health risks, and lack multimodal presentation.  Minimal or no rewards and incentives are provided to staff members for participation, and services to spouses and family members are not available.  Most such programs lack meaningful assessment.  

More conventional programs are "activity-oriented" and have established an ROI of between 1:2.5 and 1:3.5.8 These programs may have a greater emphasis on health and risk reduction, even though the efforts are relatively broad and not personalized.  They may have some generalized emphasis on health cost management, even though not necessarily aimed at specific elevated risks.  Most are site-based and voluntary, with spouses included only rarely.  Modest rewards and incentives may be utilized to advocate participation.  Formal evaluation may be weak.

The newest and most economically viable programs are "results-oriented" and exemplify the health and productivity management model.  These programs consistently produce return rates of 1:4 or greater within a 12-24 month period.8   Such programs are strongly focused on the reduction of specifically identified high risks and the management of health costs.  They are generally voluntary, but use strong financial and other incentives and rewards to promote participation.  They are multi-component in nature (address all primary risks), and have both onsite and virtual modalities of operation.  The interventions are highly targeted and individualized, and available to spouses as well as workers.

For corporations, the expense of providing healthcare insurance for their employees is of great significance.  Those costs have been growing at yearly rates between 6% and 14%. Chapman's 2007 systematic review published an average reduction in medical care costs of 26.5% as a result of Company Wellness Programs.  His review covered 60 of the most scientifically valid studies, with an average of 3.77 years of study.

Absenteeism due to illness is another cost driver.  Chapman's review reports an average decrease in sick leave of 25.3%.   Cost for Worker's Compensation was reduced by 40.7%, and disability costs by 24.2%. There is also an emerging literature on the costs of presenteeism (reduced productiveness).11,13  In one study, every risk reduced through a wellness program yielded a 9% decrease in presenteeism (and a 2% decrease in absenteeism).

Some companies have achieved a zero percent rise in medical expenditures across at least brief periods of time.10  Doing so requires 90-95% participation of the employee population in focused wellness drives, with 75%-85% of the staff members falling into the low risk category.10  Although robust efforts to cut the risk status of those in moderate or high risk categories must be made, the needs of currently healthy staff members must be addressed as well to avoid increases in risk-status.

Given the size of the federal workforce, important cost savings in the government's contribution to health care insurance premiums for employees could be achieved if a majority of that population were participating in active wellness programs.  Similarly, improvements in absenteeism, worker's compensation, disability, presenteeism, and turnover as a result of robust Workplace Health Promotion Programs would yield substantial fiscal advantages for the government.

References

1.   Aldana, Steven G.  (2001)   Financial Impact of Company Health Promotion Programs:  A Comprehensive Review of the Literature.   Am J Health Promotion 15(5):296-320.
2.   Chapman, Larry.  (1998)   The Role of Incentives in Health Promotion.  The Art of Health Promotion  2(3):1-8.
3.   Chapman, Larry.   (2003)   Biometric Screening in Health Promotion:  Is it Really As Important as We Think?  The Art of Health Promotion  7(2):1-12.
4.   Chapman, Larry.  (2005)   Meta-Evaluation of Corporate Wellness Programs Economic Return Studies: 2005 Update.  The Art of Health Promotion, July/August, 1-15.
5.   Chapman, Larry.   (2006)   Employee Participation in Company Health Promotion Programs and Company Health Promotion Programs:  How Important are Incentives, and Which Ones work Best?   North Carolina Medical Journal   67(6):  431-432.
6.   Chapman, Larry, Lesch, Nancy, and Passas Baun, Mary Beth.   (2007)   The Role of Health and Wellness Coaching in Company Wellness Programs.   The Art of Health Promotion, July/August, 1-12.
7.   Chapman, Larry.  (2007)   Proof Positive:  An Analysis of the cost-Effectiveness of Worksite Wellness.  Northwest Health Management Publishing, Seattle, WA.
8.   Chapman, Larry.  (2007)   An In-Depth Look at the Economic Evidence for Rewarding Health Behavior Change.   Workshop presentation at the World Research Group “Rewarding Healthy Behaviors for Health Plans and Employers” Conference, Orlando, FL, January 23-24.
9.   Edington, Dee.   (2001)   Emerging Research:  A View from One Research Center.  American Journal of Health Promotion 15(5): 341-349.
10.   Edington, Dee W.  (2007)   Health Management as a Serious Business Strategy.  Presentation at the World Research Group “Rewarding Healthy Behaviors for Health Plans and Employers” Conference, Orlando, FL, January 23-24.
11.   Pelletier, Barbara, Boles, Myde, and Lunch, Wendy.  (2004)  Changes in Health Risks and Work Productivity.   Journal of Occupational and Environmental Medicine, 46(7): 746-754.
12.   Pelletier, Kenneth R.  (2005)   A Review and Analysis of the Clinical and Cost-Effectiveness Studies of comprehensive Health and Disease Management Programs at the Job Site: Update VI 2000-2004.  JOEM 47(10)1051-1058.
13.   DeVol, Ross, Bedroussian, Armen, et. al.  (2007)  An Unhealthy America:  The Economic Burden of Chronic Disease.  Report released by the Milken Institute.   www.milkeninstitute.org.
14.   Partnership for Prevention.  (2008) Investing in Health:  Proven Health Promotion Practices for Workplaces.   http://www.prevent.org/images/stories/2008/investinginhealth_finalfinal.pdf.

Company America is increasingly investing in employee wellness because it is good business.  In order to meet productivity demands, employers must rely on a healthy, productive workforce to succeed in the highly competitive global marketplace.  Over a hundred research studies in both corporate and governmental settings have documented the economic advantages of Company Wellness Programs, including reduced absenteeism, reduced injuries and workman’s compensation expenditures, reduced health care expenditures, reduced employee turnover, as well as increased productivity, greater worker satisfaction, and improved morale.1-10  

The more recent literature reflects improvements in wellness programming along with greater return on investment.  In general, the more focused and intensive the program, the greater benefit realized.  To enhance their performance federal government Workplace Wellness Programs may be able to incorporate some of the features described.  Employee wellness programs determined to have beneficial returns on investment frequently include the following features:

1.   Health and productiveness management model
Programs characterized by this model focus attention on identification and reduction of specific risks or behaviors such as smoking, lack of physical exercise, excess weight, unhealthy diet, high cholesterol, high Blood Pressure, stress, depression, and so on.  High-risk employees are specifically targeted for intervention, even though the most efficacious programs also direct efforts towards healthy employees in order to maintain their low-risk status.  This model emphasizes outcomes as opposed to simply offering wellness activities for their own sake.  

2.   Health risk appraisal
Use of a computerized health risk appraisal (HRA) instrument with individualized feedback and recommendations is almost universal in thriving programs.  Employees take the questionnaire each year in many cases.  The HRA serves to expand awareness, provide direction, and arouse individuals to better specific behaviors.  In some cases, the customized report is directly linked to appropriate resources related to identified risks.  Research indicates that the use of an HRA is effective if it is followed by some kind of educational or therapeutic intervention for identified risks.  It often serves as the entry point into wellness programs.

3.   Biometric Testing
Many programs combine the results of the health risk appraisal with measurement of each employee’s biometrics, including weight and Body Mass Index (BMI), Blood Pressure (BP), blood lipids, fasting glucose, and assorted other metrics.  Combining the results of the HRA with biological measures results in a more accurate risk profile.   Computer health risk appraisals frequently incorporate biometric data in their risk analysis.

4.   Incentives
workers are generally given monetary or other important rewards for completing an HRA, participation in a program or class, specific accomplishments such as stopping smoking, losing weight, or exercising, and for maintaining healthy status and/or behaviors.  In many cases the monetary incentives are associated with reductions in medical insurance premiums.  Some programs use disincentives as well as incentives, such as charging workers who smoke higher rates for their medical insurance contribution.

5.   High participation rates
Successful programs use rewards and incentives to drive participation rates up.  They also market their programs extensively, and may use contest or challenge strategies to heighten enthusiasm and promote participation.

6.   Wellness coaching
employees with identified risks or desire to improve their health habits may be periodically coached via phone by trained wellness coaches.  Wellness Coaching helps employees set and achieve realistic lifestyle-related objectives and goals including those discussing stress, work life balance, smoking, weight, physical exercise, and various behavior modifications.  Three or more sessions are generally provided.  In some intensive programs, the coaching extends to actual disease management intervention for employees with identified elevated-risk diseases.

7.   Multiple formats
Programs may offer wellness content in online, paper, and seminar formats to support stimulating variety and alternatives in order to accommodate the needs of all workers.  In addition to on-Site physical exercise and healthy eating programs, on-line programs, e-mail reminders and notices, printed newsletters and materials, and employer sessions are common dissemination strategies.

8.   Senior Leadership support
Enthusiastic and persistent endorsement by upper management is critical to achieving high rates of participation.  When senior executives are wellness role models themselves the effects of endorsement are enhanced.

9.   Frequent contact
Effective programs have successive contact of some sort with every employee.  This may be through marketing efforts (e.g., posters, e-mail notices, reminders, or messages, etc.), bulletin boards, newsletters, employee meeting presentations, discussion in new employee orientation, supervisory sessions, etc.   The key is to enhance employee awareness of health and wellness opportunities and reinforce the corporate emphasis on wellness through successive and multiple “touches”.

10.   Open enrollment
To promote high participation rates employees must have easy access to the wellness programs and activities.  Open and uncomplicated enrollment processes achieve this.  Some corporations automatically enroll all employees and then allow those who do not wish to take part to “opt-out”.  This practice has been determined to boost enrollment rates in some settings.

11.   Family involvement
Many programs advocate spouses and other family members to take part in the corporation wellness activities and to adopt a healthy lifestyle along with the designated employee.  It is far easier for the employee to have a healthy lifestyle if his/her family does so as well.

12.   Smoking cessation
Because smoking and other tobacco use is the number one threat to health it is vital to offer staff members effective and convenient assistance with quitting.  Access to smoking cessation pharmaceuticals is frequently part of such programs.  In-house programs offer the most convenient access to these services, although on-line or phone-based programs may be available as well.  

13.   Exercise
Regular physical activity is a core component of every wellness program.  Workers must be strongly encouraged to engage in regular physical activity.  Most programs provide either periodic or continuous onsite opportunities, and some locations have onsite gyms, swimming pools, walking trails, etc.  Discounted or paid memberships to community exercise facilities is a common alternative to onsite facilities.

14.   Weight management
Because obesity is a major threat to health it is imperative that programs offer effective assistance with weight control.  Robust encouragement from management to shed excess weight is valuable.  Web-based programs, workplace programs, or discounted access to weight control programs in the community may all be available.  Long-term follow-up is essential for maintenance of weight loss.

15.   Stress management
Workplace stress is perhaps the most common complaint among staff members and a primary contributor to absenteeism, presenteeism (reduced productivity), and low morale.  Almost all efficacious wellness programs offer assistance with personal and workplace stress.  Some programs refer staff members to outside resources for more weighty conditions like depression and anxiety disorders, but most offer internet based or frequent worksite general stress reduction programs.  Some organizations endeavor to structure the work environment to minimize stress, both physically and operationally.

16.   Wellness screenings/immunizations
employees are actively encouraged to complete recommended medical care screenings for Blood Pressure, blood lipids, BMI, colorectal and breast cancer, and others.  Annual influenza immunizations are also encouraged.  Some sites offer these services at the workplace.  Incentives are often awarded for completion of these screenings/immunizations.

17.   On-Site health care
Actual provision of onsite primary care medical services is a growing trend.  The rapidly escalating costs of medical care insurance for staff members has stimulated this trend.  Some businesses have found that it is less expensive to support primary care services themselves than to fund those services through health insurance.  Onsite care also reduces the amount of time staff members would otherwise spend away from the workplace getting such services.

References

1.   Aldana, Steven G.  (2001)   Financial Impact of Corporate Wellness Programs:  A Comprehensive Review of the Literature.   Am J Health Promotion 15(5):296-320.
2.   Chapman, Larry.  (1998)   The Role of Incentives in Health Promotion.  The Art of Health Promotion  2(3):1-8.
3.   Chapman, Larry.   (2003)   Biometric Screening in Health Promotion:  Is it Really As Important as We Think?  The Art of Health Promotion  7(2):1-12.
4.   Chapman, Larry.  (2005)   Meta-Evaluation of Company Health Promotion Programs Economic Return Studies: 2005 Update.  The Art of Health Promotion, July/August, 1-15.
5.   Chapman, Larry.   (2006)   Employee Participation in Company Wellness Programs and Company Wellness Programs:  How Important are Incentives, and Which Ones work Best?   North Carolina Medical Journal   67(6):  431-432.
6.   Chapman, Larry, Lesch, Nancy, and Passas Baun, Mary Beth.   (2007)   The Role of Health and Wellness Coaching in Company Wellness Programs.   The Art of Health Promotion, July/August, 1-12.
7.   Chapman, Larry.  (2007)   Proof Positive:  An Analysis of the cost-Effectiveness of Job Site Wellness.  Northwest Health Management Publishing, Seattle, WA.
8.   Chapman, Larry.  (2007)   An In-Depth Look at the Economic Evidence for Rewarding Health Behavior Change.   Workshop presentation at the World Research Group “Rewarding Healthy Behaviors for Health Plans and Employers” Conference, Orlando, FL, January 23-24.
9.   Edington, Dee.   (2001)   Emerging Research:  A View from One Research Center.  American Journal of Health Promotion 15(5): 341-349.
10.   Edington, Dee W.  (2007)   Health Management as a Serious Business Strategy.  Presentation at the World Research Group “Rewarding Healthy Behaviors for Health Plans and Employers” Conference, Orlando, FL, January 23-24.
11.   Pelletier, Barbara, Boles, Myde, and Lunch, Wendy.  (2004)  Changes in Health Risks and Work Productivity.   Journal of Occupational and Environmental Medicine, 46(7): 746-754.
12.   Pelletier, Kenneth R.  (2005)   A Review and Analysis of the Clinical and Cost-Effectiveness Studies of comprehensive Health and Disease Management Programs at the Worksite: Update VI 2000-2004.  JOEM 47(10)1051-1058.
13.   DeVol, Ross, Bedroussian, Armen, et. al.  (2007)  An Unhealthy America:  The Economic Burden of Chronic Disease.  Report released by the Milken Institute.   www.milkeninstitute.org.
14.   Partnership for Prevention.  (2008) Investing in Health:  Proven Health Promotion Practices for Workplaces.   http://www.prevent.org/images/stories/2008/investinginhealth_finalfinal.pdf.