Category — Employee Wellness Newsletter

Information to evaluate your program comes from regularly collected screening and follow-up data of your program that look at process and outcomes of your program.

The Worker Health Program has available a computerized case-management system which includes queries that allow easy assessment of process and outcome results at any point in time.

Process Evaluation

Process assessment looks at the  Worksite Wellness Program’s impact as seen at various points in time.

Information that is gathered from the various forms that wellness staff members fill out ought to supply you with the following:

• How many employees were screened?
• How many workers who were referred to a doctor went?
• How many workers who expressed interest in health improvement programs went?
• How many employees who were referred to health improvement programs went?
• How many employees who went to health improvement programs completed them?
• How many employees are in follow-up caseload?

You can use this sort of process evaluation to evaluate and learn about the health of your program.

Outcome Assessment

A central intention of the program is to improve the health of employees. Information on how to judge how well your program is meeting this intention is called “outcome assessment” because you are evaluating the end results or outcome of your program.

In wellness programs, objectives are gauged by specific (outcomes) behavior changes and reductions in health risk levels. Have workers lowered their Blood Pressure (BP)? Have they lost weight? Are they working out more? Is alcohol consumption at a safe level? By way of example these are the types of questions you can ask to learn if you are reaching your objectives:

• For employees with elevated Blood Pressure (BP) (140 / 90 or higher or on medication) at screening, what percentage have it under control (below 140 / 90) a year later?
• What is the modification in average Blood Pressure levels among all workers with elevated Blood Pressure 1 year after evaluation? Two years later?
• For employees with high blood cholesterol levels (above 240) at screening, what percentage has reduced their cholesterol to borderline-high levels (200-239)?
• For staff members with borderline-elevated blood cholesterol levels, what percentages have reduced their cholesterol to the desirable range (below 200)?
• What is the change in average cholesterol levels among all employees with high and borderline-high blood cholesterol levels 1 year after evaluation? Two years later?
• For employees who were overweight at assessment, what percentage have lost 20 pounds or more a year later? Ten pounds or more? What is the average weight loss?
• For staff members who were tobacco users at screening, what percentages have quit smoking? For at least a year?
• For workers whose level of alcohol consumption put them at-risk at assessment, what percentage have quit drinking alcohol? Are consuming alcohol at levels considered safe by CDC standard procedures? Have reduced their drinking, but are still at-risk?
• For employees, what percentages are exercising at least three times a week for at least 20 minutes?
• If fitness levels were measured, what percentages have improved fitness?

Set a regular time such as every 6 months to look at which employees your program is reaching and how effective it is at helping them cut their health risks. Use this information to make new decisions about how to direct your program efforts. Then make the change you need to improve your program.

Some may feel that an assessment is an extravagance; it is not. Evaluation is a crucial part of a wellness program. You will need to know what is working and what is not. Decision-makers who fund the program need to be updated on the performance of the program. Assessment will support you with crucial data to maintain and expand the program and convince management to continue to support the program.

Counselors ought to follow up on staff members at least every 6 months throughout the career of the employee at the worksite. The goals of follow-up are to:

• Involve workers who have health risks in treatment and risk reduction programs.
• Involve all workers in health improvement programs and workplace-wide wellness activities.
• Support workers in carrying out the risk reduction or health improvement activities they have chosen.
• Help workers comply with their treatment regimens.
• Prevent relapse.
• Prevent staff members from dropping out.
• Help workers maintain behavior changes.

Follow-up can be conducted in person, by phone, mail, and via computer if the technology is available. Most preferable is an in-person contact. Computer programs which can do case load management are available to help counselors track information and perform follow-up.

Priorities for Follow-Up

People with multiple health risks must be at the top of the list. People in key positions such as union leaders or department heads with health risks must also be contacted early so that they learn what the program is about and can share the information with others.

People who need a healthcare evaluation for high Blood Pressure or blood lipids should also be targeted early. Many staff members will have seen their doctors as a result of the screening, but some will need more encouragement to do so. Those with no health risks can be followed up annually.

A follow-up counseling session can take 20 to 45 minutes. At minimum, follow-up must include those who were told to seek healthcare assessment for high Blood Pressure readings, high cholesterol readings, or borderline high blood cholesterol readings with 2 or more other risk factors.

It may include those who were identified as at-risk for one or more of the other primary risk factors: at-risk levels of alcohol consumption, being overweight, and having low HDL.

Follow-Up With Physicians

A letter (see forms) ought to be sent to the physician or clinic of each employee who has elevated Blood Pressure (BP), elevated cholesterol, or is under a physician’s care.

The letter ought to explain the program and ought to include the employee’s relevant, current health measurements.

Along with the letter, send a self-addressed return envelope. Follow-up with the physician should be repeated every 6 months until it is demonstrated that the employee is under satisfactory control.

Contacting the physician is valuable for three reasons:

• The doctors receive staff members’ health measurements taken at the workplace.
• You receive the Blood Pressure (BP) and cholesterol readings the doctor takes and information on the treatment the doctor prescribes. Many times the employee does not have this information or does not remember it. The information can be used when counseling the employee.
• Follow-up encourages physicians to pay closer attention to heart disease risk factors among their patients.

The menu approach offers employees a range of options to support lifestyle changes. It allows people to choose the kind of help that suits their schedules and preferences.

The four basic types of programs include:
• Classes
• Minigroups
• Guided self help
• Individual counseling

Classes

Classes (8 or more) can be an effective means of providing education and social backing for behavior change. The length of a class can vary depending on topic requirements. It is not sufficient to offer only classes at a workplace.

Many staff members are under time constraints with after work commitments and even though they may be interested they simply cannot participate because of their schedules.

staff members may be very eager to begin a program but because of lack of participants to meet class quotas, the program is canceled. Many national companies such as the American Heart Association, American Cancer Society, Weight Watchers, etc. offer classes; you should have little trouble in identifying a provider for class type programs.

You may want to contact your local hospital, health department, or YMCA for possible options. For selecting a vendor to provide a program you may want to review the section on program structure.

Minigroups

When there is not enough interest to set up a class, those who are interested in a given health topic can be formed into a minigroup (2 to 7).

The minigroup can cover the same content as a class but do so in a less formal manner. Presentation of information and discussion is the major format of the minigroup.

Guided Self-Help

Most workers do not want formal help in making health changes; they prefer to do it on their own. In guided self-help, the wellness counselors offer support, materials, and encouragement.

Meeting times can be arranged and contact can be made either in person, by phone, or computer. Materials can be made available at the workplace, or mailed to the individual. Some worksites now make information available via intranets or the Internet.

Individual Counseling

One of the most successful ways to help individuals change and better their health status is counseling (or coaching) on a one-on-one basis.

In published studies, wellness programs which incorporated individual counseling as part of the program process achieved significantly higher participation rates and achieved greater risk reduction/risk elimination than standard group programs. Research studies have determined that individual counseling is both cost effective and cost productive.

A wellness counselor must be trained in assessment techniques, for in certain situations, they may be required to both screen individuals and counsel them. They must know how to do the following:

• Review employee health risks
• Contact employees who have health risks.
• Counsel staff members on a one-on-one basis, helping them set objectives, solve problems, and get expert help when they need it.
• Help workers follow their treatment recommendations and make lifestyle and health behavior changes.
• Recruit employees into health improvement programs, such as weight loss and tobacco cessation.
• Work with workers on a one-on-one basis using guided self-help.
• Conduct classes and minigroups if necessary.
• Work with Employee Health Promotion Program Committee participants to plan and conduct worksite-wide wellness activities.

Wellness counselors are health generalists; they must have basic knowledge about a wide range of health subject matters and health risks.

Counselors must be able to talk with staff members about their healthcare issues and the treatments prescribed by their doctors. They ought to have a great overview of diet, exercise physiology, pathophysiology of disease, pharmacology, psychology, and behavior change skills.

The educational program should include approaches to stress awareness/reduction at the environmental level and at the individual level.

Social, physical, and employer stressors ought to be explained and methods to ease or elevate stressors ought to be presented. At the individual level how changes in attitudes and behaviors help one to cope with stressors; learning techniques to minimize stress response, such as meditation, relaxation response, and exercise.

Content of the program must offer the following:
• Identifying sources of stress
• Relationship of stress to health
• How the individual experiences stress, personal, family, work
• Solutions for coping and managing stress
• Techniques for lowering stress
• Value of stress, both negative and positive
• Practical steps of incorporating stress reduction into lifestyle

Personnel conducting stress management programs should have training in psychology, behavioral sciences, or related disciplines such as mental health professionals, counselors, health educators, psychologists, and psychiatrists. Training in a reputable program on how to teach the stress management course including group process skills is a must.

A nutrition education program ought to include a nutritional needs assessment, education counseling, and referral as crucial.

Educational sessions and materials must include the following information:

• The relationship of diet and chronic diseases
• Improving eating patterns
• Relationship of nutrition and proper weight maintenance
• Exercise
• Stress
• Blood Pressure (BP)
• Cholesterol
• Diabetes and other chronic diseases.
• Nutritionally accurate information regarding the relationship of health to diet, including cholesterol, fats, fiber, alcohol, carbohydrates, salt, sugar, and vitamin/mineral supplementation.

Methods for identifying healthier foods and incorporating low-calorie, high nutrient foods into eating habits. Guidelines for working on eating habits should be based on or consistent with national recommendations such as The Food Guide Pyramid.

Instructor must be a registered dietitian, registered nurse, or have a baccalaureate degree or higher in health education with training in diet. If an allied health professional instructs the program, a consultation and review of the program design by a registered dietitian is recommended.

It is recommended that tobacco cessation programs subscribe to the Code Of Practice for Smoking Cessation Programs.

Smoking cessation programs ought to be multi-component with a focus on skills to build beneficial voluntary behavior modification practices. Useful techniques include implementing reasons for quitting, understanding the smoking habit, various techniques for stopping and remaining a non-smoker, overcoming the problems of quitting, short-term objective setting, weight control, stress management, effect of exercise, relationship of alcohol consumption to urges to smoke. Use no aversive or scare tactics.

In programs that use aids such as the “patch” or medications such as “Zyban” appropriate consultation ought to be available on the usage of these aids.

The instructor ought to have formal training in smoking cessation from a nationally recognized company such as American Heart Association, American Cancer Society, American Lung Association, or a nationally recognized commercial program such as Smoke Enders.

Evaluation of success is at times very dubious in tobacco cessation programs. Measurement of success should include participation rate, including the number beginning the program, the number completing the program, and the average number per session. Also included, number and percent who stopped smoking at the end of the program, and the number and percent who had not resumed smoking by the end of one year.

Participatory physical activity programs must include education on benefits of regular exercise and risks of a sedentary lifestyle, its impact on cardiovascular health and diseases, its relationship with weight control and stress management, and aerobic exercise options. Discussion and practice of safe principles of exercise – warm up, cool down, frequency, intensity, duration, flexibility and strength components. The program follows ground rules by the American College Of Sports Medicine.

Safety precautions ought to include the following:

• Informed consent prior to implementing exercise with clear and complete written and verbal standard procedures of possible risk, purpose of exercise, exercise format to be followed, opportunity for questions, and a signed informed consent with date.
• A screening/evaluation of participants to determine if healthcare evaluation is significant for exercise such as the Physical Activity Readiness Questionnaire (PAR-Q, see forms).
• Measurements of Blood Pressure and resting heart rate are useful evaluation information to determine exercise readiness.
• Participants who fail screening are medically referred and must obtain a written clearance from their physician to exercise.
• The basic content of an aerobic physical activity program must include:

Warm up   5 – 10 minutes
Aerobic exercise   20 – 40 minutes
Cool down   5 – 10 minutes

Exercise instructors ought to have education and training in exercise physiology, physical education, physical therapy or comparable discipline, or possess a current certification by a nationally recognized sports medicine or exercise association, and be CPR certified.

Program available is consistent with scientific and medical recommendations for weight loss, reflects a multi-disciplinary approach which offers four components: behavioral, exercise, nutrition, and maintenance, and is in accordance with the document Guidance For Treatment Of Adult Obesity. It includes:

• Screening to verify that the colleague has no medical or psychological conditions which would make weight loss inappropriate, and to identify the colleague’s level of health risk, classifying participants not only on excess body weight, but also on the basis of associated medical conditions and central heath risk.
• Referral for participants who are morbidly obese who would require medical guidance for weight loss.
• Informed consent, explanation of potential physical and psychological risk from weight loss and regain, likely long-term success of program, full cost of the program, credentials of the employee.
• Identification of contributing factors to colleague’s weight status, serving as the basis for an individualized weight loss plan which includes the weight objective and plans for nutrition, exercise, and behavioral components.
• Weight intention of attendant is reasonable based on personal and family weight history not solely on height and weight charts; initial weight loss intention does not exceed loss of 10% of body weight, 1-2 pounds per week.
• Explanation of unsafe weight loss methods.
• Daily calorie level is adjusted to meet each attendant’s recommended rate of weight loss.
• Daily caloric intake is not less than 1,000 calories; if less, physician monitoring is required.
• Food plan designed so participants can select foods which meet 100 percent of all the Recommended Daily Allowance (RDA) except for calories. Nutritional supplementation can be used to achieve RDAs, however ought to not greatly exceed RDAs.
• Nutrition education encouraging permanent healthful eating habits based on The Food Guide Pyramid.
• Participant involved in meal planning and food selection.

The protein, fat, carbohydrate, and fluid content of the food plan meet safety recommendations:

Protein   Between 0.8 and 1.5 grams of protein per kilogram of intention body weight, but no more than 100 grams of protein a day.
Fat   10 – 30 percent calories as fat.
Carbohydrate   At least 100 grams per day.
Fluid   At least one liter of water daily.

• Exercise component ought to be a important portion of the program and be both didactic and experiential.
• Participant is appropriately screened for exercise using a assessment questionnaire such as the Par-Q Readiness Assessment (see forms). Instruction on recognizing untoward responses to exercise.
• Participants work towards 30-60 minutes of exercise 5-7 days per week.
• No appetite suppressant prescription drugs.
• Maintenance plan provided for continued backing.
• Weight control programs must be conducted by a registered dietitian or by degreed health professionals with training in nutrition with consultation by a registered dietitian.
• Trained lay leaders may assist  if supervised by nutrition professional.

Note: There’s an interactive version of Guidance for the Treatment of Adult Obesity at e-Guidance for the Treatment of Adult Obesity.

A program is required to support appropriate interpretation of cholesterol screening results, including a caution that a single measurement neither excludes nor establishes a diagnosis of their blood cholesterol.

Follow national ground rules:

Total Cholesterol
Desirable cholesterol   < 200 mg/dl
Borderline cholesterol   200 – 239 mg/dl
High cholesterol   > 240 mg/dl

HDL
Desirable HDL    > 35 mg/dl
Low HDL    < 35 mg/dl

Refer cholesterol assessment participants to health care as follows:

Total Cholesterol
< 200 mg/dl    Recheck cholesterol in five years, if history of coronary heart disease or if two or more CHD risk factors are detected refers to risk reduction program or health professionals, as appropriate.
200 - 239 mg/dl    If history of CHD or if two or more other risk factors are detected, refer to medical care or risk reduction service within two months; if no stated history of CVD or less than two other risk factors, reassess blood lipid status within 1-2 years.
> 240mg/dl    Refer to healthcare within two months.

HDL
> 35 mg/dl   If fewer than 2 risk factors and borderline total cholesterol, refer to risk reduction service, as appropriate. Reassess HDL in 1-2 years.

Provide the following:
• The relationship of blood lipids, high Blood Pressure (BP), and other risk factors.
   o Risk factors include: elevated Blood Pressure 140/90 or higher or on hypertension medication; current cigarette smoking; family history of premature CHD; diabetes mellitus; age – male > 45 years, female > 55 years or premature menopause without estrogen replacement therapy.
   o Negative risk factor: high HDL 60 mg/dl or greater (subtract one risk factor).
   o Risk factors such as family history, smoking, high fat or other unhealthy diet, and lack of exercise lead to the development of cardiovascular disease (CVD).
• Definitions and causes of high blood lipids and HDL, desirable levels, the meaning and limitations of a single measurement, the cause of variability, and the need for multiple measurements prior to diagnosis.
• Wide range of treatment options, including diet (e.g., significance of controlling fat intake less than 30 percent of total calories from fat, less 10 percent saturated fats), less than 300 mg. of cholesterol per day, well-balanced diet, weight maintenance or reduction, exercise, and medication.
• Importance of following prescribed treatment and professional advice.

Appropriate health care or allied health professional trained in measurement of Blood Pressure, referral protocols, and delivering educational messages to participant conducting Blood Pressure programs. These programs are necessitated to follow national instructions.

• National guidelines for Blood Pressure protocols:
   o Calibration of Blood Pressure (BP) measuring equipment
   be done at least annually.
   o Two or more measurements of attendant’s Blood Pressure ought to be taken.
   o Referral of participants with high Blood Pressure (BP) readings to personal physician for further assessment.

• Systolic/Diastolic Follow-Up:
   o Normal:   <130 / <85
      Action: Recheck in 2 years
   o High Normal:   130-139 / 85-90
      Action: Recheck in 1 year

• Hypertension:
   o Stage 1 (Mild):   140-159 / 90-99
      Action: Confirm within 2 Months.
   o Stage 2 (Moderate):   160-179 / 100-109
      Action: Refer to source of care within 1 month.
   o Stage 3 (Severe):   180-209 / 110-119
      Action: Refer to source of care within 1 week.
   o Stage 4 (Very Severe):   >210 / >120
      Action: Refer to source of care immediately.

• Appropriate educational messages:
   o Normal:   <130 systolic and <85 diastolic
      Action: No referral. If on treatment, then inform attendant that Blood Pressure is under good control today and must continue seeing and following treatment program.
   o High Normal:   130-139 systolic and/or 85-89 diastolic
      Action: Recommend that colleague have Blood Pressure (BP) rechecked within 1 year unless under treatment. Advise colleague that the readings are in a high normal range that needs rechecking. In the interim, suggest that one of the most effective means to reduce Blood Pressure (BP) is to bring weight into normal range and to exercise.
   o High:   >140 systolic and/or >90 diastolic
      Action: Refer to physician for further assessment within 2 months unless the level is within urgent, emergency, or isolated systolic hypertension levels. If already on treatment, advise participant of readings and need to get Blood Pressure to a intention of 140/90 or less.
   o Isolated Systolic Hypertension:   140-159 systolic and < 90 diastolic in a attendant 65 years of age or older.
      Action: Advise colleague to inform physician of readings at next visit and consider advice regarding weight loss and exercise if appropriate.
   o Urgent:   180-209 systolic and/or 110-119 diastolic
      Action: Recommend obtaining healthcare assessment within 1 week.
   o Emergency:   >210 systolic and/or >120 diastolic
      Action: Get immediate medical care attention.

• Provides the following:
   o Written results, referral instructions, and an explanation of Blood Pressure levels given to each participant with individualized counseling, including advice about the interval of time recommended when the participant ought to be checked again.
   o Utilizes the recommendations in The Fifth Report Of The Joint National Committee on Detection, Assessment and Treatment of High Blood Pressure, March 1994.
   o Written and audiovisual materials that are informative, easy to be aware of, and useful while containing scientifically accurate information.
   o Relationship of elevated Blood Pressure and other risk factors, such as family history, smoking, high fat and unhealthy diet, lack of exercise, in the development of cardiovascular disease, including stroke, kidney disease, heart attack, and other diseases.
   o Definition and causes of elevated Blood Pressure (BP).
   o Importance of following prescribed treatment.