RESEARCH AND PRACTICE

Results of the 2004 National Worksite Health Promotion SurveyI Laura Linnan, ScD, CHES, Mike Bowling, PhD, Jennifer Chiidress, MS, CHES, Garry Lindsay, MPH, CHES, Carter Blakey, Stephanie Pronk, MEd,

Sharon Wieker, and Penelope Royall, MSW, PT

Worksites are important public health settingsbecause the majority of US adults spend con-siderable amounts of time at work, and thework environment exerts an independent in-fluence on employee health. Addressing boththe work environment and individual healthbehavior is essential to producing gains inemployee health.'"^ In addition, the "health"of a business depends on strategies that man-age both business costs and employee healthcare costs. Thus, tracking employer efforts topromote health is warranted.

In the United States, the first nationalworksite health promotion survey was con-ducted in 1985, and follow-up surveys wereconducted in 1992, 1999, and 2004. Thesesurveys serve as national benchmarks and asindicators of change over time. One majorworksite health-related goal included inHealthy People 2010 is to increase to at least7 5 % the number of employers that offer acomprehensive health promotion program foremployees."*'' We examined data form the2004 National Worksite Health PromotionSurvey to monitor the prevalence of worksitehealth promotion programs, policies, services,and supportive environments and to assessthe implications of the survey's results forpublic health practice and research.

METHODS

Study Design and SampleThe 2004 National Worksite Health Pro-

motion Survey gathered information from across-sectional, nationally representative sam-ple of US worksites. The sample was drawnfrom the Dun & Bradstreet database^ of allprivate and public employers in the continen-tal United States. To the extent possible, thesurvey's procedures followed those used inprevious national surveys''* so that between-survey comparisons could be made.

Questions addressed spécifie worksitesrather than the companies to which theworksites belonged. The survey involved adisproportionate stratified sampling design

Objectives. We examined worksite health promotion programs, policies, andservices to monitor the achievement of the Healthy People 2010 worksite-relatedgoal of 75% of worksites offering a comprehensive worksite health promotionprogram.

Methods. We conducted a nationally representative, cross-sectional telephonesurvey of worksite health promotion programs stratified by worksite size and in-dustry type. Techniques appropriate for analyzing complex surveys were used tocompute point estimates, confidence intervals, and multivariate statistics.

Results. Worksites with more than 750 employees consistently offered moreprograms, policies, and services than did smaller worksites. Only 6.9% of re-sponding worksites offered a comprehensive worksite health promotion pro-gram. Sites with a staff person dedicated to and responsible for health promo-tion were significantly more likely to offer a comprehensive program, and sitesin the agriculture and mining or financial services sector were significantly lesslikely than those in other industry sectors to offer such a program.

Conclusions, Increasing the number, quality, and types of health promotion pro-grams at worksites, especially smaller worksites, remains an important publichealth goal. {Am J Public Health. 2008:98:1503-1509. doi:10.2105/AJPH,2006.100313)

with 35 strata defined according to 2 cate-gories: number of employees (fewer than 50,5 0 – 9 9 , 100-249, 250-749, 750 or more)and US Standard Industrial Classificationcode (agriculture/mining/construction,finance/insurance/real estate, transportation/communications/utilities, business/professionalservices, manufacturing, wholesale/retailtrade, public administration/government).

Because of the preponderance of work-sites with fewer than 50 employees, weoversampled sites with more than 50 em-ployees to ensure that estimates would beappropriate for all sites of all sizes. We re-port results only for nongovernmental work-sites with 50 or more employees because(1) point estimate variances were unstablefor sites with fewer than 50 employees and(2) previous national surveys omitted gov-ernment workplaces.

Data Collection ProceduresTrained interviewers conducted the 2004

survey by telephone (each interview requiredapproximately 20 minutes). At each worksite,respondents were identified as being "directlyresponsible for health promotion or Wellness"or as having an "in-depth knowledge of thesetypes of programs at the worksite."

Response rates were enhanced via severaltechniques. For example, respondents wereprovided with a fact sheet describing the im-portance of partidpating in the survey, an-swers to typically asked questions, and a toll-free telephone Une to establish a convenientinterview time. Also, interviewers were pro-vided access to a telephone number lookupservice to assist in contacting employers thatdid not answer after 5 call attempts. Finally,standardized guidelines^ were used to recon-tact sites initially unwilling to take part to en-list their partidpation.

MeasuresKey measures included worksite size (total

number of full- and part-time employees), in-dustry type (Standard Industrial Classificationcode), number of years the worksite had of-fered a health promotion program (labeled"experience"), and barriers to offering ahealth promotion program. "Comprehensive"health promotion programs were defined asthose that incorporated all of the 5 key ele-ments outlined in Healthy People 2010:(1) health education (i.e., skill developmentand lifestyle behavior change, along with in-formation dissemination and awareness build-ing), (2) supportive sodal and physical work

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RESEARCH AND PRACTICE

environment (i.e., support of healthy behav-iors and implementation of policies promotinghealth and reducing risk of disease), (3) inte-gration (i.e., integration of the program intothe organization's structure), (4) linkage (i.e.,linkage to related programs such as employeeassistance programs), eind (5) worksite screen-ing and educaton (i.e., programs linked to ap-propriate medical care).

Data AnalysisAll analyses were carried out with the

SURVEYFREQ and SURVEYLOGISTIC pro-cedures in SAS/STAT,'" in which Taylor ex-pansion approximations are used to calculatestandard errors and their corresponding 9 5 %confidence intervals for stratified weighteddata." Weights were computed as the inverseof selection probabilities and were adjustedfor nonresponse. Twenty-three worksites fromthe 7 strata representing sites with fewer than50 employees were misclassified and thuswere reallocated and weighted to the correctsize strata. Analyses excluding and includingthese 23 reclassified sites yielded identicalresults.

We calculated point estimates with 9 5 %confidence intervals for all of the measuresexamined and used the Rao—Scott x^ statisticto assess differences according to size and in-dustry type." The level of significance was setat a < . 0 5 . We used the Wald x^ statistic tocompare logistic regression models fit togroups with and without a comprehensivehealth promotion program.'^

RESULTS

Sample DescriptionWe conducted a total of 1553 interviews

with worksites from the different size and in-dustry categories. Respondents were weightedacross industry and size categories, and sam-ple distributions reflected those in the popula-tion of all eligible worksites. The overall re-sponse rate (corresponding to response rate 3of the American Association for Public Opin-ion Research'^ guidelines) was 59.7%.

The sample size was 730, excluding govern-mental worksites and those with fewer than50 employees. The site size breakdown was asfollows; 179 sites with 50 to 99 employees,229 sites with 100 to 249 employees, 211

sites with 250 to 749 employees, and 111sites with more than 750 employees. Industrycategories represented were manufacturing(n= 198), finance (n=85), wholesale or retail(n=117), transportation (n=73), agriculture(n=86), and business or professional (n= 171).

Most survey respondents were directors ormanagers (60.5%) and were members of ei-ther a human resources or benefits depart-ment (52.7%). Approximately 3 9 % of re-spondents reported a 10% to 15% increasein health care costs in recent years; 31.0%reported an increase of less than 10%,18.7% reported an increase of more than20%, and 8.5% reported an increase of15% to 20%. Overall, 2.5% indicated thatthey did not offer health care benefits.

Staffing, Experience, and FundingThe majority of worksites (64.6%) em-

ployed at least 1 full- or part-time staff personwho was directly responsible for health pro-motion and worksite Wellness. Of the siteswith health promotion programs, 60.8% indi-cated that their program had been in placefor 5 years or less,. 8.7%, for 6 to 9 years,and 30.5%, for 10 or more years. The healthplan was identified as the leading source offunding for programs (e.g., health screenings,health risk appraisals, disease management)other than health awareness and informationprograms, which were most Irequentlyfunded by the employer (47.7%). In all cases,2% or fewer of responding worksites identi-fied employees or outside vendors as primarysources of funding.

Approximately 2 6 % of worksites reportedusing incentives to increase employee partici-pation. Incentives involving gifts and dis-counts were mentioned most often, followedby cash incentives. The 48 sites that offeredcash incentives reported that the meanamount offered (before taxes) per person peryear was $556.88 (SD=$176.70). No differ-ences according to worksite size or industrytype were observed in regard to use ofincentives.

Evaluation Metiiods, Support, andBarriers to Success

When asked about methods used in pro-gram delivery, respondents most Irequentiyreported using printed materials, followed by

the Internet, in-person strategies, and the tele-phone. For example, in the health awarenessand information programming category,46.0% of sites reported using printed materi-als, 28.1% reported using the Internet,24.4% reported using in-person methods,and 11.4% reported using telephone ap-proaches. This pattern was consistent in thedifferent program categories with the excep-tion of health risk appraisals; in this category,an identical percentage of respondents(11.0%) reported use of print materials andin-person strategies, whereas 7.8% reporteduse of the Internet, and 6.4% reported use oftelephone approaches.

Approximately 70% of respondents indi-cated that their health promotion programsupported the organization's business strat-egy, 67.5% believed that the program was in-tegrated into the overall strategy the em-ployer used to address health care, and66.2% reported that it was linked to otherkey organizational areas. However, only49.5% of sites used data to guide program di-rection, and only 30.2% had a 3- to 5-yearstrategic plan in place for worksite healthpromotion.

The most commonly reported barriers orchallenges to the success of health promotionprograms were lack of employee interest(63.5%), staff resources (50.1%), funding(48.2%), participation on the part of high-riskemployees (48.0%), and management sup-port (37.0%). No differences in barriers werereported on the basis of industry type orworksite size, with the single exception thatworksites with more than 750 employeeswere significantly more likely than weresmaller sites to report lack of participationamong high-risk employees (P=.OO2).

Overall, 19.4% of worksites reportedusing health risk appraisals, and there werestatistically significant differences accordingto worksite size. For example, only 11.3% ofsites with 50 to 99 employees used healthrisk appraisals, as compared with 45.8%of sites with more than 750 employees(P<.001). When asked about what theyused to evaluate program success, respon-dents most often cited employee feedback(73.2%), employee participation (57.4%),workers' compensation costs (57.1%), healthcare claims costs (57.0%), and time lost or

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RESEARCH AND PRACTICE

absenteeism (43.9%). Approximately 4 4 . 1 %

of sites expected a return on investment for

their program; of these sites, 36.2% ex-

pected a return on investment within 12 to

17 months, 23.9% expected it within 18 to

23 months, and 13.4% expected it in less

than 12 months.

Programs, Activities, Screenings, and

Disease Management

The most common types of programs of-

fered were employee assistimce programs

(progrsuns typically offering mental health or

counseling services; 44.7%), followed by

back injury prevention programs or activities

(45%), stress management programs (24.9%),

nutrition programs (22.7%), health care con-

sumerism programs (21.6%), and weight

management programs (21.4%). There was a

clear dose-response relationship in that work-

sites vÁÜi more employees offered more pro-

grams, classes, and activities (Table 1). The

only exception to this pattern was HIV/AIDS

education and health care consumerism; no

differences by worksite size reached statistical

significance.

Respondents were asked whether, in the

past 12 months, they had offered hesilth

screenings to their employees and their fami-

lies through the worksite, health plan, or both.

Blood pressure screenings were most fre-

quentiy offered (36.4%), followed by alcohol

or drug abuse support (35.9%), blood choles-

terol screenings (29.4%), diabetes screenings

(274%), and cancer screenings (21.8%).

Again, sites with more employees consistently

offered more screening services. Between

70% and 8 5 % of worksites with more than

750 employees reported offering all of these

services (blood pressure screening, 84.9%;

blood cholesterol screening, 80.5%; alcohol

or drug abuse support, 70.7%; cancer screen-

ing, 70.2%; and diabetes screening, 70.2%)

(Table 1).

In terms of disease management programs,

2 6 . 1 % of sites offered cardiovascular disease

programs, 2 5 % offered diabetes programs,

16.4% offered obesity programs, and 15.6%

TABLE 1-Selected Health Promotion Programs and Services, t>y Worksite Size: Natlonai WorksiteHeaith Promotion Survey, 2004

Programs or activities

Employee assistance

Smoking cessation

Physicai activity

Choiesteroi reduction

Nutrition

Stress management

Weight management

Back Injuiy prevention

Heaith care consumerism'

HiV/AiDS'

Screenings or counseiing services

Cancer screening

Diabetes screening

Biood pressure screening

Biood choiesteroi screening

Aicohol or drug abuse support

Disease management programs

Diabetes

Asthnia°

Cancer'

Depression'

Hypertension'

Back pain'

Cardiovascular disease

Chronic obstructive puimonaiy disease'

Obesity

High-risk pregnancy

Total (n-730),% (95% Ci)

44.7(39.28,50.13)

18.6(14.51,22.46)

19.6(15.54,23.67)

19.9(15.55,24.14)

22.7(18.16,27.24)

24.9(20.10,29.86)

21.4(16.94,25.93)

45.0(39.28,50.65)

21.6(16.76,26.48)

14.6 (10.53,18.70)

21.8(17.45,26.09)

27.4(22.47,32.25)

36.4(30.98,41.74)

29.4(24.50,34.39)

35.9(30.76,41.09)

25.0(20.10,29.83)

19.1(14.84,23.39)

22.5(17.66,27.28)

20.5(16.11,24.87)

22.9(18.10,27.60)

20.1(15.59,24.57)

26.1(21.14,31.10)

15.6 (11.62,19.61)

16.4(12.22,20.53)

18.6(14.22,22.94)

50-99 Employees (n = 179),%(95%a)

32.4(23.49,41.28)

8.8 (3.51,14.12)

9.0 (3.67,14.30)

16.4(9.02,23.87)

11.0(4.61,17.34)

17.6(9.92,25.19)

11.3 (5.11,17.40)

37.2(27.70,46.67)'

16.5(8.64,24.34)

11.3 (4.55,18.12)

14.3(7.82,20.74)

19.0(11.50,26.56)

27.1(18.22,35.92)

21.8(13.77,29.91)

28.6(20.14,37.03)

21.8(13.45,30.08)

15.8(8.64,22.95)

17.5(9.61,25.44)

15.5(8.44,22.64)

20.1(11.87,28.31)

16.1(8.71,23.42)

20.1(12.73,29.22)

13.3 (6.59,19.98)

11.9 (5.12,18.61)

14.8(7.39,22.14)

100-249 Empioyees(n-229),%(95%Ci)

48.07(39.03,57.12)

19.4(12.66,26.08)

23.6(16.11,31.11)

17.5(11.41,23.55)

30.4(21.92,38.85)

27.7(19.44,35.92)

24.8(16.79,32.86)

46.1(37.08,55.11)

27.0 (18.59,35.35)

14.2(7.54,20.92)

22.1(14.90,29.27)

27.7(19.67,35.68)

35.8(27.15,44.35)

26.8(19.13,34.49)

37.3(28.96,45.65)

22.4(15.40,29.39)

20.8(13.97,27.65)

25.8(17.78,33.74)

24.3(16.88,31.69)

23.3(15.94,30.72)

22.3(14.86,29.72)

27.8(20.04,35.59)

14.3(8.55,20.05)

16.8(10.00,23.56)

18.8(12.35,25.21)

250-749 Empioyees(n-211),% (95% Cl)

63.3(52.40,74.24)

32.0(21.92,42.17)

28.5(19.50,37.42)

29.3(19.78,38.86)

34.0(23.50,44.45)

32.3(22.20,42.49)

34.1(23.81,44.43)

55.7(44.88,66.56)

22.7(14.69,30.69)

24.9(15.51,34,38)

29.4(20.06,38.67)

39.9(29.39,50.32)

51.5(40.41,62.69)

43.5(32.94,54.20)

45.0(34.20,55.78)

33.6(23.67,43.53)

18.7(12.08,25.37)

27.9(18.39,37.38)

25.6(16.92,34.36)

28.1(19.44,36.77)

23.4(14.75,31.95)

30.3(20.51,40.04)

21.7(13.07,30.25)

29.1(19.27,38.92)

22.7(14.43,31.05)

>750Empioyees(n-lll),%(95%Ci)

84.2(69.70,98.62)

68.1(53.13,83.14)

66.1(49.15,83.10)

42.1(23.80,60.45)

43.0(24.71,61.35)

54.3(35.18,73.39)

56.1(37.14,75.14)

81.5(71.80,91.17)

27.6(13.20,42.02)

16.8(6.97,26.72)

70.2(55.57,84,85)

70.2(54.99,85.46)

84,9(73.16,96.63)

80,5(68,00,93.01)

70.7(54,39,86,94)

48.2(28.63,67.73)

39.4(19.10,59.66)

28,3(14,62,41.88)

23,2(11,51,34,95)

29.6(13,94,45,26)

32.3(15.71,48.96)

50,9 (31,34,70.36)

29,3(9,53,49.06)

16.6(7.70,25.56)

41.4(21.23,61.49)

Note. Cl=confidence interval,

"Nonsignificant between-group difference.

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RESEARCH AND PRACTICE

offered chronic obstmctive pulmonary dis-ease programs. Sites with more than 750 em-pioyees were more likely to offer cardiovascu-lar disease (50.9%), diabetes (48.2%), andhigb-risk pregnancy (41.4%) programs thanwere other worksites. Smaller worksites wereless likely to offer all types of disease manage-ment programs (Table 1). Differences accord-ing to worksite size were significant in thecase of obesity, cardiovascular disease, high-risk pregnancy, and diabetes programs.

Work Environment Programs or Policies

With respect to providing an environmentsupporting physical activity, 27.6% of work-sites offered on-site shower facilities, 14.6%had an on-site fitness facility, 13.5% offeredfitness or walking trails, and 6.2% providedsignage to encourage stair use. Sites withlarger numbers of employees were morelikely to offer a supportive environment forphysical activity. For example, 63.8% ofemployers with more than 750 employees

offered shower facilities (vs 20.9% of thosewith 50 to 99 employees), 49.6% (vs 9.8%)offered an on-site fitness facility, 40.5% (vs7.7%) offered a fitness or walking trail, and11.4% (vs 2.1%) promoted stair use withsignage.

Overall, 2 4 % of worksites had a cafeteria(allowing them a chance to offer healthy foodselections). Approximateiy 74% of sites withmore than 750 employees had a cafeteria, ascompared with 41.9% of sites with 250 to749 employees, 24.5% of sites with 100 to249 employees, and 12.9% of sites with 50to 99 employees. Most sites (79.6%) hadfood or beverage vending services, with thelargest sites more likely to provide such ser-vices. Overall, 37.4% of worksites reportedlabeling healthy food choices, and 5.6% of-fered promotions for healthy food choices(Table 2).

Approximately 4 0 % of worksites com-pletely prohibited smoking on worksite prop-erty, and 56.5% restricted smoking to outside

areas only; 12.4% provided employees fitnessbreaks at work. Overall, only 6.1% of sites of-fered catering policies to ensure that healthyfood options were available at companyevents; 12.4% of sites with more than 750employees reported having a catering policyin place. Overall, worksite policies prohibitingalcohol use (91.1%), drug use (93.4%), andfirearm use (85.8%) were prevalent, whereasoccupant protection policies for company ve-hicles (45%) were not. At each size category,the percentages of worksites that reportedhaving a policy increased as the number ofemployees increased.

Programs and Policies by industry Type

In general, no differences in health promo-tion programs, activities, or screenings; diseasemanagement programs; work environments;or policies by industry type were observed.However, sites in the transportation/communi-cations/utilities and agriculture/mining/construction categories were significantly less

TABLE 2-Seiected Viotk Environment and Poiicy Ciiaracteristics, by Worksite Size: Nationai Wori<siteHeaitii Promotion Survey, 2004

Physical environmentOn-site fitness centerOn-site shower facilitiesSignage promoting stair useFitness/walking trailsFood/beverage servicesCafeteria

Has a cafeteriaHealthy food choices labeled

Special promotions offered

Policies

Fitness breaks provided

Catering policy

Smoking policy

Smoking completely prohibited

Smoking restricted to designated inside areas

Smoking restricted to outside areas

Alcohol use prohibited

Drug use prohibited

Occupant protection policy (vehicles)

Firearms prohibited

Incentives to promote participation

Total (n-730),

%(95%CI)

14.6(9.97,19.14)

27.6(22.87,32.36)

6.2(3.57,8.85)

13.5 (9.66,17.28)

79.6(74.5,84.7)

24.0(19.39,28.65)

37.4(26.32,48.56)

5.6(3.07,8.09)

12.4 (8.59,16.21)

6.1 (0.00,11.49)

39.9(34.12,45.65)

34.7(27.81,41.48)

56.5(49.24,63.77)

91.1(87.46,94.75)

93.4(90.30,96.54)

45.0 (39.18,50.98)

85.8(81.75,90.01)

25.9(20.0,31.82)

50-99 Employees,

%(95%CI)

9.8 (2.20,17.30)

20.9(13.59,28.15)

2.1(0.12,4.01)

7.7(2.17,13.13)

70.8(61.47,80.17)

12.9 (5.92,19.97)

34.6(6.50,62.75)

3.9(0.00,8.03)

11.0 (4.59,17.48)

6.3 (0.85,11.79)

34.2(24.66,43.73)

32.0(21.01,43.03)

50.8(38.90,62.67)

86.3(79.55,92.96)

91.8(86.37,97.36)

49.0(39.22,59.00)

83.0(75.66,90.43)

23.4(12.75,34.10)

100-249 Employees,

% (95% Cl)

13.17(5.63,20.71)

29.7(21.43,37.99)

11.7 (5.14,18.32)

13.9(7.22,20.64)

82.1(74.16,90.01)

24.5(17.02,31.95)

28.8(11.39,46.26)

5.4(1.37,9.42)

13.0(7.02,18.95)

5.7(1.37,9.93)

45.6 (36.52,54.61)

36.4(25.25,47.46)

56.5(44.59,68.35)

93.2(87.67,98.75)

94.4(89.46,99.30)

38.9(29.83,48.00)

87.5(81.09,93.97)

• 27.5(18.11,36.84)

250-749 Employees,

% (95% Cl)

17.5(9.46,25.50)

32.4(23.28,41.50)

4.2(1.57,6.74)

22.1(12.62,31.59)

95.9(92.67,99.21)

41.9(30.75,52.98)

32.4(16.50,48.37)

7.4 (3.62,11.12)

13.5(6.08,20.97)

4.7 (0.00,10.35)

40.8 (29.98,51.60)

39.3(25.88,52.73)

70.3(59.31,81.30)

98.5 (97.02,100.00)

94.2 (88.36,100.00)

45.6 (34.40,56.72)

87.4(79.72,95.05)

27.7(17.70,37.63)

> 750 Employees,%(95%CI)

49.6(29.98,69.24)

63.8(45.54,82.11)

11.4 (3.45,19.24)

40.5 (21.83,59.16)

95.4(91.12,99.61)

74.1(59.13,88.71)

73.1(53.64,92.63)

18.6(4.46,32.71)

17.6(4.21,31.37)

12.4(1.69,23.09)

48.5(28.91,68.26)

36.3(18.94,53.56)

77.4(64.17,90.61)

99.2(98.18,100.00)

99.2(98.18,100.00)

53.2 (35.54,71.03)

96.3(92.11,100.00)

28.7(12.17,46.22)

Note. Cl – confidence interval.

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RESEARCH AND PRACTICE

TABLE 3-lncorporation of Key Elements of a Comprehensive Program, by Worksite Size: National WorksiteHealth Promotion Survey, 2004

Health education

Supportive social and physical

environment

integration

Linkage to reiated programs

Worksite screening

All 5 eiements

Total (n = 730),

% (95% CI)

26,2(21,54,30,84)

29,9(24,67,35,03)

28,6(23,37,33,74)

41,3(35,87,46,71)

23,5 (18,68,28,27)

6,9 (3,87,10,02)

50-99 Employees (n=179),

% (95% CI)

17,8(10,37,25,32)

24,0(15,28,32,73)

20,6(12,24,29,05)

29,6(20,68,38,43)

15,8 (8,07,23,49)

4,6(0,00,9,36)

100-249 Employees (n=229),'

% (95% CI)

26,2 (18,80,33,67)

32,5(24,40,40,68)

33,3(24,85,41,75)

43,7(34,66,52,70)

25,3(17,58,33,05)

6,0 (1,72,10,33)

250-749 Employees (n-211).

% (95% CI)

38,1(27,61,48,49)

33,5(23,43,43,63)

30,9(20,62,41,17)

59,3 (47,87,70,82)

30,5(20,99,39,96)

11,3 (3,80,18,76)

> 750 Employees (n-111),

% (95% Ci)

70,3(54,22,86,40)

53,7 (34,70,72,80)

61,4 (43,20,79,54)

80,5(65,61,95,36)

62,4(44,10,80,76)

24,1(4,03,44,21)

P

<,001

,04

,002

<,001

<,001

,03

Woie, CI = confidence inteivai,

likely to offer nutrition programs than weresites in the other industry categories, and sitesin the agriculture/mining/construction cate-gory were less likely to offer diabetes screen-ing programs (data not shown).

Comprehensive Programs

Only 6,9% of worksites offered a compre-hensive worksite health promotion program(i,e,, a program incorporating all 5 key elementsdefined in Healthy People 2010; Tahle 3), Sig-nificcint differences according to worksite sizewere apparent with respect to provision of acomprehensive program; 24,1% of sites withmore than 750 employees offered such a pro-gram, as compared with 11,3% of sites with250 to 749 employees, 6,0% of sites with100 to 249 employees, and 4,6% of siteswith 50 to 99 employees. Sites in the manu-facturing (8,7%) and business/professionalservices (8,3%) categories were more likely tooffer comprehensive programs than sites inthe wholesale/retail (5,7%), transportation(2,9%), finance (2,4%), and agriculture/mining (1,4%) categories.

When we examined each of the 5 key ele-ments individually, we found that linkages torelated programs (41,3%) were most com-monly reported, followed by supportive socialand physical environments (29,9%), integra-tion of the program into the organizationalstiTjctiore (28,6%), health education (26,2%),and worksite screenings (23,5%), Worksiteswith fewer employees were less likely to offera comprehensive program in general Eind werealso less likely to offer any 1 of the 5 key ele-ments. Although 80,5% of worksites withmore than 750 employees offered linkages to

TABLE 4-Relatlve Odds of Providing of a Comprehensive Health Promotion Program, byWorksite Characteristics: 2004 Nationai Worksite Health Promotion Survey

No, of empioyees

50-99 (Ref)

100-249

250-749

> 7 5 0

Experience'

Industry type

Manufacturing (Ref)

Finance

Whoiesaie/retaii

Transportation

Agricuiture/mining

Business/professionai services

Staff person in piace

Unadjusted OR (95% Ci)

1,00

1,34(0,35,5,14)

2,66 (0,70,10,13)

6,66 (1,42,31,23)*

0,59 (0,22,1,60)

1,00

0,26(0,09,0,73)*

0,63 (0,20,1,97)

0,31 (0,07,1,33)

0,15(0,03,0,86)*

0,94(0,31,2,83)'

29,86 (7,13,125,07)*

Muitivariate Adjusted OR (95% CI)

1,00

0,97(0,25,3,83)

1,75 (0,44,7,03)

4,41 (0,92,21,07)'

0,52 (0,21,1,35)

1,00

0,29(0,10,0,82)*

.1,06(0,31,3,61)

0,40 (0,09,1,90)

0,15(0,02,0,96)*

1,2(0,41,3,49)

10,26(1,97,53,41)*

Note. OR=odds ratio; CI=confidence interval,

"Number of years program had been in piace; the reference categoiy was programs in piace for iess than 5 years,*P<,05,

related programs, only 29,6% of those with50 to 99 employees did so (P<,001),

Table 4 depicts the likelihood of providinga comprehensive worksite health promotionprogram according to worksite size, industrytype, experience, and whether sites had astaff person dedicated to and responsible forhealth promotion. Both unadjusted (bivariate)and adjusted (multivariable) logistic regres-sion results are shown, along with point esti-mates and 9 5 % confidence intervals. Unad-justed results indicated that worksites withmore than 750 employees were 6,7 timesas likely as sites of all other sizes to offer a

comprehensive health promotion programand that sites in the agriculture and financecategories were significantly less likely thanwere sites in the other industry categories tooffer a comprehensive program. Sites with astiiff person dedicated to health promotionwere nearly 30 times as likely to offer a com-prehensive program compared with siteswithout such a staff person.

The adjusted model showed that evenafter we controlled for worksite size, experi-ence, and industry type, sites with a dedi-cated staff person were 10,3 times morelikely than were sites without a staff person

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RESEARCH AND PRACTICE

dedicated to health promotion to have acomprehensive worksite health promotionprogram (P=.O5; Table 4). In addition, theadjusted model showed that sites in the agri-culture and finance categories were signifi-cantly less likely than were sites in the otherindustry sectors to have a comprehensiveprogram (P=.O5). Although worksites withmore than 750 employees were 4.4 times aslikely as sites of other sizes to have a com-prehensive program in place. Observed dif-ferences in worksite size only trended towardstatistical significance (P=.O6).

DISCUSSION

One of the objectives of Healthy People2010 was for at least 7 5 % of worksites tooffer a comprehensive health promotion pro-gram, yet only 6.9% of our responding work-sites met this criterion. Sites with more than750 employees offered more health promo-tion programs, services, and screening pro-grams; had more health-promoting policies inplace; and were more likely to have health-supportive work environments than wereworksites with fewer employees. This patternwas consistent with previous national work-site surveys. '̂* Given that small businesses(those with fewer than 500 employees) repre-sent 99.7% of all US employers and employ50.1% of the private-sector workforce,''' it isapparent that important opportunities to im-prove the public's health are being missed.'^

In previous worksite surveys, induding the1999 survey, metrics different from those de-scribed for the present survey were used todefine types and levels of health promotionprogramming.''*'" In the 2004 NationalWorksite Health Promotion Survey, we be-lieved that it was important to monitorprogress according to the Healthy People 2010definition of a "comprehensive" health promo-tion program.

However, we also used broad, more-traditional means of documenting the extentto which worksite health promotion programsare available. Specifically, 9.7% of respon-dents indicated that they offered health edu-cation programming, a supportive work envi-ronment, and worksite screening programs,whereas 16.7% of respondents reportedthat they offered at least health education

programming and a supportive work environ-ment (data not shown). Thus, even whenmore-inclusive definitions of health promotionprograms were applied, a low percentage ofworksites reported offering these programs.Moreover, significant differences by worksitesize persisted.

Few differences in health promotion pro-gramming, policies, and work environmentsby industry type were observed. Worksites inthe manufacturing and business categorieswere more likely to offer comprehensive pro-grams, but small employers in each industrycategory were less likely to offer nearly alltypes of programs and services. Thus, differ-ent types of worksites may require differenttypes of health promotion programs, policies,and practices, and a special emphasis onsmaller worksites is needed if these worksitesare to reach Healthy People 2010 objectives.

Despite relatively stable levels of healthpromotion programming among sites withmore than 750 employees, there was a no-ticeable decline from 1999 levels in program-ming among sites with fewer than 750 em-ployees. This result may reflect a truedecrease in programming, may representmeasurement error (minor changes in thewording of questions may have generated dif-ferent responses), or may demonstrate thatdifferent cross-sectiond survey samples (evennationally representative samples) producedifferent and difficult-to-compare results.

One observation that supports a true dropin the number of health promotion programsoffered is that worksites in the present surveyreported significantly more perceived barriers(on identical questions) to offering health pro-motion programs than did worksites in the1999 survey.* In our survey, 63.5% of work-sites reported that lack of employee interestwas a barrier to offering heedth promotionprograms, as compiired with 49.6% of work-sites in 1999 (P=.OO3). Lack of resourceswas cited as a barrier by 63.4% of employersin 2004 and 36.8% in 1999 (P=.O2); lackof partidpation by high-risk employees, lackof managernent support, conflicts with workdemands, and lack of access to data were alsocited at significantiy higher rates. These re-sults add credence to the possibility that areal decrease in programming occurred be-tween 1999 and 2004.

In contrast to the observed drop in pro-gramming between 1999 and 2004, re-ported policies and environmental supportsremained stable during this period. Almost30% of worksites reported that their sodaland physical environment at work was sup-portive of health.

Approximately 30% of worksites reportedthat their health promotion program hadbeen in existence for at least 6 years. Our re-sults also indicated that sites with a staff per-son dedicated to health promotion were sig-nificantiy more likely to report having acomprehensive health promotion program.Although all of the factors just described(dedicated staff, polides, environmental sup-ports, and experience) are signs of perma-nence, the present findings reveal significantroom for improvement

The most significant shortcoming, one thathas persisted over time, is that worksites withsmall numbers of employees are less likelyand (potentially) less able than large employ-ers to offer health promotion programs. Morework must be done with smaU businesses tomake a "business case" for health promotion,to develop new methods for reaching employ-ees, and to determine the employer and em-ployee incentives (e.g., tax credits, benefit dis-counts) that are most effective in supportingworker health.

LimitationsOur study had several strengths as well as

limitations. An importsmt strength is thatour data were derived from a nationally rep-resentative Scimple of worksites, allowingtentative comparisons between the presentsurvey and the 1999 survey. However, be-cause of the variability of weights in 2 0 0 4(resulting from the disproportionate natureof the sampling, whereby smaller sites wereselected with considerably lower probabili-ties than larger sites), the precision of theconfidence intervals for industry compar-isons was less than ideal. In addition, re-sponse rates in surveys of the general popu-lation are declining, and moderate rates ofnonresponse may have a negative effect onpoint estimates and comparisons over time.Although adjustments for nonresponse havepartiy addressed this issue, nonresponse biasmay remain.

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RESEARCH AND PRACTICE

Our data represent, in the case of eachworksite, the opinions of a single individualaligned with management; thus, caution in in-terpreting our results is warranted given evi-dence suggesting that employees' perceptionsof access to and participation in worksitehealth promotion programs may vary consid-erably from employers' perceptions.'^ In addi-tion, although a standardized survey adminis-tration protocol was used, certain surveyitems that included définitions (e.g., "programintegration" and "linkage") may have takenon different meanings for respondents acrossand within worksites. Because respondentsanswered questions with respect to their par-ticular worksite (as opposed to the companyto which the worksite belonged), their re-sponses may not reflect the situations assod-ated with all health promotion programssponsored by a given company. Finally, dataon intervention quality and program effectson employee health were not gathered in thesurvey.

ConclusionsThere is a need for regular monitoring and

implementation of evidence-based worksitehealth promotion and health protection pro-grams. Employers can use information gath-ered from such programs for benchmarkingpurposes as they work toward achieving theobjectives of Healthy People 2010. At a timewhen health care costs and work demandsare rising, it is disturbing that few health pro-motion programs are available to employees.Our results can also be used to create part-nerships between employers, employees,health plans, policjmiakers, and health organi-zations with the goal of mobilizing workplacesto improve the public's health. Additional re-search that helps identiiy or develop effectiveworksite-based interventions, particularly forsmall businesses, is essential. •

About the AuthorsLaura Linnan and Mike Bowling are with the Departmentof Health Behavior and Health Education, School of PublicHealth, University of North Carolina, Chapel Hill. JenniferChildress and Garry Lindsay are with Partnership for Pre-vention, Washington, DC. Carter Blakey and PenelopeRoyall are with the Office of Disease Prevention andHealth Promotion, Rockville, Md. At the time of the study,Stephanie Pronk and Sharon Wieker were with WatsonWyatt Worldwide, Minneapolis, Minn.

Requests for reprints should be sent to Laura Linnan,ScD, CHES, School of Public Health, University of NorthCarolina, CB #7440, Chapel Hill, NC 27599-7440(e-mail: [email protected]).

This article was accepted February 26, 2007.

ContrihutorsL. Linnan developed the research questions and createdfirst drafts of the article. M. Bowling conducted all ofthe analyses and drafted key parts of the Methods andResults sections. J. Childress, G. Lindsay, C. Blakey,S. Pronk, S. Wieker, and P. Royall developed the surveyinstruments and implementation procedures and pro-vided extensive feedhack on all drafts of the article.

AcknowledgmentsThe Robert Wood Johnson Foundation provided initialfunding to Partnership for Prevention in support of the2 0 0 4 National Worksite Health Promotion Survey.

The survey was a joint effort of Partnership for Pre-vention and Watson Wyatt Worldwide, with the sup-port of the United States Department of Health andHuman Services. A workgroup convened by Partner-ship for Prevention guided the development, imple-mentation, and analysis of the survey; the workgroupincluded experts from the Centers for Disease Controland Prevention, the National Center for Health Statis-tics, the Office of Disease Prevention and Health Pro-motion, and the University of North Carolina atChapel Hill.

We thank Glorian Sorensen for helpful feedback onearly versions of this artide.

Note. The views and opinions presented in this arti-cle are solely those of the authors, and the authors as-sume full responsibility for any errors or misrepresenta-tions. Statements do not necessarily represent theofficial position of the US Department of Health andHuman Services or any other federal department oragency.

Human Participant ProtectionNo protocol approval was needed for this study.

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