Company Health Promotion

The most common screening performed in wellness programs is heart health assessment.

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

The health professional conducting the screening then provides a consultation and helps set goals with the participant.

The backbone of wellness programming at the worksite is health testing. It’s the first major activity a business should do when first beginning a wellness program.

Biometric screening is often used along with the administration of a Health Risk (Assessment|Appraisal} .

The most effective way to screen is to utilize a health expert trained in wellness screening techniques and counseling to privately and individually assess participants.

This wellness expert takes a brief health history and measures blood pressure 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 may 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.

Biometric testing may be done on an annual basis and used to monitoring health risks within the worksite.

A biometric testing program needs to provide multiple opportunities for participation. the service must be provided for all the various shifts of a business. the screening program must be conducted in highly visible areas so the process can be observed.

Reluctant employees often like to be able to see what the program is about before they participate. When wellness screeners are not busy, they should perform outreach going to areas where employees gather and try to recruit employees.

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

Objectives 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. Objectives like mission statements provide direction in a program.   

Objectives are specific and provide a means of measurement of the program to determine effectiveness. There are two kinds of objectives, process and outcome.    

Process goals 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 betterment programs

• Satisfaction of program participants

• Number of participants who were medically referred and saw their doctor

• Number of promotional activities

• Number of participants seen in follow-up

Example of outcome goals are –

• Number of participants who improved fitness level

• Number of participants who decreased cholesterol level

• Number of participants who lost weight, body fat

• Number of participants who quit tobacco use

• Number of participants with high blood pressure who lowered their blood pressure

• 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 high blood pressure or cholesterol years later

Wellness committees are important in that they develop a sense of ownership in the program, and facilitate various tasks involved in wellness programming at the workplace.

The committee ought to be composed of a cross-section of workers representing various occupations, levels, and subgroups with the organization.

A common mistake is filling the committee with the most health/fitness-conscious individuals  in the company. Do not rely solely on volunteers to fill a committee. Be sure that your committee members have enough power in the company to run an effective wellness program.

The wellness committee is made up of staff members from the workplace. It oversees the wellness program and helps carry it out.

The committee should meet about once a month to review the previous month’s activities and plan future ones. When the program is just beginning, the committee may meet on a weekly basis until things get going.

Committee members do not carry out medical procedures, counsel customers, or handle confidential medical information. Wellness specialists perform these tasks.

In general, the committee’s duties fall into three areas –  planning, promoting, and helping to run programs.

Planning the programs can include –

• Finding space for activities

• Planning and organizing worksite-wide events like contests

• Reviewing reports prepared by the program staff and making recommendations

Promoting the program can include –

• Recruiting workers to participate in screening and health betterment programs

• Encouraging staff members to participate in follow-up counseling

• Organizing promotional strategies using newsletters, signs, bulletin boards, computers, and other media available within the workplace

Helping to run the program can include –

• Setting up equipment for various activities

• Assisting to conduct worksite-wide activities

• Monitoring all activities and investigating  the performance of the professional staff

• Acting as wellness mentors to fellow workers

The size of the wellness committee will be dependent on the size of the organization. Choose members by asking day management to nominate or appoint workers.

Make an announcement through flyers, memos, and meetings to recruit potential members. Explain the purpose of the committee, duties and responsibilities, and the time commitment.

Recognize your wellness committee volunteers. Allow them to participate in programs at a decreased cost. Hold appreciation breakfasts/lunches/dinners.

Print names of committee members on corporation 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. Develop awards certificates for members.

The following may be used as a guide for committee size –    

• Less than 300 employees   2 to 4

• 300 to 1,000 employees   4 to 6

• 1,000 staff members or more   6 to 12

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

It includes colleague support from family, friends, and colleagues. This support can help one adopt healthful lifestyles. Tools are available to audit a company.

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

Some healthy culture signs in a business are –

• Employees communicate openly

• Leaders support diversity and opinion

• Employees have fun

• Policies support wellness

• Staff Members are encouraged to grow

• Workers work together as a team

• Employees’ skills and talents are matched to their jobs.

• Flexible work schedules are available

• Corporations consider staff members as their most valuable asset

Effective wellness programs try to create 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 corporation policies and organizational traditions encourage wellness.

• Effective programs work at the group and organizational level to build support for healthful lifestyle choices.

• Effective programs set clear target goals and goals for the health betterment of the worksite.

An initial health testing can include a recent survey of employees’ interests as part of the assessment. Successful wellness programs are designed to meet the needs and interests of the staff members.

The information you need to get from a recent survey depends on the scope of your program. A sample survey can be acquired in the HOPE Publications Web site.

If you plan to adapt this sample survey or develop your own survey, keep the following hints in mind –

• Ask mainly closed-choice questions, especially if you will be sending the survey to a big number of employees. Closed-choice questions provide specific options and are easy to tabulate. You may want to use a computer for data entry and analysis.

• Invite comments, suggestions and recommendations, or ask open-ended questions after the survey. Open-ended items are more challenging to summarize.

• Include a brief explanatory cover letter with the survey with the signature of the corporation president. Be certain to include a statement about confidentiality and anonymity.

• Ask a group of representative workers to review the survey before it’s distributed. Find out if the questions will be understood by workers and won’t be objected to.

• Include demographic information at the starting or end of the survey. Consider various ways that you might analyze the responses by demographic characteristics (gender, age, shift, site, department, etc.).

When considering who ought to get the survey, a simple rule is when you’ve under 500 workers, everybody ought to receive one. the public relations advantage of everybody receiving a recent survey can be significant.

Over 500 staff members, a sample of the work population will suffice. A sample saves on costs and time. You could want to consider consulting with a statistician to determine an appropriate sample size for your worksite.

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

Getting support 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 to educating management. Provide concise fact sheets on the advantages of wellness programs for management.

When surveys and interviews are completed, tally the surveys and write brief summaries of the interviews. Provide these reports to management.

Once completed present a brief executive summary to management. Highlight several fascinating 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 wellness committee members itemizing each response. Give a short article about the survey in the business newsletter.

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

Comprehensive wellness programs involve all workers, deal with all major health risks, offers choices, and target both the workers and the worksite environment; provide periodic analysis of its results.     

Comprehensive wellness programs emphasize follow-up and offers support for the employee if he/she is employed. Studies have shown this approach to be highly successful. Key components are planning, implementation, and analysis.   

Planning comprehensive wellness programs involve performing a needs and interest assessment, appointing a wellness committee, choosing  wellness providers, establishing goals/objectives for the wellness program, advertising and marketing/promoting the program, and establishing procedures to ensure confidentiality.   

Implementation of robust wellness programs consist of five major tasks –    

1   Medical screening and referral

2   Follow-up and counseling employees

3   Follow-up with doctors

4   Health improvement programs

5   Organizing worksite-wide activities.

Evaluation involves monitoring wellness programs to find out when it’s working and to help you refine it. Measuring success shows what you have achieved, helps justify costs, and provides information for management to support continued programming.   

Extensive wellness programs involve all workers, deal with all major health risks, offers options, and target both the workers and the worksite environment; provide periodic evaluation of its results.     

Robust wellness programs emphasize follow-up and offers support for the worker since he/she is employed. Studies have shown this approach to be highly successful. Key components are planning, implementation, and investigation

Planning extensive wellness programs involve performing a needs and interest assessment, appointing a wellness committee, choosing  wellness providers, setting goals/objectives for the wellness program, marketing/promoting the program, and establishing procedures to ensure confidentiality

Implementation of robust wellness programs consist of five major tasks –

• Medical testing and health risk (assessment|appraisal}

• Follow-up and counseling employees

• Follow-up with physicians

• Health betterment and illness prevention programs

• Organizing worksite-wide wellness program activities.

Evaluation involves monitoring wellness programs to find out when it’s working and to help you refine it.

Measuring success shows what you have achieved, helps justify costs, and provides 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.     

Wellness 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 studies on this topic and a number of systematic reviews.

Health risks increase costs.  Medical and health 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, Employee’s Compensation costs, short-term disability, and decreased productivity (”presenteeism”).

Early employee wellness 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 may  be characterized as “fun-oriented”.  Participation is entirely voluntary, and there is no particular focus on the reduction of specifically identified high risks.  

Interventions and activities aren’t personalized, and there is no emphasis on the management of healthcare costs.  These programs are usually site-based only, lack choices to address all of the major behaviorally-related health risks, and lack multimodal presentation.  

Minimal or no incentives are provided to workers for participation, and services to spouses and family members are not available.  Most such programs lack meaningful investigation.  

More conventional programs are “activity-oriented” and have shown an ROI of between 1 – 2.5 and 1 – 3.5.8 These programs may have a greater emphasis on health and risk reduction, although the efforts are relatively broad and not personalized.  

They may have some generalized emphasis on health cost management, although not necessarily aimed at specific high risks.  Most are site-based and voluntary, with spouses included only rarely.  

Modest incentives could  be utilized to encourage participation.  Formal analysis could  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’re normally voluntary, but use strong financial and other incentives to promote participation.  

They’re multi-component in nature (address all major risks), and have both onsite and virtual modalities of operation.  The interventions are highly targeted and individualized, and offered to spouses in addition to workers.

For companies, the cost of providing health insurance for their employees is of excellent importance.  Those costs have been increasing at annual rates between 6 percent and 14 percent.

Chapman’s 2007 systematic review7 stated an typical reduction in healthcare costs of 26.5 percent as a result of employee wellness programs.  His review covered 60 of the most scientifically valid studies, with an typical of 3.77 years of study.

Absenteeism due to disease is another cost driver.  Chapman’s review7 reports an typical reduction in sick leave of 25.3 percent.   Cost for Employee’s Compensation was reduced by 40.7 percent, and disability costs by 24.2 percent.

There’s also an emerging literature on the costs of presenteeism (reduced productivity).11,13  In one study, every risk decreased through a wellness program yielded a 9 percent reduction in presenteeism (and a 2 percent reduction in absenteeism).11

Some companies have achieved a zero percent increase in healthcare costs across at least brief periods of time.10  Doing so requires 90-95 percent participation of the staff member population in focused wellness programs, with 75%-85 percent of the workers falling into the low risk category.10     

Although comprehensive efforts to lower the risk status of those in moderate or high risk categories must be made, the needs of currently healthful staff members must be addressed as well to avoid increases in risk-status.   

Given the size of the federal workforce, meaningful cost savings in the government’s contribution to health insurance premiums for workers could be achieved when a majority of that population were participating in active wellness programs.     

In like fashion, improvements in absenteeism, employee’s compensation, disability, presenteeism, and turnover thus of extensive worker wellness programs would yield substantial fiscal benefits for the government.   

References   

1   Aldana, Steven G.  (2001)   Financial Impact of Wellness Programs –   A Robust Review of the Literature.   Am J Wellness 15(5) – 296-320.

2   Chapman, Larry.  (1998)   the Role of Incentives in Wellness.  The Art of Wellness  2(3) – 1-8.

3   Chapman, Larry.   (2003)   Biometric Screening in Wellness –   is it Really as Important as We Think?  the Art of Wellness  7(2) – 1-12.

4   Chapman, Larry.  (2005)   Meta-Evaluation of Corporate Wellness Economic Return Studies –  2005 Update.  The Art of Wellness, July/August, 1-15.

5   Chapman, Larry.   (2006)   Employee Participation in Corporate Wellness and 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 Wellness Coaching in Corporate Wellness.   the Art of Wellness, July/August, 1-12.

7   Chapman, Larry.  (2007)   Proof Positive –   an Analysis of the cost-Effectiveness of Corporate 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 Companys” Conference, Orlando, FL, January 23-24.

9   Edington, Dee.   (2001)   Emerging Research –   A View from One Research Center.  American Journal of Wellness 15(5) –  341-349.

10   Edington, Dee W.  (2007)   Health Management as a Serious Company Strategy.  Presentation at the World Research Group “Rewarding Healthful Behaviors for Health Plans and Corporations” Conference, Orlando, FL, January 23-24.

11   Pelletier, Barbara, Boles, Myde, and Lunch, Wendy.  (2004)  Changes in Health Risks and Be sure to 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 robust Health and Disease ManagementPrograms 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 Condition.  Report released by the Milken Institute.   www.milkeninstitute.org.

14   Partnership for Prevention.  (2008) Investing in Health –   Proven Wellness Practices for Workplaces.   http – //www.prevent.org/images/stories/2008/investinginhealth_finalfinal.pdf.

Corporate America is increasingly investing in staff member wellness because it’s good company.  In order to meet productivity demands, businesses must rely on a healthful, productive workforce to succeed in the highly competitive global marketplace.  

Over a hundred studies in both corporate and governmental settings have documented the economic benefits of staff member wellness programs, including decreased absenteeism, decreased injuries and workman’s compensation costs, decreased health care costs, decreased staff member turnover, as well as increased productivity, greater staff member 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 effectiveness federal government staff member wellness programs may  be able to incorporate some features described.  Worker wellness programs shown to have positive returns on investment often include the following features –    

1   Health and productivity management model

Programs characterized by this model focus attention on identification and reduction of specific risks or behaviors like smoking, lack of exercise, excess weight, unhealthful diet, high cholesterol, high blood pressure, stress, depression, and so on.     

High-risk workers are in particular targeted for intervention, although the most successful programs also direct efforts towards healthy workers for maintain their low-risk status.  This model emphasizes outcomes as opposed to simply offering wellness activities for their own sake.     

2   Health risk (assessment|appraisal}

Use of a computerized health risk (assessment|appraisal}  instrument with individualized feedback and recommendations is almost universal in successful programs.  Staff Members take the questionnaire annually in many cases.     

The HRA serves to elevate awareness, provide direction, and motivate person to improve specific behaviors.  In some cases, the personalized report is directly linked to appropriate resources related to identified risks.     

Research indicates that the use of an HRA is effective if it’s followed by some type of educational or therapeutic intervention for identified risks.  It often serves as the entry point into wellness programs.   

3   Biometric analysis

Many wellness programs combine the results of the health risk (assessment|appraisal} with measurement of each employee’s biometrics, including weight and Body Mass Index , blood pressure, cholesterol, fasting glucose, and assorted other metrics.     

Combining the results of the HRA with biological measures causes a more valid risk profile.   Computerized health risk (assessment|appraisal}s often incorporate biometric data in their risk analysis.   

4   Wellness Program Incentives

Employees are frequently given monetary or other significant rewards for completing an HRA, participation in a program or class, specific accomplishments like stopping use of tobacco, losing weight, or exercising, and for maintaining healthful status and/or behaviors.     

In many cases the monetary incentives are associated with reductions in health insurance premiums.  Some programs use disincentives as well as incentives, such as charging workers who smoke higher rates for their health insurance contribution.   

5   High wellness program participation rates

Successful programs use incentives to drive participation rates up.  They also market their programs comprehensively, and may use contest or challenge strategies to heighten enthusiasm and encourage participation.   

6   Wellness coaching

Employees with identified risks or desire to improve their health habits might  be periodically coached via telephone by trained health coaches.     

Coaching assists employees set and achieve realistic lifestyle-related objectives including those addressing stress, work life balance, tobacco use, weight, physical activity, and various behavior modifications.     

Three or more sessions are normally offered.  In some intensive programs, the coaching extends to actual disease management (DM) intervention for staff members with identified high-risk diseases.    

7   Multiple formats

Programs might offer wellness content in online, paper, and seminar formats to provide stimulating variety and alternatives in order to accommodate the needs of all workers.     

In addition to onsite exercise and healthful consuming events, on-line programs, e-mail reminders and notices, printed newsletters and materials, and workplace classes and workshops are common dissemination strategies.   

8   Executive management support

Enthusiastic and frequent endorsement by  senior level management is vital to achieving high rates of participation.  When senior executives are wellness role models themselves the effects of endorsement are enhanced.   

9   Frequent contact

Successful programs have frequent contact of some sort with every worker.  This could  be through advertising efforts (e.g., posters, e-mail notices, reminders, or messages, etc.), bulletin boards, newsletters, staff meeting presentations, discussion in new worker orientation, supervisory sessions, etc.      

The key is to enhance staff member awareness of wellness opportunities and reinforce the corporate emphasis on wellness through frequent and multiple “touches”.   

10   Open enrollment

To encourage high participation rates employees must have easy access to the wellness programs and activities.  Open and uncomplicated enrollment processes achieve this.     

Some businesses automatically enroll all employees and then allow those who don’t wish to participate to “opt-out”.  This practice has been shown to improve enrollment rates in some establishings.   

11   Family involvement

Many programs encourage spouses and other family members to participate in the corporation wellness activities and to adopt a healthy lifestyle along with the designated worker.  It’s far easier for the worker to have a healthy lifestyle if his/her family does so as well.   

12   Smoking cessation

Because tobacco use 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 tobacco cessation pharmaceuticals is often part of such programs.  In-house programs provide the most convenient access to these services, although on-line or telephone-based programs could  be available as well.     

13   Physical Activity

Regular exercise is a core component of every wellness program.  Workers ought to be strongly encouraged to engage in regular exercise.     

Most programs provide either periodic or continuous on-site opportunities, and some locations have on-site fitness clubs, swimming pools, walking trails, etc.  Discounted or compensated memberships to community exercise facilities is a common alternative to on-site facilities.   

14   Weight management

Because obesity is a major threat to health it’s imperative that programs offer effective assistance with weight control.  Extensive encouragement from  upper management to shed excess weight is important.     

Online programs, worksite programs, or discounted access to weight control programs in the community may all be available.  Long-term follow-up is critical for maintenance of weight loss.   

15   Stress management

Workplace stress is perhaps the most common complaint among employees and a major contributor to absenteeism, presenteeism (reduced productivity), and low morale.     
   
Almost all successful wellness programs offer assistance with personal and workplace stress.  Some programs refer workers to outside resources for more serious conditions like depression and anxiety disorders, but most offer online or frequent onsite general stress reduction programs.     
   
Some businesses endeavor to structure the work environment to minimize stress, both physically and operationally.   

16   Health testings/immunizations

Staff Members are actively encouraged to complete advised biometric screenings for blood pressure, cholesterol, BMI, colorectal and breast cancer, and others.     

Annual influenza immunizations are also encouraged.  Some sites provide these services at the worksite.  Incentives are often awarded for completion of these screenings/immunizations.    

17   Onsite health care

Actual provision of onsite primary care medical services is a growing trend.  The rapidly escalating costs of medical care insurance for workers has stimulated this trend.     

Some businesses have found that it’s less costly to provide primary care services themselves than to fund those services through medical insurance.     

On-Site care also decreases the amount of time employees would otherwise spend away from the worksite getting such services.    

References   

1   Aldana, Steven G.  (2001)   Financial Impact of Wellness Programs –   A Comprehensive Review of the Literature.   Am J Wellness 15(5) – 296-320.

2   Chapman, Larry.  (1998)   the Role of Incentives in Wellness.  The Art of Wellness  2(3) – 1-8.

3   Chapman, Larry.   (2003)   Biometric Screening in Wellness –   is it Really as Important as We Think?  the Art of Wellness  7(2) – 1-12.

4   Chapman, Larry.  (2005)   Meta-Examination of Corporate Wellness Economic Return Studies –  2005 Update.  The Art of Wellness, July/August, 1-15.

5   Chapman, Larry.   (2006)   Worker Participation in Corporate Wellness and 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 Wellness Coaching in Corporate Wellness.   the Art of Wellness, July/August, 1-12.

7   Chapman, Larry.  (2007)   Proof Positive –   an Analysis of the cost-Effectiveness of Corporate 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 Businesss” Conference, Orlando, FL, January 23-24.

9   Edington, Dee.   (2001)   Emerging Research –   A View from One Research Center.  American Journal of Wellness 15(5) –  341-349.

10   Edington, Dee W.  (2007)   Health Management as a Serious Company 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 Be sure to 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 robust Health and Illness Management (DM)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 Illness.  Report released by the Milken Institute.   www.milkeninstitute.org.

14   Partnership for Prevention.  (2008) Investing in Health –   Proven Wellness Practices for Workplaces.   http – //www.prevent.org/images/stories/2008/investinginhealth_finalfinal.pdf.