Effects of an employee wellness program on physiological risk factors, job satisfaction, and monetary savings in a South Texas University
IV TABLE OF CONTENTS Abstract i Dedication ii Acknowledgements iii Table of Contents iv Chapter I - INTRODUCTION 1 Background and Setting 1 Statement of the Problem 3 Theoretical Framework 4 Purpose of the Study 6 Research Questions 6 Operational Definitions 7 Glossary of Terms 8 Limitations 10 Assumptions 10 Significance of the Study 11 Chapter II-REVIEW OF LITERATURE 13 Introduction 13 Individual Components 14 Physiological Factors 14 Individual Behavior 14 Agency Components 16 Wellness as an Employer Issue 16
V Higher Education's Role in Wellness 17 Financial Implications of Wellness Programs 21 Return on Investment 23 Absenteeism, Presenteeism, and Productivity 24 Program Components 27 Program Design 27 Prevention 30 Incentives 31 Job Satisfaction and Wellness 33 Culture 37 Legal Aspects 38 Summary 39 Chapter III - METHODOLOGY 41 Introduction 41 Setting 42 Research Design 42 Intervention 44 Subject Selection 44 Instrumentation 45 Data Collection 47 Data Analysis 48 Chapter IV - RESULTS 51 Introduction 51
vi Quantitative Results 51 Profile of All Subjects 51 Profile of Completers 55 Analysis of Pretest Data on Physiological Risk Factors 59 Analysis of Pretest Data on Medical Spending and Absences 60 Analysis of Pretest Data on Job Satisfaction 61 Analysis of Pretest and Posttest Data 65 Analysis of Effect Size 78 Covariate Analysis 81 Summary of Quantitative Results 81 Qualitative Results 82 Summary of Qualitative Results 84 Power Analysis 85 Chapter V - SUMMARY, CONCLUSIONS, AND DISCUSSION 92 Introduction 92 Summary of Quantitative Results 94 Summary of Qualitative Results 95 Conclusions 96 Discussion 97 Implications 102 Recommendations for Further Studies 103 References 104 Appendix A, Institutional Review Board 114
vii Informed Consent 114 IRB Board Application 116 IRB Approval 121 Appendix B, Instrumentation 122 Hand Grip Strength Norms 122 Sit and Reach Flexibility Norms 122 V02 Max Norms 123 . Blood Pressure Norms 124 Body Mass Index Table 124 Fitness Assessment Data Sheet 125 Job Satisfaction Survey 126 Health Risk Assessment Survey 127 Appendix C, Focus Group Questions 131 Appendix D, Focus Group Transcriptions 132 Appendix E, Curriculum Vitae 144
Vl l l LIST OF TABLES AND FIGURES Tables 1. Profile of All Participants 53 2. Profile of Completer Participants 57 3. Physiological Factors - Pretest Measures 60 4. Medical Spending and Absences at Pretest 61 5. Analysis of Job Satisfaction at Pretest 62 6. Means and Standard Deviations for Pretest and Posttest Measures of Strength... 66 7. Repeated Measures ANOVA Summary Table - Strength 66 8. Means and Standard Deviations for Pretest and Posttest Measures of Flexibility 67 9. Repeated Measures ANOVA Summary Table - Flexibility 68 10. Means and Standard Deviations for Pretest and Posttest Measures of V02 Max 68 11. Repeated Measures ANOVA Summary Table - V02 Max 69 12. Means and Standard Deviations for Pretest and Posttest Measures of Body Mass Index 69 13. Repeated Measures ANOVA Summary Table - Body Mass Index 70 14. Means and Standard Deviations for Pretest and Posttest Measures of Systolic Blood Pressure 70 15. Repeated Measures ANOVA Summary Table - Systolic Blood Pressure 71 16. Means and Standard Deviations for Pretest and Posttest Measures of Diastolic Blood Pressure 71 17. Repeated Measures ANOVA Summary Table - Diastolic Blood Pressure 72 18. Means and Standard Deviations for Pretest and Posttest Measures of Job Satisfaction 72
IX 19. Repeated Measures ANOVA Summary Table - Job Satisfaction 73 20. Means and Standard Deviations for Pretest and Posttest Measures of Medical Costs 73 21. Repeated Measures ANOVA Summary Table - Medical Costs 74 22. Means and Standard Deviations for Pretest and Posttest Measures of Medical Co-payments 74 23. Repeated Measures ANOVA Summary Table - Medical Co-payments 75 24. Means and Standard Deviations for Pretest and Posttest Measures of Other Medical Costs 76 25. Repeated Measures ANOVA Summary Table - Other Medical Costs 76 26. Means and Standard Deviations for Pretest and Posttest Measures of Absenteeism 77 27. Repeated Measures ANOVA Summary Table - Absenteeism 77 28. Between Group Mean Difference Effect Sizes 79 29. Within Group Mean Difference Effect Size 80 Figures 1. Maslow's Hierarchy of Needs 6 2. Hettler's Wellness Wheel 28 3. Pretest, Posttest Comparison Group Design 43
1 CHAPTER I INTRODUCTION Background and Setting Obesity rates have become a major issue in the past few decades. With industrialization, refrigeration, and mass production, food has become readily available in abundance in the United States. The most available and portable "fast food" tends to be toward the unhealthy end of the spectrum, with high calories and fat. This concept of fast food has been in existence since the 1950s, but has become obsequious in the last two to three decades. The other part of the equation is the level of physical activity performed by the average citizen. A concurrent development of industrialization was the declining reliance on manual labor to accomplish day to day activities. Driving and mechanization have created a culture where little physical effort is required to complete a typical day. The combination of these two components, readily available abundant food and no requirement for physical activity, has created the epidemic we call obesity. The documentary film, Super Size Me (Spurlock, 2004), brought attention to these issues in mainstream popular culture when Morgan Spurlock stopped exercising and ate only MacDonald's food for 30 days. During this time period, his physiological changes were tracked and showed rapid decline. According to the Centers for Disease Control, in 2006, Texas, along with 20 other states, listed 25% to 29% of their adults as obese (U. S. Department of Health and Human Services, 2007). Obesity is a significant contributing factor in several chronic diseases such as diabetes, cardio-vascular disease, hypertension, osteoarthritis, and several more (Combs, 2007, p.l). Unhealthy employees can affect the productivity of businesses and
2 the amount the company pays for employee insurance coverage. Health insurance premiums have increased by an average of 68% for employers since 2001 (Combs, 2007, p.l). Obesity cost Texas businesses an estimated $3.3 billion in 2005 (Combs, 2007, p.37). Employers had little interest in becoming involved in such a personal issue until it created an economic impact for them. The connection is that chronic diseases exacerbated by obesity affect employee productivity, absenteeism, workers compensation claims, insurance rates, and ultimately the company's financial equation. Although corporate fitness and wellness program sponsored by employers have been in existence since the 1970s (Pickens, 2007), this has primarily been a benefit of large employers in the public sector. As obesity rates continue to rise, there is greater urgency for involvement from employers to contribute toward and encourage a healthy workforce as this can affect the employers' finances. As of 2006, there were 4,276 higher education institutions in the country (National Center For Education Statistics, 2007), with 145 in Texas (Texas Higher Education Coordinating Board, 2008). These institutions range in enrollment size as well as in the number of people employed based on their mission, programs, and funding. These institutions are significant employers, relative to volume, in their cities and regions. At a university in South Texas, there are approximately 1,000 benefits-eligible employees, and the institution ranks as the fifteenth largest employer in the region (Corpus Christi Regional Economic Development Corporation, 2007). Insurance premiums paid by employers in Texas rose by 29.3% from 2001 to 2004 (Combs, 2007, p. 15). "Studies conclude that each dollar spent on wellness
3 programs generates an average savings of $3.48 on health care expenses and an additional $5.82 in reduced absenteeism costs" (Combs, 2007, p. 38). It would be a valuable investment for the institution to financially support more wellness programming for its employees. This programming could help create an improved culture of wellness and healthy behavior across the campus and in the community. Our environment, including the influence of our family and friends affects our health. If one's family and friends are overweight, it is more likely for them to become overweight, according to a Harvard researcher who examined obesity and social network data from the long-running Framingham Heart Study (Powell, 2007). On the other hand, if employees are assimilated into a culture of wellness, it is more likely that they will practice healthier behaviors and participate in a fitness and wellness program. Statement of the Problem At the above-mentioned South Texas University, to be referred to as the University, employee demographics reflect that of the region with a high percentage of Hispanic employees. The Hispanic population in Nueces County, as of 2006, was 58.8%, white at 34.9%, and black at 4.4% (U. S. Census Bureau, 2007). There was also a spectrum of socio-economic levels among the workforce at the University. Pay rate range is positively skewed, that is, upper administration and faculty at the high end and a large number of Physical Plant Department laborers, custodians, and support staff at the low end. Since 2003, a small wellness program had existed at the University, where 20 employees participate each semester with no out of pocket fees. Other employees wishing to participate may do so by paying for a membership for $90 per semester. Since students
4 pay for the facilities and programs, it is Texas law that non-students participating must pay as well (Texas Statutes, 2007). Historically, less than 20% of eligible employees purchased on-campus recreation memberships each year. If access to exercise programs were included in the employee compensation package, more employees would likely participate in regular fitness programs, particularly those employees with less disposable income. Although university presidents support such programs in concept, financial officers of universities have not demonstrated support through allocating financial resources to these programs for employees (National Intramural Recreational Sports Association, 2006). Little research exists where employees in a higher education setting have been the participants. Data are needed to lend support to the argument that fitness and wellness programs would have a positive economic, physiological, and job satisfaction impact in a higher education environment. Theoretical Framework The study was grounded by Albert Maslow's theory of motivation, the Hierarchy of Needs. Maslow's book on Motivation and Personality included the original theory with five levels: physiological, safety, social, esteem, and self actualization (1970, pp. 35- 46). "Maslow points out that the hierarchy is dynamic; the dominant need is always shifting. For example, the musician may be lost in the self actualization of playing music, but eventually becomes tired and hungry so he or she has to stop. Moreover, a single behavior may combine several levels. For example, eating dinner is both physiological and social. The hierarchy does not exist by itself, but is affected by the situation and the general culture. Satisfaction is relative. Finally, he notes that a satisfied need no longer
5 motivates. For example, a hungry man may be desperate for food, but once he eats a good meal, the promise of food no longer motivates him" (Brown, 2004). Herzberg, Mausner, and Snyderman applied Maslow's Hierarchy to workplace motivation. In The Motivation to Work (Herzberg et al., 1959, pp.113-114), job attitude factors were separated into two levels, hygiene factors and motivators. The hygiene factors are associated with conditions that surround the doing of the job. Examples of hygiene factors are supervision, interpersonal relations, physical working conditions, salary, company policies, benefits, and job security. When hygiene factors are not adequately met, the result is poor job attitudes. Interestingly, when hygiene factors are at an optimal level, job attitudes did not move up positively, but stopped in a neutral zone. In order for job attitudes to be positive, the other set of factors needs to be examined. The set of factors which create positive job attitudes are grouped together in what Herzberg et al. called "motivators" (p. 114). These are job factors which reward the needs of the individual to reach their aspirations. These items affect positive job attitude and improvement in performance that employers seek to have from employees. This group of factors "revolves around the need to develop in one's occupation as a source of personal growth" (p. 115). An employee wellness program may include educational information on individual wellness where participants acquire and apply knowledge. This application can lead to personal growth in knowledge, self esteem, and self actualization. These higher order elements in Maslow's (Figure 1) and Herzberg et al.'s theories can contribute to employee engagement, resulting not only in individual growth and satisfaction, but in employees who are more motivated and productive in their work environment.
6 Figure 1. Maslow's Hierarchy of Needs (Brown, 2004) / / SELF- \ /ACTUALI ZATI ON \ /Pur sue Inner Talent \ /Creativity Fulfillment:, / SELF-ESTEEM \ / Achievement Mastery \ ' Recognition Respect \ BELONGING - LOVE Friends Family Spouse Lover ' SAFETY \ Security Stability Freedom from Fear ^ PHYSIOLOGICAL \ Food Water Shelter Warmth \ i More recently, Hettler's wellness wheel has gained attention as a more suitable model for describing the interconnectedness of the six components of wellness (National Wellness Institute, 2008), and how physical wellness has the potential to impact other areas of wellness such as occupational. The model is circular, rather than hierarchical. Purpose of the Study If they exist on campuses, employee wellness programs in higher education settings are delivered primarily through campus recreation departments, human resource departments, or a combination of these two areas. Research by campus recreation professionals might not be considered a priority (Haines & Farrell, 2006). Therefore, existing data and studies on the effectiveness of programs in this setting are not extensive. The study collected and analyzed data that corroborated research done in corporate wellness and applied it to the University's setting. Research Questions The study was guided by the following research questions:
7 Quantitative Research Questions: 1. What is the effect of participation in an employee wellness program on physiological risk factors? 2. What is the effect of participation in an employee wellness program on job satisfaction? 3. What is the effect of participation in an employee wellness program on monetary savings of individual employees? 4. What is the effect of participation in an employee wellness program on absenteeism? Qualitative Research Questions: 1. What are the perspectives of the participants on the effectiveness of the employee wellness program? 2. What are the perspectives of the participants' supervisors on the effectiveness of the employee wellness program? Operational Definitions Physiological risk factors are any attributes or characteristics that may increase the likelihood of developing a disease or injury (World Health Organization, 2008). For the purposes of this study, blood pressure, body mass index, cardio-respiratory endurance, strength, and flexibility defined the risk factors. Job satisfaction is "a positive emotional state that reflects and affective response to the job situation" (Peterson and Dunnagan, p. 973,1998). For the purposes of the study, level job satisfaction was demonstrated by the number of questions receiving the
8 response "yes" on the Wellness Councils of American (WELCOA) job satisfaction survey to indicate positive sentiments toward the participant's job. Absenteeism is the absence of an individual from work for reasons of personal injury or illness as self reported by the individual on the Health Risk Assessment survey. Monetary savings is operationally defined by the reduction in spending dollars on medicines, co-payments for doctors' visits, and medical services payments as reported by the participants. Perspectives of the participants and of the participants' supervisors were measured by their responses to focus group questions. Glossary of Terms Blood Pressure - Systolic pressure is the pressure of the blood flow when the heart beats. Diastolic pressure is the pressure between heartbeats. Blood pressure is measured in millimeters of mercury, which is abbreviated mm Hg. (American Heart Association, 2008). Body Mass Index (BMI) is a number calculated from a person's weight and height. BMI provides a reliable indicator of body fatness for most people and is used to screen for weight categories that may lead to health problems. (Centers For Disease Control And Prevention, 2008). Cardiorespiratory endurance is the capacity of the hearth and lungs to deliver blood and oxygen to working muscles. Dynamometer - an instrument to measure grip hand strength.
9 Equal Employment Opportunity (EEO) category four (clerical and secretarial) or below (technical, paraprofessional, skilled crafts, service/maintenance) will be selected to participate in the study. Fitness is the state or condition of being physically sound and healthy, especially as the result of exercise and proper nutrition. It can be a state of general mental and physical well-being (The Free Dictionary, 2008). Flexibility refers to the ability to move the body parts through a wide range of motion without undue strain to the joints and muscles (The Free Dictionary, 2008). Motivation is operationally defined as the inner force that drives individuals to accomplish personal and organizational goals (Lindner, 1998). Muscular Strength is the amount of force a muscle can exert while contracting. Obesity for adults is defined as someone who has a BMI of 30 or higher (Centers for Disease Control and Prevention, 2008). A BMI between 25 and 29.9 is considered overweight. Sit and reach test - a test to measure hamstring flexibility. Sphygmomanometer - an instrument used to measure systolic and diastolic blood pressure. The term wellness was first used by H. A. Dunn in 1961 and defined as "an integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable within the functioning environment" (Sivik, Butts, Moore, & Hyde, p. 136, 1992). V02 Max - measures aerobic fitness and maximal oxygen uptake (About.com, 2008).
10 Limitations Measurable results for return on investments studies for wellness programs can take three to five years (Combs, 2007, p. 2). The length of the study's intervention was approximately 12 weeks which could have influenced the outcome measures. Variation existed in the degree of effort put forth by participants, which may have affected the amount of change or progress made during the intervention. Attrition occurred from numerous sources unrelated to the study, such as illness, death of a family member, increase in workload, and failure to complete the medical screening. Cost per participant to administer the program limited the size of the study group. This must have affected the statistical significance of the findings. The external validity was limited to the non-probability sample of the staff of the University. Outcome measures were limited to selected physiological factors, job satisfaction attitudes, and monetary spending on medical care. Assumptions By recruiting participants from employment categories in the Physical Plant Department and clerical support across campus, there was an assumption that these individuals had limited disposable income. For both the experimental and comparison groups, it was assumed that there was little opportunity for independent fitness or wellness programs beyond that offered in the study. It was also assumed that individuals in the comparison group did not pursue lifestyle changes during the course of the study which could lower their health risk factors significantly. For the qualitative component, it was assumed that the participants shared honest responses regarding the effectiveness of the wellness program.
11 Significance of the Study In the realm of employee wellness, campus recreation has the opportunity to make a significant contribution to their respective institutions. Often, facilities for fitness and wellness exist on campuses for student use. Programs may be available to faculty and staff with varying degrees of services. These programs are often delivered by campus recreation or in collaboration with Human Resource Departments (National Intramural Recreational Sports Association, 2006). It is uncommon, though, to have the fitness programs included as part of the employee's compensation package. Higher education institutions fill a range of employment positions including many at lower paying positions for laborers and support staff with little disposable income for joining fitness centers. Disparities in risk factors for cardiovascular health exist across socioeconomic status (Mensah, Mokdad, Ford, Greenlund, & Croft, 2005). Much research has already been done in corporate settings demonstrating the value to the company of offering employee fitness and wellness programs. Employee wellness programs in a higher education setting benefit both the individual and the organization. Benefits to the individual include lowering risk factors associated with chronic disease and lowering out of pocket expenses for health and medical care. The individual may also experience feeling more energetic and be able to cope better with stressful situations. Benefits to the organization include improved job attitudes that lead to improved performance, productivity, and longevity in the job. Further financial benefits to the organization may be reduced claims on insurance and the potential for lowering insurance premiums with healthier employees.
12 By demonstrating that an economic impact exists by reducing spending on health care and medical costs in this setting, the information may be used to justify inclusion of recreation access as a benefit of employment or to at least offset a portion of the cost of such programs. This study may serve as a replicable model that could be used at other campuses to demonstrate the physiological, job attitude, and economic impact in other settings, and with different demographics.
13 CHAPTER II REVIEW OF LITERATURE Introduction Extensive information is readily available on the benefits of exercise. Chapter II is organized into three major areas: individual components, agency components, and program components. Within the individual components section are the subsections of physiological and behavioral items. The agency components section includes wellness as an employer issue, higher education's role in wellness, financial implications of wellness programs, return on investment, and a subsection on absenteeism, presenteeism, and productivity. The program components area includes program design, prevention, incentives, job satisfaction, culture, and legal aspects. Article searches were conducted using EBSCO, ProQuest, and Gale databases. In addition, specific site data bases from the Centers for Disease Control and Prevention and American College of Sports Medicine were searched for articles on employee wellness, job satisfaction, and monetary savings through exercise programs. References from cited sources in germane articles were also followed. Employee wellness programs, including an exercise component, have been in existence since the 1970s at corporations. Numerous research studies have been conducted in corporate settings in the realm of employee wellness and fitness programs with varying points of focus (Musich & Edington, 2000). In the higher education setting, however, limited studies have been done on the effectiveness of such programs. In this study, the focal points are on the effects of participation in an employee wellness
14 program on lowering physiological risk factors through exercise and education, job satisfaction, and the potential monetary savings in health care costs. Individual Components Physiological Factors Initially, concerns about employee well being were centered in workplace safety to prevent injuries. As programs developed over time, they have come to include, and often focus on, fitness activity programs. Physiological measurements are universally accepted as indexes of progress and success of activity programs on fitness and wellness. As of 2007, in Texas, nearly two thirds or 64.1% of the state's adult population was overweight or obese (Combs, 2007). There is a strong correlation between overweight and obesity and high risk of chronic diseases, such as coronary heart disease, hypertension, stroke, high cholesterol, diabetes, osteoarthritis, and certain cancers (Combs, 2007). Through measurement of physiological factors, such as weight, body mass index, blood pressure, cholesterol, and fitness indicators, individual health can be quantitatively compared to standards and for an individual over time. Individual Behavior Although aggregate data are reported relative to the nation's and state's health status, individuals are to be held accountable for their lifestyles and behavioral choices. Individual choices, such as eating habits, physical activity levels, tobacco and alcohol use, are connected with the incidence of chronic disease (Torrens, Breslow & Fielding, 1982; Combs, 2007; Schult, McGovern, Dowd, & Pronk, 2006). "People generally do not change their behavior without good reasons that outweigh the pain and annoyance associated with giving up longstanding habits" (Hall, 2008, p. 13). Shult et al. (2006)
15 commented that "many people do not want to change their health-threatening behaviors, even when they are aware of the risks they are taking" (p. 545). Changing people's habits related to physical activity has proved to be a challenging task (Haskell et al 2007; U. S. Department of Health and Human Services, 2003). In order for individuals to begin or attempt change, readiness and motivation need to exist (Hall, 2008; Schult et al., 2006). Worksite programs may provide the motivation or reduction in barriers that some individuals need to help them alter lifestyle behaviors (Aldana, Merrill, Price, Hardy & Hager, 2004). Another motivating factor to embark on behavioral changes to improve health is the increasing financial accountability that the individual has for healthcare expenses. With higher out of pocket costs to the individual, the health plan member takes greater responsibility in decisions (Schult et al., 2006; Hall, 2008). Individuals may enthusiastically begin exercise programs, such as with New Year's resolutions, but may not sustain participation. Getting high participation rates and maintaining behavior changes over time are considered to be the two major and universal challenges to the success of health promotion and disease prevention programs (Manly, 1999; Schult et al., 2006). Clark reported that in 2008, 58% of businesses offered work site fitness programs while utilization was only at 15%. On a more positive note, people who have adopted healthy and fit lifestyles tend to be consistent. They are more likely to take advantage of worksite programs whereas sedentary or inactive employees do not (Clark, 2008; Shepard, 1992; Marshall, 2004).
16 Agency Components Wellness as an Employer Issue Dunn (1961) first coined the term for wellness and described it as an integrated method of functioning designed to maximize the potential of which the individual is capable within, the functioning environment. If individual behaviors are the crux of the problem with poor health, why is it so important for employers to be involved? The answer lies in following the money trail. The incidence of obesity and chronic diseases has increased to such a high level in recent history that the financial balance sheets of businesses are affected. Employers have a heightened awareness that employees who are overweight, obese, lack physical activity, or use tobacco not only have poorer health and productivity, they are gaining an understanding of how this affects the financial health and productivity of the company. "Chronic health conditions affect a majority of workers across the broad range of knowledge-based and production-based jobs, and these conditions significantly impacted work impairment, absenteeism, and medical costs" (Collins et al., 2005, p. 555). This justifies employer involvement in providing health prevention and disease prevention programs, because it is the employing agency that provides the health benefit coverage for their employees. Currently, there appears to be an enhanced public interest and calls for integration of well-being and wellness activities into the responsibility of employers (Hillier et al., 2005), and employer decisions can dramatically influence the health care system (Schult et al., 2006; U. S. Department of Health and Human Services, 2003; Collins et al., 2005). These programs are a way to protect the company's investment in its human resources. There is a strong indication that "many health