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Systematic Review of the Impact of Worksite Wellness Programs
Karen Chan Osilla, PhD; Kristin Van Busum, MPA; Christopher Schnyer, MPP; Jody Wozar Larkin, BSN, MLIS; Christine Eibner, PhD; and Soeren Mattke, MD, DSc
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Systematic Review of the Impact of Worksite Wellness Programs

Karen Chan Osilla, PhD; Kristin Van Busum, MPA; Christopher Schnyer, MPP; Jody Wozar Larkin, BSN, MLIS; Christine Eibner, PhD; and Soeren Mattke, MD, DSc
Analysis of studies of worksite wellness programs suggested mixed impact on health-related behaviors and cost, with insufficient evidence regarding absenteeism and mental health.
Objectives: To analyze the impact of worksite wellness programs on health and financial outcomes, and the effect of incentives on participation.

Methods: Sources were PubMed, CINAHL & EconLit, Embase, Web of Science, and Cochrane for 2000-2011. We examined articles with comparison groups that assessed health-related behaviors, physiologic markers, healthcare cost, and absenteeism. Data on intervention, outcome, size, industry, research design, and incentive use were extracted.

Results: A total of 33 studies evaluated 63 outcomes. Positive effects were found for threefourths of observational designs compared with half of outcomes in randomized controlled trials. A total of 8 of 13 studies found improvements in physical activity, 6 of 12 in diet, 6 of 12 in body mass index/weight, and 3 of 4 in mental health. A total of 6 of 7 studies on tobacco and 2 of 3 on alcohol use found significant reductions. All 4 studies on absenteeism and 7 of 8 on healthcare costs estimated significant decreases. Only 2 of 23 studies evaluated the impact of incentives and found positive health outcomes and decreased costs.

Conclusions: The studies yielded mixed results regarding impact of wellness programs on healthrelated behaviors, substance use, physiologic markers, and cost, while the evidence for effects on absenteeism and mental health is insufficient. The validity of those findings is reduced by the lack of rigorous evaluation designs. Further, the body of publications is in stark contrast to the widespread use of such programs, and research on the effect of incentives is lacking.

(Am J Manag Care. 2012;18(2):e68-e81)
Because of the emphasis the Affordable Care Act places on worksite health promotion, employers have increasingly offered worksite wellness programs, but little research has evaluated the current impact of these programs.

  • We analyzed a total of 33 studies published since 2000 that evaluated the characteristics, impact, and incentives of worksite wellness programs.

  •  Studies suggest mixed impact on health-related behaviors and cost, with insufficient evidence for effects on absenteeism and mental health.

  •  Lack of rigorous evaluation designs reduces the internal validity of these findings.
Employers have increasingly offered worksite wellness programs to employees and their families to decrease their cost of providing healthcare coverage and improve their employees’ productivity. The goals of these programs are to promote healthy lifestyles and prevent disease with educational (eg, diet counseling) and motivational (eg, provision of incentives for lifestyle changes) approaches. 1 In 2009, 58% of US employers offered at least 1 wellness program.2 In 2010, consumer participation in programs rose from 19% to 22%.3 This trend is likely to accelerate, as the Patient Protection and Affordable Care Act emphasizes prevention.4 The law provides wellness program start-up grants for small firms, establishes a 10-state demonstration program to reward program participation, and establishes technical assistance for evaluating programs. The law also gives employers greater latitude in rewarding staff for healthy lifestyles by raising the rewards for program participation. The limit, set at 20% of the cost of coverage, will increase to 30% in 2014, and the secretaries of Health and Human Services, Labor, and the Treasury will jointly have the authority to raise it as high as 50%.

Reflecting their growing importance, several reviews of worksite wellness programs and their components have been published. Baicker et al5 assessed the impact of 32 programs on medical costs and absenteeism that were published since 1982 and found that programs typically return 3 dollars for every dollar invested, which is consistent with other research suggestive of savings.1,6-9 Other studies have found positive effects as well,10-12 including evidence for certain components of wellness programs (eg, health risk assessment).13

Despite these findings, a review is needed on the current impact of wellness programs to examine how employers have responded to current policy and programmatic priority changes. We conducted a systematic review of wellness programs to understand:

• What are the characteristics of the worksite wellness


• What impact do programs have on outcomes?

• What types of incentives are provided for program uptake and what is their impact?

This review contributes to the evidence base in several ways. We considered outcomes beyond medical cost and absenteeism to include behavior change and health effects. Only studies with a comparison strategy were included, to maximize validity of the findings. We also limited our scope to studies about comprehensive programs that were published after 2000 to yield a more accurate reflection of current programs. Finally, we looked at the use of incentives for program uptake.


Data Sources

We conducted a keyword search covering PubMed, CINAHL & EconLit (EBSCO), Embase, Web of Science, and Cochrane from January 2000 through June 2011 (see the Appendix). Additional articles were identified through reference searches of recent literature reviews or meta-analyses.

Article Selection

Articles were included if they had a control or other comparison group and evaluated outcomes of comprehensive worksite wellness programs (ie, multiple wellness components focused on health promotion or disease prevention). We excluded opinion and theory articles, reviews, articles without a comparison group, non-English language and non-US articles, articles published before 2000, and articles that focused exclusively on disease management.

Two investigators (KCO, KVB) independently evaluated articles for inclusion based on title and abstract review, and then full text review. A third investigator (SM or CS) served as tie breaker in case of discrepancy.

Data Extraction

We extracted type of intervention, setting, and research design from each study. Programs and worksites were classified by type, size, and industry.14

We categorized the quality of the design using methods adapted from previous meta-analyses15,16: controlled trials with random assignment, prospective studies with nonrandomly assigned comparison groups, and observational designs with internal comparison groups (eg, participants vs nonparticipants).


Identification of Evidence

We identified 1546 articles from our search and 9 through bibliography searches of review articles (Figure). We excluded 1492 upon title and abstract review. A total of 62 full-text articles were assessed for eligibility; 29 were not eligible (eg, noncomprehensive programs, international, no comparison), yielding a final sample of 33 articles.

Sample Characteristics

Of the 33 studies, 22 reported company size (Table 1); 8 studies were done in medium-sized companies, while only 1 reported on a small worksite. Of the 33 studies, 29 reported the industry. About half were conducted in companies that provided services, which is comparable to the distribution of industries in the overall economy.

Program modality varied substantially, as 31 studies reported multiple delivery methods (23 reported 3 or more). The most common modality was self-help or educational materials and/or individual coaching or counseling.

Program Outcomes

A total of 63 outcomes were evaluated between the 33 studies (Table 2). The most common were exercise (n = 13), diet (n = 12), and physiologic markers (n = 12). Others reported on healthcare cost (n = 8), smoking (n = 7), alcohol use (n = 3), absenteeism (n = 4), and mental health (n = 4). The majority of studies (64%) used self-reported data for at least 1 outcome. About three-fourths of the observational designs reported beneficial outcomes compared with about half of the randomized trials.

Program Impact

Table 3 provides a detailed description of the outcomes and data measured in each study.

Exercise. Thirteen studies evaluated exercise and 8 (62%) found improvements in physical activity. Of these 8 studies, 3 were randomized control trials (RCTs)21,39,43 and 5 utilized a control group with nonrandom assignment34 or observational designs.25,27,31,41 All 4 that utilized observational designs showed positive effects on exercise, whereas only 3 of the 7 RCTs found a beneficial effect. Only 1 of these 3 RCTs had a follow-up period longer than a year and a sample size larger than 100.21

Of the 8 studies with positive effects, 4 showed substantial changes, such as employees being twice as likely to exercise27 and increasing walking by 103 minutes a week.43 Two others had smaller effects21,25 such as improved exercise frequency, but no improvements in aerobic activity.21 Two studies did not report the magnitude of the impact.34,41 Half of the 13 studies had follow-up periods of less than 1 year, and the maximum follow-up period was 4 years.

Diet. Of the 12 studies that evaluated diet, 6 (50%) found improvements in diet21,22,26,27,34,41 including higher fruit and vegetable consumption and lower fat and energy intake. Of these 6, 3 utilized an RCT,21,22,26 2 of which had a follow-up period longer than a year.21,49 One study had a nonrandom comparison group41 and 2 had an observational design.27,41 A total of 2 of the 3 studies with observational designs and 1 of the 2 studies with a nonexperimental comparison group found improvements in diet, while fewer than half of the studies with RCTs found significant effects. Overall, effects were small, such as an increase of 0.7 servings of fruits and vegetables per day21 or an average of 0.2 fewer fast food meals per week.26

Physiologic Markers. Twelve studies evaluated physiologic markers such as body mass index (BMI), cholesterol levels, and blood pressure. Six of these found improvements in 1 or more outcomes, including BMI or weight,19,31,34,41,44,45 diastolic blood pressure,41 and body fat mass.44 Effects included decreases in BMI by 0.04 kg/m2 among program participants,34 4.3% reduction in BMI,41 and 1% reduction of diastolic blood pressure.41 Of these 6 studies, 3 used an RCT19,44,45 and 3 used a nonexperimental comparison group34 or an observational design.31,41 None of the RCT studies showing a positive effect had a sample size larger than 100. The 6 studies that did not report a positive impact were RCTs (n = 3) and observational studies (n = 3).

Smoking. A total of 6 of 7 studies found higher quit rates29,35,40,46 or less tobacco use.27,41 Two found that approximately 10% more individuals in the intervention group quit smoking compared with the control group29,40 and another reported participants were almost 4 times more likely to reduce smoking than nonparticipants.27 All RCTs reported positive effects,29,35,40,46 as did 2 observational studies.27,41 Of the 4 RCT studies showing higher quit rates, 3 had a follow-up period longer than 1 year. Sample sizes in all studies ranged from about 420 to 1130 in each group.

Alcohol Use. Three studies evaluated alcohol use as an outcome using an RCT design. Two compared a motivational interviewing–based intervention with a no-treatment control group,18,23 and 1 study evaluated a counseling-based treatment program compared with a no-counseling control group.29 Of the 3 studies, 2 reported reductions in alcohol18,23 such as decreased drinking on weekends and frequency of intoxication23 and 0.4 fewer days of alcohol consumption per week.18 One study found no impact,29 which may be attributed to the small sample size and a 3-year follow-up.

Healthcare Cost. Eight studies evaluated the impact of wellness programs on healthcare cost and all but 1 study17 found significant decreases. Effects included a reduction in direct medical cost between $176 and $1539 per participant per year.30,37,38 Other studies took a broader view and found $613 savings when including disability cost savings47 and $180 savings when combining healthcare cost and absenteeism. 48 Of the 7 studies finding a cost reduction, only 1 study utilized an RCT, which had a follow-up period longer than a year.37 The other studies utilized a nonrandom comparison group30,32,36,38 or observational designs.47,48 The study finding no impact on cost also had an observational design.17

Of the 8 studies, 5 conducted return on investment (ROI) analyses and found returns between $1.65 and $6.00 saved for every dollar invested.30,36-38,48 These studies included the RCT,37 3 nonrandom control designs with a follow-up period between 4 and 7 years,30,36,38 and an observational design with a 7-year follow-up.48

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