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Systematic Review of the Impact of Worksite Wellness Programs
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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.
Absenteeism. Four studies evaluated absenteeism costs, as defined by the estimated cost of missed workdays. Each of these studies found significant effects, expressed as an ROI of $15.60 per dollar spent,17 $1350 saved per employee in short-term disability costs,27 0.1% point risk reduction in illness days,31 and $180 saved per participant per year when including healthcare cost.48 All 4 studies used observational designs.

Mental Health. Four studies evaluated program impact on perceived mental health20 and stress.22,27,41 Butterworth et al20 used a nonrandom control design and found that employees receiving the intervention improved their mental health by 3 points on the 12-Item Short Form Health Survey, while control participants had no improvement. Cook et al22 used an RCT and found no significant differences on stress. Ozminkowski et al41 used an observational design and found that individuals receiving the intervention had a 6.1% risk reduction for stress. An observational study27 found that individuals in a telephone-based health promotion program were 2 times as likely to practice stress management compared with nonparticipants.

Use of Incentives

Incentives to encourage program enrollment and participation were common; 23 (70%) of the studies offered incentives (Table 4). A total of 10 studies offered incentives for participation, 5 for survey completion, 2 for program enrollment, and 6 for a combination of enrollment, participation, and/or survey completion. Two evaluated the impact of incentives on health-related standards. Herman et al31 compared the impact of a virtual wellness program on participants who received a $150 incentive for logging minutes exercised compared with those who did not. Compared with the nonincentivized group, incentivized participants had improvements in health-related behaviors and body weight but not smoking rates. Merrill et al36 found offering financial incentives encouraged employees to participate in wellness activities, but they did not include a nonincentivized comparison group.


We analyzed a total of 33 studies published since 2000. Our goals were to examine the characteristics of current wellness programs, evaluate the impact these programs had on outcomes such as health-related behaviors and medical costs, and assess the use and potential impact of program incentives.

Most programs were conducted in the services industry and in medium-sized to large businesses. Most programs utilized self-help and educational materials, and focused on improving health-related behaviors like diet and exercise. Consistent with previous research,1,6-12 we found that studies mostly report positive impact on outcomes, but only half of these studies utilized an RCT design. Finally, we found that 70% of the programs offered incentives, but only 2 evaluated the impact of these incentives on health behavior outcomes and participation.31,36

Wellness programs were multifaceted in their delivery and evaluation. It is common for programs to use a combination of self-help and counseling to target several health behaviors. 49 All but 2 studies had multiple delivery methods and more than half evaluated several outcomes. Combinations of approaches and outcomes were too heterogeneous to detect patterns by outcome. Future research is needed comparing the impact of different types of approaches or modalities (eg, Web vs printed materials).

While most studies found improved outcomes, our results confirm the concern that programs are often not evaluated with strong research designs.50 When evaluations used observational designs, positive effects were found for three-fourths of the outcomes, whereas positive effects were found for only about half of the outcomes evaluated with RCTs. Without an RCT design, a causal effect between the program and outcome cannot be drawn reliably, and nonexperimental designs are more prone to selection bias. Additional limitations of these studies include small sample sizes and short follow-up periods. Only 2 studies had more than 120,000 participants, while others had as few as 50 to 2000 participants. Follow-up was 2 years or less for 70% of the studies, and studies with shorter follow-up tended to show more positive results. For example, 19 of the 29 studies (66%) that reported at least 1 significant finding had follow-up assessments of 2 years or less.9,17-23,25,26,31,35,37,39-41,43,44,46 Use of self-reported findings in 21 of the 33 studies may also impact validity, especially if participants were aware of program assignment.

Fifty-five percent of the studies focused on programs that targeted health-related behaviors. About half found improved diet- and exercise-related outcomes, but the effects were small, especially for dietary behavior, or not reported explicitly. Further, fewer than half of RCTs on diet and exercise reported favorable findings. Studies on substance use mainly focused on tobacco use as opposed to alcohol or drug use. While all 3 studies evaluating alcohol outcomes were RCTs, very few studies evaluated programs for early substance use problems.18,51 Of the 7 tobacco studies with RCTs, 6 had reasonably large samples and meaningful effects. However, these positive effects should be interpreted with caution because findings were either not significant at longer follow-up40 or not for all employees (eg, hourly and not salaried workers).46 Studiestypically used nonparticipants as a comparison, increasing the risk of selection bias, although 1 study used propensity score matching to adjust for this bias.30 Future studies should control for observable differences between wellness program participants and nonparticipants, and use additional calculations to interpret the strength of program impact.

Despite the volume of studies on healthcare cost and absenteeism published prior to 2000,5 only 8 studies met our criteria. Most studies were excluded due to the lack of a comparison strategy. Only 5 studies provided a calculation of ROI, in contrast to previous research1,5-9 that found a solid body of literature providing evidence for cost savings. This is important because those reviews included predominately older studies, and it is unclear whether the type of interventions and scale of opportunities are comparable to what is observed today. Only 1 of the 7 studies showing costs savings utilized an RCT, making it difficult to determine whether reduced costs and associated behavior change can be fully attributed to the programs. Further, evidence of program impact on absenteeism is limited because all 4 studies used observational designs.

To summarize, the published studies included in our review since 2000 provide mixed evidence for a positive impact of workplace wellness programs on health-related behaviors, substance use, physiologic markers, and healthcare cost, and there is insufficient evidence for effects on absenteeism and mental health. Use of weaker evaluation designs in more than half of the studies limits the strength of the evidence.

We found that incentives were offered in 70% of the studies, but only 2 studies evaluated the impact of incentives on participation and outcomes and 1 of them did not have a nonincentivized comparison group. No studies evaluated unintended consequences of incentives. Thus, the literature does not allow us to assess unintended effects of incentives (eg, on availability and affordability of coverage). Typical incentive amounts were small, ranging from $5 to $150, and some programs tiered incentives depending on level of engagement. Those amounts are well below incentive levels that are commonly used today, which are typically $200 to $400

per person per year.52 Further, companies do not appear to be offering incentives close to the ceiling amount specified by the HIPAA Nondiscrimination Requirements.53-55 Further research is needed on the effect of different levels of incentives on outcomes and health behaviors.

Our study has several limitations. First, we included only English-language studies and their chosen outcomes published in peer-reviewed journals, which may lead to bias because successful interventions are more likely to be published. Second, it is difficult to generalize our conclusions because wellness programs were very heterogeneous, outcomes were not systematically operationalized, and calculations of effect sizes were not consistently reported. Lastly, many studies relied on self-report with the potential of differential recall and reporting.

In conclusion, published evaluations of worksite wellness programs yielded mixed results. The number of publications that met our inclusion criteria is in stark contrast to the widespread use of such programs. Recent industry surveys indicate that employers plan to continue expanding their use of wellness programs.56 Thus, a dynamic and innovative industry appears to have outpaced the underlying evidence, a phenomenon already observed for disease management programs. 57 Given the great interest in these programs and the emphasis the Affordable Care Act places on worksite health promotion, further research is needed. Future studies will need strong evaluation designs, sufficient follow-up, and adequate power to detect meaningful differences. Lastly, better evidence is needed to understand the impact of incentives for program participation, behavior change, and risk factor reduction.


The authors thank Wilma Tilson, PhD, Anja Decressin, PhD, Keith Bergstresser, PhD, and Elaine Zimmerman, PhD, for their stimulating and constructive comments on an earlier draft. The manuscript expresses the views of the authors and not official policy of the Department of Labor (DOL) or the Department of Health and Human Services (DHHS).

Author Affiliations: From RAND (KCO), Santa Monica, CA: RAND (KVB, CS, SM), Boston, MA; RAND (JWL), Pittsburgh, PA; RAND (CE), Arlington, VA.

Author Disclosures: The authors (KCO, KVB, CS, JWL, CE, SM) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (KCO, CS, JWL, CE, SM); acquisition of data (KVB, CS, JWL); analysis and interpretation of data (KCO, KVB, CS, SM); drafting of the manuscript (KCO, KVB, CE, SM); critical revision of the manuscript for important intellectual content (KCO, CE, SM); obtaining funding (SM); and administrative, technical, or logistic support (KVB, CS, JWL).

Funding Source: This manuscript was developed under contract DOLJ089327414 to the Employee Benefits Security Administration, DOL, and the Office of the Assistant Secretary for Planning and Evaluation, DHHS. The study reflects the opinion of the authors and not official policy of DOL or DHHS.

Address correspondence to: Soeren Mattke, MD, DSc, RAND Corporation,20 Park Plaza, Suite 720, Boston, MA 02116. E-mail:
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