This study aimed to evaluate an existing wellness programme and to assess the distribution of lifestyle and clinical risk factors in an employed adult population, voluntarily presenting for health risk appraisal. The first important finding was the low percentage of participation in a health risk appraisal offered on site at work among employees (mean 26%) and that participation varied significantly different between sectors. Despite the low level of participation, our rates were similar to that reported in a comprehensive workplace intervention which gave employees the opportunity to participate in a variety of health promotion programmes [8
]. The study by Aldana et al was conducted over 2-years with 23% of the employees participating in the first year and 20% during the second [20
]. Similar to our findings, the majority of their participants were female.
A posteriori analyses was conducted in order to determine if the results differed between companies with higher response rates, compared to those with lower response rates. We divided the companies into tertiles based on participation, and then conducted an analyses of variance (ANOVA) to determine if there were significant differences in the health and behaviour profile according to levels participation. There were no significant differences in age, both chronological age and risk-related age, Body Mass Index (BMI), cholesterol concentration, and habitual levels of physical activity in the high versus the low responders. Conversely, the companies with the highest response rates had significantly higher blood pressure, more total risk factors for NCD and lower daily fruit and vegetable consumption than those with the lowest response rates. Thus the wellness days in the companies with the highest attendance seemed to be attracting employees at increased risk of non-communicable diseases. It is therefore important to address attendance and uptake in worksite-based programmes. This is supported by Kwak et al who advocates the reporting of participation rates in order to correctly interpret results and implications of the research findings [9
It has been previously demonstrated that the success of recruiting employees in health risk screening is influenced by the interest shown from the company's management, as well as, internal advertising and marketing strategies [21
]. In these 18 companies, low levels of participation may be a reflection of poor marketing and advertising prior to the wellness days. The poor uptake could also be attributed to availability of staff on the wellness day, which was only offered approximately once per year. For example, the transport sector comprised of airline companies, and the low level of participation may be in part due to the fact that some staff was not available on the wellness day. The solution in this case, would be to offer the health and wellness events on more than one day per year in order to attract more participants.
Since one of the aims of these wellness days is to offer individuals an opportunity to determine their health status, particularly those at increased risk, the advertising plays an important role in attracting as many volunteer participants as possible. Leslie et al. used e-mail communication to increase participation in workplace-based health intervention programmes [23
], which was followed up with a telephone call resulting in an uptake of 79% [23
]. Other factors which could increase participation is the provision of incentives [24
] and also the establishment of employee advisory boards who have management involvement, a level of autonomy and also company commitment [25
]. Therefore, the recruitment for wellness days, particularly if they are only one-day events, should begin earlier than the one-week time period used in the current study and should also consider including direct contact with the employee.
Participation in workplace based interventions which include health risk assessments, has also been associated with decreased short term disability days away from work [26
]. Serxner et al found that employees who participated in a health risk assessment at least once per year significantly decreased days away from work by 5%, compared to a 15% increase among non-participants [26
]. The potential benefits of increasing participation would therefore include future costs associated with absenteeism and training temporary personnel. Bias in interpretation was subsequently addressed by adjusting inter-sectoral comparisons for percentage participation in the health risk appraisal.
The second important finding in our study was that risk-related age was significantly higher than chronological age and this risk-age difference was greatest in the Manufacturing sector. The risk-related age is a reflection of the presence of risk factors such as smoking, inadequate physical activity and fruit and vegetable intake, elevated cholesterol and a BMI greater than 24.9 kg/m2
. These are all modifiable risk factors, and comprehensive interventions may reduce risk-related age and possibly result in a 'gain' in years [27
]. The inter-sectoral differences may be used by health insurers in identifying companies which are likely to benefit most from intervention programmes. Improved health status and lifestyle habits has been associated with reduction in health care costs, increased productivity and decreased absenteeism [29
]. These findings are supported by Serxner et al. 2001 who found that employees who have high blood pressure, high cholesterol and are overweight have higher rates of absenteeism and also related medical costs [27
This research study is among the few in South Africa (SA) which allows for the comparison of the health status of the corporate sector to that of the general SA population. This is due in part, to the fact that the South African Demographic Health survey was recently completed in 2002–2003. Secondly, measures were, in some instances, comparable, due to the similarity of definition of risk factors and risk questionnaires between the two surveys, as well as risk cut-points. For example, the men in the present study had a higher prevalence of overweight and obesity compared to the general male population [2
]. Conversely, women in the present study had a lower prevalence of overweight and obesity, compared to that of the SADHS. The differences between the employed adults and general population may be due to differences in educational and socio-economic status. The SADHS reported that the prevalence of overweight was highest among men in urban settings and those who were educated [2
], which reflects the participants in the current study. In addition, SAHDS showed that women with the lowest levels of education were the most obese [2
], while most of the women in our study had some form of higher education.
Furthermore, the individuals screened as part of this study report lower levels of participation in physical activity than the general population. This has important implications since physical activity is associated with decreased risk of disease, but also, with greater levels of productivity and lower rates of absenteeism, which is important in the corporate sector [14
]. Indeed, our results showed that those with higher levels of weekly physical activity reported significantly fewer days away from work the previous month. This is supported by Jacobson and Aldana (2001) who investigated the relationship between the frequency of aerobic activity and illness-related absenteeism among US workers (n = 79 070) representing 250 worksites [14
]. Even only one day of physical activity per week was associated with significantly reduced absenteeism compared to those employees who were inactive, and further reductions were observed when comparing 2 days to one day of physical activity [14
This research study has also shown a tendency for the clustering of risk factors and a large percentage of our participants had 4 or more risk factors (88%). Data from the 'StayWell' programme showed that employees with 4 or more risk factors were 1.75 times more likely to have higher absenteeism rates than those with fewer risk factors [27
]. Our study corroborates these findings where those with a higher number of risk factors had significantly more days away from work, and also more days with performance adversely affected by poor mental or physical health. Therefore, it is likely that reducing the number of risk factors will have important implications in worksite settings, reducing both the direct and indirect costs associated with absenteeism.
Clustering of risk factors has also been associated with diseases such as hypertension, heart disease and diabetes [30
]. Results from our study shows that insufficient physical activity was coupled with the presence of additional risk factors among employees such as insufficient fruit and vegetable intake (80%), smoking (61%), overweight or obese (31%), increased serum cholesterol concentration (19%) and elevated blood pressure (12%). These results suggest that increasing habitual physical activity may positively impact on the other risk factors, and subsequently lower the overall risk profile of individuals. Indeed, previous research has suggested that physical activity may act as a catalyst and entry point for improving diet and stopping smoking [10
]. Reductions in risk factors that could therefore potentially be achieved by increasing habitual physical activity could decrease the risk of morbidity and mortality [26
]. In addition, by decreasing the total number of risk factors, the total number of days absent from work can also be decreased [27
The health risk assessment has been regarded as an entry point in comprehensive health promotion programmes and precedes the implementation of targeted interventions [31
]. Completing a self-reported questionnaire such as the one used in our study to determine the prevalence of risk factors and to calculate risk-related age, may increase an individual's awareness of risk factors and aspects of their life that could improve. This increased awareness could be the first step in initiating change and improving health status, and risk-related age. Pelletier et al (2004) administered an online health risk appraisal on behalf of a health care provider to employees at baseline and again one-year later [32
]. No other interventions were reported in their study, yet there were significant risk reductions observed for dietary habits, elevated serum cholesterol, and non-significant reductions in inactivity and BMI [32
]. The potential health and cost benefits that can be obtained by following up the health risk assessment with an intervention could be greater than by only offering screening activities. Thus, interventions could be targeted successfully at those categorised as 'high risk' or 'moderate risk' [31
] since those in the higher risk categories could show greater improvements in health [12
Another important finding in our study was there was a knowledge-behaviour "gap", with a large percentage of employees believing that their dietary habits were healthy, despite consuming less than the recommended 5 servings of fruit and vegetables per day. These results highlight the gap in knowledge and/or awareness and the need for interventions which include an educational component. This is supported by Cook et al's (2001) findings where a higher nutrition knowledge score was associated with increased vegetable intake, and belief in healthy nutrition was reflected with increased fruit consumption [33
Health risk has been associated with both increased presenteeism and absenteeism [32
]. Thus, another noteworthy finding from our study was that the total number of days adversely affected by poor mental or physical health was less than the number of days away from work. These results may provide an indirect indication of presenteeism, suggesting that the employee is at work, but experiencing low levels of productivity. It has been widely established that health and well-being impact on work performance and job satisfaction [34
Another important outcome of this study was that it allowed for inter-sectoral comparisons for risk factors and self reported health status. There were significant differences for each of the health and lifestyle measures among the various sectors. However, no single sector consistently emerged as having the healthiest or least healthy employees. Consequently, intervention strategies should be based on the individual requirement or health status of the various sectors or companies.
The main limitation of this study is that employees volunteer to participate in the wellness days, thus our results may be biased towards those willing to participate. However, Goetzel et al. reported that there were no significant differences in the average number of risks at baseline between participants and non-participants in Johnson and Johnson's Health and Wellness programme [12
We acknowledge that this was an opportunistic study, evaluating an existing wellness programme. However the findings do provide some insight into the health profile of the South African corporate population, and underscores the need for further, and more representative research.