2013 UNIDAS Congress Health Promotion Programs (A Perspective) Presented by Professor Robert C. Karch, Ed.D. American University School of Education, Teaching, and Health Washington, DC, USA.

College of Arts and Sciences School of Education, Teaching and Health AMERICAN UNIVERSITY College of Arts and Sciences School of Education, Teaching and Health BS in Health Promotion (18 Years) MS in Health Promotion Management (33 Years) National Center for Health and Fitness 33 Years and 30 Million Dollars in External Research/Contract Activity

Some Facts Based in Washington, DC at American University Unique global forum of established Health Promotion Professionals and prestigious institutions Personal and institutional links in 60+ countries Global communication network with interdisciplinary partnerships Currently establishing Regional Coordinating Centers - ( IIHP-RCC) 33 Years of experience in Health Promotion Education Developing On-line Executive/Professional Education Programs

Health Promotion Programs Why? What? Who? Where? How?

WHY? Why Health Promotion? Why now? Why Your/My/Every Country? Why UNIDAS Nacional? Why You? – Why Me?

The WHY? Humanistic/Civil Issues Business/Competitive Issues Cost - $/Savings/ROI Productivity Sustainability Competitiveness (National/Global) Recruitment - Retention Growth Cost - Not just $ - Other The Human Condition Civil Society Humanistic Concerns Spiritual Concerns The right thing to do!!!

Unsustainable Cost Pressure Source: 2011 Milliman Medical Index

Or to look at it another way… Source: Alliance of Community Health Plans

Or to look at it a third way… Income: $59,858 Source: Alliance of Community Health Plans

Health is more than health care Drivers of health Where money spent Health is more than health care Social and economic factors Physical environment Healthy behaviors 30% 10% 40% Medical services 20% Medical services 8% Other 4% Healthy behaviors 88% Where do U.S. health care dollars actually go? INTRODUCE BUSINESS CASE Current challenges in health care This diagram illustrates how far removed we are in the current state from where our focus needs to be – both as individuals and within the system. When we look at what drives an individual’s health, according to David Kindig, a University of Wisconsin population health expert, who argues that there are multiple determinants of health outcomes, we see that Medical services only contribute 20% of actual health care spend. Healthy behaviors account for 30 percent, and in fact, where you live, your access to education, safety, and a healthy environment contribute a whopping 40%. [CLICK] Now, where do you think we, in the U.S. as a whole, actually spend our dollars on health care? That’s right. 88% of our total spend is on medical services. As a system, we need to align our spending with the elements that actually determine health. [NEXT SLIDE)

Why You?? Why Me?? Why US?? and Why UNIDAS & Why Self Insure?? My Answer!!!

Shorter Lives, Poorer Health The U.S. health disadvantage has multiple causes and involves some combination of inadequate health care, unhealthy behaviors, adverse economic and social conditions, and environmental factors, as well as public policies and social values that shape those conditions.

This Fact Drives Me!! My “WHY” Punch Line It is a sobering (sickening) thought; we might live longer than our children!! According to the World Health Organization we are the first generation whose children's life expectancy may not be as long as their parents if present trends continue. This Fact Drives Me!!

The WHAT? What is Health Promotion?? What can/does it mean for a company? (Owners, Management, Employees, Dependents, Customers, Competitors) What is Health Promotion ?

LANGUAGE “If language is not correct, then what is said is not what is meant. If what is said is not what is meant, then what must be done remains undone. Hence, there must be no arbitrariness in what is said. This matters above everything.” - Confucius R.C. Karch

Prevention vs. Promotion To Prevent or Prevention Pre - Coming before Vent – Letting/Getting out To Promote or Promotion Pro - For and/or in support of Motion – Action - Movement - Advocate

Promotion and Prevention “To start” Pre – vention “To stop” R.C. Karch

World Health Organization PAHO Definition of Health Promotion “Health promotion is a process of enabling people to increase their control over, and to improve, their health” (Empowerment) R.C. Karch 11

Mental Health WHO defines mental health as a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community. Mental health promotion is an umbrella term that covers a variety of strategies, all aimed at having a positive effect on mental health. R.C. Karch

Positive Health State of health beyond an asymptomatic state. Concept of positive health usually concerns the quality of life and the potential of the human condition. Notion of positive health may include self-fulfillment, vitality for living and creativity. The concept of positive health is central to the philosophy of health promotion. R.C. Karch

Total Health A state of complete physical, mental, and social wellbeing and not merely the absence of disease and infirmity. In the context of health promotion, health is considered less as an abstract state and more as a means, as a resource which permits people to lead an individually, socially, and economically productive life. R.C. Karch

Health Continuum Wellness Illness Premature Death Disability Signs Attitudes Health Behaviors Premature Death Symptoms Knowledge Health Promotion Traditional Medicine No discernible illness or wellness Wellness Illness Source: Michael O’Donnell - Definition of Health Promotion American Journal of Health Promotion Summer, 1986 R.C. Karch

A model of health promotion; Downie, Fyfe, & Tannahill, 1992 Health Education Health Protection Prevention A model of health promotion; Downie, Fyfe, & Tannahill, 1992 R.C. Karch

The American University’s Optimal Wellness The American University’s National Center for Health Fitness Optimal Wellness Model To obtain optimal wellness individuals must assume responsibility for the continual development and maintenance of the Physical, Spiritual, Emotional, Social, Intellectual, and Environmental components of their health, consistent with the culture in which they reside.   R.C. Karch 1979

WHO Healthy Workplace Framework

Empowerment Promotion of the abilities of people so that they can form their social conditions and rule their own lives. Their self-esteem is reinforced, their capabilities are promoted. They are most likely to work together with other people to achieve their goals. R.C. Karch

Processes of empowerment can not be produced only promoted! Empowerment (Cont.) In this approach even people with little ability or in extreme critical situations are seen as having strengths and resources. (Key Point) Processes of empowerment can not be produced only promoted! R.C. Karch

The Last What slide - What is Driving Change? Unsustainable costs of health care The Patient Protection and Affordable Care Act The obesity epidemic* The increase in diabetes The overall relative decline in health The recognition that health is more than health care

For Today A Dual Task We must attempt to Prevent Diseases while We Promote a Healthy and Self- Empowered Active Lifestyle! A Big and Complex Challenge!!

Example -The Complexity in - Tackling Obesity Complexity…Health as an outcome of a multitude of factors that interact in a highly complex, dynamic, and inter-related system Source: Vandenbroeck, Goossens, & Clemens. (2007). Foresight: Tackling Obesities: Future Choices –Obesity System Atlas.

WHO?? For today (this hour) it is just you and me!!! But then - Everyone!!!

Key Settings – Touch Points WHERE?? Key Settings – Touch Points Government Agencies Workplace Settings* Workplace Health Associations (UNIDAS)* Faith Based Organizations Grocery Stores/ Pharmacies Schools Home Everywhere!!! (Do you know of a place where Health is not important??)

Where? - A Choice to Think About - The Doctor’s Office or The Workplace?? Total Non-sleep Hours 24 Hrs. Day ( – 8 Hrs. Sleep) = 16 Hrs. X 365 Day Year = 5840 Hours per year!! Total working Hours 5 Days a week 8 hours a day = 40 Hours week X 50 weeks =2000 Hours year!! Question? - How many hours a year do you spend with your Doctor??? (2hrs = a 1000 to 1 Ratio!!) & (Proximity Increases Success!! ) Just so you know - I love seeing my Doctor!!!!

The Worksite Setting Population access Significant reach into the population (Again note Proximity) Significant frequency to intervention exposure Significant access to tools, vehicles, resources, etc. that may be mobilized to increase awareness and PA behavior change Worksites can identify the population of interest Employees Employees and dependents Targeted subgroups of interest Interventions can be designed at various levels that interact with the individuals receiving the intervention Individual - Inter-personal - Organizational & Environmental

The Worksite Setting Work matters for health Unemployment is a major determinant of health Worker health may be affected by the organization of work, the policies at work, the relationships at work, etc. Health matters for work Chronic conditions may be exclusion criteria for job fit Fitness for duty tests as indicators of inclusion criteria Healthy workers and a healthy culture appear to be a good business strategy Worksite health promotion also is a sound public health strategy and fosters economic growth in the community

Broader context Employer recognize the need to: Reduce healthcare spending Reduce illness burden Reduce the likelihood of becoming ill Make healthy choices easy choices Maintain or improve economic vitality Reduce waste Increase longevity Enhance national security Prepare communities for the workforce

Opportunity and Responsibility About one half of all of the people of the world are Employees!! A Karch Maxim HE + HC1 + HC2 + HC3 = HW If companies create Healthy Employees - Healthy employees will create Healthy Companies - Healthy Companies will then create Health Communities - Healthy communities will then create Healthy Countries - Healthy Countries will then create A Healthy World!!

Workplace Health Promotion: a Win-Win-Win Scenario!! Employers benefit: Improved morale, higher productivity, enhanced recruitment and retention ( corporate image) Employees benefit: Improved quality of life through better health, more control over work, better balance of work and social life Families and Communities Benefit ( But - Who is the First Winner??) R.C. Karch

HOW? Critical Elements for Successful Outcomes!!

Leadership & Culture!!

Essential Elements List Guidance toward Integrated Health and Safety Programs Organizational Culture and Leadership Develop a “Human Centered Culture” Demonstrate Leadership Engage mid-level management Program Design Establish clear principles Integrate relevant systems Eliminate recognized occupational hazards Be consistent Promote employee participation Tailor programs to the specific workplace Consider incentives and rewards Find and use the right tools Adjust the program as needed Make sure the program lasts Ensure confidentiality Program Implementation and Resources Be willing to start small and scale up Provide adequate resources Build accountability Communicate strategically Program Evaluation Measure and analyze Learn from experience TOTAL WORKER HEALTH™ Source: NIOSH Essential Elements List (see http://www.cdc.gov/niosh/TWH/essentials.html).

Program Best Practices Leadership and Strategy Organizational commitment Shared program ownership Identified wellness champions Program connected to business objectives Supportive policy, physical, and cultural environment Policy Development and Enforcement (Benevolent Policies) Evaluation Program measurement and evaluation Operations Clearly defined operations plan Effective communications Scalable, sustainable, and accessible programs Assessment, screening, and triage Effective interventions Meaningful participation incentives Integration and Data Practices Integration of program components at the point of implementation Integration across multiple organizational functions and departments Integrated data systems Efficient and effective data practices Data privacy and confidentiality

Five Guiding Principles for a Healthy Workplace! Meet the needs of all employees, regardless of their current level of health; (Do not forget the Dependents!!) Recognize the needs, preferences and attitudes of different groups of participants; Recognize that an individual’s “lifestyle” is made up of an interdependent set of health habits; Adapt to the special features of each workplace environment; and Support the development of a strong overall health policy in the workplace. (Health Canada) R.C. Karch

Value through design Companies across a variety of industries report benefits: Lower health care costs Greater productivity Higher morale ROI can be as high as 6:1 (Note ?) Six Essential Pillars for Successful Programs: Engaged leadership at multiple levels Strategic alignment with the company’s identity and aspirations A design that is broad in scope and high in relevance and quality Broad accessibility Internal and external partnerships Effective communications

The value of Health-Dollars and Sense ROI Literature Review Systematic review and meta-analysis Conclusion: Worksite Health Promotion programs can generate positive ROI for medical- and absenteeism-related savings: Medical: 3.27 : 1 Absenteeism: 2.73 : 1

Facing the challenges in health care Drivers of health Where money spent Facing the challenges in health care Social and economic factors Physical environment Healthy behaviors 30% 10% 40% Medical services 20% Medical services 8% Other 4% Healthy behaviors 88% Where do U.S. health care dollars actually go? INTRODUCE BUSINESS CASE Current challenges in health care This diagram illustrates how far removed we are in the current state from where our focus needs to be – both as individuals and within the system. When we look at what drives an individual’s health, according to David Kindig, a University of Wisconsin population health expert, who argues that there are multiple determinants of health outcomes, we see that Medical services only contribute 20% of actual health care spend. Healthy behaviors account for 30 percent, and in fact, where you live, your access to education, safety, and a healthy environment contribute a whopping 40%. [CLICK] Now, where do you think we, in the U.S. as a whole, actually spend our dollars on health care? That’s right. 88% of our total spend is on medical services. As a system, we need to align our spending with the elements that actually determine health. [NEXT SLIDE)

Evaluation Determining the Degree of Success Some Factors to Consider What to measure? (Clinical Outcomes, Financial Savings, Productivity, etc.?) 2. When to Measure ? ( every day, week, month, quarter, year?) 3. How to measure? (Self report, data driven, cost saving, ROI?) 4. Who to measure? (Everyone, Employees, dependents a sample?) 5. Other Factors? (effect of incentives, rewards, time of exposure, increased rentention, and/or profits, etc., etc.)

Net population health improvement of 8%. Soource Risk transitions based on HA-derived risk levels among employees over 2 years (N=1,087) 21% 66% 13% Without health and well-being programs, the net employee population’s health may get worse by 7% per year Got Better Stayed the Same Got Worse Baseline 44% Low Risk 36.3% 14.4% Baseline 24% Moderate Risk 13.2% 15.1% 33.5% 2.5% 0.2% Baseline 24% High Risk 0.8% 4.5% Baseline 7% Disease: Well Managed This 2-year health and well-being program was associated with a ROI of 3:1 Net population health improvement of 8%. 87% did not get worse 25.0% 1.3% Baseline 1% Disease: Poorly Managed Source: HealthPartners Health Assessment Database, 2011

Integrated Worker Health Protection and Promotion TOTAL WORKER HEALTH™

Integrated (Synergistic) Approach Building Healthier and Safer Workplaces Traditionally, workplace health protection and promotion programs have operated independently The “silo” approach has limited overall effectiveness in optimizing worker health and safety Integration of health promotion, safety, and environmental programs, policies, protocols, and processes will allow for synergy in improving worker health and safety A safer workforce is a healthier workforce and vice versa

Moving Beyond Available Evidence “Well, I can see that it works in practice, but does it work in theory?” —Garret Fitzgerald Evidence of what works needs to be applied in the context of the workplace environment Inflexible focus on program fidelity may limit adoption of programs with sustained success Practice-based evidence can only be generated if solutions are successfully implemented Worksite health promotion programs will only deliver on their promise when supported as a business strategy with leadership support and accountability!!!!!

Thank You Very Much For this Opportunity! & Questions and/or Comments

Bob Karch can be reached - Phone 202-297-1219 rkarch@american.edu rckki@aol.com