5
Implementing Integrated Health Programs

Integration of worksite health promotion and occupational health and safety provides a means for improving worker health behavior (Sorensen et al., 1996b, 1998; Sorensen and Barbeau, 2004). Following the management systems approach described previously, this chapter provides an overview of the characteristics of effective integrated health programs and approaches to setting program priorities; examines strategies for program implementation and evaluation; and explores implications for NASA. The chapter also reviews integrated workplace health programs and the implications for NASA occupational health programs.

Many organizations in both the private and public sectors are faced with similar challenges, that is, they are expected to do more with less and do it faster, better, and cheaper. Such expectations require a highly motivated and productive workforce. This, in turn, is dependent on a workforce that is mentally and physically healthy and a work environment that promotes learning, collaborative work, and enables the workforce to embrace frequent change. Occupational health strategies for advancing these workplace and workforce challenges require planning and implementation approaches that go well beyond traditional workplace health and safety constructs which employ isolated, segregated programs in a non-coordinated fashion. The latter is inadequate as a means to advance optimal health status and workforce productivity.

The integrated health approach is one which links programs into a single process emphasizing outcome, coordination, synergy, and measurement (Goetzel et al., 2002). In its most comprehensive form it ties together health promotion initiatives, medical benefits design and incen-



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Integrating Employee Health: A Model Program for NASA 5 Implementing Integrated Health Programs Integration of worksite health promotion and occupational health and safety provides a means for improving worker health behavior (Sorensen et al., 1996b, 1998; Sorensen and Barbeau, 2004). Following the management systems approach described previously, this chapter provides an overview of the characteristics of effective integrated health programs and approaches to setting program priorities; examines strategies for program implementation and evaluation; and explores implications for NASA. The chapter also reviews integrated workplace health programs and the implications for NASA occupational health programs. Many organizations in both the private and public sectors are faced with similar challenges, that is, they are expected to do more with less and do it faster, better, and cheaper. Such expectations require a highly motivated and productive workforce. This, in turn, is dependent on a workforce that is mentally and physically healthy and a work environment that promotes learning, collaborative work, and enables the workforce to embrace frequent change. Occupational health strategies for advancing these workplace and workforce challenges require planning and implementation approaches that go well beyond traditional workplace health and safety constructs which employ isolated, segregated programs in a non-coordinated fashion. The latter is inadequate as a means to advance optimal health status and workforce productivity. The integrated health approach is one which links programs into a single process emphasizing outcome, coordination, synergy, and measurement (Goetzel et al., 2002). In its most comprehensive form it ties together health promotion initiatives, medical benefits design and incen-

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Integrating Employee Health: A Model Program for NASA tives, short- and long-term disability, including programs for worker compensation, lifestyle, disease management and care, with additional evaluation of the effects of presenteeism on health status. A growing body of evidence shows that factors related to worker well-being—other than those addressed by traditional occupational health programs—have a quantifiable affect on workplace productivity, underscoring the value of extending programs beyond traditional health, safety, and health promotion, and into the realm of health-related behavioral change (Goetzel et al., 1998a; Burton et al., 1999; Sorensen et al., 2004). WORKSITE MODELS FOR HEALTH BEHAVIOR CHANGE The health behavior change approach is based on a strong theoretical foundation. Theoretical models developed by the behavioral and social sciences have guided research on health behavior change. Various theoretical frameworks suggest that worker health is the result of a complex interplay of factors involving the individual worker, the immediate work environment, and factors within the larger contexts in which both the individual worker and the worksite are embedded (Robins and Klitzman, 1988; Sorensen et al., 1995; Baker et al., 1996; Stokols et al., 1996). The social-contextual model (Sorensen et al., 2003, 2004) integrates multiple social and behavioral theories to describe factors influencing social disparities in health behaviors. Structural forces may influence the social context of workers’ lives, reflected, for example, in their material circumstances or experiences of discrimination, and ultimately may shape health behavior outcomes. In their research, this team of investigators has applied this model to the design interventions for working class and multi-ethnic populations, aimed at health behavior changes such as tobacco control, diet, and physical activity. By applying this model in behavior change strategies, it may be possible to change some elements of the workers’ social context, and also to enhance the quality and relevance of interventions through an understanding of the social realities of workers’ lives. The social-ecological model (see Chapter 3 and Table 3-1) provides a structure for incorporating theories that operate at various levels of influence, including at the individual, interpersonal, organizational, community, and public policy levels. This approach builds on an array of social and behavioral theories including the Health Belief Model (Rosenstock, 1982; Rosenstock et al., 1988), Theory of Planned Behavior (Expectancy X Model) (Ajzen, 1991; Montano et al., 1997), Social Cognitive Theory (Bandura and Walters, 1963; Baranowski et al., 1997), the Transtheoretical Model (Prochaska and DiClemente, 1994; Prochaska et al., 1997), and the Community Organization Model (Minkler and Wallerstein, 1997).

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Integrating Employee Health: A Model Program for NASA In following the social-ecological model, it is important that integrated health programs include efforts both to create healthy work environments and support individual workers to change health-related behaviors. Accordingly, the effectiveness of occupational health and worksite health promotion programs can be enhanced when coordinated interventions aim to promote worker health through direct education for individuals and their families by building social support and establishing social norms that encourage healthy behaviors, by assuring that policies and management actions provide a healthy workplace, and through linking worksite efforts to broader community and public policy initiatives that promote worker health (Linnan et al., 2001) (see also Figures 3-2 and 4-2). This model also provides a framework for moving beyond the individual as the locus of intervention and responsibility for health, in recognition of management’s central role in worker health (Sorensen, 2000). Thus, effective programs need to be aimed at and coordinated across multiple levels of influence. The following discussion provides a structure for the specific program information presented below. Environmental and Organizational Systems Environmental- and organizational-level systems include the organizational context, management, and policy structures that support worker health by providing a healthy and safe work environment. Reducing the potential for hazardous work exposures within the work environment is the first line of defense for ensuring occupational health and safety. These environmental systems can also present both barriers and facilitators to individual worker health choices in the worksite. For example, social norms, availability, and accessibility are strongly influenced by environmental-level systems (Schmid et al., 1995). Management commitment to an integrated worker health program provides a key foundation for success (DeJoy and Southern, 1993; Sorensen, 2000). Programs for Individual Employees Management participation in individual-level programs is essential to their success. Leaders can become role models, uniting the organizational vision for health with its mission, as well as providing support and encouragement for employee participation. Programs at the individual or interpersonal level focus particularly on educating individual workers and building social norms supportive of worker health, through mechanisms such as educational classes or one-on-one training programs (Refer to Chapter 2 for a description of NASA’s preventive health programs, the NASA Occupational Health website, and the NASA Health Promotion

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Integrating Employee Health: A Model Program for NASA and Wellness Team). Such efforts require solid support from management in order to reduce structural barriers influencing workers’ participation. Particular efforts may be needed to address disparities in access to programs. For example, blue-collar and service workers are less likely than white-collar workers to participate in health promotion programs (Gebhardt and Crump, 1990; Glasgow et al., 1993; Sorensen et al., 1996a; Morris et al., 1999). Supervisors may serve as gatekeepers and may need clear guidance to provide workers with access to health promotion activities—for example, by allowing employees to attend events on work time (Morris et al. 1999). For maximum reach, interventions must target workers at varying stages of readiness to make changes, including, for example, programs that require minimal contact for those not yet ready to make health-related changes (such as health fairs); incentives and competitions; and group programs aimed at building skills to make health behavior changes (Prochaska et al., 1997). Recent advances in tailoring messages to individual workers provide promise for increasing the efficacy of these interventions (Willemsen et al., 1998). NEEDS ASSESSMENT As noted previously, a critical requirement for integrating traditional health and safety with occupational and nonoccupational disability and health benefits is collaboration with health benefits program administrators and access to health benefits utilization data. This concept of integration is illustrated in Chapter 4, Figure 4-2, and examples are provided in the figure legend. In the private sector, leading employers have made their health plan contracts conditional upon specific requirements for the creation of integrated databases from all health plan suppliers. NASA’s health benefits are provided under the Federal Employee Health Benefits Program, which, in 2004, included over 350 different plans covering more than 9 million employees, retirees, former employees, family members, and former spouses (Tingwald, 2004). Currently, the administration of this government-wide health benefits program does not provide for agency-specific utilization data. Such a deficiency thwarts efforts to improve occupational health care through agency-specific approaches to health care consumption behavior of NASA employees. Assessment Tools A variety of resources and tools are available to assess the health and wellness needs of the workforce population. In choosing and evaluating health and wellness assessment instruments, it is important that NASA

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Integrating Employee Health: A Model Program for NASA follow standard guidance on measurement instrument reliability and validity. The instruments used should be periodically reviewed to ensure reliability and validity within the NASA system (Gulliksen and Messick, 1960; Gulliksen, 1987). The basic tool for needs assessment is the Health Risk Appraisal (HRA). Included in the HRA are the tools used to address issues of mental wellness and productivity. Health care services assessments are discussed in Chapter 4. Health Risk Appraisals The HRA comprises a questionnaire, risk estimation, and educational information. This instrument is commonly used in worksite preventive healthcare to identify the likelihood that an individual will develop a preventable or chronic disease based on personal, medical, and lifestyle indicators. It is also used as a health promotion technique to assess health status and the need for health intervention in employee and other populations (Foxman and Edington, 1987). More often, however, the HRA serves as a component of needs assessment, health education, and behavior change (incentive or motivation) programs. Application of the HRA has changed over time. For example, early worksite health promotion programs often consisted solely of HRAs combined with screening, apparently under the assumption that medical or risk information as such would motivate large numbers of participants to reduce their health risks. Subsequent experience showed that effectively supporting risk reduction required integration of the HRA into a comprehensive health promotion process that would include follow-up education and behavior-change components (Schoenbach et al., 1987; Terry, 1987; Anderson and Staufacker, 1996; Edington et al., 1999). The HRA not only allows employees to identify their own health risks and behaviors and make modifications to improve their health, but accounts for malleable risk factors affecting the health status of a population. This is an important resource of information to support baseline data for organization-wide as well as site-specific prioritization of employee health needs, and to enable development of appropriate intervention programs. As an awareness and education tool, the HRA has been shown to be useful. However, when used as a predictor of risk or cost, as a program management or evaluation tool, or as a stand-alone behavior change program, its validity has not been clearly demonstrated (Edington et al., 1999). In choosing the most appropriate HRA, it is important to evaluate which instrument will best meet an organization’s objectives. More comprehensive tools with lifestyle and medical indicators are recommended for health education and gatekeeping/incentives (see below for discussion of incentives) (Hyner et al., 1999). Common considerations when de-

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Integrating Employee Health: A Model Program for NASA ciding on an HRA package are the inclusion of aggregate data reports, additional preventive health programming or materials, and retesting capabilities (Donnelly, 1993; Turner, 1995). To increase its impact, an HRA can be integrated into the medical benefits plan so that data obtained from it can be used by medical plan providers to recruit participation in disease management and other care coordination efforts. Tools for Assessing Mental Wellness As a part of the HRA, an assessment of stress experienced by employees may be of value. Ideally, the impact of stress would also be assessed via stress-related risk factors for chronic disease, such as high blood pressure, as well as the influence on performance of acute stress. Brief instruments for the assessment of perceived stress include the Perceived Stress Scale and the Hassles Scale (Cohen et al., 1983; Cohen, 1986; DeLongis et al., 1988). These, or related instruments, focus on individual stress regardless of its source. Stress imposed in part by the worksite should also be assessed with an instrument such as the Job Content Questionnaire (Karasek et al., 1998). As with all items of the HRA, the utility of these instruments should be periodically evaluated. An important assessment of stress unrelated to the HRA is manager and co-worker subjective evaluations of productivity and non-adaptive changes in work style, such as over-narrowing of a solution set or increased irritability with co-workers. Manager training could be designed to involve managers in the early identification and amelioration of worksite stress. Assessing Productivity-Presenteeism Incorporated into many contemporary HRAs are questions aimed at defining presenteeism in the workplace. Presenteeism is health-related productivity loss while at paid work and may include: time not on task (i.e., in the workplace, but not working); decreased quality of work (e.g., increased injury rates, product waste, product defects); decreased quantity of work; unsatisfactory employee interpersonal factors (e.g., personality disorders); and unsatisfactory work culture (Loeppke et al., 2003; Chapman, 2005). Such measurement is in its infancy and currently consists of self-reported questionnaires that address an individual’s ability to perform effectively on the job. In a study by the American College of Occupational and Environmental Medicine (ACOEM) Expert Panel, Loeppke et al. (2003) discussed and identified the core characteristics that an instrument should have to adequately assess workplace productivity loss. The core characteristics were grouped into four categories: supporting scientific

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Integrating Employee Health: A Model Program for NASA evidence, applicability to a variety of occupations and disease states, ability to support business decision-making (i.e., ability for data to be translated into a monetary unit), and practicality. THE PROGRAM IMPLEMENTATION PROCESS The program implementation process relies on careful planning, beginning with the needs assessment. Employee involvement in planning and priority setting can help to assure that workers participate fully in the program. This section outlines key components of successful implementation. Employee Involvement Employee participation in program planning can assure that programs respond to worker needs, readiness, cultural requirements, and priorities; and are situated within the overall context of the work organization, thereby enhancing program effectiveness. Typically, worker input may be provided through health and safety committees, health and wellness committees, or through joint coordination across committees. Health and safety committees provide an integral framework for engaging workers and management in joint efforts to promote a healthy workplace; the roles of this committee could logically be expanded to include health improvement efforts aimed at promoting healthy behaviors. Alternatively, health and wellness committees may take the lead in planning health promotion programming, and may coordinate with occupational health and safety committees to design integrated health efforts. In considering the composition of these committees, it is important to provide equal representation and voice to workers from diverse groups. For example, participation of line workers in committees may be constrained by concerns about workers’ time away from their jobs, or, because of obvious power differentials in joint worker-management committees, workers may hesitate to express their concerns in the presence of management (Sorensen, 2000). Alternate methods may be employed to gain worker input in program planning; for example, through focus group interviews or informal conversations with diverse groups of workers. Worker participation has additional benefits for worker health. Participation in program planning and learner-centered educational methods may contribute to the development of skills that may be applied across health issues, such as problem identification, problem solving, and communication skills (Luskin et al., 1992; Wallerstein and Weinger, 1992; Blewett and Shaw, 1995; Baker et al., 1996).

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Integrating Employee Health: A Model Program for NASA As noted above and on the agency’s occupational health website (http://ohp.nasa.gov/), NASA has established a multidisciplinary health and wellness committee to help guide planning for worker health initiatives, with representation from multiple NASA centers. This committee meets quarterly to review relevant reports such as Healthy People 2010, and develops campaign topics to be distributed throughout the agency. This committee aims to standardize outreach efforts to employees; communicate health and wellness information to employees; identify resources; and coordinate and plan programs, including identifying quarterly campaign topics and identifying and evaluating educational materials. An important component of employee involvement is representation by both civil servants and contract workers on the planning committee. Improving participation, however, is not enough. Population health management programs focus on the overall health goal, managing participation to reduce the most costly risks in the population. This means reaching the right individual with the right programs when they are ready to benefit from them (Serxner et al., 2004). Incentives Along with managing participation in programs (see above), successful implementation of integrated workplace programs depends on achieving a significant participation rate among eligible employees. Across these varying programs, it is important to provide incentives for workers to participate. Consumer- and patient-focused financial incentives, even if modest, have been shown to be effective in the short run for simple preventive care and distinct, well-defined behavioral goals. A comprehensive meta-analysis demonstrated that, for preventive interventions such as obtaining clinical preventive services (e.g., immunizations and screening tests) and initiating health improvement behaviors (such as tobacco cessation, weight loss and increased physical activity), incentives are effective and important (Isaac and Flynn, 2001; Ozminkowski et al., 2002). Terry et al. (1999) and Wang et al. (2002) showed that HRA response rates increase as a function of the intensity of recruitment efforts and financial incentives. Kane et al. (2004) found that economic incentives worked as a behavioral change incentive approximately 73 percent of the time. Cash incentives (as opposed to coupons, vouchers, gifts, “in-kind” awards, etc.) produced the greatest behavioral effect and demonstrated a dose-response relationship (Kane et al., 2004). All incentives, of various forms including spending account credits, gift cards, cash, or lower premiums on medical plans, tend to increase participation in the HRA. There is less evidence that incentives directed at individuals alone can sustain long-term improvement in behaviors and health outcomes. System-level

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Integrating Employee Health: A Model Program for NASA cultural expectations and aligned incentives at multiple levels are most likely to produce sustained behavioral change (Kane et al., 2004). Once incentives are in place, however, they are difficult to eliminate (Serxner et al., 2004). Barriers Health Disparities Health risks are not evenly distributed among workers, and for this reason, it is important that integrated health programs consider the particular needs and concerns of diverse groups of workers. Disparities may exist between occupational groups, different racial or ethnic groups, and regular versus contractual workers. As noted in Chapter 2, approximately 75 percent of NASA workers are contractual employees. Exposures on the job as well as high-risk-related behaviors are concentrated among those in working-class occupations, meaning those employed in blue-collar or service occupations (Giovino et al., 2000; Barbeau et al., 2004) or in low supervisory, technical, semi-routine or routine occupations (National Statistics, 2004). These workers have higher work-related injury and illness rates than do professional employees (NIOSH, 2000). Blue-collar occupation and lower educational levels are also associated with negative health behaviors such as tobacco use (Giovino et al., 2000; Barbeau et al., 2004; CDC, 2004), overweight status (Galobardes et al., 2000; Everson et al., 2002; Mokdad et al., 2003; Sarlio-Lahteenkorva et al., 2004), poor nutrition (USDHHS, 2000a), and low levels of physical activity (USDHHS, 1996). These workers are also less likely to participate in health promotion programs. It is also important to attend to disparities in worker health outcomes by race and ethnicity. Risk-related behaviors are disproportionately concentrated among some racial and ethnic minorities (USDHHS, 1996; USDHHS, 2000a; USDA/USDHHS, 2005). There is also evidence indicating that workers of color are more likely than other workers to be exposed to workplace hazards (Frumkin et al., 1999). Programs must be designed to attend to the cultural norms and priorities of ethnically diverse populations (IOM, 2002), the implications of acculturation, the potential for discrimination, and related social contextual issues (Sorensen et al., 2004). It may be necessary to take special steps to engage diverse employees in integrated health programs—including male and female workers across multiple occupational groups, racial and ethnic groups, and from the ranks of both regular employees as well as contractual workers. Supervisors may serve as gatekeepers controlling access to programs (Morris et al., 1999)—for instance, to keep production lines moving, supervisors may

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Integrating Employee Health: A Model Program for NASA refuse to permit employees to participate in programs during the workday. These workers may face other barriers to participating, such as overtime, shift work, a second job, car-pooling to work, long distances between the plant and the employee’s home, and responsibilities at home (Alexy, 1990). Worksites also need to consider family-responsive policies as a crucial component of the organizational culture supportive of worker health (Glass and Fujimoto, 1994). Other Barriers Belza et al. (2004) examined barriers and facilitators to physical activity perceived by underserved, ethnically diverse older adults in a community. In this study, health was reported as both a facilitator and a barrier to exercise. Other reported barrier issues were weather, transportation, and personal safety. Another study by John and Ziebland (2004) examined barriers to increasing consumption of fruits and vegetables among participants in a randomized controlled trial in primary care. This study found a variety of barriers among different groups in the population. Women reported that their partners and children were barriers to their efforts to eat more fruits and vegetables. Individuals on limited incomes reported the cost of fruits and vegetables as barriers. Some members of the population reported unexpected changes in their daily routines as unanticipated barriers to fruit and vegetable consumption. Participation in a cardiac rehabilitation program was reported by men and women to be hindered by concomitant illness, lack of transportation, and inconvenient timing of the program (Lieberman et al., 1998). Minimizing Barriers Management support can help to minimize barriers to participation by placing high priority on a comprehensive program supporting worker health, with the same levels of support communicated for different groups of workers. It is also important to examine ways to structure programs around the schedules of line workers, bringing programs to their work areas, or scheduling programs during break times (refer to Chapter 2 for discussion of workforce composition). Health Education and Awareness Activities Health education and awareness activities take many forms, ranging from hard-copy literature dissemination to web-based resources and tools; and labor-intensive activities such as “brown-bag” or “lunch and learn” seminars or health fairs. These are useful means for increasing awareness,

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Integrating Employee Health: A Model Program for NASA are low in cost, and are popular with employers as starting points for dialogue with employees about health issues. However, these are not particularly effective as isolated activities in promoting any meaningful health behavior change (Robbins et al., 1987; Erfurt et al., 1991; Heaney and Goetzel, 1997). If on-site medical personnel are available, referral for additional support or case management can be made. Provision for privacy protection and the safeguard of protected health information are essential in these intervention activities. Increasingly, prevention efforts are being linked to medical benefits and health plans as either components of the coverage or incentives for willing participants (Stein et al., 2000; Lewis et al., 1996). Health education programs include both worksite-wide initiatives, and efforts designed for helping individual workers make health behavior changes (Moher et al., 2003; Sorensen, 2000). The impact of a particular program is a product of both its efficacy in changing behavior and its reach, that is, the proportion of workers affected either through their direct participation, or indirectly through diffusion of health messages throughout the worksite (Abrams et al., 1996; Glasgow et al., 1999). Programs targeting individual workers have been found to be more efficacious in changing workers’ health behaviors (Moher et al., 2003). The overall impact of comprehensive worksite-wide programs may actually be greater, however, given that these programs aim to reach a broad audience within the worksite, and may have an impact on social norms and social support, thus creating an overall climate supportive of worker health (Hunt et al., 2005; Hunt et al., forthcoming). Regardless of whether programs are delivered one-on-one to individual workers or to groups of employees, it is important that programs are employee-centric, and are designed accordingly, to respond to worker priorities, concerns and readiness to make health behavior changes. Opportunities for Integration As described in Chapter 3, to create and support a healthy and productive workforce, integrated health programs must move toward programs that are integrated across multiple functions in the work organization rather than segregated within “silos,” and that are employee-centric rather than driven by employer priorities. Figure 4-2 illustrates the functions within the organization that can be integrated in order to promote and sustain worker health, ranging from health risk appraisals to behavioral health programs, disease case management, and occupational safety efforts; examples are given in the figure legend. Thus, an integrated approach to improving the health of employees involves going beyond traditional medical or occupational health to include a variety of fitness and

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Integrating Employee Health: A Model Program for NASA impact both stress and productivity. Training should also include how to recognize and handle the stressed or mentally ill individual, in conjunction with EAP personnel; Developing financial- and benefit-designed incentives to encourage employee participation in health promotion and disease management programs. (4) NASA should reexamine the allocation of resources at the center level for periodic health examinations, in consideration of an integrated risk factor reduction program, and evaluate the data requirements, periodicity, and effectiveness of existing occupationally-related medical screening examinations. To achieve this goal requires a clear rationale, policy, and practice that drive accomplishment and resource allocation at the center level. The Committee recommends the following strategy: Establish appropriate databases to provide health metrics to inform the evaluation process; Define desired goals for periodic health examination programs and medical surveillance data requirements; Stratify health and safety requirements into occupationally mandated standards; Link health promotion and disease prevention examinations, if and when uniformly performed, through a standardized process, to the employee’s primary health provider and the Health Risk Appraisal. (5) NASA should conduct program-specific evaluations to ensure the effectiveness and appropriate use of available resources. Ideally, each program should include some level of evaluation integrated into the program implementation process that will inform program staff about reach, acceptability, participation, and effectiveness. REFERENCES Abrams DB, Orleans CT, Niaura RS, Goldstein MG, Prochaska, JO, Velicer, W. 1996. Integrating individual and public health perspectives for treatment of tobacco dependence under managed health care: A combined stepped-care and matching model. Annals of Behavioral Medicine 18(4):290–304. Ajzen I. 1991. The theory of planned behavior. Organizational Behavior and Human Decision Process. 50(2):179–211. Aldana SG. 2001. Financial impact of health promotion programs: A comprehensive review of the literature. American Journal of Health Promotion 15(5):296–320. Alexy B. 1990. Workplace health promotion and the blue collar worker. American Association of Occupational Health Nurses (AAOHN) Journal 38(1):12–16. Alexy B. 1991. Factors associated with participation or nonparticipation in a workplace wellness center. Research in Nursing and Health 14(1):33–40.

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