The Workplace: a Key Setting to Fight Chronic Disease in Emerging Countries

A South African Perspective

April 11-12 London 2013!

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The Global Healthy Workplace Awards & Summit will highlight:!

!  The importance of employer health programmes!!  The emerging better practices and innovations!!  Opportunity to replicate around the world!

Non-Communicable Disease in Sub-Saharan Africa

Dalal S, Beunza JJ, Volmink J et al., 2011. Int J Epidemiol.

Non Communicable disease Communicable disease

Injuries Maternal, perinatal, nutritional

Similarly, the INTERHEART study that included nineAfrican nations and 43 other countries found that fiverisk factors (smoking, hypertension, abdominal obes-ity, diabetes mellitus and elevated ApoB/ApoA-1 ratio)accounted for 90% of the risk for a first myocardialinfarction in the African sites.14,19

Other social and environmental changes in SSA alsolikely play a role such as changes in air quality andearly childhood exposures.15,20 These lead to increasedprevalence of NCD risk factors such as hypertension,abdominal obesity and abnormal blood lipids.1,15,20 Ifaction is not taken, one estimate shows that US$84billion in lost productivity could occur due to heartdisease, stroke and diabetes in the 23 low- andmiddle-income countries (four of which are in SSA),which would account for 80% of worldwide NCDmortality by 2015.8

Thus, NCDs represent a largely ‘silent’ epidemic inSSA. We review the literature and summarize WorldHealth Organization (WHO), and InternationalAgency for Research on Cancer (IARC) data onNCDs in SSA with the goal of reporting on theburden of NCDs measured by morbidity and mortalityand the prevalence of NCD risk factors.Due to the large scope, we were not able to address

neuropsychiatric diseases and chronic lung diseases.

MethodsWe searched the Medline database using NationalLibrary of Medicine Medical Subject Heading(MeSH) search terms to cover each condition. Thesewere ‘heart diseases’, ‘stroke’, ‘diabetes mellitus type2’ and ‘Neoplasms not Benign Neoplasms’ combined

with the term ‘Africa south of the Sahara’. We usedthe limit function to limit search results to articles inEnglish and to human studies. In order to identifystudies reporting prevalence, incidence and mortalityof each condition, we repeated the search excludingreview articles (MeSH NOT ‘Review’). Data were ex-tracted using a standard form (S.D. extracted data onheart diseases, stroke and cancer, J.J.B. extracted dataon diabetes mellitus type 2). We also consulted art-icles listed in references of retrieved articles and fromdiscussions with colleagues with SSA experience.Our inclusion criteria were community-based studies

conducted in any SSA country that reported on dis-ease or risk factor prevalence, incidence or mortalityfor each of the key diseases in our investigation (heartdiseases, stroke, diabetes mellitus type 2 and cancer).We excluded hospital-based studies as they are notrepresentative of the general population because ofwidespread lack of health-care access. Hospital-basedstudies were used to extract data on diabetes mellituscomplications. Due to the comparatively smallnumber of studies we did not use criteria for evaluat-ing the quality of the study. We did not restrict oursearch to specific dates, and made every attempt toobtain older articles (for example, those published inthe 1960s and 1970s). We read at a minimum eachabstract to screen for relevance, and read in full thosewhich met our inclusion criteria.We also analysed publicly available WHO Global

Burden of Disease and WHO STEPS data sets on esti-mated and projected causes of death for differentworld regions and prevalence of diabetes mellitus inSSA. We analysed the International Agency forResearch on Cancer (IARC) public databases forcancer incidence and projections for SSA.

ResultsSearch results for cardiac diseases excluding reviewpapers returned 1494 manuscripts, 1201 of whichwere in English and limited to human studiesdating from 1965. The stroke search yielded 149manuscripts; 127 met the criteria for language andhuman studies. Diabetes mellitus search results were348 overall, with 321 in English and humans. Thereported prevalence of heart diseases, stroke anddiabetes mellitus from community-based studies areprovided in Tables 2–4; all numbers are for crudeprevalence unless otherwise noted. Crude andage-standardized cancer incidence from five cancerregistries included in the IARC database are presentedin Table 7.Commonly reported risk factors in the literature

from community-based studies of CVDs in SSA arereported in Table 5; hypertension, smoking and obes-ity were the most frequently reported. Half (50%) ofthese studies were conducted in South Africa. Alcoholuse, hypercholesterolaemia and sedentary behaviourwere infrequently measured.

0

10

20

30

40

50

60

70

2000 2005 2010 2015 2020 2025 2030

Year

Per

cen

t

Noncommunicable diseases

Communicable diseases

Injuries

Maternal, perinatal, nutritional

Figure 1 Estimated proportions of age-standardizedmortality rates by cause in SSA. SSA mortality estimateswere standardized to the WHO World Standard Population.Source: WHO. Global Burden of Disease. Projections ofmortality and burden of disease, 2002–2030.7

NON-COMMUNICABLE DISEASES IN AFRICA 3

at University of C

ape Town on M

ay 26, 2011ije.oxfordjournals.org

Dow

nloaded from

Non-Communicable Disease in Sub-Saharan Africa

Dalal S, Beunza JJ, Volmink J et al., 2011. Int J Epidemiol.

Disproportionate burden of both infectious and chronic diseases compared to other world regions.

Cardiac diseases and their risk factors are increasing in SSA.

Complex relationship between overweight and underweight

Diabetes prevalence ranges from 2.5% in Seychelles to 16% in DR-Congo (WHO-Steps)

Lack of health resources leads to late diagnosis, poor blood glucose control.

Additionally burdened by rheumatic heart disease, HIV/AIDS and other factors that impact on cardiovascular outcomes.

Wastin

g

Stunting

Underweight

Overw

eight

Obese0

5

10

15

20

25

Prev

alen

ce (%

of c

hild

ren

ages

1-8

yrs)

(Source: NFCS; Steyn et al. 2005)

• 67% of all people living with HIV (22 million) are in SSA

• 60% of whom are women

• Limited access to ARV’s and those who are have increased risk of dyslipidemia and dysglycemia

UNAIDS  2008  

Compe0ng  health  agenda:  global  view  of  HIV  infec0on  2007  

Physical Activity in Africa

Guthold  R,  Louazani  SA  et  al  2011,  Am  J  Prev  Med  

0  

20  

40  

60  

80  

100  

120  

Men  

Women  

Bradshaw et al., SA BOD: Estimates of Provincial Mortality 2000

Men Women Persons0

250

500

750

1000CommunicableHIV/AIDSNCDInjuries

Group

Popu

latio

n (p

er 1

00 0

00)

Burden of Disease in South Africa

Cause of Death (per 100 000 population)

South African Employees (n=11 472)

Patel et al., 2012, JOEM

Risk  Factor  Profile  of  SA  Employees  

Chol BMI BP PA Smoking0

20

40

60

80

100At riskNo Risk

Behaviour

Percentage

Physical  Ac0vity  

0    Addi0onal  Risk  Factor  

1  Addi0onal  Risk  Factor  

 

2  Addi0onal  Risk  Factor  

3  Addi0onal  Risk  Factor  

4  Addi0onal  Risk  Factor  

Physically  AcCve  

88   223   211   114   30  

InacCve   168   591   815   481   157  

Chi-square: 43.55; p <0.00001

Kolbe-­‐Alexander,  2013,  in  prepara5on  

Physical Activity and Additional Risk factors for NCD

The  number  and  cost  of  doctors  visits  is  significantly  higher  in  the  group  with  more  than  2  risk  factors,  even  aQer  adjusCng  for  age  

and  use  of  chronic  medicaCon  

Healthcare expenditure and risk factor profile

Risk  Factors  and  Healthcare  U0lisa0on  

The  main  aim  of  this  study  was  to  measure  the  effecCveness  of  a  worksite  health  promoCon  programme  on  improving  health  behaviour  and  associated  biological  risk  factors  for  CVD  among  South  African  employees  at  increased  risk  for  cardiovascular  diseases.    

Aim

Working on Wellness: WOW

Par0cipants Eligibility  Criteria   SCORE:  10%  of  more  

BMI  >  30  Not  pregnant,  at  least  12  months  remaining  if  contract  worker  

Process  

Methodology: Participants

Kolbe-Alexander et al., , BMC Public Health, 2012

Wellness  Day  

SCORE  Calculated  

RandomisaCon  at  company  

level  

Eligible  employees  invited  

IntervenCon   Control  

Measurements:  Health  Risk  Assessment

Self Report Measures

Clinical  Measures  

Height  Weight  BMI  

Blood  Pressure   Cholesterol  (Finger  prick)  

Glucose  (Finger  prick)  

Healthcare  Expenditure  

Hospitalisa0on   Doctor  ‘s  visits    &  cost  

Chronic    Medica0on  

Out  of  pocket  expenses  

Wellness Day Measures

Kolbe-Alexander et al., , BMC Public Health, 2012

Participant Characteristics at Baseline Total (n=762)

6-I (n = 194)

3-I (n = 153)

CTL (n = 415)

Male/ female % 47% / 43% 37% / 55% 48% / 39% 44% / 46%

Age (years) 37.8 (9.9) 37.7 (9.6) 41.0 (10.9) * 36.7 (9.5) #

BMI (weight/ height2) 32.8 (5.7) 33.8 (5.0) 33.5 (5.5) 32.2 (6.1) §

Waist (cm) 101.3 (13.1.0) 101.1 (10.6) 102.9 (12.7) 100.9 (14.4)

Systolic Blood Pressure (mmHg)

126.5 (14.6) 125.0 (14.1) 128.6 (14.4) 126.5 (14.9)

Diastolic Blood Pressure (mmHg)

82.6 (11.4) 82.4 (11.0) 83.6 (10.5) 82.3 (11.9)

Total Cholesterol 4.7 (1.1) 4.7 (1.1) 5.0 (1.1) * 4.6 (1.0) #

Physical Activity (minutes/week) [median and mode}

120 (60) 120 (90) 120 (60) 120 (60)

Total Number of risk factors

2.6 (1.1) 2.6 (1.0) 2.8 (1.1) 2.4 (1.1)

•  6-I and 3I significantly different; # 3-I and CTL significantly different; •  § 6-I and CTL significantly different

Working on Wellness Preliminary Results

BMI   Waist   SBP   DBP   Chol   Glucose   SiVng  Time  

Days  Ill  health  

INT  6  

INT  3  

CTL  

     

     

     

     

     

     

     

Kolbe-Alexander et al., , BMC Public Health, 2012

The  Discovery  Healthy  Company  Index:    Using  organisa0onal  aZributes  to  promote  workplace  

physical  ac0vity  in  South  Africa

Discovery  Health’s    obejc0ves  of  HCI  

1)  publicise the workplace as a setting for health improvement;

2)  document employer health promotion efforts in this area and recognize organizations adopting best practices; and

3)  assess the health behaviors of employees at companies that aspire to become the healthiest companies in South Africa.

Patel et al, 2012, JOEM

Research  opportuni0es  from  HCI  Article: JOM201673 Date: October 3, 2012 Time: 17:34

ORIGINAL ARTICLE

The Healthiest Company IndexA Campaign to Promote Worksite Wellness in South Africa

Deepak Patel, MD, MSc, Ron Z. Goetzel, PhD, Meghan Beckowski, MPH, Karen Milner, MA, PhD,Mike Greyling, MSc, Roseanne da Silva, BScHons, FIA, Tracy Kolbe-Alexander, BSc, PhD,

Maryam J. Tabrizi, MS, and Craig Nossel, MBChB, MBA

Objective: To describe a 2010 initiative to encourage companies in SouthAfrica to adopt workplace health promotion programs. Methods: Data doc-umenting organizational efforts to improve workers’ health were collectedfrom 71 participating employers and 11,472 workers completing health as-sessments. Organizational and employee health were scored on the basisof responses to the surveys that asked about facilities and programs of-fered, leadership support for health promotion, and employees’ health status.Results: In its first year, the initiative recruited 101 organizations and 71qualified for the award. Results aggregated across these companies focuson elements constituting organizational and individual health, with specificmeasures that companies can review to determine whether they and their em-ployees are “healthy.” Conclusions: The Healthiest Company Index provideduseful baseline data to support employers’ efforts to develop and implementeffective and impactful health promotion programs.

A cross the globe, and more recently in South Africa, the work-place is being recognized as an important setting for initiating

health promotion programs aimed at improving the health and well-being of employees.1–6 There are compelling reasons for this newinterest, primarily related to the increasing burden of chronic dis-eases on individuals, organizations, communities, and societies.

According to the World Health Organization, in 2005 noncom-municable chronic diseases (NCCD) accounted for approximately35 million deaths worldwide, with 80% of these deaths occurringin middle- and low-income countries.7,8 Current projections are thatchronic diseases will be responsible for 388 million deaths glob-ally in the next 10 years, and that 36 million of these deaths couldpotentially be prevented.9

What makes these statistics more worrisome is that we now

[AQ1]

[AQ2]

[AQ3]

have the tools at our disposal to address modifiable health risk fac-tors, including smoking, physical inactivity, poor diet, high stress,and excess alcohol consumption, but we are not fully leveragingthese tools.8 One underused tool is providing evidence-based healthpromotion and disease prevention programs at the workplace. De-spite mounting evidence recently assembled in careful literaturereviews10,11 that workplace programs improve the health of workersand lower organizational costs, only a minority of employers offercomprehensive and multicomponent programs—the kind likely to

From the Discovery Health (Dr Patel), Johannesburg, South Africa; Institute forHealth and Productivity Studies (Dr Goetzel), Rollins School of Public Health,Emory University, Atlanta, Ga; Truven Health Analytics (Dr Goetzel andMss Beckowski and Tabrizi), Washington, DC; University of Witswaterstrand(Dr Milner, Mr Greyling, and Ms da Silva), Johannesburg, South Africa;University of Cape Town (Dr Kolbe-Alexander), Cape Town, South Africa,and Discovery Health (Mr Nossel), Johannesburg, South Africa.

Disclosure: The authors declare no conflict of interest.Address correspondence to: Ron Z. Goetzel, PhD, Institute for Health and

Productivity Studies, Rollins School of Public Health, Emory University,and Consulting and Applied Research, Truven Health Analytics, 4301Connecticut Avenue, NW, Suite 330, Washington, DC 20008; E-mail:ron.goetzel@thomsonreuters.com.

Copyright C! 2012 by American College of Occupational and EnvironmentalMedicine

DOI: 10.1097/JOM.0b013e3182728d61

achieve population health improvements and cost savings.12 Further-more, recent evidence suggests that worksite health promotion pro-grams can achieve a positive return-on-investment of approximately$3.00 saved to $1.00 invested for both medical- and absenteeism-related costs.10 Other benefits include improved worker morale andpositive company branding.

Although there is substantial research being performed onthis topic in the United States,12–14 very little information is cur-rently available on the prevalence of health promotion initiatives atworkplaces in other countries and on the state of health and well-being of international workers.

Against this background, Discovery Health, a South Africanprivate health insurer, initiated a joint project with researchers fromthe Departments of Psychology and Statistics and Actuarial Scienceat the University of the Witwatersrand in Johannesburg, the HumanBiology Department at the University of Cape Town, and the Institutefor Health and Productivity Studies at Emory University to identifyand study the “healthiest” companies in South Africa, on the basisof a set of metrics that evaluated individual employee and overallcompany “wellness.” This article describes the initial launch of theHealthiest Company Index initiative, which garnered participationfrom 71 employers and 11,472 of their workers.

HEALTH PROMOTION IN SOUTH AFRICAIn South Africa, the workplace has been a neglected arena

for health promotion, particularly in the area of NCCD. Like othertransitioning economies, South Africa is experiencing a burgeoningepidemic of NCCD linked to lifestyle. Relative to baseline valuesin 1997, NCCD showed a fivefold increase in 2004.15 After humanimmunodeficiency virus and AIDS, lifestyle-related chronic diseasesare the leading causes of death and disability in South Africa.16 Theepidemic growth of NCCD has been driven by major economic andsocial changes that include rapid urbanization and dramatic changesin individual lifestyle.17 These changes have been recorded in allsections of the population but are most evident among employedindividuals, with health insurance, living in urban areas.18

There is limited evidence18–20 that some companies in SouthAfrica provide health promotion programs to their employees.According to Sieberhagen et al,21 employee wellness programs werefirst introduced to the mining industry in the 1980s. In the last twodecades, health promotion initiatives have been adopted by otherindustries as well. Programs common among employers includetraining in occupational safety, employee assistance program, andscreening and counseling for human immunodeficiency virus andAIDS. Because of sparse financial and health improvement outcomesdata, public knowledge and support for workplace health promotionin South Africa are limited.

In conducting the Healthiest Company Index campaign, wesought to (1) publicize the workplace as a fruitful setting for healthimprovement, (2) document employer health promotion efforts inthis area and recognize organizations adopting best practices, and (3)assess the health behaviors of employees at companies that aspire tobecome the healthiest companies in South Africa.

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

JOEM ! Volume 00, Number 00, 2012 1

1)  To  esCmate  the  burden  of  chronic  diseases  of  lifestyle  on  South  African  companies  

2)  To  assess  the  prevalence  of  worksite  faciliCes  within  South  African  workplaces  

3)  To  assess  the  extent  to  which  SA  employees  engage  in  healthful  behaviours/acCviCes  

•  Employers  enrolled  

•  Provided  list  of  eligible  employees  

•  Completed  employer  quesConnaire  

•  Email  invitaCons  to  employees  

•  Data  collecCon  period  •  IncenCves  to  respond  

Methodology  

Patel et al, 2012, JOEM

•  Vitality  age  as  a  basis  –  CombinaCon  of  risk  factors  

•  BMI,  Physical  AcCvity,  NutriCon,  Smoking,  Alcohol,  Chronic  condiCons  

•  Other  measures  

–  Health  knowledge  (4  tests)  –  OccupaConal  stress  – MoCvaCon  to  change  

– Workplace  faciliCes  

Employee  and  Employer  Data  Collected  

Number  of  employers  

Number  of  employees  

Number  of  responses   Response  Rate  

Small   28   1  813   1  028   56.7%  

Medium     49   10  553   4  046   38.3%  

Large   24   46  371   8  504   18.3%  

101   58  737   13  578   23.1%  

Response  Rates  2011  

Vitality  Age:  2011  and  2012  Comparison  

Physical  Ac0vity:  2011  versus  2012  

Self-­‐Reported  Health  Status  and  Risk  Factor  Profile  

Most  frequently  reported  worksite  health  promo0on  programmes  

Wellness  Ini0a0ve   Prevalence  One  centralized  locaCon  where  employees  can  find  informaCon  about  their  health  and  wellness  benefits  and  find  relevant  resources  

49%  

Cardiopulmonary  resuscitaCon  training   49%  

Emergency  preparedness  training   45%  

Training  to  avoid  workplace  injuries  and  workplace  safety  promoCon   35%  

Health  Risk  Assessment  IncenCves   25%  

Support  and  resources  for  managing  chronic  pain  and  musculoskeletal  injuries  

25%  

Pregnancy  and  childbirth  preparaCon  classes  and  support   25%  

Ergonomic  assessments  and  training   19%  

Automated  external  defibrillator  training   11%  

Worksite  Health  Promo0on  for  Physical  Ac0vity  Element   Companies  who  offer  

this  element  Employees  using  element  in  last  12  months  

Stairwells  that  are  well-­‐lit,  accessible,  clearly  marked  

86%   93%  

Company  sponsored  fitness  events   54%   38%  

Showers  and  change  room  faciliCes   47%   39%  

Physical  acCvity  programs   40%   33%  

Signs  posted  by  elevators  and  stairwells  to  encourage  use  of  stairs  

19%   Not  asked  

Outdoor  exercise  areas  such  as  fields,  running  tracks,  walking  trails  

18%   32%  

Strength  training  equipment   16%   45%  

Cardiovascular  training  equipment   15%   46%  

Discounted  memberships  to  off  site  physical  acCvity  faciliCes  

12%   Not  asked  

Physical  Ac0vity  and  Self-­‐reported  health  status  

Physical Activity

Excell

ent

Good Fair

Poor

Very P

oor

25

50

75

100

125

Self Reported Health Status

Phys

ical

Act

ivity

(min

utes

per

wee

k)*  

Kolbe-Alexander, 2012, in preparation

Kolbe-Alexander, 2012, in preparation

Physical  Ac0vity:  Facili0es  and  self  reported  behaviour  

Total

Phys A

ct

Inacti

ve

56

57

58

59

60

61

62

Tota

l Fac

ility

Sco

re

Total

Phys A

ct

Inacti

ve

6.5

7.0

7.5

8.0

Exe

rcis

e Fa

cilit

y S

core

The odds of employees meeting physical activity guidelines decreased by 17% (OR=0.83, 95% CI: 0,74-0,93) per one less facility at each worksite.

The number of facilities at each company explained 5.4% of the variance in PA among employees (r=0.054; p=0.036)

Conclusion

•  The burden of non-communicable diseases are increasing in Sub-Saharan Africa.

•  South African employees are at increased risk of non-communicable disease (NCD).

•  The worksite intervention program has some degree of success for improving clinical measures among employees at increased risk of NCD.

•  The Discovery Healthy Company Index provides a benchmark of workplace health and intervention programs.

•  The provision of physical activity facilities plays a small, but significant role on self-reported physical activity.

•  Additional workplace interventions which aim to reduce the prevalence of risk factors for NCD is warranted.