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Worksite Health and Wellness Programs in India

Abraham Samuel Babua,⁎, Kushal Madanb, Sundar Kumar Veluswamya,Rahul Mehrac, Arun G. Maiyaa, d

aDepartment of Physiotherapy, School of Allied Health Sciences, Manipal University, Manipal, Karnataka, IndiabSir Ganga Ram Hospital, New-Delhi, IndiacIndian Health Alliance, Canon City, COdDr. TMA Pai Endowment Chair in Exercise Science and Health Promotion, Manipal University, Manipal, Kamataka, India

A R T I C L E I N F O

Statement of Conflict of Interest: see pag⁎ Address reprint request to Abraham Sam

Sciences, Manipal University, Manipal-57610E-mail address: abrahambabu@gmail.com

0033-0620/$ – see front matter © 2014 Elseviehttp://dx.doi.org/10.1016/j.pcad.2013.11.004

A B S T R A C T

Keywords:

Worksite health and wellness (WH&W) are gaining popularity in targeting cardiovascular(CV) risk factors among various industries. India is a large country with a larger workforce inthe unorganized sector than the organized sector. This imbalance creates numerouschallenges and barriers to implementation ofWH&Wprograms in India. Large scale surveyshave identified various CV risk factors across various industries. However, there is scarcityof published studies focusing on the effects of WH&W programs in India. This paper willhighlight: 1) the current trend of CV risk factors across the industrial community, 2) theexisting models of delivery for WH&W in India and their barriers, and 3) a concise evidencebased review of various WH&W interventions in India.

© 2014 Elsevier Inc. All rights reserved.

WorkplaceIndiaCardiovascular riskOccupational health

Diseases have adverse social, psychological and economicconsequences, not only on the individual but also on the well-being of the affected families. In India, the total burden fromnon-communicable diseases (NCDs) is expected to rise from40% in 1990 to nearly 75% of all deaths by 2030.1,2 NCDs place asignificant financial burden on the individual as only about10% of the Indian population is covered by some form ofhealth insurance, resulting in a greater proportion of out-of-pocket expenditures.3 Studies indicate that cardiovascular(CV) diseases (CVDs) and cancer drive 10% and 25% of theaffected families into poverty, respectively.4

In fact, CVDs account for the maximum burden of NCDsboth worldwide and in India. CVD also impacts the produc-tivity of the working age adults who are the economic engineof the country. In 2010, India lost about 6% of its grossdomestic product (GDP) secondary to premature deaths andpreventable diseases.3 Public health interventions are essen-

e 506.uel Babu, MPT, Assistant4, Karnataka, India.(A.S. Babu).

r Inc. All rights reserved

tial to combat the burden of CVD. In growing recognition ofthis need in India, there has been a paradigm shift in publichealth initiatives from a communicable disease centricapproach to a one that includes CVD in its ambit.

Worksite health andwellness (WH&W) programs are beingrecognized as an important strategy for promoting health andreducing the burden of CVD, both at the primary and at thesecondary level.5 These programs are employer initiativesdirected at improving the health and well-being of workersand, in some cases, their dependents. These programsmay bestructured as primary, secondary and tertiary preventionprograms.5,6 The Healthy People 2010 project in the UnitedStates (US) made worksite health promotion one of itsstrategic goals by stating “75% of all the worksites (irrespec-tive of their size) would develop comprehensive WH&Wprograms”. In an effort to work towards this goal, theAmerican Heart Association (AHA) began supporting these

Professor, Department of Physiotherapy, School of Allied Health

.

Table 1 – Comparison of percentage prevalence of CV riskfactors in the study by Mohan et al. and in the generalpopulation (CURES study).

Cardiovascularrisk factors

Mohan et al.(n = 1167)

General population(CURES; n = 2350)

Diabetes 11.9% 14.3%Hypertension 25.4% 20%Awareness 42.3% 32.8%Treatment 66.7% 70.8%Control 55.2% 45.9%

Generalized obesity 44.5% 28.1%Abdominal Obesity 42.1% 49.2%Dyslipidemia 40.2% 41%Metabolic syndrome 34.1% 18.3%

Abbreviations and Acronyms

AHA = American HeartAssociation

NCDs = noncommunicablediseases

CURES = Chennai Urban RuralEpidemiology Study

CHD = coronary heart disease

CV = cardiovascular

CVD = cardiovascular diseases

DM = diabetes mellitus

ESI = Employee State Insurance

GDP = gross domestic product

HTN = hypertension

IC Health = Initiative forCardiovascular Health Researchin Developing Countries

ICMR = Indian Council of MedicalResearch

PA = physical activity

US = United States

WH&W = worksite health andwellness

WHO = World HealthOrganization

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initiatives to help re-duce the burden ofCVD.7 Subsequently,the Healthy People2020 goal was modi-fied with the aim ofincreasing the pro-portion of employedadults who have ac-cess to and participatein employer-based ex-ercise facilities andex-ercise programs in theUS.8Costeffectivenessanalyses indicate thatthere can be signifi-cant financial benefitsto an organizationby investing in healthpromotion programs;anywhere from 2.3 to5.9 times the return oninitial investment.9

India has one ofthe largest workingpopulations in theworld. Data from In-dia’s National SampleSurvey Office suggestthat 40% of thecountry’s populationof 1.2 billion are insome form of employ-ment; comprising 56%

and 23% of the country’s male and female population,respectively.10 With such a large proportion of workingpopulation, an effective worksite wellness and health policycould act as a means of providing access to basic andpreventive healthcare to a greater proportion of the Country’spopulation and combat the rising burden of CVD specificallyand NCDs in general. This paper will discuss the various CVrisk factors in India while highlighting the value of WH&Wprograms for promoting CV health and the current state ofthese programs in India.

CV risk factors in India

CVD has risen to be the major cause of death in India and it isexpected to rise to an alarming 36% by 2030.11 Prematuredeaths due to CVD, stroke and diabetes mellitus (DM) areprojected to increase cumulatively, and India stands to lose237 billion dollars during the ten year span between 2005 and2015. The number of cases of coronary heart disease (CHD)was estimated at 22.37 million in 2004 in both the rural andurban areas. This high number has been thought to be due toearly CVD occurrence as well as the occurrence of the diseasein individuals considered to have a presumably favorable CVrisk factor profile.11

The INTERHEART study’s South Asian componentestablished the role of behavioral and conventional riskfactors in the prediction of CVD risk among Indians.12 Theyfound that CV risk factors such as smoking, abnormal lipids,hypertension (HTN), DM, high waist–hip ratio, sedentarylifestyle, psychosocial stress, and lack of consumption offruits and vegetables collectively accounted for more than90% of acute CHD events among South Asians. This hasfurther been supported by data from various cross-sectionalstudies.13–17 As an expansion to this research, similar findingswere also observed in the Chennai Urban Rural EpidemiologyStudy (CURES) (Table 1).18

CV risk factors among the Indianindustrial population

Data from industrial areas have found a high prevalence ofbehavioral risk factors, central obesity, HTN and DM in aselect group of middle and high-income young urbanmales.19 This high prevalence of risk factors and CVD werealso seen among young men as a result of poor awarenessand control.20 It has been seen that only a third of those whohad HTN were aware of their status and among those aware,only 38% had an adequate control of blood pressure.Similarly, only a third of those who had DM were aware oftheir status and among those aware, only 31% had anadequate control of blood glucose. This lack of awarenesswas seen among a comparatively young (<50 years) malepopulation in a North Indian industrial setting.20 The IndianCouncil of Medical Research (ICMR), a Government of Indiaundertaking, proposed the ICMR Sentinel Surveillance Sys-tems for CVD in Indian industrial populations to study riskfactors among industrial populations (Table 2).21 The surveyfound a high prevalence for CVD risk factors (10.1% for DM,56.3% for pre-HTN and >30% for obesity) among therelatively young population. This prevalence was despitethe fact that more than 50% were involved in moderatephysical activity (PA). Another industry survey identifiedlifestyle-related illnesses accounting for 27% of illnessesamong employees. A quarter of the respondent firms lostapproximately 14% of their annual working days due tosickness.22 It has also been seen that people tend to give up

Table 3 – Summary of best practices for WH&W programsused in developed countries.

Assessment: • Baseline employee survey to understandtheir needs and planning of the objectives ofthe program.• Review of goals of the project with the seniormanagement along with involvement of the tradeunion representing the employees should be heldto obtain their input and buy-in• Assessment of environmental health issues

Planning: • Formation of the “Health Promotion Team”including senior management, human resourcesdepartment, organization conducting the healthpromotion program, managers and employees.• Written documentation on the process of thehealth promotion program and the how theoutcomes should be measured and written.• Designation of ‘health ambassadors’ withinthe workforce to spread the message and bepeer leaders.• Well laid out communications plan on how therationale, goals, process and the progress of theproject will be communicated to the employees onan ongoing basis.• Announcements of the program goals andactivities to the workplace staff at least 1–2months prior to initiating the program.

Table 2 – Age-adjusted prevalence of CVD risk factors inindustrial population from the ICMR Sentinel SurveillanceProject.

Risk factorsICMR SentinelSurveillance Systems

Hypertension 26%Overweight BMI ≥23 kg/m2 46.7%Central obesity 32%Dyslipidemia 37.5% (age 15–64 years)

62% (age 20–59 years)Metabolic syndrome 24.8%Current tobacco use 40.2% (men), 14.9%(women)

Abbreviations: ICMR, Indian Council of Medical Research.

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some of their routine physical activities as they move up thesocioeconomic ladder, thus increasing their risk for CVD.23

Many developed economies have seen significant reduc-tions in CV mortality over the last few decades throughadoption of WH&W. This could be due to a greater emphasisplaced on reduction of risk factors and improved medicaltreatments.24 However, India is still in the early stages ofimplementation of various programs targeting reduction inCVD risk factors.

• Training of staff using a standard educationalmodule

Implementation: Initiate educational programs, counseling andhealth related activitiesOpportunities for the employees to meet with theprogram managersEmployee incentives to increase participation.Change health related policies and environmentto promote a healthy lifestyle

Evaluation: • Distribution of health reports to the employees,human resources department and seniormanagement in a confidential manner• Constant feedback should be obtained from theemployees to ensure that the program meetstheir needs• Reassessment of all measures done at leastevery 2–3 years

Current WH&W delivery models in India

Various models have been put forward by various interna-tional organizations. A summary of the best practices forWH&Whas been summarized in Table 3. Nevertheless, regionspecific models are important if success of these programs isto be ensured.

In order to promote regional success, WHO-India devel-oped a schematic model to help promote WH&W in India.They rely on the formation of a wellness committee whichperforms a situation analysis (i.e., health survey, health riskassessment and interest survey).25 Based on these assess-ments, the committee plans a specific program keeping inmind the allocated budget for this venture. Constant evalu-ations and monitoring are followed so as to allow formodifications of policies and establishment of best practices.Once feasibility and sustainability of the program areascertained, it can then be expanded as required.

The workplace-based Health Education Intervention modeladdressing PA, skill-oriented knowledge and motivationalmessages, among other NCD risk factors such as unhealthydiets, tobacco use, and high blood pressure is a joint initiativeof the Initiative for Cardiovascular Health Research in Devel-oping Countries (IC Health) and the All India Institute ofMedical Sciences.23 A comprehensive program targeting mul-tiple risk factors through different strategies is another modelthat can be employed for Indian industries at various levels.26

Interventions for the individual, family, peers and worksitethrough one-on-one interactions, educational material, moti-vational sessions and policy modifications were made use offor targeting multiple risk factors. Another simpler modelfocused on promoting health with respect to the psychosocialwork environment, physical work environment and lifestyle

with a great emphasis placed on the role of the worksitewellness committee in promoting WH&W.27

From an employer’s perspective, such programs increasepresenteeism, improve productivity, reduce absenteeism andhealth care costs paid by the employer.5 To achieve these goals,the health promotion process typically consists of assessinghealth risk of the employees and subsequently promotinghealthy lifestyles through various methods. Achieving thedesired outcomes can take anywhere from six months tothree years. Despite this long duration, WH&W can be imple-mented in a structured manner with consistency, with goodlongitudinal follow-up and well-definedmeasurable outcomes.Nevertheless, these programs typically target younger individ-uals as they are the majority of the workforce and if anemployee leaves the company, there is no follow-up. Also, thelabor sector of Indian economy consists of roughly 500 millionworkers.28 Of these, about 94% work in unincorporated,unorganized enterprises ranging from pushcart vendors to

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home based diamond and gem polishing operations. Consider-ing the large volume of small and medium scale industries inIndia, the models of implementation for large organizationscannot be implemented. Thus, it has been suggested toimplement simple, cost-effective strategies for these industriesviz., outsource health check-ups, provide vouchers for localgym use, educate the employees on health through pamphletsand other cost-effective methods.25

In the developed economies, these programs are typicallyexecuted by private companies, insurance companies (gov-ernmental or private) or non-profit organizations. This is,however, not the case in Indiawith the Government insuranceschemes like the Employee State Insurance (ESI) scheme. TheESI, is the largest, compulsory, health insurance scheme inIndia and covers the lower income factory workers. Unfortu-nately, the scope of these Government-sponsored schemes isnot comprehensive enough to include WH&W programs.

The Government in India has also taken steps in improv-ing WH&W by establishing the National Institute for HealthPromotion and Control of Chronic Diseases under the CentralHealth Education Bureau as a subordinate organization ofDirectorate General of Health Services, Ministry of Health andFamily Welfare.11 The 12th five year plan has proposedpossible strategies like executive health programs and initi-ation of fitness and yoga centers, to promote a healthyworkplace. Besides these initiatives from the Government,there have also been various non-governmental organiza-tions involved withWH&W in India as identified by theWorldEconomic Forum which includes the Confederation of IndianIndustry, Public Health Foundation of India and IndianAssociation of Occupational Health.29 With the involvementof these organizations and WHO-India, there is scope for thecountry to develop a successful health promotion programthat meets the needs of the employer and the employees.This will in future translate to development of best practicesand principles relevant for the working community in India.

Evidence based review supporting worksite healthand wellness programs for India

Evidence supporting the use of WH&W programs isavailable for numerous western countries. A recent reviewdemonstrated improvements in various outcomes like CVrisk factors, healthcare costs and absenteeism.30 WH&Wprograms have been shown to reduce sick leave absentee-ism, healthcare costs and compensation by 28%, 26% and30%, respectively.31

A scoping search was performed to identify studies donefrom India and within the Indian context. There were a smallnumber of published articles identified from this search. Onekey study was done by Prabhakaran et al., using a multicom-ponent education program among various industries.26 Thisstudy demonstrated significant reduction in blood pressureand improvement in CV risk profile. Recently, an integratedapproach using education, screening and behavioral inter-ventions was used to promote tobacco cessation.32

Despite the dearth of published literature in scientificdatabases like MEDLINE or, CINAHL, a search of grey literature

identified various WH&W programs in Indian companies. TheRightManagement survey in 2009 found that 63% of employeesfrom India felt that their company actively promoted healthandwell-being, whichwas higher than those reported from theUS (60%), Canada (65%) and United Kingdom (47%).33 Thissuggests the success of WH&W programs established by a fewleading Indian companies. TheWorld Economic Forum, togeth-er with World Health Organization (WHO)-India and the PublicHealth Foundation of India, has described various WH&Wprograms of leading Indian companies and their outcomes ina very comprehensive document on WH&W in India.25

An interesting observation from the search of greyliterature was that most of the studies/programs focusedmore on occupational health and safety than on promotingCV health. Nevertheless, research in occupational health andworksite programs is at a basic level, comprising predomi-nantly of cross-sectional studies.34 Operational research inhealth promotion at workplace from public health perspectivefrom India is currently lacking.

Challenges with implementation and adherence

In 2005, the Indian economy had an estimated loss of aboutnine billion dollars due to loss of labor supplies and savingssecondary to CVD, stroke and DM. This loss to the economy isexpected to rise to 54 billion dollars by 2015.35 Thoughcumulative estimates of loss to economy through all prevent-able diseases are not available, it is safe to assume that thenumbers will be more than double of that through chronicdiseases alone. This is a huge burden on a developingeconomy and makes it imperative to have preventivemeasures implemented through WH&W. Implementation ofWH&W programs in India is a mire of challenges which canbe at the level of the industry (i.e., attitudes, employers andemployees) or the policy maker (i.e., policy, program reachand manpower) (Table 4). Nevertheless, the leading barrier tosuch programs is thought to be the global financial crisis andthe high burden of NCDs in India.25

Policy

Though India has over 40% of its total population engaged ingainful employment, currently there is no comprehensivelegislation for occupational health, safety and health pro-motion that covers employees in all economic sectors.34 Outof the 21 work sectors in India, only four have healthstatutes to regulate occupational health and safety.34,36

Following amendments to The Factories Act (1948) in 1987,it became mandatory for industries listed in Schedule I toconduct pre-employment, periodic medical examinationand monitoring of work environment. Current legal man-dates are geared to address the most basic parameters likepreventing abuse, improving safety in workplace andprotecting environment from industrial pollution; and nottowards implementation or reinforcement of preventivehealth programs in workplace.37 Division of responsibilitiesbetween Ministry of Health, which has its mandate overprimary healthcare, and Ministry of Labor, which has control

Table 4 – Barriers to WH&W in India at the worksite andadministrative levels.

WorksiteAttitudes Lack of awareness

Poor focus on preventive careEmployer relatedbarriers

Poor visibility of leadership in WH&WProfit versus time spent in WH&WAcceptance from UnionsHigh attrition rates

Employee relatedbarriers

Lack of interest in preventive programsAvoidance of regular health check-upsfor fear of job security

AdministrationPolicy Lack of legislation enforcing WH&W

Limited budget for WH&WPrograms Tailored for the organized IT sectors and

not so much for the unorganized sectorResources Lack of trained health care professionals

to offer services for WH&W

Abbreviations: IT, Information technology; WH&W, Worksite healthand wellness.

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over occupational safety and health has diluted the focus onpreventive healthcare at workplace. WH&W programs arealso disadvantaged by the budgetary allocation they receivewith only about 4.6% of the GDP available for healthcareexpenditure, the majority of which is spent on curativehealthcare rather than on health promotion.38,39

Program reach

India has an extremely large proportion (93%) of its workforceemployed in the unorganized sector, thus taking themoutside the purview of legal provisions of occupational healthlike the Factories Act.40 Among its total workforce, 52% areself-employed and 18% are engaged in casual labor. Theremaining proportion of workforce is engaged in micro-smalland medium enterprises.10,41 In most unorganized sectors,employers recruit between 1 and 20 employees under micro-small and medium enterprise categories and recruit nonewhen they are self-employed. Such small enterprises lackorganizational structure and are usually not covered underhealth insurance programs like the ESI scheme and are mostlikely to be excluded from preventive WH&W programs.42,43

Globalization of the Indian economy has led to a rapidgrowth in information technology and business processoutsourcing companies. Though this sector constitutes asmall fraction of the total workplace, they are progressivein implementing policies and are leading the way inimplementing workplace health promotion programs.25

For worksite health promotion to be an effective approach,initiatives like those in information technology sectorsneed to be taken for the unorganized sector throughinnovative means.

Manpower

In the organized manufacturing sector alone, there is anestimated deficit of 58% factory medical officers and 59%

safety officers.44 There are no estimates available for thetotal number of healthcare specialists required for India’stotal workforce. Extrapolating the shortage of healthcaremanpower in the organized sector and considering thestate of affairs of health in the unorganized sector, it is safeto assume that availability of skilled healthcare profes-sionals for evaluation and implementation of WH&W isgrossly inadequate.

What lessons can we learn from other countriesregarding WH&W programs?

A key lesson learned from developed economies is thatprivate health promotion companies can take the leadershiprole and provide the desired outcomes. The motivationalforces for initiating the health promotion programs may bedifferent in India versus in the developed economies. Forexample, in the US, reducing the cost of healthcarecost borne by the employers is one of the key motivationalforces followed by improving productivity and reducingabsenteeism.45 In Asia, from an employer’s perspective,improving workplace safety, improving workplace morale/engagement and improving productivity and reducing ab-senteeism tend to be the highest priorities.45 The authors arenot aware of a survey that only focuses on India. From anemployee’s perspective, improving workplace safety, in-creasing PA and reducing stress tend to be the highestpriorities. It is critical that the health promotion programsaddress the needs of the employer and the employee for theprogram to be successful. The two are often linked. Forexample, reducing stress and having overall better physicaland mental health lead to better morale and better produc-tivity and less absenteeism.

Future directions for research and practicalprogram implementation25

This review highlights various aspects on WH&W in Indiawhich need to be addressed in the coming years. Large crosssectional studies on CV risk factors and disease among theworking sector are important information required fromIndia. This information will add to the on-going surveys andwill provide a strong base for the initiation of large scaleintervention trials in the worksite.

Feasibility studies and small scale pilot studies are also animportant requirement from India. Since India has a greatdiversity in the working sector, studies need to be performedin various worksites and sectors to understand how WH&Wcan support the entire working community in India. Initiatingawareness campaigns using a ‘bottom-up approach’ will helpin creating a demand for health. Capacity building in the areaof WH&W is crucial to help curb the rise in NCDs. The longterm goal for research in India will be to develop bestpractices and initiate policy changes with support from theGovernment and Insurance companies to help promote andsustain WH&W programs in India.

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Acknowledgments

Mr. Sundar Kumar Veluswamy is supported by a three-yearfellowship under the Structured PhD Program at ManipalUniversity, Manipal, India.This manuscript was not funded by any grant support.

Statement of Conflict of Interest

All authors declare that there are no conflicts of interest.

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