Key Factors in Employee Health and Wellness Program

In today’s society there are many primary factors that influence people’s health behaviors.  Consider the following list in maintaining participation in your program:

1.    TIME. Workers are busy, so the more you can work activity and healthy eating into their existing schedules, the better your chances for success.  Example: A walk at lunch doesn’t take away from existing time, it just uses it differently.  Also review the time of the day and length of any activity you might be promoting, since both time components may be factors.
2.    ACCESS. How accessible is your Employee Health and Wellness Program.  Is it onsite or at a nearby site?  Do you offer access at breaks or outside of normal work hours?
3.    KNOWLEDGE. Workers need to know “Why” they are participating (the benefits) and also will need information about the “How to” in areas that are not commonly known.
4.    COST. Make sure that you can provide no cost or decreased cost Employee Health and Wellness Programs will help participation rates.  Coupled with incentives for participation, rates of participation will likely increase dramatically.
5.    INCENTIVES. Some staff members need incentives to get started in a Employee Health and Wellness Program.  A full list of Employee Health and Wellness Program incentive options can be on the website.

Key Time Periods in Employee Health and Wellness Program

Good habits are frequently difficult to develop.  There tends to be some critical times when staff members drop out or fall off of a physical activity or diet program.   The first key time zone seems to be around 6 weeks.   If staff members can start and stay consistent with a program through the first 6 weeks, they have made a fairly serious commitment to incorporate the habits into their lifestyle.  The second key time is at about 6 months.  Those who made it past 6 weeks may get bored and/or distracted from their program after several months.  If staff members can get past 6 months and sustain behavior through a full set of weather seasons, they have a very good chance of making the changes permanent.

Consider these time periods and think about how you can “boost” your workers to get them past these critical time markers.  Promoting individual or group “challenges”, using incentives, or increased publicity/marketing are a few of the things you can do to help get your workers through these key time periods

Goal Setting for Employee Health and Wellness Program

Setting goals has been shown to lead to better participation and more staff members making a strong commitment.  Whether it be a team goal of walking the equivalent of once around your state or an individual goal of so many miles or minutes of activity, the fact that there is something concrete to shoot for increases the likelihood staff members will stick with the program.

Buddy Systems or Team Goals for Employee Health and Wellness Program

The social aspects of improving one’s health cannot be underestimated.  Many studies point to tight social groups being the backbone for a successful campaign because each individual has a commitment to something bigger than themselves and besides, it’s just more fun for most staff members. Build your program around some type of teams or partners and see what happens.

Team “Campaigns” for Employee Health and Wellness Program

Some staff members like competition and others don’t.  Nevertheless, a worksite wide campaign has the advantage of keeping the message more visible and alive.  Encourage campaign participation, but make it voluntary so that those who prefer that type of motivation can join while others can participate in their own way and at their own pace.  If the idea of a campaign seems like too much work, consider tapping into existing campaigns where someone else provides resources for you.

Incentives for Employee Health and Wellness Program

Incentives are frequently helpful in maintaining or raising interest.  Significant incentives such as cash or health insurance rebates have proven to be very strong motivators for staff member participation.  However, even smaller incentives can be beneficial.  Listed below are some sample incentives:
• Achievement awards. Verbal praise and a pat on the back are motivational to some, but a token of recognition of achievement may offer more. A colorful certificate to congratulate an staff member for achieving a health-related goal is one example.
• Public recognition. Announced recognition at campaign mid-point or wrap-up festivities.
• Food. Include some healthy foods to kick-off, revitalize or wrap up a wellness campaign.
• Entertainment. Events serve a purpose in jump-starting, reenergizing or wrapping up a campaign.  Having entertainment of any kind can boost morale.
• Merchandise.  There is a long list of merchandise incentives, including sports equipment and small gift certificates to use at local merchants.
• Monetary rewards. Nothing says incentive better than cash.  Worksites that have used cash or rebates as an incentive have shown much higher participation rates.
• Time off. Maybe the next best incentive to cash, or for some staff members even better.  This type of incentive makes good business sense if the number of absences drops significantly and attendance is used as one of the criteria.

1. Improved Morale - When the organizational culture begins to change as a result of your health promotion efforts, you and your workers may actually begin to see and feel a new level of energy within the organization.  Ultimately, one of the most ambitious goals of any broad-based health promotion program is to attempt to influence the attitudes and actions of the organization’s most valuable resource — its workers.
2. Reduced Turnover - As we all know, staff member replacement costs can be quite high for any kind of organization.  The effort and expense associated with running employment ads, reading applications, checking references, interviewing qualified candidates, hiring and training a new staff member can be a serious burden on any organization.  In light of the challenges that high staff member turnover pose, many companies are looking to health promotion programs as an additional perk that can help to prevent workers from jumping ship.
3. Increased Recruitment Potential - In the midst of a very tight labor market, companies are forced to pull out the stops in order to recruit new talent.  In some instances, health promotion can prove to be a very valuable tool in sealing the deal.
4. Reduced Absenteeism - When an staff member misses work in a organization setting, the entire organization is forced to absorb his/her responsibilities.  Even in the event of the occasional absence caused by things like colds and the flu, work can back-up and tensions can build.  Even worse is a long-term absence caused by a major health event that requires hospitalization and/or rehabilitation.  By preventing certain types of illness caused by poor lifestyle habits, health promotion programs can play an important role in decreasing rates of absence.
5. Health Care Cost Containment - Most companies don’t start a health promotion program with cost containment in mind.  However, cost containment for certain health problems should be considered a viable goal by many companies.
6. Improved staff member Health Status - One of the greatest advantages of a well-designed health promotion initiative is the promise of improved health.  There is a growing body of evidence that suggests well-designed health promotion initiatives can successfully impact such behaviors as tobacco use, high-risk alcohol use, and more.

The Employee Health and Wellness Program management world is evolving rapidly. Each month, there are new research findings that support the premise that Employee Health and Wellness Programs and disease management have a long-term impact on health care costs. Many large companies that started Employee Health and Wellness Programs three to five years ago are showing savings in health, disability, and workers compensation costs. Small to mid-size companies are watching all this and wondering where to start with wellness.

Getting upper management support and budget approval is one of the challenges at the beginning of a Employee Health and Wellness Program. This is the case because Employee Health and Wellness Programs can be expensive, averaging $150-300 per staff member per year in large companies. Most of the savings are not realized for a number of years. This long-term investing is hard for companies on the move.

The key to success for Employee Health and Wellness Programs is to take a strategic approach. Here are ten steps to consider when starting a Employee Health and Wellness Program.

1. Start with upper management. Without upper management support, a health promotion strategy can fall flat. Start with the health of your executive team and discover your wellness champions at the top of the organization.
2. Assess the problem. Look at your health care claims and analyze the trends. Which conditions are driving your medical, disability, and workers’ compensation claims and which are modifiable? What’s worked and what hasn’t thus far? What is the long-term impact of doing nothing?
3. Hold an initial wellness meeting. Invite your primary stakeholders both inside and outside the organization. Ask your broker to facilitate the meeting and invite primary health vendors including health, disability, Employee Assistance Program (EAP), fitness, and occupational nursing. Review claims and utilization information and identify primary areas of concern. Look at current offerings and see how they can be tailored to the needs of the population.
4. Consider both healthy and unhealthy workers. Since 85 percent of claims are usually attributed to 15 percent of claimants, it is essential to reach those with the most costly conditions while also reaching staff members who are at risk for developing preventable diseases in the future. Voluntary Employee Health and Wellness Programs such as lunchtime wellness seminars miss many of the staff members who need them most. Consider initiatives that are population-wide or target intact workgroups. Wellness incentives help but do not motivate everyone.
5. Set short-term goals for the Employee Health and Wellness Programs. Set some realistic short-term goals based on your primary areas of concern. Are there any plan design changes that could have an immediate impact on spending? Are there some programmatic actions that could have immediate results?
6. Determine what workers are thinking. Hold some focus groups to determine where staff members are with wellness. What’s working? What isn’t? How much interest do staff members have in the Employee Health and Wellness Programs? What obstacles and barriers are workers experiencing when they try to change behavior?
7. Make sure you have a high-impact Employee Assistance Program (EAP). Your first wellness dollars should go into upgrading your Employee Assistance Program (EAP). A highly utilized Employee Assistance Program (EAP) can provide a foundation for all of your future wellness activities. A good Employee Assistance Program (EAP) is a trusted link to the hearts and minds of workers. At no additional cost, the Employee Assistance Program (EAP) can provide needed follow-up coaching and personal attention for workers who are working on modifiable health behaviors or involved in disease management initiatives. Nutritionists, fitness, pregnancy, and stress management specialists are all part of a high-value Employee Assistance Program (EAP).
8. Set three to five year goals for health care savings and measure them. Get help from your broker and insurance carrier help you on long-term goals for your health, disability, and workers compensation plans. Start program metrics that will help you to measure return on investment. Go beyond participation rates, completion rates and program satisfaction. Measure changes in readiness, changes in behavior, and changes in risk factors. Start rigorous methods to measure health care savings over the long term.
9. Set goals for organizational health. Consider the more intangible benefits of a wellness initiative and quantify them whenever possible. Include staff member turnover rates, cost of new hires, staff member morale, benefit satisfaction information, and employer of choice issues in setting goals. Start ways to measure success in these areas.
10. Add specifics to your short and long-term plan. Include a Employee Health and Wellness Program strategy, a communication strategy, and a Employee Health and Wellness Program incentive strategy that will fit with your corporate culture. Focus on integration of related components along a health continuum with communications that are focused, simple, and human. Start a budget that includes primary components such as consumer education, health promotion, health risk assessments, and regular biometric screens.

Employers can also benefit from Employee Health and Wellness Programs. According to recent research, employers’ benefits are:

• Enhanced recruitment and retention of healthy workers
• Reduced health care costs
• Decreased rates of illness and injuries
• Reduced staff member rates of absence
• Improved staff member relations and morale
• Increased productivity

A U.S. Department of Health and Human Services report revealed that at worksites with physical activity initiatives as components of their Employee Health and Wellness Programs have:

• Reduced health care costs by 20 to 55 percent
• Reduced short-term sick leave by six to 32 percent
• Increased productivity by two to 52 percent

Thanks to modern medicine, life expectancy for Americans has continually increased. How much we enjoy these additional years, however, depends greatly on how we have lived our lives. If our quality of life is to remain high so that we can fully enjoy these extra years, we must practice good eating habits, be active and refrain from using tobacco products.

Furthermore, stress, distractions and the pressures of the job can take its toll on the staff member, which makes it important that a Employee Health and Wellness Program is implemented. Today, all across America, Canada, Europe and Asia, top Employee Health and Wellness Programs are being used to help improve staff member conditions at work and reduce the cost of worker health care.

Some of the top Employee Health and Wellness Programs currently in use today include:

Health Risk Assessments (HRAs)

Health Risk Assessment is a top Employee Health and Wellness Program currently in use globally. Organizations that implement it determine the safety and health concerns of workers by the assessment of appropriateness of the facilities and equipment against the needs of the workers.

It can, for example, guide the organization into determining how much air quality within an office room affects the users and then help the assessment team to come up with the measures necessary to correct the problem. An HRA can also evaluate the level of exposure workers have to certain hazardous or dangerous materials and practices.

Immunizations

This isn’t always practiced in every country since there are regions where government sponsored immunization shots are available. However, it has also become an important component of the top Employee Health and Wellness Programs in many companies in North America.

Immunization, flu shots, such as those used to combat flu, for example, are offered to workers for free.

Employee Assistance Programs (EAPs)

Employee Assistance Programs (EAPs) consist of a wide variety of services. It can range from providing educational resources to workers regarding health issues to sponsoring health services and medical care. In many companies, medical and insurance have also become a staple part of their benefits system.

Weight Management Programs

This is another Employee Health and Wellness Program that companies use, particularly those that offer in-house commissary or cafeteria services. Instead of serving richer, high-calorie fare, cafeterias offer options for a healthier diet, usually in the form of low-calorie foods and sugar substitutes.

Employee Wellness Newsletters - Health Education Programs

One of the top Employee Health and Wellness Programs that companies can implement is a self-powered tool using a newsletter to promote wellness, coupled with a visible campaign. The campaign may be done periodically and focus on a specific topic, such as tobacco use hazards, cancer, stress, carpal tunnel syndrome, safety in the workplace, etc.

The newsletter in itself can be an effective method to deliver information to workers or members of an organization but it is far from perfect. Some workers, for example, may not read the newsletter in its entirety or even pay attention to it. If the issues outlined in the newsletter are promoted through an active and highly visible campaign, it will be easier to maximize positive results.

Physical Fitness and Exercise Programs

Another top health promotion program for companies is one that involves physical activities. Companies frequently sponsor physical fitness-related events such as marathons and organization sports initiatives to promote workers to remain fit or lose excess weight. In mid- to large-sized companies, companies may even pay for gym memberships or in-house physical fitness facilities.

Employee Health and Wellness Program Incentives

Some of the top Employee Health and Wellness Programs implemented by companies involve incentive rewards. This involves organization-sponsored initiatives that reward workers for achieving specific wellness goals. Participation in health campaigns and signing up for Employee Health and Wellness Programs are two of the most commonly rewarded schemes. Rewards can range from special recognitions to points (for bigger rewards) to specific gifts. In a few cases, cash may also be used.

However, incentive systems have had mixed reactions and levels of success. But it continues to be one of the top choices among companies who are willing to modify it in order to fit their unique needs.

Group Activities

In many companies, companies take advantage of peer pressure in order to encourage workers to participate in Employee Health and Wellness Programs. This is currently one of the favorite worker Employee Health and Wellness Programs currently in use today and growing in popularity. Peer pressure is frequently leveraged to help promote competitions and to persuade workers to be active in organization-sponsored health fairs.

Employee Health and Wellness Programs: The Good

• A sampling of return on investment for Employee Health and Wellness Programs: Bank of America: 600%; General Motors:370%; Pepsico: 300%; Citibank: 465%; and the Washoe County School District leading the pack at a whopping 1,560%. (Campbell,J., Wellness Improvement Experts, www.wellnessimprovementexperts.com, Albuquerque, New Mexico.)
• Companies with Employee Health and Wellness Programs have realized a 28 percent reduction in sick leave, a 26 percent reduction in adjunctive health care costs and a 30 percent reduction in disability and workers compensation costs. (Health Affairs, Volume 21, No.2, March, 2002.)
• The Washoe county School District in Northern Nevada realized a $15.60 return on investment for every dollar spent due to a 20 percent reduction in rates of absence. (Hardy,A. (2005). At the Top Of The Class. WELCOA’s Absolute Advantage Magazine, 5(1), 14-20.)
• Employee Health and Wellness Programs provide the structure, encouragement, incentives and ongoing support that many individuals need in order to make lifestyle changes.
• Employees also realize returns on their efforts. FiServ, a financial services technology organization, gave workers who filled out a health risk assessment a significant discount on their health insurance premium. (Holland, Kelley, The New York Times, July 22, 2007.)

Employee Health and Wellness Programs: The Bad

The flip side of the argument centers on basic human rights. Do we want/need our employer to tell us to eat our veggies or lose 30 pounds? Some companies are doing just that and at least one lawsuit has resulted because of it.
• Three hundred companies have requested assistance from a national employment and labor law firm to institute more aggressive Employee Health and Wellness Programs.(Cornwell, Lisa, Associated Press, Albuquerque Journal, September 10,2007.)
• Clarian Health, based in Indianapolis, Will begin decreasing staff member paychecks by $10.00 for every staff member who has a Body Mass Index (BMI) of greater than 29.9 because not enough workers were utilizing their wellness services.(Cornwell, Lisa, Associated Press, Albuquerque Journal, September 10,2007.)
• Scott Rodrigues filed a suit against his prospective employer, Scotts Miracle-Gro, because he believed the organization’s antitobacco use policy violated his civil rights. The organization has a policy against hiring workers who smoke and Mr. Rodrigues’drug screen was positive for nicotine.(Holland, Kelley, The New York Times,July 22,2007.)
• staff member advocates are concerned that health discrimination may not be covered under the Americans with Disabilities Act.(Cornwell, Lisa, Associated Press, Albuquerque Journal, September 10,2007.)

Penalizing workers by hitting them where it hurts the most,their pocketbook, does not appear to be a favorable approach to molding human behavior.
Such tactics may result in increased resentments and retaliation, primarily in the form of rates of absence and presenteeism (decreased productivity on the job.) Voluntary, incentive-based initiatives, such as the one in the Washoe County School District, can and do produce results. A positive attitude on the part of management along with an opportunity for workers to have a stake in the decision-making may yield the greatest dividends to both employer and staff member.The motivation and resolve needed to change unhealthy lifestyle habits can best be derived from the basic tenets of encouragement, respect and support.

Wellness Fair Participation - Identify your audience
• Employees only, whole family, retirees?
• Community involvement? Theme?

Wellness Fair Time Line
• Set a date and time Allow 4-6 months of planning time

Wellness Fair Planning
• Identify health-related screenings, tests, other activities you’ll offer Identify educational literature and other learning opportunities Wellness Fair will provide Include any “fun” activities, or food/beverage needs for the fair

Wellness Fair Location & Logistics
• Consider location big enough to accommodate the largest volume of staff members at “peak time” periods
• Determine how booths/stations will be set up

Wellness Fair Vendors
• Target relevant health/safety-related community and corporate vendors to provide services, educational materials, incentives and giveaways

Wellness Fair Marketing
• Determine marketing tools to be used to inform workers/participants (posters, mailings, e-mail)
• Determine any incentives or giveaways that will be included in the fair or used to promote participation in the fair

Wellness Fair Scheduling
• Coordinate timing and events with staff and/or volunteers

Wellness Fair Personnel
• Schedule appropriate experts Physician or similar health care personnel to provide patient consultation for review of blood draw lab results
• Nurse(s) to administer vaccinations
• Administrative/all-purpose individual to facilitate paper work, finger sticks and to provide general assistance
• Pharmacist or pharmacist assistant if appropriate Dietitian for nutritional counseling suggested personnel designated for health fairs

Footnotes

1 The Robert Wood Johnson Foundation via Reuters Health E-Line.
2 Kaiser Daily Health Policy Report, (9/11/03)
3 www.cdc.gov/nccdphp/dnpa/press/archive/lower_cost.htm
4 “Is Stress Nibbling Away at Your Bottom Line?” By Stephen Alper, Nov. 15, 2002.
5 Health Promotion in the Workplace, Michael P. O’Donnell, page 415.
6 http://www.bmpcoe.org/bestpractices/internal/dayto/dayto_6.html

Nationwide Insurance is seeing results from a small incentive program initiated by one of the organization’s onsite nurses. To promote lunchtime walking, the staff member has informally launched a “shoelace program” modeled after the karate-belt color system. Employees progress through the color scale until they reach “black-lace” status. The reward system has resulted in more workers making commitments to walk during their lunch hour.

At the high end of the reward spectrum, some companies pay cash to workers who meet wellness goals. LuK, Inc. offers workers $250 for kicking the tobacco habit and remaining smoke free for 12 months. For logging fitness points that add up to 10 miles a month, workers are eligible for health assessments, which can result in reward amounts of up to $225.

The most effective motivator, according to Gordian research, comes through linking participation in Employee Health and Wellness Programs directly to insurance premiums. Doing so clearly demonstrates to workers the positive effects of wellness on their own health care costs. frequently, the first step in linking wellness programming to insurance coverage is lowering deductibles for wellness care or eliminating deductibles altogether. By adding this benefit, companies can promote workers to undertake routine screenings and other procedures to respond to health problems before they become chronic. Early detection benefits both patient health and employer health costs.

Incentivizing Employee Health and Wellness Program participation with health care credits

More frequently, employers are going beyond increased wellness care coverage and looking to demonstrate the importance of wellness by linking participation to workers’ bottom lines. Worthington Industries has recently rolled out a program that allows workers to eliminate their portion of the insurance premium by enrolling in a Healthy Choices Employee Health and Wellness Program.

During the first year of the Healthy Choices program, workers and their spouses complete Personal Health Assessments and medical screenings to determine their levels of health risks. Nurses, dietitians and physical fitness specialists are available to help moderate- and high-risk participants develop individual action plans for improved health through the use of educational materials, behavior modification, telephone help from third-party program health coordinators, and formal health management initiatives. By completing the assessments, workers earn their full premium credit. Because some plans at Worthington require no staff member contribution, a cash award takes the place of a credit in those cases.  During year two of the program, the wellness bar is raised slightly. To continue to receive the wellness credit, participants in the moderate- to high-risk category will be required to work at setting goals with third-party health coordinators.

Year three raises the bar again, requiring participants to show progress in meeting goals and to continue to work with health coordinators to reach goals.

After year three, Worthington Industries workers will be on the wellness track. The organization believes that will mean a healthier workforce and cost savings for workers and the organization. The well being of Worthington workers is the foundation of this program, and both workers and the company are expected to benefit from the long-term advantages of the Healthy Choices Employee Health and Wellness Program.

While Worthington has taken a broad approach to wellness, other companies have found success in offering incentives in specific areas. Longaberger, for example, offers a discount on health care policies for workers who do not use tobacco. An individual staff member who doesn’t use tobacco saves $7 per bi-weekly pay. For tobacco-free workers with family coverage whose families are also tobacco-free, the savings increases to $14 per pay.

The next step: Penalizing harmful behaviors

As it stands, health care is the only type of insurance that doesn’t focus on penalizing for behaviors that put the insured party at risk. With health care costs rising so dramatically, that could soon change. Just as an accident likely raises auto insurance premiums, increasing premiums for those who engage in unhealthy behaviors is a possible next step in employers’ attempts to manage health care costs.

Reports that workers would support this type of action are stacking up. One Ohio employer conducted an informal survey that indicated workers would consider it a morale boost if health-conscious workers were relieved of some of the burden of subsidizing care for workers who engage in behaviors that adversely affect their health. Whether or not this type of program gains popularity, one thing is sure: the need to control the rise in health care costs is becoming ever more pressing.

Take the first step

Whatever the strategy, from offering workers health resources to providing incentives for healthy behaviors, employers have a real opportunity to improve morale and productivity, reduce rates of absence and control health care costs through wellness. The first step is committing to taking one, no matter what size effort is appropriate for your organization.

Big strides start with small steps.

Stretching initiatives are another effective tool in injury prevention. According to the Best Practices in Manufacturing Web site, Dayton Parts, Inc. (DPI) in Harrisburg, Pa., conducted research that revealed approximately 80 percent of all manufacturing injuries occurred within the first two hours of each shift. After implementing a program that required production workers to stretch for 10 to 15 minutes at the beginning of their shifts, they saw a dramatic reduction in injuries.

While the DPI Employee Health and Wellness Program costs about $75,000 a year to operate, in conjunction with other organization initiatives, it has helped bring the annual cost of workers’ compensation from $700,000 to $200,000 per year.6

To help prevent lengthy absences and reduce workers’ compensation claims, Honda instituted a work recovery program. Through the program, workers who have had an injury can work in a modified job—getting better. Employees in the program spend their work days receiving physical conditioning to increase overall fitness, physical therapy to restore functionality, health education and nutrition counseling. The program is based on information that shows fewer work days are lost when an staff member stays connected to the work environment.

The Ohio Bureau of Workers’ Compensation, www.ohiobwc.com, provides a “10-Step Business Plan” as a guide for companies in providing Employee Health and Wellness Programs that aim to reduce injuries. The plan includes information on safety and health initiatives to prevent occurrences of on-the-job accidents, including:

staff member involvement - To ensure the success of any Employee Health and Wellness Program, workers must participate in the safety and health-management process. This can be done through safety and health audits, accident investigations, or by forming safety and health involvement teams, focus groups or committees.

Orientation and training plan - Conduct orientation and training sessions to educate workers on the organization’s safety policies. These sessions should include procedures for the safe use of machinery and tools, chemical hazards and how to prevent contact or exposure, specific job/task safe practices, and hazard recognition and prevention.

Communication - Open communication keeps workers informed and provides suggestions and feedback on the effectiveness of the Employee Health and Wellness Program. Through memos, bulletin boards and staff meetings, important health and safety information can be conveyed throughout the organization, keeping all management staff and workers knowledgeable about the organization’s safe practices.

The organization plan also outlines incentives for post-injury procedures, including:

Medical treatment and return-to-work practices - arly return-to-work strategies help injured or ill workers return to work in a timely manner. Companies should establish a disability management policy to help injured or ill workers obtain quality medical treatment, making their transition back to work quick and effortless.

Timely notification of claims - Employers should document workplace injuries immediately after they occur and promptly send that documentation to a claims handler. Quickly providing claim information demonstrates care and concern for the injured staff member, prevents delays and confusion with the claim process, and reduces the potential for abuse or needless litigation.

Record keeping - Internal documents should be kept to record work-time injuries and to assess the success of the organization’s safety efforts. Organization audits, surveys and injury or illness reports can all be used to analyze which safety practices and policies have proven successful, and what areas of health and wellness need improvement.