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Cost and consequence analysis of the Healthy Choices at Work programme to prevent non-communicable diseases in a commercial power plant, South Africa


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Background: The workplace is an ideal setting for the implementation of a health promotion programmes to prevent non-communicable diseases (NCD). There are limited resources assigned to workplace health promotion programmes in low-and middle-income countries (LMIC). Aim: This study aimed to conduct a cost and consequence analysis of the Healthy Choices at Work programme. Setting: This study was conducted at a commercial power plant in South Africa. Methods: Incremental costs were obtained for the activities of the Healthy Choices at Work programme over a two-year period. A total of 156 employees were evaluated in the intervention, although the effect was experienced by all employees. An annual health risk factor assessment at baseline and follow up evaluated the consequences of the programme. Results: The total incremental costs over the two-year period accumulated to $4015 for 1743 employees. The cost per employee on an annual basis was $1.15 and was associated with a −10.2mmHg decrease in systolic blood pressure, −3.87mmHg in diastolic blood pressure, −0.45mmol/l in total cholesterol and significant improvement in harmful alcohol use, fruit and vegetable intake and physical inactivity (p 0.001). There was no correlation between sickness absenteeism and risk factors for NCDs. Conclusion: The cost to implement the multicomponent HCW programme was low with significant beneficial consequences in transforming the workplace environment and reducing risks factors for NCDs. Findings of this study will be useful for small, medium and large organisations, the national department of health, and similar settings in LMICs.
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African Journal of Primary Health Care & Family Medicine
ISSN: (Online) 2071-2936, (Print) 2071-2928
Page 1 of 8 Original Research
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Darcelle D. Schouw1
Robert Mash1
1Department of Family and
Emergency Medicine, Faculty
of Medicine and Health
Sciences, University of
Stellenbosch, Cape Town,
South Africa
Corresponding author:
Darcelle Schouw,
Received: 04 Aug. 2019
Accepted: 15 Jan. 2020
Published: 22 June 2020
How to cite this arcle:
Schouw DD, Mash R. Cost
and consequence analysis
of the Healthy Choices at
Work programme to prevent
non-communicable diseases
in a commercial power plant,
South Africa. Afr J Prm Health
Care Fam Med. 2020;12(1),
a2217. hps://doi.
© 2020. The Authors.
Licensee: AOSIS. This work
is licensed under the
Creave Commons
Aribuon License.
Non-communicable diseases (NCDs), such as cardiovascular disease, cancer, chronic respiratory
disease and diabetes, were responsible for 70% of global deaths in 2015, with more than three-
quarters of these deaths occurring in low- and middle-income countries (LMICs).1,2 Risk factors
for NCDs are greatly interconnected with environmental factors and increased urbanisation.3 In a
study on 23 selected LMICs, chronic NCDs accounted for 50% of the gross burden of disease.4 The
global increase of NCDs is of both epidemiological and economic concerns as they have a
substantial impact on health, health services and organisational productivity.4,5 The World
Economic Forum has identified chronic diseases as one of the most significant threats to global
economic growth and estimated a cumulative loss to the global economy of $7 trillion between
2011 and 2025.5,6
In South Africa (SA), the burden of NCDs contributes to 57% of all deaths and is accompanied
by significant impairments such as amputations, blindness, hemiparesis and speech problems.7
There is a substantial impact on the quality of life of individuals and families.8,9 The impact of
NCDs is predicted to increase further in SA over the next decade.10 In SA, between 2006 and
2015, diabetes, stroke and coronary heart disease caused an estimated loss of $1.88 billion to the
gross domestic product.11 Organisations are impacted by direct and indirect costs of high
absenteeism and staff turnover as these diseases lead to morbidity in the working-age population,
with obese workers costing organisations in the USA 49% more than their non-obese colleagues
in terms of leave with pay.12 The direct costs include sick leave days, medical referrals and costs
Background: The workplace is an ideal setting for the implementation of a health promotion
programmes to prevent non-communicable diseases (NCD). There are limited resources assigned
to workplace health promotion programmes in low-and middle-income countries (LMIC).
Aim: This study aimed to conduct a cost and consequence analysis of the Healthy Choices at
Work programme.
Setting: This study was conducted at a commercial power plant in South Africa.
Methods: Incremental costs were obtained for the activities of the Healthy Choices at Work
programme over a two-year period. A total of 156 employees were evaluated in the intervention,
although the effect was experienced by all employees. An annual health risk factor assessment
at baseline and follow up evaluated the consequences of the programme.
Results: The total incremental costs over the two-year period accumulated to $4015 for 1743
employees. The cost per employee on an annual basis was $1.15 and was associated with a
-10.2mmHg decrease in systolic blood pressure, -3.87mmHg in diastolic blood pressure,
-0.45mmol/l in total cholesterol and significant improvement in harmful alcohol use, fruit and
vegetable intake and physical inactivity ( p < 0.001). There was no correlation between sickness
absenteeism and risk factors for NCDs.
Conclusion: The cost to implement the multicomponent HCW programme was low with
significant beneficial consequences in transforming the workplace environment and reducing
risks factors for NCDs. Findings of this study will be useful for small, medium and large
organisations, the national department of health, and similar settings in LMICs.
Keywords: cost and consequence; incremental costs; risk factors; prevention; NCDs;
workplace; LMIC.
Cost and consequence analysis of the Healthy Choices at
Work programme to prevent non-communicable diseases
in a commercial power plant, South Africa
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related to replacing absent employees, although indirect
costs include losses from reduced productivity.13 Many of
the deaths caused by NCDs are premature and occur in
people of working age (36–64 years).10
Underlying these diseases are a number of behavioural risk
factors such as tobacco smoking, harmful alcohol use,
physical inactivity and an unhealthy diet.14 Interventions,
therefore to prevent NCDs, focus on reducing harmful alcohol
levels and tobacco smoking as well as improving physical
activity and a healthy diet.5 Lifestyle behaviours are not just a
matter of individual choice and control, but are also influenced
by the environment in which individual decision-making is
The World Health Organization (WHO) has identified the
‘best buys’ for LMICs to prevent and control NCDs.16 A ‘best
buy’ is an intervention that is very cost-effective, feasible and
culturally acceptable and adds on average an additional year
of healthy life.17 According to WHO, the following should be
considered when selecting such interventions: effectiveness,
cost-effectiveness, affordability, capacity to implement,
feasibility according to national circumstances, impact on
health equity and its place within a menu of population-wide
and individual interventions.16 Despite numerous potential
interventions for the prevention and control of NCDs, choices
regarding which interventions should be prioritised are
critical, as resources in most countries are limited.
The SA National Department of Health, in its ‘Strategic Plan
for the Prevention and Control of Non-Communicable Diseases
2013–2017’, promulgates a balance between individual-level
and population-based strategies to prevent NCDs. Prevention
and postponement of NCDs are more effective and less costly
than treating those who become ill.18 NCDs in SA pose a
challenge to economic development and there is a need for a
priority-setting agency that assesses cost-effectiveness,
accessibility and feasibility of diverse interventions.19 The
national health budget does not include funding for robust
health and costing data for NCDs to enable planning, budgeting
and evaluation of activities.19
The workplace is an important setting for the prevention and
control of NCDs.20 Workplace health promotion programmes
(WHPPs) adopt a twofold approach that attributes a healthy
lifestyle both to the individual’s responsibility and behaviour
and to the influence of the environment that is outside the
individual’s control.21 Organisations that implement WHPPs
may subscribe to one or both approaches. The WHO’s ‘best
buys’ found no conclusive cost-effectiveness analysis for
interventions in the workplace, but nevertheless made some
recommendations on the basis of the available evidence. These
recommendations include (1) implementing nutrition
education and counselling to increase fruit and vegetable
uptake and (2) implementing multicomponent workplace
physical activity programmes.22 In a systematic review, aligned
to the WHO approach, 89% of LMICs had no studies on
‘best buys’. More than half of the studies reported effectiveness
for group interventions in reducing tobacco, but found weaker
evidence for interventions aimed at individuals. Because most
of the LMICs have not conducted such research, consideration
should be given to evaluate cost-effectiveness of interventions,
while focusing on national priorities and interventions with the
strongest evidence base.23 Recommended interventions for
NCD risk factors in LMICs include making workplaces tobacco
smoke-free with health information and warnings, reducing
salt intake in food and implementing media campaigns on
physical activity.24
There are relatively few studies showing the cost-effectiveness
of WHPPs in Africa. Studies in Africa have shown that the
NCD burden has increased and occurs concurrently with HIV,
with workplace wellness programmes showing promise.19
However, the urban poor and unemployed have little access to
these programmes. The families of the deceased carry the
biggest brunt with two-thirds of poor households having no
insurance for funeral costs and succumb to a loss of income
from the deceased wage earners.25 In the USA, a WHPP with
fire fighters showed a 10% reduction in cardiovascular events,
but with an incremental cost-effectiveness ratio of $1.44 million
per event prevented.13 A study evaluating the cost-effectiveness
of a WHPP focusing on healthy eating in Ireland concluded
that an organisational system-level dietary intervention was
more cost-effective than individual education in terms of
improved quality of life and reduced absenteeism.26 In a
review of the economic impact of worksite interventions to
promote healthy diet and physical activity, there was evidence
of a 25% – 30% reduction in absenteeism and medical costs
over 3–4 years.27 However, in a study of 44 UK worksites,
exploring a WHPP designed to reduce physical inactivity, the
intervention was not cost-effective.28
In many countries, including SA, policy focuses on occupational
health and safety rather than on disease prevention in the
workplace, and there is a lack of empirical evidence to support
the cost-effectiveness of WHPPs.29 The literature on WHPPs in
Africa has focused on short-term feasibility or pilot studies.30
Therefore, further research on the cost-effectiveness of
interventions for the prevention of NCDs in the SA workplace
is needed. The aim of this study therefore was to determine the
incremental costs and consequences of the Healthy Choices at
Work (HCW) in terms of improvement in risk factors for NCDs
and sick leave absenteeism.
Study design
This study was an incremental cost and consequence study of
the HCW programme at a commercial power plant in the
Western Cape, SA.31,32 An incremental cost analysis was
performed for additional costs incurred to the organisation
resulting from the actions of the HCW. This study compared
the incremental costs of implementing the HCW programme
over 2 years with the consequences in terms of changes in
risk factors for NCDs and sick leave.
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This study was conducted at a commercial power plant
within a nature reserve close to Cape Town, SA. The 1743
permanent employees had a wide range of occupations,
which included engineers, plant operators, physicists,
technicians, artisans and support staff working in shifts.
The power plant included a health and wellness department
that conducted routine annual health risk assessments
(HRAs) on self-selected employees and provided occupational
health services. All staff members in the organisation
were entitled to 180 days of sick leave over a 3-year cycle
and were insured for medical care. The on-site health and
wellness department conducted periodic medicals (physical
examination, medical investigation of lung function, hearing,
vision, heat stress and full blood counts on employees). Food
was subsidised and provided by an external company which
was contracted to operate the canteen and vending machines.
The power plant operated in a highly pressurised environment
because of the lack of generation capacity in SA relative to the
increased demand for electricity. Employees worked very
intensively during outages when generation was halted for
routine maintenance.
The Healthy Choices at Work programme
The HCW intervention, which took place over 2 years, was
implemented by participatory action research with a
cooperative inquiry group (CIG) and is more fully described in
a separate publication.33 A diverse CIG made up of 11 key
decision-makers across the organisation (one financial manager,
one wellness manager, one senior occupational health nurse,
three engineering managers, two project management advisors,
one industrial relations manager, one quality control officer
and a manager from the organisation’s training department)
led the intervention. The intervention focused on four key
1. Catering and the provision of food: A new wellness
meal (a low-fat, low-salt option with additional vegetables
and fruit) was made available to employees on all shifts
at no additional cost to them and was actively promoted
to all workers via in-house daily newsflash articles, work
team sessions and multimedia presentations. Healthy
affordable snacks were also sold at the cafeterias, and
fruit was provided as a healthy snack to employees
working extended shifts.
2. Opportunities for physical activity: Areas were identified
within the surrounding nature reserve for walking,
running and cycling, and functional exercise classes were
held four times a week. First Friday sports took place
once a month and staff members were released from their
duties to participate in 2.5 km/5 km walks, a 10 km run or
a 25 km cycling. Employees were also encouraged to
participate with their families in weekend park runs
within their own communities.
3. Provision of health and wellness services: The HCW
included two annual HRAs during the intervention. The
HRAs provided feedback on NCD risk and the health and
wellness team offered counselling to employees on
behavioural change. Staff at the Health and Wellness
department participated in a 3-day training course on
brief behavioural change counselling using the 5 As (Ask,
Alert, Assess, Assist and Arrange) approach in a guiding
style to assist employees in making healthy lifestyle
4. Managerial buy-in and participation: The management
team consisted of an executive committee with 10–12
senior managers led by a general manager. Managers
approved the prevention programme and led by example
in choosing wellness meals, marketing activities,
participating in physical activities and promoting health
by broadcasting discussions of their own behavioural
Evaluaon of incremental costs
Incremental costs to the organisation that were associated
with implementing the HCW were calculated for the 2-year
period. Incremental costs were defined as additional costs
that were incurred on top of existing expenditure. For
example, allowing employees to participate in first Friday
sports did not alter the cost of salaries and therefore these
costs were not included, although the purchasing of additional
exercise equipment was included. Research-related costs
were excluded.
Activities that led to incremental costs were identified by the
CIG for the four key areas of the intervention (catering,
physical activity, health and wellness and management
support). The information on costs was sourced from the
organisation’s financial system by the finance manager and
entered into an Excel spreadsheet.
These costs are reported in the ‘Results’ section according to
the four main areas of intervention, which were further
analysed in terms of the cost per capita and cost per annum.
Evaluaon of changes in risk factors for non-
communicable diseases
A before-and-after study evaluated the changes in risk factors
for NCDs, and the methods are fully reported elsewhere.35 The
study population was all permanent employees working at
the power plant, and there were no specific exclusion criteria.
A sample of 156 employees was randomly selected. Sample
size calculations confirmed the power of this sample to detect
meaningful changes in risk factors for NCDs over time.36
Participants were assessed at baseline and 24 months by
means of questionnaires, physical measurements and clinical
tests performed by trained health professionals from the
health and wellness department. The questionnaires included
data on demographic information, medical and family
history, medication use, diet, physical activity, alcohol
consumption and psychosocial stress factors. The Global
Physical Activity Questionnaire (GPAQ) was used to quantify
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levels of physical activity.37 Data on alcohol use were collected
by using the validated Alcohol Use Disorders Identification
Test (AUDIT) questionnaire.38 Questions on tobacco smoking,
fruit and vegetable intake were extracted from the South
African Demographic Health Survey Questionnaire.39
Questions on psychosocial stress at work or at home were
obtained from the organisation’s in-house HRA questionnaire.
Clinical tests included blood pressure, blood glucose and
total cholesterol, with physical measurements of body mass
index, waist-to-hip ratio and a 10-year cardiovascular risk
assessment. Blood pressure was measured by using
standardised procedures for systolic and diastolic blood
pressures.40 Point-of-care testing for random blood glucose
and total cholesterol utilised a finger prick capillary blood
sample.41 Standing height, weight and waist and hip
circumferences were measured and body mass index and
waist-to-hip ratio were calculated.41 A 10-year cardiovascular
risk was assessed for each participant.42
Data were captured in an Excel spreadsheet and checked for
errors or omissions. Data were then analysed using the
Statistical Package for the Social Sciences (SPSS) Version 24.1,
IBM, New York.
Metabolic equivalence of task metabolic equivalence of task
(MET) minutes were calculated from the GPAQ data. A
minimum of 600 MET minutes per week was required to be
considered physically active. The AUDIT questionnaire
included 10 questions with a 4-point Likert scale that gave a
possible total score of 40. Respondents with a score of 7 or less
were categorised as sensible drinkers, those with a score of 8–19
were categorised as potentially harmful drinkers and those with
a score of 20 or more were categorised as potentially dependent
drinkers. Descriptive analysis was used to calculate the mean
and standard deviation or frequency and percentage of all
variables at baseline and follow-up.
Paired t-tests were used to compare the mean differences for
normally distributed numerical data (e.g. blood pressure,
blood glucose, total cholesterol, body mass index, waist
circumference, waist-to-hip ratio [WHR]) from baseline to
follow-up at 2 years. McNemar’s chi-square test was used to
compare paired binary categorical data from before to after
(e.g. psychosocial stress, smoking, fruit and vegetables).
Statistical significance was set at p < 0.05.
Evaluaon of changes in sick leave
Changes in sick leave related to NCDs were evaluated on the
same sample of 156 employees as described above in the
before-and-after study. Employee data on sick leave were
collected on an annual basis by the Human Resources
Information System. For this study, data were extracted on
the study sample at baseline for the year prior to this study
and at 2-year follow-up for the second year of the study
intervention. Sick leave was measured in the following ways:
The Gross Sickness Absentee Rate (GSAR) measured
person days lost because of sick leave as a percentage of
the total potential working days. The GSAR is always
expressed as a percentage and is the international
standard used for comparison of sickness absenteeism
between companies, other work forces and countries.43
The ideal GSAR to aim for in SA is between 2% and 5%.44
The absentee frequency rate (AFR) is the number of
absence incidents per person for a given period and is
calculated as the total number of absence incidents over a
12-month period divided by the number of employees
over a 12-month period. Only the number of incidents
and not the duration is calculated and a favourable AFR
is less than 0.5.44
All data were captured on an Excel spreadsheet and checked
for errors or omissions before analysis using IBM SPSS
software version 25.1. Descriptive analysis was used to
calculate the mean and standard deviation of GSAR and AFR
before and after the intervention. Pearson’s correlation
coefficient (r) test was conducted to investigate the relationship
between GSAR and AFR for systolic blood pressure, diastolic
blood pressure and total cholesterol, assuming that they were
normally distributed. A one-way between-subjects analysis of
variance (ANOVA) was conducted to compare the effect of
fruit and vegetable intake and psychosocial stress on GSAR
and AFR.
Ethical consideraon
Ethics approval was obtained from the Health and Research
Ethics Committee (HREC) of Stellenbosch University
(S15/08/165) and permission was obtained from the power
plant to conduct this study. Written consent was obtained
from each participant of the study.
Incremental costs
Table 1 shows the incremental costs for the four key areas
targeted in the intervention. The total incremental cost to the
company was R59 183, which equated to an average of
R29 591 per annum. The average incremental cost per
employee for implementing the HCW was estimated as
R33.95 ($2.3) over 2 years or R16.98 ($1.15) per annum.
For physical activity, the incremental costs included the costs
of equipment for functional exercise activities (e.g. mats,
balls, skipping ropes) and the first Friday sports (e.g. colour
TABLE 1: Incremental costs for acvies.
Intervenon Cost for acvies,
Cost for acvies,
US $
Opportunies for physical acvity 31 583 2143
Catering and the provision of food 11 400 773
Provision of health and wellness services 16 200 1099
Managerial buy-in and parcipaon 0 0
Total 59 183 4015
, Exchange rate at 11 December 2019 of 1 Rand to US $0.068.
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powder). For catering activities, additional fruit was provided
during outages. For health and wellness services the costs
included the training of nine health professionals in brief
behavioural change counselling. There were no incremental
costs for the managers.
Changes in risk factors
The mean age of the participants was 42.7 years (standard
deviation [s.d.] = 9.7) and 64% were male. Table 2 presents the
changes in behavioural and psychosocial risk factors for NCDs
that were associated with the intervention. There were
significant reductions in harmful alcohol use, physical
inactivity and improved fruit and vegetable intake. There was
no change in tobacco smoking. Participants reported
significantly improved relationships with colleagues and self-
perceived health that could possibly be attributed to the
intervention. There were also significant improvements
(Table 3) in mean systolic blood pressure (-10.2 mmHg),
diastolic blood pressure (-3.87 mmHg) and total cholesterol
(-0.45 mmol/L). There was no change in overweight, obesity
or random glucose.
Changes in sick leave
Tables 4 and 5 show the relationship between changes in sick
leave and changes in risk factors. Overall, there was no
meaningful correlation between sick leave and risk factors,
although a decrease in alcohol intake was weakly associated
with an increase in sick leave.
The HCW was associated with significant improvements
in risk factors for NCDs that are likely to be clinically
meaningful. This study also suggests that the HCW is a
highly affordable intervention. Significant improvement in
risk factors for NCDs was seen with minimal incremental
costs to the company. The cost to implement the
intervention was approximately $1 per individual per
annum, which is important for LMICs where resources are
constrained. The WHO ‘best buys’ approach defined a
number of criteria to assess interventions, and these are
used to structure the discussion: affordability, capacity to
implement, feasibility according to national circumstances,
impact on health equity and the need to implement a
combination of population-wide policy interventions and
individual interventions.5 The HCW programme has the
potential to be considered a ‘best buy’ when assessed
according to these criteria.
TABLE 2: Change in behavioural and psychosocial risk factors (N = 137).
Risk factors Baseline
Behavioural risk factors
Sensible alcohol drinker (AUDIT score < 8) 78.2 93.5 0.001
Harmful alcohol drinker (AUDIT score 8–19) 21.0 4.8 -
Dependent alcohol drinker (AUDIT score > 20) 0.8 1.6 -
Tobacco smoking 25.0 21.8 0.344
Inadequate fruit and vegetable intake
(< 5 porons/day)
73.2 35.8 ˂ 0.001
Insuciently acve (<600 MET minutes/week) 55.9 34.7 ˂ 0.001
Psychosocial factors
Relaonship with colleagues 21.1 11.3 0.015
Lack of recognion 18.8 18.8 1.000
Lack of resources to do my work 29.5 30.3 1.000
Lack of meaningful work 15.1 13.5 0.664
Relaonship with my supervisor 9.8 12.0 0.664
Lack of clarity concerning work outputs 20.9 15.7 0.265
Personal nances 29.8 18.3 0.008
My health or family member’s health 22.3 10.8 0.006
Relaonship with family and children 16.0 13.7 0.690
Relaonship with my partner or spouse 13.3 9.2 0.210
Emoonal and mental health concerns 8.8 4.7 0.227
I have challenges with addicons 3.3 0.8 0.250
AUDIT, Alcohol Use Disorders Idencaon Test; MET, metabolic equivalence of task.
TABLE 4: Relaonship of sick leave and categorical risk factors.
Risk factors Mean change
s.d. pMean change
in AFR
s.d. p
Change in fruit and vegetable intake
Increase in intake (n = 29) -0.67 2.9 0.017 -0.52 1.9 0.892
No change in intake (n = 55) 0.51 4.4 -0.25 3.0
Decrease in intake (n = 9) -1.0 3.1 -0.56 2.8
Change in perceived personal and family health
Increase in stress (n = 4) 0.95 0.8 0.918 -1.75 2.9 0.087
No change in stress (n = 73) -0.16 4.8 -0.23 2.8
Decrease in stress (n = 16) -0.86 3.4 -0.37 2.3
Change in relaonship with colleagues
Increase in stress (n = 4) -1.99 3.1 0.711 0.50 1.7 0.552
No change in stress (n = 68) -0.10 3.7 -0.03 2.6
Decrease in stress (n = 19) -2.13 7.1 -1.53 3.0
GSAR, gross sickness absentee rate; s.d., standard deviaon; AFR, absentee frequency rate.
TABLE 3: Change in metabolic risk factors (N = 137).
Risk factors Baseline Follow-up Mean of the
95% CI p
Mean s.d. Mean s.d.
Systolic blood
pressure (mmHg)
131.6 18.5 121.4 14.6 -10.2 -7.3: -13.2 < 0.001
Diastolic blood
pressure (mmHg)
83.4 13.7 79.5 8.8 -3.87 -1.8: -5.8 ˂ 0.001
Total cholesterol
5.6 1.1 5.1 1.1 -0.45 -0.3: -0.6 ˂ 0.001
Random glucose
5.7 1.5 6.0 2.0 0.31 -0.6: 0.2 0.069
Body mass index
29.0 5.5 29.0 5.7 -0.05 -0.4: 0.3 0.760
circumference (cm)
92.1 14.3 92.2 14.4 0.05 -1.1: 1.0 0.926
rao (cm)
0.86 0.1 0.87 0.1 -0.00 -0.0: 0.0 0.484
s.d., standard deviaon; CI, condence interval.
TABLE 5: Correlaon of sick leave with numerical risk factors.
Correlaon Pearson correlaon (r)p
GSAR vs. systolic blood pressure 0.171 0.096
GSAR vs. diastolic blood pressure -0.102 0.325
GSAR vs. total cholesterol -0.168 0.101
GSAR vs. AUDIT -0.258 0.011
GSAR vs. METS -0.048 0.642
AFR vs. systolic blood pressure -0.087 0.399
AFR vs. diastolic blood pressure -0.160 0.118
AFR vs. total cholesterol -0.154 0.135
AFR vs. AUDIT -0.259 0.011
AFR vs. METS -0.002 0.981
GSAR, gross sickness absentee rate; AUDIT, Alcohol Use Disorders Idencaon Test; METS,
metabolic equivalence of task; AFR, absentee frequency rate.
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The implementation of HCW was very affordable when
compared with other types of interventions. For example,
using the Internet as a vehicle for health promotion to impact
physical activity as well as fruit and vegetable intake was
more costly ($425 per person) and not effective.45 The cost to
implement a system-level dietary modification intervention
to reduce absenteeism in the workplace was $56 per employee
per annum.26
Programmes such as HCW that focus primarily on
environmental modification rather than education from
health professionals in the workplace are more likely to be
affordable.23 The HCW programme also appears more
affordable than some community-based interventions for
reduction in systolic blood pressure ($62 per person for a 1
mmHg decrease versus $1 per person for a 10 mmHg
decrease), especially as the HCW cost was not limited to an
effect on blood pressure alone.46
Capacity to implement
Sufficient and trained capacity was provided in the form of a
dedicated team of professionals from the organisational
health and wellness department as well as from the
operational sectors in the organisation and CIG. The alcohol
policy and subsidised policy on providing wellness meals
was incorporated in the organisational regulations. Future
capacity can be increased by incorporating a train-the-trainer
programme whereby volunteers within the organisation are
invited as health and wellness champions and trained on
how to implement WHPP. An example of such a programme
is the Work@Health T3 Programme, an evidence-based
curriculum whereby employees and contract staff are trained
in health promotion to train other employees. The Work@
Health programme is effective in that the curriculum can be
adapted to the context and culture of the organisation and
therefore build on the internal capacity to sustain health
promotion in the workplace.47
Feasibility according to naonal circumstances
This study shows the feasibility of utilising currently
available resources to relieve the burden of NCDs amongst
employees. However, the HCW relied on significant indirect
costs (extended time given off for participation in sport,
staff within the organisation rendering the necessary
services, clinical testing, media and advertising and
occupational health services) made possible by the
commitment of the senior management team of the
Impact on health equity of intervenons
Inequalities in health status were indirectly addressed as the
whole organisation was open to participate in the activities
and enjoyed the benefits of the HCW programme. In broader
terms, the HCW programme contributed to improving health
equity for permanent and contract staff by partnering with
community and government organisations to participate in
additional wellness activities and receive education on
NCDs. Health equity was a leader-driven priority, whereby
all staff members were encouraged to participate in activities,
irrespective of their employment status within the
organisation. However, full equity was not afforded to
contract workers as they did not have the same advantages of
permanent employees (access to private medical insurers,
time off incentives and access to healthcare facilities on the
commercial plant).
The need to implement a combinaon of
populaon-wide policy intervenons and
individual intervenons
The HCW programme itself targeted the whole workplace-
based population and not just individuals in its systematic
changes to the environment, although it also included
individual-level interventions such as behavioural change
counselling. Implementation of WHPPs of this nature
throughout SA workplaces could contribute to policy
interventions that target the employed population.
Although we were unable to calculate an incremental cost-
effectiveness ratio for the HCW, we believe that given the
very low cost it is likely to meet the WHO best buy criteria of
< $100/disability adjusted life year (DALY) for LMICs.16 If
additional funding can be obtained, such a calculation will be
There was no relationship between the HCW programme
and the reduced sick leave. Absenteeism because of illness
may have been influenced by many different factors,
which could mask any impact of the HCW on sickness
from NCDs. The time frame may be too short to determine
the impact of the HCW on NCDs and there are
complications such as cardiovascular events. As the impact
of the HCW will only be felt years later, the HCW needs
further evaluation to determine effectiveness on
absenteeism. The correlation between a reduction in
harmful alcohol use and an increase in sick leave was
unexpected. The reduction in alcohol use was attributed to
the HCW intervention, and it is difficult to explain why
this would lead to an increase in sick leave. Elsewhere a
similar phenomenon has been noted, but attributed to a
link between reduction in alcohol intake and the
development of other illnesses.48 Other studies found a
U-shaped relationship between alcohol consumption and
sickness absenteeism such that people who abstained from
alcohol had higher sickness absenteeism than people who
consumed alcohol moderately.49
Although the incremental costs and consequences have
been compared in this study, it would have been helpful to
calculate an incremental cost-effectiveness ratio. A mini
Markov model has been developed for the South African
Page 7 of 8 Original Research
hp:// Open Access
context to assess the incremental cost effective ratio (ICER)
for interventions on risk factors for NCDs. Unfortunately
the model is available only in the United States, and
additional funds would be needed to analyse the data. This
study did not measure indirect costs (salaries, treatment,
clinical tests, travelling, reimbursements, catering, devices,
etc.) already paid for by the organisation or costs associated
with NCDs borne by the employee.
The before-and-after study design cannot prove the
effectiveness of the HCW per se but has allowed the
researcher to measure changes in risk factors associated
with the intervention. The whole organisation was
exposed to the intervention, which made the selection of
a control group difficult. Improvements in risk factors
could be because of other confounding factors, although
prior to the intervention the annual HRAs suggested a
progressive increase in risk as retrieved from employee
medical records.
As the HCW appears to be cost-effective, the programme
could be implemented in other medium and large
enterprises, which have similar organisational settings to
potentially deliver the programme.
Further evidence of cost-effectiveness should be obtained
from experimental study designs that include full cost-
effectiveness analysis and measurement of the impact on
The low-cost and beneficial consequences of the HCW
support the inclusion of such WHPPs in the National
Department of Health’s policy on NCD prevention and
This study has demonstrated low incremental costs and
substantial beneficial consequences in terms of risk factors
for NCDs in the HCW programme. Despite reductions in risk
factors, there was no reduction in sick leave. This study
supports the value of WHPPs in the SA policy context for
similar large and moderate enterprises to reduce the risk of
NCDs. Future studies should formally measure the
incremental cost-effectiveness ratio and also assess the effect
on productivity.
The authors are grateful to the management, participants and
the cooperative inquiry group at the commercial power plant
for their participation, who helped to design the HCW
Compeng interests
The authors have declared that no competing interests
Authors’ contribuons
D.D.S. conceptualised the study. All data were collected and
analysed by D.D.S. This article was written by D.D.S. and
revisions were made by R.M. Both authors approved the final
draft of the article.
Funding informaon
The authors would like to thank the Harry Crossley
Foundation at Stellenbosch University (S15/08/165) and the
Chronic Disease Initiative of Africa (CDIA) for the funding of
this study.
Data availability statement
Data sharing is not applicable to this article as no new data
were created or analysed in this study.
The views and opinions expressed in this article are those of
the authors and do not necessarily reflect the official policy or
position of any affiliated agency of the authors.
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... From 2011 to 2025, the cumulative lost output with non-communicable diseases is projected to be US$7.28 trillion in LMICs which is approximately a loss of US$500 billion per year [25]. Cardiovascular diseases including hypertension account for nearly half this cost [26]. ...
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Introduction Hypertension is a major threat to public health globally. Especially in sub-Saharan African countries, this coexists with high burden of other infectious diseases, creating a complex public health situation which is difficult to address. Tackling this will require targeted public health intervention based on evidence that well defines the at risk population. In this study, using retrospective data from two referral hospitals in Burundi, we model the risk factors of hypertension in Burundi. Materials and methods Retrospective data of a sample of 353 randomly selected from a population of 4,380 patients admitted in 2019 in two referral hospitals in Burundi: Military and University teaching hospital of Kamenge. The predictive risk factors were carried out by fixed effect logistic regression. Model performance was assessed with Area under Curve (AUC) method. Model was internally validated using bootstrapping method with 2000 replications. Both data processing and data analysis were done using R software. Results Overall, 16.7% of the patients were found to be hypertensive. This study didn’t showed any significant difference of hypertension’s prevalences among women (16%) and men (17.7%). After adjustment of the model for cofounding covariates, associated risk factors found were advanced age (40–59 years) and above 60 years, high education level, chronic kidney failure, high body mass index, familial history of hypertension. In absence of these highlighted risk factors, the risk of hypertension occurrence was about 2 per 1000 persons. This probability is more than 90% in patients with more than three risk factors. Conclusion The relatively high prevalence and associated risk factors of hypertension in Burundi raises a call for concern especially in this context where there exist an equally high burden of infectious diseases, other chronic diseases including chronic malnutrition. Targeting interventions based on these identified risk factors will allow judicious channel of resources and effective public health planning.
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Background: The WHO's "best buys" and other recommended interventions are a menu of policy options and cost-effective interventions for the prevention and control of major noncommunicable diseases (NCDs). The menu has six objectives, implementing which by member states is expected to promote the achievement of the nine NCD targets by 2025. In line with their context, countries can select from the menu of best buys and other recommended interventions. Iran adopted its national action plan on NCDs, 2015, including global as well as some specific goals and targets. This study had two objectives: analyzing the gaps to reach the national targets on NCDs; and prioritizing the best buys and other recommended interventions based on multi-criteria decision-making (MCDA) method for the context of Iran. Methods: This is a mixed-methods study. We used qualitative textual evidence (documentary content analysis) and MCDA for prioritization of interventions based on five criteria, including a number of people to be potentially affected by the intervention, cost-effectiveness of the intervention, attributable burden (DALY per 100,000), hospitalization and variations among income levels. Data related to five criteria for each intervention were extracted from national studies and relevant international organizations. The weight of each criterion determines based on the opinions of national experts. Results: Out of 105 actions and interventions recommended by WHO, only 12 of them were not on the national agenda in Iran, while the six missed interventions were related to objective number 4. Only one of the best buys Group's interventions was not targeted (vaccination against human papillomavirus, two doses of 9-13-year-old girls), for which arrangements are being made for the implementation. Encouraging and educating healthy dietary habits and increasing public awareness about the side effects of smoking and exposure to second-hand smoke, e.g., through mass media campaigns, are among the interventions in need of serious prioritization. The priority of interventions was independently calculated in the area of risk factors and clinical preventive interventions. Conclusion: Due to limited resources, low and middle-income countries (LMICs) need to identify and prioritize more cost-effective and more equitable interventions to combat the NCD epidemic. Based on our findings, we advocate more investment in the mass and social media campaigns to promote a healthy diet, avoid tobacco use, as well as the inclusion of some effective clinical preventive interventions into the national action plan, along the long pathway to tackle NCDs and ultimately reach sustainable health development in Iran. The use of the MCDA approach assisted us in formulating a simultaneous use of efficiency and equity, and other indices for prioritizing the interventions.
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Background: The workplace is an important setting for the prevention of non-communicable diseases (NCDs). Policies for transformation of the workplace environment for occupational health and safety in South Africa have focused more on what to do and less on how to do it. There are no guidelines and little evidence on workplace-based interventions for NCDs. Objective: The aim of this study was to learn how to transform the workplace environment in order to prevent and control cardio-metabolic risk factors for NCDs amongst the workforce at a commercial power plant in Cape Town, South Africa. Methods: The study design utilized participatory action research in the format of a cooperative inquiry group (CIG). The researcher and participants engaged in a cyclical process of planning, action, observation and reflection over a two-year period. The group used outcome mapping to define the vision, mission, boundary partners, outcomes and strategies required. At the end of the inquiry the CIG reached a consensus on their key learning. Results: Substantial change was observed in the boundary partners: catering services (78% of progress markers achieved), sport and physical activities (75%), health and wellness services (66%) and managerial support (65%). Highlights from a 10-point consensus on key learning included the need for: authentic leadership; diverse composition and functioning of the CIG; value of outcome mapping; importance of managerial engagement in personal and organizational change; and making healthy lifestyle an easy choice. Conclusion: Transformation included a multifaceted approach and an engagement with the organization as a living system. Future studies will evaluate changes in the risk profile of the workforce, as well as the costs and consequences for the organization.
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Aims To estimate differences in the strength and shape of associations between alcohol use and diagnosis‐specific sickness absence. Design A multi‐cohort study. Participants (n = 47 520) responded to a survey on alcohol use at two time‐points, and were linked to records of sickness absence. Diagnosis‐specific sickness absence was followed for 4–7 years from the latter survey. Setting and participants From Finland, we had population cohort survey data from 1998 and 2003 and employee cohort survey data from 2000–02 and 2004. From France and the United Kingdom, we had employee cohort survey data from 1993 and 1997, and 1985–88 and 1991–94, respectively. Measurements We used standard questionnaires to assess alcohol intake categorized into 0, 1–11 and > 11 units per week in women and 0, 1–34 and > 34 units per week in men. We identified groups with stable and changing alcohol use over time. We linked participants to records from sickness absence registers. Diagnoses of sickness absence were coded according to the International Classification of Diseases. Estimates were adjusted for sex, age, socio‐economic status, smoking and body mass index. Findings Women who reported drinking 1–11 units and men who reported drinking 1–34 units of alcohol per week in both surveys were the reference group. Compared with them, women and men who reported no alcohol use in either survey had a higher risk of sickness absence due to mental disorders [rate ratio = 1.51, 95% confidence interval (CI) = 1.22–1.88], musculoskeletal disorders (1.22, 95% CI = 1.06–1.41), diseases of the digestive system (1.35, 95% CI = 1.02–1.77) and diseases of the respiratory system (1.49, 95% CI = 1.29–1.72). Women who reported alcohol consumption of > 11 weekly units and men who reported alcohol consumption of > 34 units per week in both surveys were at increased risk of absence due to injury or poisoning (1.44, 95% CI = 1.13–1.83). Conclusions In Finland, France and the United Kingdom, people who report not drinking any alcohol on two occasions several years apart appear to have a higher prevalence of sickness absence from work with chronic somatic and mental illness diagnoses than those drinking below a risk threshold of 11 units per week for women and 34 units per week for men. Persistent at‐risk drinking in Finland, France and the United Kingdom appears to be related to increased absence due to injury or poisoning.
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Objective To evaluate the costs, benefits and cost-effectiveness of complex workplace dietary interventions, involving nutrition education and system-level dietary modification, from the perspective of healthcare providers and employers. Design Single-study economic evaluation of a cluster-controlled trial (Food Choice at Work (FCW) study) with 1-year follow-up. Setting Four multinational manufacturing workplaces in Cork, Ireland. Participants 517 randomly selected employees (18–65 years) from four workplaces. Interventions Cost data were obtained from the FCW study. Nutrition education included individual nutrition consultations, nutrition information (traffic light menu labelling, posters, leaflets and emails) and presentations. System-level dietary modification included menu modification (restriction of fat, sugar and salt), increase in fibre, fruit discounts, strategic positioning of healthier alternatives and portion size control. The combined intervention included nutrition education and system-level dietary modification. No intervention was implemented in the control. Outcomes The primary outcome was an improvement in health-related quality of life, measured using the EuroQoL 5 Dimensions 5 Levels questionnaire. The secondary outcome measure was reduction in absenteeism, which is measured in monetary amounts. Probabilistic sensitivity analysis (Monte Carlo simulation) assessed parameter uncertainty. Results The system-level intervention dominated the education and combined interventions. When compared with the control, the incremental cost-effectiveness ratio (€101.37/quality-adjusted life-year) is less than the nationally accepted ceiling ratio, so the system-level intervention can be considered cost-effective. The cost-effectiveness acceptability curve indicates there is some decision uncertainty surrounding this, arising from uncertainty surrounding the differences in effectiveness. These results are reiterated when the secondary outcome measure is considered in a cost–benefit analysis, whereby the system-level intervention yields the highest net benefit (€56.56 per employee). Conclusions System-level dietary modification alone offers the most value per improving employee health-related quality of life and generating net benefit for employers by reducing absenteeism. While system-level dietary modification strategies are potentially sustainable obesity prevention interventions, future research should include long-term outcomes to determine if improvements in outcomes persist. Trial registration number ISRCTN35108237; Post-results.
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Background Non-communicable diseases (NCDs) are the leading cause of death and disability worldwide, with low-income and middle-income countries experiencing a disproportionately high burden. Since 2010 WHO has promoted 24 highly cost-effective interventions for NCDs, dubbed ‘best buys’. It is unclear whether these interventions have been evaluated in low-income and lower-middle-income countries (LLMICs). Aim To systematically review research on interventions aligned to WHO ‘best buys’ for NCDs in LLMICs. Methods We searched 13 major databases and included papers conducted in the 83 World Bank-defined LLMICs, published between 1 January 1990 and 5 February 2015. Two reviewers independently screened papers and assessed risk of bias. We adopted a narrative approach to data synthesis. The primary outcomes were NCD-related mortality and morbidity, and risk factor prevalence. Results We identified 2672 records, of which 36 were included (608 940 participants). No studies on ‘best buys’ were found in 89% of LLMICs. Nineteen of the 36 studies reported on the effectiveness of tobacco-related ‘best buys’, presenting good evidence for group interventions in reducing tobacco use but weaker evidence for interventions targeting individuals. There were fewer studies on smoking bans, warning labels and mass media campaigns, and no studies on taxes or marketing restrictions. There was supportive evidence that cervical screening and hepatitis B immunisation prevent cancer in LLMICs. A single randomised controlled trial supported polypharmacy for cardiovascular disease. Fourteen of the ‘best buy’ interventions did not have any good evidence for effectiveness in LLMICs. Conclusions We found studies on only 11 of the 24 interventions aligned with the WHO ‘best buys’ from LLMIC settings. Most LLMICs have not conducted research on these interventions in their populations. LLMICs should take action to implement and evaluate ‘best buys’ in their national context, based on national priorities, and starting with interventions with the strongest evidence base.
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Context Effective community-based interventions are available to control hypertension. It is important to determine the economics of these interventions. Evidence acquisition Peer-reviewed studies from January 1995 through December 2015 were screened. Interventions were categorized into educational interventions, self-monitoring interventions, and screening interventions. Incremental cost-effectiveness ratios were summarized by types of interventions. The review was conducted in 2016. Evidence synthesis Thirty-four articles were included in the review (16 from the U.S., 18 from other countries), including 25 on educational interventions, three on self-monitoring interventions, and six on screening interventions. In the U.S., five (31.3%) studies on educational interventions were cost saving. Among the studies that found the interventions cost effective, the median incremental costs were $62 (range, $40–$114) for 1-mmHg reduction in systolic blood pressure (SBP) and $13,986 (range, $6,683–$58,610) for 1 life-year gained. Outside the U.S., educational interventions cost from $0.62 (China) to $29 (Pakistan) for 1-mmHg reduction in SBP. Self-monitoring interventions, evaluated in the U.S. only, cost $727 for 1-mmHg reduction in SBP and $41,927 for 1 life-year gained. For 1 quality-adjusted life-year, screening interventions cost from $21,734 to $56,750 in the U.S., $613 to $5,637 in Australia, and $7,000 to $18,000 in China. Intervention costs to reduce 1 mmHg blood pressure or 1 quality-adjusted life-year were higher in the U.S. than in other countries. Conclusions Most studies found that the three types of interventions were either cost effective or cost saving. Quality of economic studies should be improved to confirm the findings.
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Currently, in some countries occupational health and safety policy and practice have a bias toward secondary prevention and workers' compensation rather than primary prevention. Particularly, in emerging economies, research has not adequately contributed to effective interventions and improvements in workers' health. This article, using South Africa as a case study, describes a methodology for identifying candidate fiscal policy interventions and describes the policy interventions selected for occupational health and safety. It is argued that fiscal policies are well placed to deal with complex intersectoral health problems and to focus efforts on primary prevention. A major challenge is the lack of empirical evidence to support the effectiveness of fiscal policies in improving workers' health. A second challenge is the underprioritization of occupational health and safety partly due to the relatively small burden of disease attributed to occupational exposures. Both challenges can and should be overcome by (i) conducting policy-relevant research to fill the empirical gaps and (ii) reconceptualizing, both for policy and research purposes, the role of work as a determinant of population health. Fiscal policies to prevent exposure to hazards at work have face validity and are thus appealing, not as a replacement for other efforts to improve health, but as part of a comprehensive effort toward prevention.
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Background The leading cause of death among firefighters in the United States (U.S.) is cardiovascular events (CVEs) such as sudden cardiac arrest and myocardial infarction. This study compared the cost-effectiveness of three strategies to prevent CVEs among firefighters. Methods We used a cost-effectiveness analysis model with published observational and clinical data, and cost quotes for physiologic monitoring devices to determine the cost-effectiveness of three CVE prevention strategies. We adopted the fire department administrator perspective and varied parameter estimates in one-way and two-way sensitivity analyses. ResultsA wellness-fitness program prevented 10% of CVEs, for an event rate of 0.9% at $1440 over 10-years, or an incremental cost-effectiveness ratio of $1.44 million per CVE prevented compared to no program. In one-way sensitivity analyses, monitoring was favored if costs were < $116/year. In two-way sensitivity analyses, monitoring was not favored if cost was ≥ $399/year. A wellness-fitness program was not favored if its preventive relative risk was >0.928. Conclusions Wellness-fitness programs may be a cost-effective solution to preventing CVE among firefighters compared to real-time physiologic monitoring or doing nothing.
Small- and mid-sized employers are less likely to have expertise, capacity, or resources to implement workplace health promotion programs, compared with large employers. In response, the Centers for Disease Control and Prevention developed the Work@Health(®) employer training program to determine the best way to deliver skill-based training to employers of all sizes. The core curriculum was designed to increase employers' knowledge of the design, implementation, and evaluation of workplace health strategies. The first arm of the program was direct employer training. In this article, we describe the results of the second arm-the program's train-the-trainer (T3) component, which was designed to prepare new certified trainers to provide core workplace health training to other employers. Of the 103 participants who began the T3 program, 87 fully completed it and delivered the Work@Health core training to 233 other employers. Key indicators of T3 participants' knowledge and attitudes significantly improved after training. The curriculum delivered through the T3 model has the potential to increase the health promotion capacity of employers across the nation, as well as organizations that work with employers, such as health departments and business coalitions.