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Research Increasingly Links Health to Physical, Mental, And Spiritual Well-Being

Dr. Burke is manager, St. Vincent Sports Medicine and Wellness Services, Carmel, IN.

Summary

Wellness has gained a foothold in most healthcare delivery systems because of its focus: Keeping people well is the ultimate goal of a healthcare system.

Three generations of wellness models have evolved over the past 16 years. First-generation wellness efforts focus on reducing health risks. Hospitals have developed programs and services to improve customers' and employees' health status. And corporations are lowering health risks by offering employees worksite fitness centers, cholesterol and other screenings, and smoking-cessation programs.

Second-generation wellness efforts link wellness to benefits. Hospitals and corporations have implemented health incentive programs, structured to reward people for maintaining low ranges in their controllable health risk factors.

Third-generation wellness efforts show that connectedness can improve health. Such efforts emphasize the importance of spiritual and emotional well-being as an inextricable part of physical health and healing. Today prayer and support groups, guided imagery, and prayerful meditation are becoming more mainstream. Such wellness approaches encourage persons to think and care for themselves more holistically.

In this era of uncertainty, Catholic healthcare providers are challenged to maintain a focus on the heritage of healing ministry that gave their hospitals a purpose and mission. Most Catholic hospitals say that carrying on Christ's healing ministry is their reason for existence. But what model do hospitals use for this ministry? And is this model still adequate?

Wellness in Healthcare
Religious-sponsored hospitals frequently interpret their healing mission as holistic. Just as Christ healed the whole person, the Catholic healthcare ministry addresses the needs of body, mind, and spirit. The holistic approach to healing has become synonymous with the wellness model. Sixteen years ago Don Ardell wrote of an expanded healthcare mission, which included not just curing the body but developing humans to their full potential for well-being.¹ A few years later, John W. Travis, MD, and Regina Ryan noted that "wellness is the integration of body, mind and spirit—the appreciation that everything you do, and think and feel and believe has an impact on your state of health."²

Wellness has gained a foothold in most healthcare delivery systems because of its focus: Keeping people well is the ultimate goal of a healthcare system. And as hospitals increasingly deal with the business of healthcare, wellness now makes economic sense both for the healthcare provider holding at-risk managed care contracts and for the cost-conscious corporation.

Reducing Health Risks
How can a corporation—or its healthcare provider—reduce health risks and improve or maintain its employees' health? One way hospitals have accomplished this is by developing programs and services to improve customers' health status. Corporations are lowering health risks by offering employees worksite fitness centers, cholesterol and other screenings, and smoking-cessation programs.

These first-generation wellness programs center around reducing measurable risk factors, such as high blood pressure, high cholesterol, high percentage of body fat, smoking, nonuse of seat belts, and excessive alcohol consumption. The field of "prospective medicine," developed by Robbins and Hall, focuses on quantifying behavioral risk factors that could lead to symptoms of disease and then to the disease itself.³

The following data show that healthcare providers have accepted this approach:

• In 1986 the U.S. Department of Health and Human Services reported that nearly 66 percent of the nation's worksites with 50 or more employees had at least one health promotion program.⁴
• According to the American Hospital Association, in 1986 nearly 75 percent of all community hospitals offered health promotion programs, compared with about 50 percent of all hospitals in 1985.⁵
• Through a 1990 survey, the Wyatt Company found that, of more than 900 companies, 50 percent had smoking-cessation programs, 38 percent offered employee-fitness activities, and 36 percent provided weight-management activities.⁶
• In a Robert Half International survey, 74 percent of responding managers from U.S. firms with 20 or more employees said physical wellness programs would be the most important fringe benefit to offer employees in 1993.⁷

Linking Wellness to Benefits
Although second-generation wellness programs continue to consider health risk factors, the focus in the past few years has been away from offering programs to achieving results. Today, many hospitals are implementing health incentive programs on their own campuses and at corporate sites. These programs are structured to reward people for maintaining low ranges in their controllable health risk factors. For example:

• Some third-party administrators work with hospitals to initiate voluntary programs in which employees can be tested to determine their risk level. Persons at less risk pay lower insurance premiums.
• Some corporations use incentives (e.g., cash, prizes, special benefits) to reward people who achieve or maintain low risk factors. Omaha-based Wellness Council of America reports that such incentive programs can increase adherence to health regimens by 10 percent to 20 percent of employees.⁸ The Hay Group has called incentives "the next frontier in health cost control."⁹ A real advantage of this incentive approach to wellness is that it involves persons in prevention concepts who might not be interested otherwise. Companies are taking the incentive approach when voluntary wellness programs and screenings have been unsuccessful.

Based on such programing and structured incentives, a growing body of evidence indicates that significant changes in health status can occur:

• In 1991 General Electric estimated it saved up to $1 million in health insurance costs for employees who joined its fitness center in Cincinnati.¹⁰
• In 1990 Merrill Lynch & Company found that participants in a cholesterol screening program lowered their cholesterol by an average of 8.3 percent.¹¹
• In 1990 Robert L. Bertera reported that, based on a study at Du Pont Company, every dollar invested in workplace health promotion can yield $1.42 a year (over two years) in lower absentee rates.¹²
• An extensive four-year study through the Blue Cross/Blue Shield associations showed that health promotion participants averaged 24 percent lower healthcare costs than nonparticipants.¹³
• Using an incentive award for risk-factor reduction, St. Vincent Hospital and Health Care Center, Indianapolis, has experienced a 30 percent increase in employees with no risk factors (see "St. Vincent Wellness Services: A Brief History" at the end of this article, p. 36).

Linking Connectedness and Health
Although first- and second-generation approaches to wellness efforts have been widely accepted and incorporated, they are still limited. Both approaches focus on the physical side of the holistic model. This is understandable: These approaches are easily measurable and fit into current biomedical thinking.

However, another body of research is beginning to affect the way wellness efforts are being conceived, developed, and implemented today. It shows that healthier persons are connected with others. This research may bring a more holistic slant to wellness efforts, emphasizing the importance of spiritual and emotional well-being as an inextricable part of physical health and healing. The following studies are the most significant:

• In their research on the "hardy executive," Salvatore Maddi and Suzanne Kobasa found that persons in stressful situations who did not develop physical symptoms and disease were those who mentally saw their situation as a challenge, something over which they had control and to which they were committed.¹⁴ An attitude of inner power in facing a situation made the difference in how it affected them.
• The Alameda County, CA, study tracked the health habits of 6,928 men and women. Those who were socially isolated had a two to three times greater risk of death from both heart disease and all other causes when compared with those who felt connected to others. These results were independent of all typical cardiac risk factors.¹⁵
• G. A. Kaplan reported that when monkeys' social networks were disrupted, they developed coronary artery blockages twice as severe as those of nondisrupted monkeys with comparable cholesterol and blood pressure levels.¹⁶
• One of the most cited studies on the significance of nontraditional health risk factors is one in which genetically similar rabbits were placed on a high cholesterol diet in an effort to induce atherosclerosis.¹⁷ The researchers expected all the rabbits to develop heart disease, but only slightly more than half did—only the rabbits in the top cages. The only variable the researchers could find was that the laboratory assistant would take the rabbits out of the lower cages when she fed them and would pet and play with them. She could not reach the rabbits in the upper cages. The study was repeated with this variable, and the results were replicated. Of rabbits with comparable genetic makeup and diet, those who were petted developed 60 percent less atherosclerosis compared with the rabbits who were not petted.
• A cardiologist did a double-blind, randomized study on patients in the coronary care unit of San Francisco General Hospital. Of the 393 patients in the study, 192 had 5 to 7 people praying for them; the other 201 did not. Neither group was aware of the prayer efforts. The group that was being prayed for had fewer complications, required fewer antibiotics, and required no intubation (compared with 12 in the nonprayer group).¹⁸

These studies are only a small part of the growing body of evidence that living beings are more interconnected than most healthcare experts have suspected. The data indicate the importance of persons' connectedness to themselves, others, and a spiritual power. Such evidence has led University of California, San Francisco Medical School research cardiologist Dean Ornish, MD, to call isolation a major risk factor for heart disease.¹⁹

Wellness Model's Success
As the wellness model matures and the reduction of physical health risk factors becomes a common aspect of hospital and corporate programs, the wellness model needs to be reexamined to determine its direction for the year 2000. Healthcare providers have done a good job of making people aware of physiological health risk factors and of the importance of using seat belts, refraining from driving while intoxicated, and stopping smoking. A 1993 Lou Harris poll of 1,251 adults nationwide showed that 76 percent were nonsmokers (an all-time high) and that regular seat belt use had increased to 70 percent, up 19 percent from 1983.²⁰ Of persons responding, 88 percent reported moderate to no drinking of alcohol.

In the next decade healthcare providers will be challenged to focus on ways to enhance the mental, emotional, and spiritual well-being of patients and clients. As evidence has shown, these areas may be as significant to health status as the more traditional health risk factors.

The popularity of Bill Moyers's Healing and the Mind²¹ suggests the timing is right for a greater openness to prayer and support groups, guided imagery, and prayful meditation, all of which can have a positive effect on health. The following examples show how such approaches, which are becoming more mainstream, have encouraged persons to think of and care for themselves more holistically:

• New England Deaconess Hospital, Boston, has implemented a mind-body clinic that uses meditation, breathing techniques, and stretching in its healing program.
• Mercy Hospital and Medical Center in Chicago has established a mind-body medical institute, the first affiliate of the program at New England Deaconess Hospital.
• The University of Massachusetts Medical Center, Worcester, has developed a stress reduction clinic that uses meditation as a primary treatment modality.
• Certain assessment instruments are increasingly being used to help people evaluate the pressures and satisfactions in their work and personal world; assess their coping responses; and determine their inner resources of connectedness to themselves, others, and a spiritual power. Such assessments are excellent tools for expanding the vision of wellness from physical health risk factors to include social, emotional, and spiritual health resources of connectedness that individuals can tap into to improve their well-being.

Healing Versus Curing
Physical medicine has excelled at curing people. As Bill Moyers points out in Healing and the Mind, however, there is a distinction between curing and healing.²² Curing may not always be possible; healing is always possible.

The word "healing" means literally "to make whole." Healing therefore requires letting go of Cartesian dualism, which permits a precise split between body and spirit. Healing requires, instead, an embracing of the unity of the human being. This is the realm of the evolving wellness model and its truly holistic approaches. Where does such a model fit? Where can it further evolve? One place may be in a healthcare system that long ago acknowledged that its mission goes beyond curing the body and extends to healing the person.

NOTES

1. Don Ardell, High Level Wellness, Rodale Press, Emmaus, PA, 1977.
2. John W. Travis and Regina Ryan, Wellness Work Book, Ten Speed Press, Berkeley, CA, 1981, p. 1.
3. L. C. Robbins and J. H. Hall, How to Practice Prospective Medicine, Methodist Hospital of Indiana, Indianapolis, 1970.
4. U.S. Department of Health and Human Services, Washington, DC, 1986.
5. "Wellness Saves Dollars," Health Action Managers, April 10, 1988, pp. 2-3.
6. "Medical Benefits for Active and Retired Employees," Wyatt Company Survey Report, Chicago, 1990.
7. "Wellness Continues as a '90's Issue," Indianapolis Star, November 10, 1992, p. 5.
8. Nancy Madlin, "Wellness Incentives: How Well Do They Work?" Business and Health, April 1991, pp. 70-74.
9. Hilary Stout, "Paying Workers for Good Health Habits Catches on as a Way to Cut Medical Costs," Wall Street Journal, November 26, 1991, section B, pp. 2-4.
10. "Fitness Center Gets Couch Potatoes Moving," Wall Street Journal, April 12, 1991, section B, p 1.
11. "Mass Cholesterol Tests Work on Wall Street," Wall Street Journal, May 30, 1990, section A, p. 1.
12. Robert L. Bertera, "The Effects of Workplace Health Promotion on Absenteeism and Employment Costs in a Large Industrial Population," American Journal of Public Health, September 1990, pp. 1,101-1,105.
13. J. O. Gibbs, et al., "Worksite Health Promotion," Journal of Occupational Medicine, November 1985, pp. 826-830.
14. Salvatore Maddi and Suzanne Kobasa, The Hardy Executive, Dow Jones-Irwin, Homewood, IL, 1984.
15. L. F. Berkman and S. L. Syme, "Social Networks, Host Resistance and Mortality: A Nine Year Follow Up Study of Alameda County Residents," American Journal of Epidemiology, vol. 109, no. 2, 1979, pp. 186-204; C. A. Schoenborn, "Health Habits of U.S. Adults, 1985: The Alameda Revisited," Public Health Reports, vol. 101, no. 6, 1986, pp. 571-580.
16. G. A. Kaplan, "Social Contacts and Ischaemic Heart Disease," Annals of Clinical Research, vol. 20, nos. 1-2, 1988, pp. 131-136.
17. R. M. Nerem, M. J. Leuesque, and J. F. Cornhill, "Social Environment as a Factor in Diet-induced Atherosclerosis," Science, June 27, 1980, pp. 1,475-1,476.
18. R. C. Byrd, "Positive Therapeutic Effects of Intercessory Prayer in a Coronary Care Unit Population," Southern Journal of Medicine, vol. 81, no. 7, 1988, pp. 826-829.
19. Dean Ornish, Program for Reversing Heart Disease, Random House, New York City, 1990.
20. "More of Us Losing Battle of the Bulge," USA Today, March 12, 1993, section D, p. 1.
21. Bill Moyers, Healing and the Mind, Doubleday, New York City, 1993.
22. Moyers.

St. Vincent Wellness Services, the prevention component of St. Vincent Hospitals and Health Services, Indianapolis, offers programs designed to maximize performance and well-being. In autumn 1979 St. Vincent Wellness Services opened in Carmel, IN—the first hospital-sponsored wellness program east of the Mississippi River.

Initially serving the needs of the community, St. Vincent Wellness Services offered fitness, stress management, nutrition, and family life education programs at area libraries and churches and at St. Vincent facilities in the Indianapolis, Carmel, Zionsville, and Fishers areas.

St. Vincent Wellness Services has also developed its corporate services, which, in addition to the above programs, include screenings, executive physicals, fitness center management, and corporate consultations.

Currently nine staff members provide these services. Their areas of expertise include exercise physiology, health education, nursing, and behavior change.

St. Vincent Wellness Services annually provides services to more than 20,000 persons and 200 corporations. Most services have individual charges attached to them. Some of these are reimbursed by insurance, depending on the individual policy.

St. Vincent Wellness Services has developed a holistic wellness assessment to complement the traditional physical. These prevention-oriented assessments have become a cornerstone of St. Vincent's wellness program.

St. Vincent has been a leader in promoting wellness among its employees. In 1991 it instituted the Healthy Lifestyles program for all employees. The program rewards them for maintaining their blood pressure, cholesterol, and body fat within norms and for not smoking.