February 4th, 2009

Corporate Health Promotion Programs Discussed at World Health Assembly

The 61st annual World Health Assembly is taking place this week in Geneva, Switzerland and at this assembly; the World Health Organization (WHO) is presenting its report titled “Preventing Non-communicable Diseases (NCD) in the Workplace through Diet and Physical Activity.”

The report calls for Corporate Health Promotion Programs to be promoted and implemented worldwide.

Importance of Corporate Health Promotion Programs

The report states that Non-Communicable Disease related deaths have surpassed transferable disease related deaths and have become the leading global killers. Examples of Non-Communicable Disease’s are heart disease, diabetes and stroke. In 2005, 60% of worldwide projected deaths were caused by non-communicable diseases. They are predicting that this health trend will continue through at least 2030.

Diet, caloric intake, lack of physical activity and tobacco use are the major risk factors in the cause of Non-Communicable Disease’s. Now more than ever, the understanding of the importance of health and wellness is crucial.

Corporate Health Promotion Programs are Effective Tools

The report states that Corporate Health Promotion Programs are found to be effective in improving health-related risk factors, such as obesity, heart disease and diabetes. The report also states that Corporate Health Promotion Programs will enhance the health of employees, enhance the corporate image, enhance employee morale, reduce employee absences and sick leave, increase employee productivity, and reduce corporate healthcare costs.

Corporate Health Promotion Programs Monitoring

Finally, the report mentions that to have a successful Corporate Health Promotion Program, monitoring and evaluation through Health risk assessments and health outcomes are essential and should be included in the Corporate Health Promotion Program implementation. The evaluations ensure that the Corporate Health Promotion Program developed meets the proper needs of the employees. Workers should be reevaluated on an on-going basis to make sure the Corporate Health Promotion Program is still working, or to see if there are any adjustments that need to be made.

February 3rd, 2009

Corporate Health Promotion Program ROI

Corporate Health Promotion Program ROI: Fact or Fiction?

Corporate Health Promotion Programs … do they offer a strong return on investment? This is a question that we are sure goes through ever corporation’s mind. HR Magazine addresses the Corporate Health Promotion Program ROI topic in their June 2008 issue.

Corporate Health Promotion Program ROI: The Bottom Line

According to the article, titled “Finding Wellness’ Return on Investment,” determining Corporate Health Promotion Program ROI is not an easy thing to do for corporations because it involves a lot of different variables and time.

However, the organizations that have taken the time to determine the Corporate Health Promotion Program ROI of their Corporate Health Promotion Programs have found that it is quite significant. Not to mention, the Wellness program’s effect on the improvement of employee health and the slowing of the rate of their employee healthcare costs.

Corporate Health Promotion Program ROI Alliance

Corporate Health Promotion Program ROI is such an important aspect of today’s corporate culture, that several large organizations have come together to form the Alliance for Wellness ROI, Inc. According to the HR Magazine article, The Alliance for Wellness ROI was specifically created to address the lack of consistency in proving the value of Corporate Health Promotion Programs.

The alliance, formed by Henry Ford Health Systems, BMW of North America, Kraft Foods Global, Schlumberger Limited and MasterCare Worldwide, strongly believes in showing the value of Corporate Health Promotion Programs and want to develop a standard for how Corporate Health Promotion Programs are measured.

Corporate Health Promotion Programs Components

According the alliance, the following components should make up an corporate-offered employee Corporate Health Promotion Program:

Employee assistance Programs
Disease Management Programs (DM)
Fitness and exercise Programs
Health risk assessments
Onsite healthcare Programs
Personal wellness profiles
Preventive Health Screening and Biometric Testings and immunizations
Tobacco-cessation Programs
Telephone based Corporate Health Promotion Programs
Weight loss and weight management Programs
Self-Care Programs.

February 2nd, 2009

Summer Time Wellness

Wellness During the Summer Time

Wellness is important all year long; however if your employees haven’t gotten on the Wellness bandwagon, then now is the perfect time to get them there.

Summer Time is an ideal season to get back into shape and enhance overall Wellness. The weather is beautiful, employees can get outside and they are motivated by the thought of having to wear clothes with less coverage. Fitness, or lack of fitness, is apparent in the summer.

Wellness in the Summer Time has Advantages

There are many advantages to beginning a Corporate Health Promotion Program in the Summer Time. Employees are more likely to get outside and walk or participate in group activities during the summer than they are in the cooler months of the fall and winter. The summer months are also a great time to establish a Wellness challenge with your employees and celebrate the completion of the challenge with a participant picnic or cookout. Finally, it always seems easier to eat healthy during the summer with all the fresh vegetables and fruits that are available during this time.

Corporate Health Promotion Program Kick-off

We recommend following these steps when starting a Corporate Health Promotion Program in your office.

Pick a wellness coordinator for the Corporate Health Promotion Program who is willing and able to see it through.
Make sure that you have the support of corporate leadership.
Establish a Wellness committee
Use a Corporate Health Promotion Program survey to uncover the obstacles and goals of your Corporate Health Promotion Program
Provide Health risk assessments
Analyze the Corporate Health Promotion Program and changes as needed
Remember to stress that the Corporate Health Promotion Program is for the workers. Corporate Health Promotion Programs have been found to prevent obesity, cancer, heart disease and hypertension. taking part in in a Corporate Health Promotion Program that offers all that should be an easy decision for the corporation and for the employees.

February 1st, 2009

Corporate Health Promotion Programs in a Depressed Economy

Corporate Health Promotion Programs and Health Care Costs

Corporate Health Promotion Programs are more important now than ever. A recent article in the Wall Street Journal, with the troubles in the economy it seems that the costs of business provided healthcare keep continuing to grow and it doesn’t seem like it is going to change. The article states that during the year 2008, American organizations can expect to see an increase of 10% in healthcare costs.

This increase in healthcare costs is causing some small organizations to reduce their employee health benefits or get rid of them altogether.

Corporate Health Promotion Programs for Healthier Lifestyles

Corporate Health Promotion Programs do offer an option for small organizations. The corporations can offer discounted co-pays and deductibles to those employees that fully participate in the offered Corporate Health Promotion Program. Full participation means getting health screens, receiving a health risk assessment, and then working with their wellness coordinator to work towards a healthier lifestyle.

The healthier the employees, the lower the overall healthcare costs for the corporation. Just one lengthy hospital stay can almost deplete a small business’ healthcare budget.

Corporate Health Promotion Programs and Your Bottom Line

Corporate Health Promotion Programs offer many advantages to a corporation’s bottom-line. Corporate Health Promotion Program Statistics from Prudential Insurance show a benefit expense of $312 per individual enrolled in a Corporate Health Promotion Program compared to an expense of $574 per employee that wasn’t enrolled. Coors Brewing Company showed a positive side-effect of participant absenteeism dropping by 18%, thus greater production and less healthcare costs overall.

January 31st, 2009

Corporate Health Promotion Programs Result in a Healthier Bottom-lines

Corporate Health Promotion Programs are an excellent investment, at least according to Lincoln industries in Nebraska. CNN reported on this 565 employee business their committed investment in their employee’s wellness.

Corporate Health Promotion Programs are part of business Culture

The Corporate Health Promotion Programs, according the story, has been in place for 16 years at Lincoln, and it doesn’t seem to be going anywhere. The business has three full-time employees dedicated to the Corporate Health Promotion Program and the wellness of the employees, who receive worksite massages and a round of instructor-led stretching before they start their shifts.

Corporate Health Promotion Programs Assessed

According to CNN, one of the rules of the Corporate Health Promotion Program, which employees are not required to participate in, is that they receive quarterly checkups where assessments are completed on their weight, amount of body fat and flexibility. Based on these health assessments, the employees are then ranked from platinum all the way down to “non-medal”. To become platinum level, where you receive a business-paid climbing trip, you must achieve certain fitness levels and be a non-smoker. Smoking cessation classes are part of the Corporate Health Promotion Program.

Corporate Health Promotion Programs Result in Big Savings

The Corporate Health Promotion Program has been a wise investment for Lincoln Industries. By having healthier employees, they have seen an average of $2 million in savings in healthcare costs per year. The savings don’t stop there, since instituting a Corporate Health Promotion Program, workers’ compensation claims have gone from $500,000 per year down to less than $10,000 per year.

January 30th, 2009

Benefits of Corporate Health Promotion Programs

Corporate Health Promotion Programs Are Becoming Increasingly Popular

Corporate Health Promotion Programs are Are Becoming Increasingly popular outside the workplace, showing the ever-increasing importance of disease prevention and health risk management. Private insurance corporations, as well as state Medicaid and Medicare offices are working on ways to enhance the health of the people they insure in hopes to save money in the long run. They are finding that mini-Workplace Corporate Health Promotion Programs are definitely the way to go.

Corporate Health Promotion Programs Help with Early Intervention

A recent article that recently appeared in The Indianapolis Star, organizations, insurers and government agencies are turning to “early intervention to change the behavior of those struggling with common but dangerous health conditions, such as asthma, diabetes, heart failure and coronary heart disease.”

The strategies that they incorporated to enhance their beneficiaries’ wellness postcard reminders for different lab tests or check-ups; and possibly even phone calls from nurses to work with the patients to make sure that they are taking their medicines properly and following the lifestyle changes that were suggested by their healthcare provider.

Corporate Health Promotion Programs Provide Quality Benefits

There are more benefits to a Corporate Health Promotion Program than just the savings that an business or a state agency will see; there is the benefit to the actually patient. The patient is going to get the motivation and the incentive reward to get better or to manage their health risks by having to answer to someone, whether that someone is a full-time wellness employee at their business or a nurse affiliated with their insurance business.

January 29th, 2009

Corporate Health Promotion Programs: The Bottom-Line Enhancer

Corporate Health Promotion Programs are proven to improve productivity and reduce healthcare costs. For a business, that makes a difference in the bottom-line. Today, more than 81% of America’s businesses with 50 or more employees have some form of Corporate Health Promotion Program with the most popular being exercise, tobaccos cessation classes, back care programs, and stress management. Most organizations offer Corporate Health Promotion Programs simply because they think the benefit is worth the cost. Yet business leaders continue to ask themselves how to control huge annual increases in health insurance premiums and healthcare costs.

For many organizations, health costs can consume half of corporate profits or more. Some employer’s look to cost sharing, cost shifting, managed care plans, risk rating, and cash-based rebates or rewards. But these methods merely shift costs. Only Corporate Health Promotion Programs stand out as the long-term answer for keeping employees well in the first place.

Corporate Health Promotion Programs are an example of healthcare reform that works. Results from America’s finest organizations, summarized here, are reason enough to consider offering Corporate Health Promotion Programs. This investment in your most important asset - your employees - can have a positive impact on your bottom-line.

Corporate Health Promotion Program Statistics:

Providence Everett Medical Center, a member of the Wellness Councils of America, in Everett, Washington, saved an estimated 3 million or a cost-benefit ratio of 1 to 3.8 over 9 years of an outcomes-based Corporate Health Promotion Program. By offering financial rewards ($250 - $325) to employees who meet specific organizational and employee health initiatives the Corporate Health Promotion Program continues to meet cost containment expectations in the area of healthcare use, sick time, injuries, while improving health habits and self-care practices.

During the first 4 years of the Corporate Health Promotion Program there was a 28% average reduction in healthcare utilization compared to nine other Providence hospitals that were used as a control group.

Du Pont saw that each dollar invested in their Corporate Health Promotion Program yielded $1.42 over two years in decreased absenteeism costs at Du Pont Co. (Well workplace Gold in Delaware). Absences from illness unrelated to the job among 45,000 blue-collar staff members dropped 14% at 41 industrial sites where the Corporate Health Promotion Program was offered, compared with a 5.8% decline at 19 sites where it was not.

The Travelers Corporation claims a $3.40 return for every dollar invested Corporate Health Promotion Programs, yielding total corporate savings of $146 million in benefits costs. Sick leave was decreased 19% during the four-year study. In addition to improving the overall health of 36,000 employees and retirees by decreasing poor health habits and increasing good ones, The Travelers realized cost savings by decreasing the number of unnecessary visits to a doctor and emergency rooms. In a similar but smaller study, members of a Travelers fitness center Corporate Health Promotion Program were absent from work significantly fewer days than non-members.

The Corporate Health Promotion Program at Reynolds Electrical & Engineering Company, based in Las Vegas, cost $76.24 per employee during the two years it has been in operation. Over half of the 1,600 employees took part in the Corporate Health Promotion Program. Participants significantly lowered cholesterol levels, blood pressure, and weight and experienced 21% lower lifestyle-related claim costs than non-participant. Resulting savings: $127.89 per participant in the Corporate Health Promotion Program with a benefit to cost ratio of 1.68 to 1.

Superior Coffee and Foods, a Bensenville, Illinois-based subsidiary of Sara Lee Corporation, attributes impressive results to the success of the corporation’s broad-based Corporate Health Promotion Program. Superior showed 22% fewer admissions to a hospital, 29% shorter hospital stays, and 42% lower expenses per admission when comparing costs for this division’s 1,200 employees with costs for other divisions. Long-term disability costs were down by 40%.

With health costs per employee at $6,000, nearly twice the national average, Union Pacific Railroad introduced their Corporate Health Promotion Program to its 28,000 employees, mostly union and blue collar, in 19 Western and Southern states. Beginning with a modest health self-care initiative at an annual cost of $50 per person, the Corporate Health Promotion Program achieved a net savings of $1.26 million. In addition, a voluntary Corporate Health Promotion Program to help employees reduce health risks projected a cost-benefit ratio of 1 to 1.57 after one year. Workers in a treatment group reduceed their risk of high blood pressure (45%) and high cholesterol (34%); others moved out of the at-risk range for weight problems (30%); and 21% stopped smoking.

Average health costs of high-risk Steelcase employees- those whose lifestyles include two to four health risks such as tobacco use, little exercise, overweight- are 75% higher than those of low-risk employees. But high-risk employees at this Grand Rapids, Michigan-furniture manufacturing corporation who improved their health habits through the company’s Corporate Health Promotion Program and became low risk cut their average health claims in half thus lowering their health insurance costs by an average of $618 per year. If all high-risk employees (20% of the total employee population) in one location changed their lifestyles to become low risk, the projected savings could total $20 million over three years.

Workers at Berk-Tec, a small manufacturing corporation in Lancaster County Pennsylvania, learned self-care techniques and reduceed their corporation’s healthcare costs in one year. By using a self-care guide, the 938 employees and their family members made smart health decisions and saved $21.67 per employee and dependent a nearly 18% reduction in costs. By combining reductions in doctor visits and emergency room use, the business saved $39.06 per employee a 24.3% decrease in costs over the previous year.

A health claims-based study of 72,000 people insured through 285 Wisconsin school districts found a decreased demand for health services among those with access to Corporate Health Promotion Programs and self-care programs. Reductions in health services results in savings for the Wisconsin Education Insurance Group of as much as $4.75 for each $1 spent, higher savings were found in the group receiving access to a 24-hour phone-based nurse advice line, a self-care reference book, and health education materials.

CIGNA’s Healthy Babies prenatal Corporate Health Promotion Program delivered an average savings of $5,000 per birth by providing expectant mothers with educational materials and rewarding early and regular prenatal care. And 80% of participants had normal births without complications compared with 50% for non-participant.

With savings estimated to be as high as $8 million, the California Public Workers’ Retirement System sent its 55,000 retirees a health rist assessment followed, in some cases, with individualized reports and letters and self-care materials to encourage change and help reduce health risks among retirees and at the same time reduce the healthcare claim costs. In another study, Bank of America retirees in California who chose the full Corporate Health Promotion Program and demand reduction program showed a decrease in total direct and indirect costs of 11% compared with a rise of 6.3% for those who completed only a simple health questionnaire.

With decreased healthcare claims, health costs decreased 16% for employees in the City of Mesa (Arizona) who took part in the broad-based Corporate Health Promotion Program. The city realized a return of $3.60 for every dollar invested in the wellnss program for the city employees.

To prevent back injuries among its employees, a county in California targeted white- and blue-collar staff members, offered classes and fitness training. As a result, there was a significant increase in employee morale, decreased worker’s comp claims, health costs and sick days related to back injuries producing a net cost-benefit ratio of 1 to 1.79.

Corporate Health Promotion Programs: Savings

Corporate Health Promotion Programs offer Long-Term Savings

Corporate Health Promotion Programs, according to an article in Crain’s Detroit Business, come in two choices: Corporate Health Promotion Programs or Medical Insurance products that aim to lower costs if healthy habits are followed. Both options are good, but only one will really offer long-term health benefits for your employees and lower costs over the years.

Corporate Health Promotion Programs offer Assistance

Insurance-based products offer employees the opportunity, according to the article by Jay Green, to save money on their premiums if they follow certain steps, including performing an online health assessment, visiting their medical provider, and agree to adopt a healthy lifestyle. These plans usually involve one coach call to the employee during the first 90 days. We wonder if these brief wellness encounters will actually change a individual’s lifestyle.

It is the overall change in a individual’s lifestyle, as well as disease prevention that will lead to lower health costs in the future.

Corporate Health Promotion Programs offer convenient health risk assessments and health testing for things like diabetes, cholesterol and blood pressure. As the article states, these have initial start-up costs, but the savings accrue over time and employees are more likely to stay active in an worksite employee Health Promotion Program.

Corporate Health Promotion Programs Get Results

Finally, the article states that corporations with an effective Corporate Health Promotion Program can expect to see “500 percent lower absenteeism, 400 percent fewer disability claims, and 350 percent lower healthcare costs.” These are numbers that are very hard to argue with.

January 28th, 2009

Corporate Health Promotion Program Tends

Employers are no longer able to trim extra savings out of their health insurance programs, and most organizations have been cost shifting, asking employees to cover more of their healthcare costs. Health insurance costs continue to climb (10% or more per year) at 2-3 times the general inflation rate. With nowhere else to turn, organizations are – more than ever – looking to get employees engaged in Corporate Health Promotion Programs as a means of slowing healthcare costs and improving productivity.

For example, last year 53% of large organizations offered health risk assessments (HRAs) for their staff, up from 35% just two years earlier, according to a Mercer survey. Change is being driven by cost, but Corporate Health Promotion Programs a win-win solution for both organizations and employees.

Here are other Corporate Health Promotion Program trends organizations are implementing:

More organizations are integrating Corporate Health Promotion Programs into their benefits plans. If they want the best plans or the lowest personal costs, they need to participate in the Corporate Health Promotion Program and meeting minimum goals.

More organizations are offering worksite weight loss programs as part of the Corporate Health Promotion Program, especially after Duke University’s new research showing the high cost of overweight employees and increased cost for worker’s compensation for sedentary and overweight employees.

Employers are offering more Corporate Health Promotion Programs designed to assist employees with chronic health conditions: health coaches, nurse advice lines, telephone counseling, and self-study guides

Employers are providing more online Corporate Health Promotion Program interventions and health information resources

More organizations are providing regular worksite employee health screenings including cholesterol, glucose, A1c, blood pressure, weigh-ins, and other checks as a part of their Corporate Health Promotion Program. Some Corporate Health Promotion Programs even include bone-density checks and skin cancer screenings.

Many organizations are providing fitness programs, either in the community or worksite, as a part of their Corporate Health Promotion Program.

Corporations are providing more rewards, prizes and incentives getting engaged in Corporate Health Promotion Program activities

Some organizations are adding emphasis to maintaining health. It’s one thing to lose weight or stop tobacco; it’s another to maintain these changes. Helping employees stay engaged and maintain their health changes is important for long-term success.

Employers are putting more emphasis on keeping healthy people healthy rather than just working primarily with high-risk individuals. Research shows this approach results in a greater Corporate Health Promotion Program return on investment (ROI).

Wellness organizations are providing great resources for companys’ employees over the Internet – online wellness centers, monthly health and wellness newsetters, wellness challenges, online points tracking systems, virtual fitness programs, online wellness coaching or interventions, interactive health calculators, healthy recipes, even downloadable health tips for your iPod.

Employers who are becoming more proactive are making a big impact on their future healthcare expenses and productivity. Ohio State University announced that they expect to save $30 million dollars with their broad-based Corporate Health Promotion Program over the next 5 years!

Corporate Health Promotion Programs and prevention are sound ideas whose time has come. Health promotion is more fun and costs less than treating disease.

References: TIME in partnership with CNN, “Businesses Help Workers Lose Weight.” Website accessed July 2007.

January 27th, 2009

Establishinging a Corporate Health Promotion Program

Corporate Health Promotion Programs start and end with individual health. Individuals, after all, are able to make decisions about maintaining and / or improving their health and wellbeing. Employee Corporate Health Promotion Programs must therefore provide the tools and resources needed to assist and motivate individuals to actively participate in the program.

Individual health is only one part of beginning employee Corporate Health Promotion Programs. Below you’ll find some things to assist you in your efforts to establish a healthy atmosphere for you and your coworkers.

Encouraging Your Employer to Start an Corporate Health Promotion Program

This is the first step in beginning a Corporate Health Promotion Program. In recent times more and more organizations are beginning to see the value of promoting and supporting the health of their employees. Partnership for Prevention, a nonprofit organization, has released a sourcebook called “Healthy Workforce 2010″ (http://www.wellnessproposals.com/pdfs/tool_kits/healthy_workforce_2010.pdf). This sourcebook is an excellent resource containing information on:
• Benefits of Corporate Health Promotion Programs
• Suggestions on where to start
• Tools like surveys and evaluation forms

These resources are for both organizations and employees to lead the development and determine the effectiveness of their new Corporate Health Promotion Program. Offer it to your employer as a place to start or read it yourself and present your ideas.

Taking Part in Corporate Health Promotion Programs

Once you have an employee Corporate Health Promotion Program established, participating fully in all aspects of the program is important. Many of us know that we need to more actively engage in Corporate Health Promotion Programs to improve our health, yet have difficulty finding and taking the time to do so. These simple steps can jumpstart your participation in an employee Corporate Health Promotion Program:
• Examine the offerings that interest you and that you need for health improvement.
• Schedule time to go to the seminar or service.
• Actively following through with recommendations from the program.
• Make a decision now to improve your health. You will feel better today and tomorrow and the next day for actively moving towards wellness.

Here is a list of potential Corporate Health Promotion Programs that might be available to you at work:
• ergonomic evaluations and training classes
• lactation rooms and classes
• prenatal education
• quiet rooms for relaxation
• stress management programs
• fitness facilities
• chair massage
• nutrition education
• worksite primary healthcare services
• child care facility or resources and referral service
• tobacco cessation programs parenting classes
• elder care resource and referral service
• cholesterol, blood pressure and glucose screening programs
• flu shots
• weight management programs
• healthcare consumerism programs
• work/life programs
• wellness coach / health coach programs
• mobile mammography

More information to follow in my next posting about Employee Corporate Health Promotion Programs

January 26th, 2009

Corporate Health Promotion Programs for Small Businesses

Studies suggest that for every $1 invested in Corporate Health Promotion Programs, a corporation saves $3 to $5 in health and safety costs. Employers that invest in Corporate Health Promotion Programs reap the financial incentives through savings on healthcare costs, disability pay, absenteeism, turnover and safety problems. 

workplaces have already proven to be a great place to promote wellness. After all, people spend more time at work than doing anything else. Eighty-two percent of the U.S. population is linked in some way to a worksite. Therefore, providing Corporate Health Promotion Programs is a great way to reach a substantial number of people in your area. 

Corporate Health Promotion Programs in Small Businesses 

Unlike large organizations, small organizations often lack the resources to provide Corporate Health Promotion Programs to their employees. However, they may be the most in need of such services. Small businesses are the hardest hit by health insurance costs and have the highest rates of substance abuse. Worker well-being and physical or mental illness can also be more disruptive in a small business setting. Corporate Health Promotion Programs in small organizations also makes sense because small firms employ the majority of working citizens. 

Regardless of the size of a business, Corporate Health Promotion Programs can pay. Statistically, even if there are only 100 people in a corporation: 

• 60 sit all day to do their work

• 50 don’t wear their safety belts regularly

• 50 feel they’re under moderate stress

• 35 are overweight by 20% or more

• 30 smoke

• 27 have cardiovascular disease

• 25 or more have high cholesterol (over 200 mg/dl)

• 10 are heavy drinkers

• 10 have high blood pressure

• 5 have diagnosed diabetes and another 5 have undiagnosed diabetes

• 7 use marijuana

• 1 uses cocaine 

Bottom Line Corporate Health Promotion Program Benefits 

At least one quarter of the healthcare costs incurred by working adults can be attributed to modifiable health risks (e.g., diet, exercise, tobacco use, etc.) Fortunately, there is a way to hold back the trend. Growing research links an individual’s lifestyle behaviors to their health risk. 

The good news is Corporate Health Promotion Programs can: 

• Decrease healthcare costs

• Decrease workers’ compensation claims

• Decrease employee absenteeism

• Increase worker productivity

• Improve employee morale 

The bottom line is that Corporate Health Promotion Programs can benefit any size business — small or large.