The Impact of Worksite Wellness Programs by Size of Business: A 3-Year Longitudinal Study of Participation, Health Benefits, Absenteeism, and Presenteeism

Effects of occupational health promotion interventions on health-related outcomes among employees of small businesses and self-employed individuals: A systematic review

BACKGROUND

Compared to workers of larger companies it is less clear what health promoting interventions might be beneficial for employees of small businesses and self-employed individuals.

OBJECTIVE

Our aim was to critically appraise trials investigating health promotion programs among small business workers and self-employed individuals, by means of a systematic review.

METHODS

We conducted a search of primary studies using MEDLINE, Web of Science, LIVIVO and the Cochrane library. Our assessment followed the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions and PRISMA.

RESULTS

We identified six trials including 5,854 participants from Asia, North America and Australia. Most were of moderate methodological quality, only one was of low quality. Some of the supervised psycho-educational lifestyle programs focusing on individual behavior changes showed benefits in terms of stress reduction and increased physical activity levels among small enterprise employees.

CONCLUSIONS

There is a huge knowledge gap on evidence-based health promotion interventions for self-employed and for small business workers, especially in Europe.

Exploring presenteeism trends: a comprehensive bibliometric and content analysis

Objective

This research will conduct a bibliometric and content analysis of presenteeism from 2000 to 2023. It aims to investigate publication trends, authorship patterns, and significant publications by using presenteeism conceptualizations, measurements, determinants, consequences, and interventions analysis. The study provides valuable insights for researchers, practitioners, and policymakers about understanding and addressing workplace presenteeism issues.

Methods

The research involved conducting a bibliometric study to analyze presenteeism publication trends, authorship patterns, and significant publications. It also explored the evolution of presenteeism research over time, identifying contributing countries, institutions, and writers. The interdisciplinary nature of presenteeism research was emphasized, covering occupational health, psychology, management, and public health. The researchers have used VOS Viewer and R Studio (biblioshiny) for this study.

Results

The study identified several elements influencing presenteeism, such as health issues, work-related factors, organizational culture, and individual characteristics. It further examined the impact of organizational policies, leadership support, employee assistance programs, and health promotion activities in reducing absenteeism and enhancing employee well-being. These findings highlight the importance of addressing these factors to mitigate presenteeism issues and promote a healthier work environment.

Conclusion

This research identified deficiencies in presenteeism research and provided recommendations for future investigations in this field. It emphasized the need for standardized measures and methodologies, longitudinal studies to understand causality, and industry- and population-specific interventions. These insights can guide future research directions and interventions to address presenteeism issues in a rapidly changing work and research landscape.

Leaving no-one behind in the workplace health promotion: towards regulatory equity in the Ecuadorian micro-enterprises

The purpose of workplace public health programmes and regulations is to promote safety and health for the entire working population nationwide. Some countries limit the scope of such programmes to medium or big-sized companies, leaving out small and micro-enterprises, thus discriminating against many workers exposed to risks. This Viewpoint aims to identify inequalities in occupational health generated by the new Regulation for Workplace Health Promotion (WHP) in Ecuador. We showed how the regulation excludes all micro-enterprises and displayed the essential role of micro-enterprises in the business fabric and the Ecuadorian labour market. More than 93% of the registered companies are micro-enterprises and these include more than 25% of the employees in the formal economy. Integrating occupational health into the public health system will require deep analysis to improve protection for the working population.

Effect of the Emory Healthy Kitchen Collaborative on Employee Health Habits and Body Weight: A 12-Month Workplace Wellness Trial

INTRODUCTION

Teaching kitchens are being used to facilitate lifestyle changes with a focus on culinary and nutrition programs to improve health behaviors. Less is known regarding their use as a worksite wellness program and their influence on employees' quality of life, body weight, and adoption of healthy behaviors. We evaluated changes in self-reported healthy behaviors, overall health, and weight during a one-year multidisciplinary teaching kitchen program.

METHODS

Thirty-eight benefits-eligible employees were recruited, screened based on a priori eligibility criteria that prioritized elevated body mass index (BMI), co-morbid conditions, and high levels of motivation to make lifestyle changes, and consented to participate in The Emory Healthy Kitchen Collaborative. This 12-month program included a 10-week didactic and experiential curriculum followed by continued support and access to health coaching implemented in an academic health system university hospital workplace between 2019 and 2020. Comparative statistics, paired t-test, Mcnemar's tests, and Wilcoxon signed-rank tests were used to assess changes at four time points.

RESULTS

Participants improved diet quality (p ≤ 0.0001), increased confidence in tasting new foods (p = 0.03), and increased mindful eating habits (p = 0.00002). Significant changes were seen in physical activity levels; aerobic activities (p = 0.007), strength resistance activities (p = 0.02), and participation in yoga (p = 0.002). Most participants weighed within 5 lbs. of their starting weight at 3 months (p = 0.57).

CONCLUSIONS

A teaching kitchen intervention is an innovative model for improving employee health behaviors and general health self-perception.

Health and Productivity Management in Hospital Organizations and Work Engagement of Nurses

Objective

In Japan, there is an urgent need to strengthen efforts to retain nurses and prevent high turnover. The Japan Nurses Association has set the goal of creating a supportive work environment for nurses to work with peace of mind and improve outcomes throughout their lives. Against this background, we examined the relationship between nurses' health and productivity management and their work engagement (WE) in Japanese hospital organizations.

Design

A cross-sectional design was used.

Methods

A web-based survey was administered to full-time employed nurses working in Japanese hospitals with 100 or more beds.

Results

Total WE scores were analyzed as the objective variable; WE crude odds ratios (ORs) were significantly higher in the high group than in the low group for all indicator items related to a healthy workplace culture. For adjusted ORs, propensity scores were calculated from gender, age, years of service, years of experience, job title, marital status, work shift, frequency of exercise per week, and hours worked per week and used as moderator variables. The results showed that the adjusted ORs for the high group were significantly higher than the adjusted ORs for the low group for all items except "participation of the person in charge from the planning stage of the initiative" and "reflection of the person in charge's opinion in the planning of the initiative."

Conclusions

This study suggests that health and productivity management initiatives in hospital organizations may positively impact nurses' WE. Furthermore, it suggests that these initiatives may contribute to improving nurse retention and preventing turnover.

Developing a framework for evaluation: a Theory of Change for complex workplace mental health interventions

BACKGROUND

There is a gap between the necessity of effective mental health interventions in the workplace and the availability of evidence-based information on how to evaluate them. The available evidence outlines that mental health interventions should follow integrated approaches combining multiple components related to different levels of change. However, there is a lack of robust studies on how to evaluate multicomponent workplace interventions which target a variety of outcomes at different levels taking into account the influence of different implementation contexts.

METHOD

We use the MENTUPP project as a research context to develop a theory-driven approach to facilitate the evaluation of complex mental health interventions in occupational settings and to provide a comprehensive rationale of how these types of interventions are expected to achieve change. We used a participatory approach to develop a ToC involving a large number of the project team representing multiple academic backgrounds exploiting in tandem the knowledge from six systematic reviews and results from a survey among practitioners and academic experts in the field of mental health in SMEs.

RESULTS

The ToC revealed four long-term outcomes that we assume MENTUPP can achieve in the workplace: 1) improved mental wellbeing and reduced burnout, 2) reduced mental illness, 3) reduced mental illness-related stigma, and 4) reduced productivity losses. They are assumed to be reached through six proximate and four intermediate outcomes according to a specific chronological order. The intervention consists of 23 components that were chosen based on specific rationales to achieve change on four levels (employee, team, leader, and organization).

CONCLUSIONS

The ToC map provides a theory of how MENTUPP is expected to achieve its anticipated long-term outcomes through intermediate and proximate outcomes assessing alongside contextual factors which will facilitate the testing of hypotheses. Moreover, it allows for a structured approach to informing the future selection of outcomes and related evaluation measures in either subsequent iterations of complex interventions or other similarly structured programs. Hence, the resulting ToC can be employed by future research as an example for the development of a theoretical framework to evaluate complex mental health interventions in the workplace.

A Workplace Environmental Scan of Employed Carers During COVID-19

The carer-employee experience has undergone multiple shifts during the COVID-19 pandemic. This study seeks to understand how changes in the workplace as a result of the pandemic have impacted employed carers with their ability to perform both care obligations and paid work responsibilities. Using an online workplace-wide survey at a large Canadian firm, we conducted an environmental scan of: the current state of workplace supports and accommodations, supervisor attitudes, and carer-employee burden and health. Our findings demonstrate that while employees are generally in good health, care burden and time spent caregiving has been higher during COVID-19. Notably, employee presenteeism is higher during the pandemic than it was previously, with carer-employees experiencing significantly reduced levels of co-worker support. The most common workplace adaptation to COVID-19, work-from-home, was preferred by all employees as it allowed greater schedule control. However, this comes at the cost of reduced communications and sense of workplace culture, especially for carer-employees. We identified several actionable changes within the workplace, including: greater visibility of existing carer resources, and standardized training of managers on carer issues.

[Evaluation index for a healthy workplace culture in health and productivity management]

OBJECTIVES

This study aimed to establish a healthy workplace culture, rather than simply enhancing the content of intervention programs, aimed toward reducing health risks and maintaining and increasing productivity. Previous studies have found that the higher the awareness of employees' subjective evaluation of support for their health, the smaller is the health risk and problem of presenteeism. In health and productivity management, it is necessary to make evaluations from the employees' perspective. This study created an index of healthy workplace culture from the employees' perspective and examined its usefulness as an evaluation index for health and productivity management.

METHODS

A questionnaire survey was conducted using 20 indicators derived from a literature review of the workplace culture of health. The survey was conducted among 50 organizations that were certified as excellent healthcare corporations in 2019. A questionnaire was distributed to 886 employees in 25 cooperating organizations, and responses were received from 435 employees.

RESULTS

The analysis was performed among employees at 43 large and 263 small and medium-sized organizations, and 123 organizations with unknown certification status. Comparison by size showed that the following were significantly better in large organizations: policy on maintaining and promoting health, procedures for handling health issues, program and support for returning to work after a long absence, program and support for improving mental health, and places to consult with employees about health and safety issues. However, the following were significantly better in small and medium-sized organizations: feedback on health issues from supervisors to employees and provision of useful information about health promotion. Organizations with unknown certification status showed significantly worse results for all items. It was evident with all indicators that a strong workplace culture of health resulted in reduced health risks and diminished presenteeism.

CONCLUSIONS

The validity of the index developed in this study demands future verification. However, the index allows the degree of the workplace culture of health to be assessed and may be beneficial in health and productivity management for evaluation from the employees' perspective.

Evidence of Better Psychological Profile in Working Population Meeting Current Physical Activity Recommendations

Workplace Health Promotion (WHP) may improve health, productivity and safety and reduce absenteeism. However, although desirable, it is difficult to design tailored (and thus effective) WHP programs, particularly in small-medium companies, which rarely have access to sufficient economic and organizational resources. In this study, 1305 employees filled out an online anonymous lifestyle questionnaire hosted on the website of a non-profit organization, which aims to promote a healthy lifestyle among workers. The data show gender differences regarding stress perception and, in the working population meeting current physical activity recommendations (threshold = 600 MET·min/week), they point out the evidence of a better psychological and nutrition profile, a perception of better job performance, and improved sleep and health quality. Moreover, a unitary index (ranging from 0-100 (with higher scores being healthier)), combining self-reported metrics for diet, exercise and stress, was significantly higher in active employees (67.51 ± 12.46 vs. 39.84 ± 18.34, p < 0.001). The possibility of assessing individual lifestyle in an easy, timely and cost-effective manner, offers the opportunity to collect grouped data useful to drive tailored WHP policies and to have metric to quantify results of interventions. This potentiality may help in creating effective programs and in improving employees' and companies' motivation and attitude towards a feasible WHP.

An Ecological Study of a Universal Employee Depression Awareness and Stigma Reduction Intervention: "Right Direction"

Objective: Right Direction (RD) was a component of a universal employee wellness program implemented in 2014 at Kent State University (KSU) to increase employees' awareness of depression, reduce mental health stigma, and encourage help-seeking behaviors to promote mental health. We explored changes in mental health care utilization before and after implementation of RD. Methods: KSU Human Resources census and service use data were used to identify the study cohort and examine the study objectives. A pre-post design was used to explore changes in mental health utilization among KSU employees before and after RD. Three post-intervention periods were examined. A generalized linear mixed model approach was used for logistic regression analysis between each outcome of interest and intervention period, adjusted by age and sex. Logit differences were calculated for post-intervention periods compared to the pre-intervention period. Results: Compared to the pre-intervention period, the predicted proportion of employees seeking treatment for depression and anxiety increased in the first post-intervention period (OR = 2.14, 95% Confidence Interval [CI] = 1.37-3.34), then declined. Outpatient psychiatric treatment utilization increased significantly in the first two post-intervention periods (OR =1.89, 95% CI = 1.23-2.89; OR = 1.75, 95% CI = 1.11-2.76). No difference was noted in inpatient psychiatric treatment utilization across post-intervention periods. Unlike prescription for anxiolytic prescriptions, receipt of antidepressant prescriptions increased in the second (OR = 2.25, 95% CI = 1.56-3.27) and third (OR = 2.16, 95% CI = 1.46-3.20) post-intervention periods. Conclusions: Effects of RD may be realized over the long-term with follow-up enhancements such as workshops/informational sessions on mindfulness, stress management, resiliency training, and self-acceptance.

Examining the Implementation of Physical Activity and Healthy Eating Policies in a Large, Public Health Organization

OBJECTIVE

To examine the implementation of physical activity and healthy eating policies in eighteen locations of a large, public health organization.

METHODS

We used a mixed-methods design that included a survey of employees to describe location characteristics (ie, number of employees, race/ethnicity of employees), a survey of wellness ambassadors to determine which policies were implemented, and semi-structured, telephone interviews with wellness ambassadors to examine the barriers and facilitators to policy implementation.

RESULTS

Six locations implemented both policies, nine locations only implemented the physical activity policy, and two locations did not implement either policy. Structural characteristics and geographic spread impeded implementation, whereas leadership engagement and access to information about the policies facilitated implementation.

CONCLUSIONS

Consistent and adequate policy implementation in each location of an organization is critical to providing equity in health promotion programs for employees.

Profiles of total worker health® in United States small businesses

BACKGROUND

The Total Worker Health® (TWH) approach is a best practice method to protect and promote worker safety, health, and well-being. Central to this approach is leadership support and health and safety climates that support day-to-day use of health and safety policies and programs. There is some research that supports these relationships, but there is limited research amongst small businesses. Furthermore, it remains to be shown what role TWH business strategies, as reflected by organizational policies and programs, play in this process. The purpose of this study is to characterize small businesses by their organizations' TWH approach and assess the relationship of these approaches to employee health and safety behaviors.

METHODS

We utilized cross-sectional data from 97 businesses participating in the Small+Safe+Well study. We collected data using a business assessment tool, Healthy Workplace Assessment™, and an employee assessment tool, Employee Health and Safety Culture Survey. We used latent profile analysis at the business level to identify subgroups of businesses based on a set of characteristics from these assessments. Linear regression analysis at the employee level was used to determine profile association with employee safety and health behaviors.

RESULTS

There were two profiles characterized by the lowest (33% of all businesses) and highest (9%) levels of the indicators. There were also two profiles with higher scores on two of the different foci on either TWH business strategies (27%) or leadership and climate (31%). Employees working for a business with a profile that focused on leadership and climate, in addition to having a business strategy, reported the best safety and health behaviors.

CONCLUSIONS

Our study demonstrates that employee engagement in TWH will be highest when businesses have a strategy for how they implement a TWH approach and when they demonstrate leadership commitment to these strategies and foster positive safety and health climates. Our results offer suggestions on how to use TWH assessments to develop interventions for small businesses. More research is needed to understand whether small businesses can improve upon their profile overtime, whether these changes depend on contextual factors, and whether TWH interventions can help them improve their profile.

Effectiveness of an ergonomics training program on musculoskeletal disorders, job stress, quality of work-life and productivity in office workers: a quasi-randomized control trial study

Objectives. The increasing prevalence of musculoskeletal disorders (MSDs), especially in the neck and upper limbs, among office workers is an important issue related to health and job productivity. The present study aimed to evaluate the effect of an ergonomics training intervention on MSDs, quality of work-life and occupational psychosocial stresses among office workers. Methods. This quasi-randomized trial study was conducted in Isfahan, Iran in 2019. Outcome measures were measured in a follow-up period of 1, 3 and 6 months after the intervention. The results were analyzed using repeated-measures analysis of variance. Results. The interventions performed had a significant effect on neck, left shoulder, right wrist and left thigh discomfort. These interventions also had a significant effect on social support and physical job demands. Significant changes were detected in quality of work-life, chance of growth and security, social integration in organization and social relevance of work in life, although these changes decreased in quality of work-life. No significant differences were detected in the other measured outcomes. Conclusion. The implementation of ergonomic interventions was effective in reducing MSDs in the neck and upper limbs. It is recommended to conduct continuous training courses to control the risk of ergonomic factors affecting body discomfort.

Impact of physical activity levels on musculoskeletal symptoms and absenteeism of workers of a metallurgical company

Introduction:

Physical inactivity is the fourth biggest risk factor for global mortality. In Brazilian metallurgical industries, workers present a high incidence of musculoskeletal symptoms as one of the main causes of absenteeism.

Objectives:

To investigate the impact of physical activity levels and leisure-time physical exercise on musculoskeletal symptoms and absenteeism among administrative and production workers of a metallurgical industry.

Methods:

This is a transversal study that included 206 workers. We applied the Modified Baecke Questionnaire, leisure-time physical activity and leisure-time physical exercise domains), as well as the Nordic Musculoskeletal Questionnaire regarding symptom occurrence and severity scores (1-4), and compared levels of absenteeism. Our sample was divided into 2 groups: production and office workers.

Results:

We observed a significant difference between the groups regarding symptom severity score 3 (p = 0.03) and absenteeism (p = 0.02); the production group presented higher results. There was a correlation between leisure-time physical exercise and absenteeism (r = -0.57, p = 0.01) and between leisure-time physical activity and absenteeism (r = -0.55, p = 0.01) in the production worker group, whereas in the office worker group, leisure-time physical activity and symptom severity score 4 were correlated (r = 0.63, p = 0.02).

Conclusions:

Production workers presented higher occurrences of symptom severity score 3 and absenteeism; increased levels of leisure-time physical activity and physical exercise reduced absenteeism. Leisure-time physical activity was correlated with severity score 4 in the office worker group.

A Corporate Wellness Program and Nursing Home Employees' Health

Background: Many employed Americans suffer from chronic conditions like obesity, diabetes, and cardiovascular diseases. Worksite wellness programs provide opportunities to introduce health promotion strategies. While there is evidence of the effectiveness of workplace health promotion, this is tempered by concern that benefits may be less available to low-wage workers with inflexible working conditions. Objective: The aim was to evaluate a workplace health promotion (WHP) in the long-term care sector (skilled nursing facilities). Methods: Nursing home employees from 18 facilities within a single company were surveyed by a standardized, self-administered questionnaire. A company-sponsored WHP program was offered to the facilities, which were free to take it up or not. We categorized the facilities by level of program adoption. Cross-sectional associations were estimated between program category and prevalence of individual-level worker health indicators, adjusting for center-level working conditions. Results: A total of 1,589 workers in 5 job categories completed the survey. Average levels of psychological demands and social support at work were relatively high. Supervisor support stood out as higher in centers with well-developed WHP programs, compared to centers with no programs. There were no differences among program levels for most health outcomes. Workers in centers with well-developed programs had slightly lower average body mass index and (unexpectedly) slightly lower prevalence of non-smoking and regular aerobic exercise. Conclusions: Only small health benefits were observed from well-developed programs and working conditions did not appear to confound the negative results. This low-intensity, low-resourced workplace health promotion program may have benefited a few individuals but seems to have had only modest influence on average levels of the measured health indicators. Many nursing home employees experience obstacles to health behaviors; approaches that provide more environmental and economic supports for healthy behaviors, such as Total Worker Health®, may yield larger health benefits.

Health Risk Calculator: An Online, Interactive Tool to Estimate how Health Impacts Workers' Compensation Claim Incidence and Cost

OBJECTIVE

The purpose of this paper is to describe and evaluate a web-based, educational Health Risk Calculator that communicates the value of investing in employee health and well-being for the prevention of work-related injuries, illnesses, and fatalities.

METHODS

We developed and evaluated the calculator following the RE-AIM framework. We assessed effectiveness via focus groups (n = 15) and a post-use survey (n = 33) and reach via website analytics.

RESULTS

We observed evidence for the calculator's usability, educational benefit, and encouragement of action to improve worker health and safety. Website analytics data demonstrated that we reached over 300 users equally in urban and rural areas within 3 months after launch.

CONCLUSION

We urge researchers to consider the ways in which they can communicate their empirical research findings to their key stakeholders and to evaluate their communication efforts.

Degree of Integration Between Occupational Safety and Health Programs and Wellness Programs: First-year Results From an Insurer-Sponsored Wellness Grant for Smaller Employers

OBJECTIVE

The aim of this study was to describe levels of integration between occupational safety and health (OSH) and workplace wellness programs/practices/policies ("programs") among participants in an insurer-sponsored wellness grant program.

METHODS

We analyzed survey responses about year 1 of an insurer-sponsored grant to start a wellness program from 220 small- and medium-sized employers. Responses yielded 25 indicators of OSH-wellness integration, and 10 additional indicators to summarize multiple responses.

RESULTS

At least half of the employers (N = 220) reported some level of integration within five of seven categories of OSH-wellness integration. Employers sometimes considered ergonomics, safety, or substance exposure hazards while designing their wellness program (15%) or reduced such hazards to support their wellness program (24%). Few meaningful differences were observed by employer size.

CONCLUSIONS

Although high levels of integration were unusual, some degree of integration was common for most indicator categories.

A Brief Measure of Organizational Wellness Climate: Initial Validation and Focus on Small Businesses and Substance Misuse

OBJECTIVE

Organizations with fewer than 100 employees comprise most businesses in the United States. Since small businesses lack comparable resources, they may benefit from a simple valid tool for broadly assessing positive wellness climate, especially because climate contributes to employee wellbeing.

METHODS

Using an ethnically and occupationally diverse sample of 45 businesses (n = 1512), the current study developed and tested a brief self-report measure of organizational wellness climate.

RESULTS

Confirmatory factor analysis shows that a 9-item measure has good model fit (RMSEA = 0.06, CFI = 0.91), inter-item consistency of 0.74, and mean Rwg(j) of 0.87. The new measure is significantly positively correlated with physical health and wellbeing, and negatively correlated with substance use behavior.

CONCLUSIONS

Findings indicate that a 9-item measure has good reliability, construct, and criterion validity. Implications for practical use of the measure are discussed.

Conference Summary Understanding Small Enterprises Conference, 25-27 October 2017

Objectives

The specific objectives of the 2017 Understanding Small Enterprises Conference were to: (i) identify successful strategies for overcoming occupational safety and health (OS&H) barriers in small and medium-sized enterprises (SMEs); (ii) disseminate best practices to research and business communities; (iii) build collaborations between different stakeholders including researchers, insurers, small enterprises, government agencies; and (iv) better inform OS&H research relevant to SMEs.

Methods

A two and a half day international conference was organized, building upon three previously successful iterations. This conference brought together researchers, practitioners, and other stakeholders from 16 countries to share best practices and emerging strategies for improving OS&H in SMEs.

Findings

Cross-cutting themes that emerged at the conference centered around: 1) stakeholder and intermediary involvement; 2) what occupational health and safety looks like across different industries; 3) intervention programs (tools and resources); 4) precarious and vulnerable work and the informal sector; and 5) Total Worker Health® in SMEs.

Conclusion

A number of innovative initiatives were shared at the conference. Researchers must build collaborations involving a variety of stakeholder groups to ensure that OS&H solutions are successful in SMEs. Future OS&H research should continue to build upon the successful work of the 2017 Understanding Small Enterprises Conference.

Small business Total Worker Health: A conceptual and methodological approach to facilitating organizational change

Nearly half of Americans are employed by small businesses, and future projections suggest that the number of those employed by small businesses will rise. Despite this, there is relatively little small business intervention research on the integration of health protection and health promotion, known as Total Worker Health® (TWH). We first discuss the importance of studying small businesses in TWH research and practice. Second, we describe an example of a small business TWH intervention, Health Links™ plus TWH owner/senior manager leadership training, that we are evaluating via the Small+Safe+Well (SSWell) study. Key features of the intervention and the SSWell study include attention to multi-level influences on worker health, safety and well-being; organizational change; and dissemination and implementation science strategies via the RE-AIM model. We offer several considerations for future small business TWH research and practice both in terms of the small business context as well as intervention development and evaluation. Our goal is to provide TWH researchers and practitioners with a framework and an example of how to approach small business TWH interventions. Ultimately, through the SSWell study, we aim to provide small businesses with strong evidence to support the use of TWH strategies that are practical, effective and sustainable.