Health Links™ Assessment of Total Worker Health® Practices as Indicators of Organizational Behavior in Small Business

The Total Worker Health® (TWH) approach: a systematic review of its application in different occupational settings

BACKGROUND

The National Institute for Occupational Safety and Health (NIOSH), in 2011, developed the "Total Worker Health®" (TWH) as a holistic approach to protect and promote the workers' safety, health, and well-being. After over ten years from the TWH development, the aim of the present systematic review is to provide a comprehensive overview of the worldwide TWH initiatives.

METHODS

PubMed, Scopus and ISI Web of Science were searched for TWH studies published up to the 31st of July 2023, and 43 investigations could be included. The review was registered on the International prospective register of systematic reviews PROSPERO with the reference number CRD42023416972.

RESULTS

Issues that emerged as relevant for the TWH operationalization were the awareness about the TWH approach and fundamentals, the leadership commitment, and a participatory engagement of the workforce: these aspects all contributed to acceptable and effective setting oriented TWH plans, specifically tailored on the peculiarities of the workplace, including small enterprises and multiemployer worksites. Evaluation and continual improvement were reported as fundamental for the successful implementation of TWH initiatives. Limited resources for safety and health initiatives, in terms of time, people, and funds, together with difficulties in the identification of safety and health priorities and a poor participatory culture were recognized as obstacles to the TWH application. Training resulted the core component of the TWH leadership and workforce preparedness, with beneficial results in terms of safety culture and adoption of preventive measures.

CONCLUSIONS

Although interesting aspects emerged from our review, future longitudinal investigations should confirm the effectiveness, easy integration, and long-term sustainability of TWH models in different workplaces, in order to effectively support safe and health-enhancing works able to improve innovation and productivity.

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.

Feasibility of Implementing a Total Worker Health® Intervention During the COVID-19 Pandemic in Small and Medium Businesses : Results From the Carolina PROSPER Study

OBJECTIVE

In response to the COVID-19 pandemic's disruptive effect on employers and workers, an interdisciplinary team launched the Carolina Promoting Safe Practices for Employees' Return study to assess the feasibility of providing tailored technical assistance to small and medium North Carolina businesses using a Total Worker Health (TWH) ® approach.

METHODS

Feasibility of the approach was assessed via surveys and interviews of business representatives from four participating businesses ranging in size from 3 to 110 employees.

RESULTS

The TWH approach is feasible, that is, in demand, practical, and acceptable to protect and promote worker safety, health, and well-being. Potential challenges include implementation cost, difficulty engaging all employees, and difficulty accessing tailored health and safety materials in a timely manner.

CONCLUSIONS

Additional refinement and testing of the TWH approach postpandemic with more worksites is warranted.

Methods to improve the translation of evidence-based interventions: A primer on dissemination and implementation science for occupational safety and health researchers and practitioners

Objective

A limited focus on dissemination and implementation (D&I) science has hindered the uptake of evidence-based interventions (EBIs) that reduce workplace morbidity and mortality. D&I science methods can be used in the occupational safety and health (OSH) field to advance the adoption, implementation, and sustainment of EBIs for complex workplaces. These approaches should be responsive to contextual factors, including the needs of partners and beneficiaries (such as employers, employees, and intermediaries).

Methods

By synthesizing seminal literature and texts and leveraging our collective knowledge as D&I science and/or OSH researchers, we developed a D&I science primer for OSH. First, we provide an overview of common D&I terminology and concepts. Second, we describe several key and evolving issues in D&I science: balancing adaptation with intervention fidelity and specifying implementation outcomes and strategies. Next, we review D&I theories, models, and frameworks and offer examples for applying these to OSH research. We also discuss widely used D&I research designs, methods, and measures. Finally, we discuss future directions for D&I science application to OSH and provide resources for further exploration.

Results

We compiled a D&I science primer for OSH appropriate for practitioners and evaluators, especially those newer to the field.

Conclusion

This article fills a gap in the OSH research by providing an overview of D&I science to enhance understanding of key concepts, issues, models, designs, methods and measures for the translation into practice of effective OSH interventions to advance the safety, health and well-being of workers.

Small + Safe + Well: lessons learned from a Total Worker Health® randomized intervention to promote organizational change in small business

BACKGROUND

Leadership commitment to worker safety and health is one of the most important factors when organizations develop and implement a Total Worker Health® approach. We aimed to assess the effectiveness of a Total Worker Health ("TWH") leadership development program that targeted owners and other senior-level leadership positions on changing organizational and worker outcomes from baseline to one-year later.

METHODS

The Small + Safe + Well study included small businesses from a variety of industries in the state of Colorado, USA that were participating in Health Links™. We designed a randomized waitlisted control comparison design (RCT) to evaluate the added benefit of a TWH leadership development program. An employer assessment tool was used to assess TWH policies and programs, and an employee health and safety survey was used to assess safety leadership and health leadership practices, safety climate and health climate, safety behaviors and health behaviors, and well-being. We used a linear mixed model framework with random effects for business and employee to assess the impact of intervention on the outcomes of interest.

RESULTS

Thirty-six businesses (37% retention) and 250 employees (9% retention) met the RCT study inclusion criteria and were included in the analysis. Businesses improved their TWH policies and programs score from baseline to one-year later, regardless of leadership intervention group assignment. Neither intervention group demonstrated improvements in employee-reported outcomes.

CONCLUSIONS

This study sought to address a gap in the literature regarding small business senior leadership development for TWH. Our study demonstrates many of the challenges of conducting studies focused on organizational change in workplaces, specifically in small businesses. When designing TWH intervention studies, researchers should consider how to best engage small business leaders in interventions and implementations early on, as well as methods that are well matched to measuring primary and secondary outcomes longitudinally. Future research is needed to test the feasibility and sustainability of TWH interventions in small business.

TRIAL REGISTRATION

The trial was retrospectively registered with ClinicalTrials.gov ( ID U19OH011227 ).

Leveraging an Implementation Science Framework to Measure the Impact of Efforts to Scale Out a Total Worker Health® Intervention to Employers

The role of dissemination and implementation (D&I) science is critical to the translation of Total Worker Health^® into practice and to the success of interventions in addressing current and future implications for worker safety, health, and well-being. D&I frameworks can guide researchers to design Total Worker Health (“TWH”) delivery approaches that use flexible implementation strategies to implement the core components of programs for employers with varying contextual factors, including small/mid/large-sized businesses and different industry types. To date, there have been very few examples of applying implementation frameworks for the translation and delivery of interventions into organizational settings that require adoption and implementation at the business level to benefit the working individuals. We present a TWH case study, Health Links™, to illustrate an approach to applying an existing implementation framework, RE-AIM, to plan, design, build, and then evaluate TWH implementation strategies. Our case study also highlights key concepts for scaling-out TWH evidence-based interventions where they are implemented in new workplace settings, new delivery systems, or both. Our example provides strong support of key implementation planning constructs including early and consistent stakeholder engagement, tailored messaging and marketing, flexibility, and adaptations in implementation strategies to maximize adoption, implementation, and maintenance among participating businesses.

A pilot study of changes in Total Worker Health® policies and programs and associated changes in safety and health climates in small business

BACKGROUND

There is little longitudinal research on whether changes to Total Worker Health® (TWH) policies and programs are associated with changes in health climate and safety climate. We hypothesize that as TWH policies and programs change, employees will report changes in safety climate and health climate from baseline to 1 year.

METHODS

Twenty-five diverse small businesses and their employees participated in assessments completed approximately 1 year apart. The exposures of interest, TWH policies and programs, were measured using the business-level Healthy Workplace Assessment™ which collects information on six benchmarks. The outcomes of interest, employee perceptions of safety climate and health climate, were measured via an employee survey. We employed paired t-tests and simple linear regression to assess change over a 1-year period.

RESULTS

The mean Healthy Workplace Assessment overall score changed by 11.3 points (SD = 11.8) from baseline to Year 1. From baseline to Year 1, the mean scores of each benchmark changed in a positive direction within this sample. The mean safety climate score and health climate score changed by +0.1 points (SD = 0.2) and +0.1 points (SD = 6.4) from baseline to Year 1, respectively. The associations between changes in the overall Healthy Workplace Assessment score and health climate and safety climate scores were negligible [β = 0.01 (95% confidence interval [CI]: 0.002, 0.02), and β = 0.01 (95% CI: 0.002, 0.02), respectively].

CONCLUSION

Our study suggests that when small businesses improve upon their TWH policies and programs they experience marginal measurable improvements in employee perceptions of their workplace safety climate and health climate.

Attitudes of Company Executives toward a Comprehensive Workplace Health Management-Results of an Exploratory Cross-Sectional Study in Germany

Workplace health management (WHM) in Germany aims at maintaining and increasing the health and well-being of employees. Little is known about company executives’ attitudes toward WHM. To gain more insight, we conducted a large-scale survey in companies in the German county of Reutlingen in 2017. We sent a standardized questionnaire to 906 companies, containing inter alia 26 self-constructed declarative statements depicting company executives’ opinions on various WHM aspects; 222 questionnaires could be evaluated. By exploratory factor analysis we assigned the 26 items to six factors reflecting different attitudes toward WHM. Factor values were standardized to a scale from 0 to 10. The attitude ‘positive view of general health services in the company’, for example, achieved by far the lowest mean agreement (3.3 points). For the attitude ‘general skepticism toward WHM’, agreement and disagreement were balanced (5.0 points). Using multiple regression analyses, we searched for variables that could partially explain respondents’ agreement with attitudes. In conclusion, a general WHM skepticism was widespread, but not dominant. The idea that general health services should be offered in companies was predominantly rejected. Older respondents and respondents from smaller companies and craft enterprises were more skeptical than average about WHM and its possible extensions.

Intermediary Perspectives on Total Worker Health in Small Businesses

The future of work will include not only more small business employment, but also a need for greater consideration of more holistic approaches to addressing worker well-being. Previous research has suggested smaller firms need external assistance to add new or improve existing workplace health and safety activities. A Total Worker Health^® (TWH) approach is potentially appealing to small employers as it is intended to identify and support comprehensive practices and policies that take into account the work environment (both physical and organizational) while also addressing the personal health risks of individuals, thus being more effective in preventing disease and promoting health and safety than each approach taken separately. NIOSH researchers applied the NIOSH Small Business Intervention Diffusion Model to conduct parallel community-based TWH activities in two geographically distinct communities in a large metropolitan area. Data were collected from intermediary organizations that work with or serve small businesses about their perceptions of the TWH approach as a potential service for them to offer small firms. Intermediary organizations engaged in implementation of TWH approaches with small businesses in the respective geographic areas for approximately one year. Results indicated intermediary organizations find value in providing TWH assistance to small employers, but several challenges for intermediaries implementing TWH among small employers remain.

Education and Training to Build Capacity in Total Worker Health®: Proposed Competencies for an Emerging Field

Objective:

Establishment of core competencies for education and training of professionals entering the emerging field of Total Worker Health®.

Methods:

Compilation and distillation of information obtained over a 5-year period from Total Worker Health symposia, workshops, and academic offerings, plus contributions from key stakeholders regarding education and training needs.

Results:

A proposed set of Total Worker Health competencies aligns under six broad domains: Subject Matter Expertize; Advocacy and Engagement; Program Planning, Implementation and Evaluation; Communications and Dissemination; Leadership and Management; and Partnership Building and Coordination.

Conclusions:

Proposed set of core competencies will help standardize education and training for professionals being trained in Total Worker Health. It serves as an invitation for further input from stakeholders in academia, business, labor, and government.

Impact of Advising on Total Worker Health Implementation

OBJECTIVE

Little is understood about the mechanisms for improving the adoption and implementation of Total Worker Health® (TWH) in workplace settings. The primary objective of this study was to identify whether the delivery of TWH advising is associated with subsequent changes in TWH in small-to-medium sized businesses.

METHODS

We conducted a longitudinal study of a TWH intervention in 200 organizations completing Health Links Healthy Workplace Assessments™ between October 2016 and December 2019. Organizations were offered consultation via telephonic and live web-based advising sessions.

RESULTS

Organizations exhibited non-significant albeit positive change in assessment scores from baseline to assessment 2. Businesses receiving advising showed significant score improvements from assessment 2 to 3, versus those without advising.

CONCLUSIONS

TWH consultation may enhance adoption of organizational behaviors that promote worker health, safety, and well-being over time.

How does Organizational Climate Motivate Employee Safe and Healthy Behavior in Small Business?: A Self-Determination Theory Perspective

OBJECTIVE

This study evaluates the motivational processes between employee occupational safety and health climates and behaviors using the Theory of Self-Determination in a sample of diverse small businesses.

METHODS

We used cross-sectional data to assess whether employee safety/health intrinsic, identified, and external motives mediate the relationship between safety/health climate and behavior.

RESULTS

All three types of motivation mediated the relationship between safety and health climates and behaviors.

CONCLUSION

Small businesses seeking to engage employees in Total Worker Health efforts should build strong safety and health climates because of their influence on employees' motivation to participate in health promoting and health protective programs.

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.

Evaluation of a Total Worker Health® leadership program for small business leaders

Leaders play a critical role in the development and execution of Total Worker Health (TWH). Small businesses, in particular, can benefit from strong leadership support for TWH as the burden of work-related injury, illness and fatality, as well as poor health and well-being is high in this population. In the present study, we conducted a program evaluation of a TWH leadership development program for small business leaders using the RE-AIM framework. The goal of the program was to help change leaders' behaviors around health, safety and well-being practices following the theory of transformational leadership. Two leaders from each business participated in pre-training activities on their own, a 6-hour in-person training, and three months of access to virtual training transfer activities, including coaching and goal tracking. Our results suggest that the TWH leadership development program is effective at improving leaders' self-reported TWH leadership practices and that the in-person training was implemented successfully. However, leaders did not report improvements in their personal health and in fact reported increased levels of work stress after the program. We also observed some challenges when implementing our training transfer strategies. Our study suggests that leaders may benefit from attending TWH leadership trainings alongside other colleagues in their organization to facilitate a shared vision and goals for TWH in their organization. As a next step, it will be important to determine the program's effectiveness in changing business TWH policies and practices, employee perceptions of TWH and leadership, and employee health and safety outcomes.

International Total Worker Health: Applicability to Agribusiness in Latin America

Total Worker Health^® (TWH) is a framework for integrating worker and workplace safety, health, and well-being, which has achieved success in European and US settings. However, the framework has not been implemented in Latin America or in agricultural sectors, leaving large and vulnerable populations underrepresented in the implementation and evaluation of these strategies to improve safety and promote health and well-being. This study presents a case study of how a TWH approach can be applied to a multinational Latin American agribusiness. We describe the process and adaptation strategy for conducting a TWH assessment at multiple organizational levels and in multiple countries. We follow this with a description of a TWH leadership training that was conducted based on the results of the assessment. Finally, we describe our methods to make corporate recommendations for TWH policies and programs that were informed by the TWH assessment and leadership trainings. With this case study we aim to demonstrate the importance and feasibility of conducting TWH in Latin America.

The Importance of Small Business Safety and Health Climates During COVID-19

OBJECTIVE

This study examines employee perceptions of safety and health climates for well-being during the COVID-19 pandemic in a sample of small businesses.

METHODS

We evaluated changes to employees' work and home life resulting from COVID-19 and perceptions of safety and health climates. Cross-sectional relationships were assessed using multivariable linear regression models for a sample of 491 employees from 30 small businesses in Colorado in May 2020.

RESULTS

Employee perceptions of safety and health climates were significantly related to their self-reported well-being during the first wave of COVID-19, even when there were changes to childcare, the ability to work, and limited social contacts.

CONCLUSION

Safety and health climates may influence employee well-being even when other disruptions occur, suggesting that during emergencies, small businesses with strong climates may be better prepared to maintain employee well-being.

Change in frontline supervisors' safety leadership practices after participating in a leadership training program: Does company size matter?

INTRODUCTION

The majority of construction companies are small businesses and small business often lack the resources needed to ensure that their supervisors have the safety leadership skills to build and maintain a strong jobsite safety climate. The Foundations for Safety Leadership (FSL) training program was designed to provide frontline leaders in all sized companies with safety leadership skills. This paper examines the impact of the FSL training by size of business.

METHODS

Leaders, defined as foremen or other frontline supervisors, from small, medium, and large construction companies were recruited to participate in a study to evaluate the degree to which the FSL changed their understanding and use of the leadership skills, safety practices and crew reporting of safety-related conditions. We used linear mixed modeling methods to analyze pre-post training survey data.

RESULTS

Prior to the training, leaders from small and medium sized companies reported using safety leadership skills less frequently than those from large ones. After the training, regardless of business size, we observed that the FSL training improved leaders understanding of safety leadership skills from immediately before to immediately after the training. Additionally, leaders reported greater use of safety leadership skills, safety practices, and crew reporting of safety-related conditions from before to two-weeks after the training. However, those from small and medium sized companies reported the greatest improvement in their use of safety leadership skills.

CONCLUSIONS

The FSL training improves safety leadership outcomes regardless of the size company for which the leader worked. However, the FSL may be even more effective at improving the safety leadership skills of leaders working for smaller sized construction companies or those with lower baseline levels of safety leadership skills. Practical applications: The majority of construction companies employ a small number of employees and therefore may not have the resources to provide their frontline leaders with the leadership training they need to be effective leaders who can create a strong jobsite safety climate. The Foundations for Safety Leadership (FSL) training can help fill this gap.

Evaluating the effectiveness of labor protection policy on occupational injuries caused by extreme heat in a large subtropical city of China

On March 1, 2012, the Chinese government implemented the Administrative Measures on Heatstroke Prevention (AMHP2012) to combat the occupational health impacts of extreme heat, and reducing occupational injury was one of the main purposes. This study aimed at quantifying the intervention effects of the AMHP2012 on extreme heat-related occupational injuries and subsequent insurance payouts in Guangzhou, China. Data on occupational injuries and insurance payouts were collected from March 1, 2011, to February 28, 2013, from the occupational injury insurance system of Guangzhou. A quasi-experimental design with before-after control was adopted. Interrupted time series analysis was performed to quantify the change of occupational injuries and insurance payouts after policy implementation. The distributed lag non-linear model was used to explore whether injury claims and insurance payouts due to extreme heat decreased. A total of 9851 injury claims were included in the analysis. After policy implementation, the risk of occupational injuries and insurance payouts decreased by 13% (RR = 0.87, 95%CI: 0.75, 0.99) and 24% (RR = 0.76, 95% CI: 0.58, 0.94), respectively. The attributable fraction of extreme heat-related occupational injuries decreased from 3.17% (95%eCI: 1.35, 4.69) to 1.52% (95%eCI: -0.36, 3.15), which contributed to 0.86 million USD reduction of insurance payouts. Both males and females, low-educated, young and middle-aged workers, workers at small or medium-sized enterprises, engaging in manufacturing, and with both minor and severe injuries were apparently associated with decreased rates of extreme heat-related occupational injuries. The AMHP2012 policy contributed to the reduction of extreme heat-related occupational injuries and insurance payouts in Guangzhou, China, and this research provided novel evidence for decision-makers to better understand the necessity of implementing health protection policies among laborers under climate change.

Total Worker Health Leadership and Business Strategies Are Related to Safety and Health Climates in Small Business

The purpose of this study was to investigate the relationship between Total Worker Health® (TWH) business strategies and employee perceptions of leadership commitment and safety and health climates. Using data from 53 small enterprises and 1271 of their workers collected as part of the Small + Safe + Well (SSWell) Study, we confirm the primacy of the relationship between leadership commitment to safety and workplace safety climate. After accounting for leadership commitment to safety, business-reported policies and practices that promote the health, safety, and well-being of workers (i.e., TWH strategies) were no longer related to safety climate. In contrast, the relationship between TWH strategies and health climate were significantly associated with the level of small business leadership commitment to worksite wellness. Relatedly, our results demonstrate that leadership is a common correlate to both safety climate and health climate. Future research should investigate integrated TWH leadership development strategies as a means of simultaneously improving safety and health climates.

A Piece of the Boardroom Pie-An Interview Study Exploring What Drives Swedish Corporate Boards' Engagement in Occupational Health and Safety

OBJECTIVES

To investigate why boards of directors engage in occupational health and safety (OHS) and what influences their level of engagement.

METHODS

Thirty-four board members and chief executive officers at large companies from the manufacturing, construction, trade, and health/social care sectors were interviewed. An inductive thematic analysis was conducted.

RESULTS

Five drivers organized along a continuum explain why boards engage: legal compliance, untoward events, external expectations/regulations, business drivers, and moral values. Certain factors influence the level of engagement: board's OHS competence, owner's agenda, and competing needs.

CONCLUSIONS

Boards continuously prioritize among multiple foci. If a board's total engagement is likened to a pie, the size of the OHS slice will depend on the drivers, as well as on the influencing factors. We suggest that even boards with many drivers can down-prioritize OHS under certain conditions.

Small Business Employees' Perceptions of Leadership Are Associated With Safety and Health Climates and Their Own Behaviors

OBJECTIVE

Leadership is an important factor in creating a safe and healthy work environment. Little is known about its influence in small organizations. This study assessed the relationship between leadership, climate, and employee behavior in organizations with less than 500 employees.

METHODS

We examined organizational factors and worker perceptions of leadership and safety/health behaviors in an analysis of 1271 employees in 53 Colorado small organizations. Cross-sectional relationships were assessed using multivariable linear regression models.

RESULTS

Perceived leadership commitment to safety was associated with safety climate (β = 0.67) and safety behaviors among employees (β = 0.45). Perceived leadership commitment to worksite wellness was associated with health climate (β = 0.66) and health behaviors (β = 0.42).

CONCLUSIONS

Leadership plays an important role in creating a positive work environment around safety and health.