The role of business size in assessing the uptake of health promoting workplace initiatives in Australia

Australia’s Baby Boomer Generation, Obesity and Work – Patterns, Causes and Implications was an Australian Research Council funded project. As a part of this project, in October 2011 a telephone survey was undertaken with eligible participants from two cohort studies - the North West Adelaide Health Study (NWAHS) and the Florey Adelaide Male Ageing Study (FAMAS). The content of the survey was based on WHP literature and previous surveys addressing barriers and enablers to the implementation of WHP initiatives. Detailed descriptions of the methodology and cohorts ares available elsewhere [25–27].

In the 2011 telephone survey, eligible respondents from the two methodologically similar cohorts who were born between 1946 and 1980 (aged 30 to 65 years), had worked in the previous three years, were not self-employed, were currently working or knew their employer’s details were asked to name their place of work with 69.1 % (n = 956) supplying details. A questionnaire, a letter, and reminder letter (if required), addressed to the Managing Director, Chief Executive Officer or Human Resources representative of the organisation, was sent inviting them to participate in the workplace survey. A paper survey with a reply paid envelope was included in the package and respondents also had the option to complete the survey online with an allocated identification number. The letter outlined the importance of study, invited them to participate and ensured confidentiality. All business types (public/private) from all sectors were eligible for inclusion. Data were obtained from a total of n = 218 businesses representing n = 330 individuals (several business had more than one participant) (response rate = 34.5 %). Business size (small 2–19 employees; medium 20–200 employees; and large 200+ employees) as defined by Australian Bureau of Statistics classifications [28] was determined for this analysis from the responses in this questionnaire.

Data were collected on number of employees, whether occupational health and safety (OHS) or staff wellbeing were regular meeting agenda items (yes/no), who had responsibility for staff health and wellbeing (owner, managing director/CEO, OHS manager, human resources manager, the staff themselves, no one), and the number and type of health promotion activities currently undertaken (smoking cessation, alcohol and substance abuse, healthy food policy, physical activity, mental health and wellbeing, none, other). The employer’s representative was also asked if they believed the health promotion activities undertaken by the company were effective (very, somewhat, not, undecided), whether they believed that specific workplace health promotion programs belonged in the workplace (yes, no, undecided, don’t know) and what challenges they faced implementing these activities (funding, time, facilities, lack of management/board support, not a workplace responsibility). Respondents were also asked the perceived effect on the business if five specified health promotion programs (physical activity, healthy eating, alcohol, mental health, smoking) were introduced (already have program, adverse effect, no effect, positive effect, don’t know - with positive responses reported); to rank the extent to which they thought a range of 10 issues including work related injury, stress or burnout, alcohol, morale and work/life balance affected their workplace (with 1 = not very important and 5 = very important), and what resources they would require to increase physical activity and/or healthy eating in the workplace (written guidelines, government funding, best practice standards, consultants, information or advice about providers in the local area).

The survey was piloted tested (n = 10) and changes made based on the findings. The conventional 5 % level was used to determine statistical significance and 95 % confidence intervals were provided for estimates. Uni-variable analyses using chi-square (χ2) tests were undertaken to analyses differences in WHP practice and belief between businesses in terms of business size. Ethics approval for the workplace survey was gained by The University of Adelaide Human Research Ethics Committee.

In total, 19.3 % of responses (n = 42) were from small business (2–19 employees), 40.3 % (n = 88) from medium businesses (20–200 employees) and 40.3 % (n = 88) from large employers (over 200 employees).

The businesses assessed in this study were the workplaces of participants who were randomly selected to be included in two major cohort studies undertaken in South Australia. These businesses were classified into business size based on number of employees and results indicate that smaller workplaces have many barriers, beliefs and challenges to having health promoting workplaces.

In line with many other major studies, the overall implementation of evidence-based WHP initiates in small businesses was low [17, 29]. Over 50 % of small businesses have not embraced WHP concepts and lag behind markedly in the health-promoting activities that we specifically assessed. In common with USA studies where estimates of over 90 % of workplaces offer at least one health promoting activity [4], our study found that over 86 % of medium or large workplaces embraced at least one health promotion strategy. One of the common benefits of using a work place as a health-promoting site is based on the existing ‘community-like’ environment often found at worksites [8]. While this may be true for larger businesses, most small businesses find these policies/activities a luxury, not central to their main focus [10] and lack the infrastructure, incentives and perceived benefits to such activities. Changing these notions is a first step with many small business operators lacking the knowledge and experience to make the first step in the required changes [10].

Common barriers such as cost, time and travel associated with many other forms of community-wide health promotion interventions, are typically reduced with WHP campaigns. This is not necessarily the case with small businesses, as shown in this and other studies [16], where cost is a major reason for the lack of health promoting initiatives. The financial risk often associated with many aspects of operating a small business means that implementing perceived costly health promotion interventions receive a low priority. Such concepts as including use of company facilities, equipment and other infrastructure, and having environmentally suitable workplaces that encourages healthy activities (stairwells, healthy food supply) [14] are not practical, feasible or cost efficient within a small workplace. However as argued by Linnan [15], the growing evidence that WHP programs lead to broad-reaching improvements such as better overall employee health, morale and productivity may provide additional benefits not normally considered by small business operators and should be encouraged and promoted. Small businesses also have fewer personnel that can be assigned the responsibility of promoting these activities or guidelines or even highlighting them as an OHS consideration [15]. Notwithstanding, 85 % of our sample of small business operators/managers who had health promoting activities in their workplace, believed that their current promotion activities were effective, and believe in the value of the programs, highlighting that once adopted, positive sentiments prevail. Those small businesses who take up health promotion activities are able to see or measure the benefits. Combine this with the perceived need for resources being similar to that for all businesses suggests that we could use these ‘small business champions’ to spread the word about the positive impacts for small businesses and the creative ways they have overcome resource needs to make this happen.

The importance of the business owner in implementing change is highlighted with management support being the main challenge to implementing WHP strategies. Notably, our figure of 74 % of large businesses believing WHP to be important corresponds with other literature [23]. While other studies have shown high levels of managers believing health promotion programs to be important, [21, 23], only 31 % of small businesses in this study believed they belong in the workplace. While small business operators are not convinced health promotion programs in the workplace are effective with one in five not believing health promoting activities belong in the workplace, a further 50 % reported that they ‘did not know’ or were ‘undecided’. This latter group are a potential target to influence, especially their beliefs and knowledge about the benefits of WHP. In addition, small business respondents to this survey were less likely to report positive effects of specific health promoting programs than larger businesses with the most positive response being for physical activity (45.2 %) and healthy eating (42.9 %). In contrast, only 28.6 % of small businesses could see a positive effect of introducing an alcohol program.

An important finding of this study was the relative importance of work-life balance issues with nearly 50 % of small business respondents ranking work/life balance as a very important issue. Implementing WHP initiatives that encourage work-life balance as well as addressing the broader health and wellbeing agenda in small businesses is warranted [2]. Highlighting the benefits of health promotion programs that assist in self-management to increase knowledge and coping skills, and make ‘the healthy choices the easy choices’, is also warranted [1]. Morale, work life balance and stress all ranked highly in terms of importance for health promotion. These are clearly linked more closely to work productivity, or have received more attention than other issues. One questions whether issues such as smoking and alcohol are a low priority because they are not seen as influencing worker’s health and productivity as they are not allowed in work places, or whether people think there is already enough health promotion in this area.

Weaknesses of the study included the use of self-reported measures rather than audit techniques with potential bias and self-affirmation included in the response especially as there was no explicit instructions on whom within the company should complete the questionnaire. A further weakness was the limiting of the health promoting activities to six activities while excluding activities such as influenza vaccinations and stress management. There was also no economic assessment undertaken and no assessment of concern with privacy or breaches of confidentiality often cited as a major barrier to investing in WHP principles, especially in small businesses, and highlighted extensively in the literature [10, 18]. The definition of what constitutes a small business differs across countries and studies [23] making comparison difficult and the use of Australian Bureau of Statistics classifications of business size as arbitrary cut-offs may have limited other associations. In addition, there was a potential bias from survey non-response in this study with a response rate of 35 % and this should be seen as a weakness of the study. An additional weakness was the lack of power to link individual health outcomes to WHP workplace initiatives. No analysis was undertaken to assess the representativeness of the sample and as such the results could be biased although a relatively large number of businesses and business types were included. As the initial sample was from a cohort of people aged 30+ years and included more females than males bias may of resulted and generalizability of the results may have been compromised. In addition, validity and reliability of the questions used in the survey were un-determined. The strengths of this study include the random nature of the selection of worksites without being limited to pre-determined industry or sector-wide business types, the wide range of questions asked and the relatively large number of business assessed. The ability to eventually link the participants’ health outcomes over the life of the cohort study to workplace characteristics has much potential.

This research has shown that while workplaces on the whole are embracing health-promoting activities in the workplaces, small business and hence workers employed by small business operators, are lagging behind in implementing the required changes. Management support and change of beliefs are required for ultimate and sustained success [20]. Success will not be obtained without reorienting work practices and in small businesses this reorientation is not necessarily a priority. Commitment to changes in policies, systems and providing resources may be required [30]. Heinen [14] and others [10, 15] call on government policy interventions and financial incentives (including tax incentives) for small-based workplaces in an endeavour to increase WHP initiatives and to accelerate change. These may well be warranted. Given that funding was listed as a challenge to WHP implementation by over 60 % of businesses, tax incentives may have a significant impact on WHP. Others have argued that facilitating a culture within a workplace is often a cost neutral endeavour that can ultimately have positive effects [14]. As argued by Linnan et al. [15], and supported by these analysis, different levels of workplaces perhaps require different types of programs, policies and practices as a ‘one-size fits all approach’ is unlikely to be successful [31].

Within Australia WHP is an ongoing process with recent encouragement from government initiatives [31]. This study has filled a void on research on the requirements and needs of small businesses. The need for low cost, low-resourced, creative activities and solutions and more detailed knowledge of the benefits to employees are required [18, 31]. Corresponding knowledge improvement via mass media campaigns and promotions will also be beneficial. While the results of this research have highlighted the low uptake of health promotion initiatives in small workplaces, some positive results are evident. These include the proportion of small businesses that have WHP, responding favourably to their influence and effectiveness and the positive results for larger businesses both of which herald encouraging signs for the health of the workers of Australia.

Ethical approvals were obtained from the Research Ethics Committee of The University of Adelaide. Participation in the study was voluntary. Verbal informed consent was obtained from participants at the start of the interview. Prior to contact by the interviewers, a primary approach letter was sent informing them of the purpose of the survey including details on confidentiality and privacy, that participation was voluntary, and a contact number for queries. Participants were able to refuse to answer any questions or terminate the interview at any point.

Not applicable.