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 , 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 . While this may be true for larger businesses, most small businesses find these policies/activities a luxury, not central to their main focus  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 .
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 , 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)  are not practical, feasible or cost efficient within a small workplace. However as argued by Linnan , 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 . 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 . 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 . 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 . 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  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 . 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 . Heinen  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 . As argued by Linnan et al. , 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 .