Background
The Total Worker Health® (TWH) approach is emerging as a best practice method to protect and promote worker safety, health, and well-being. Businesses can encounter numerous obstacles in the pursuit of TWH [
1]. That is why leadership support and the creation of health and safety climates that that support day-to-day engagement in health and safety policies and programs are central to the TWH approach [
2,
3]. This is because employees will be more likely to participate in efforts to protect and promote their health if they work in an environment that cares about their health [
4,
5]. While some research supports the relationship between leadership support, safety climate and health climate, and employee participation, there has been limited research amongst small businesses. Furthermore, it remains to be shown what role TWH business strategies, the organizational policies and programs to protect and promote employee health, play in the relationship between between leadership support, safety climate and health climate, and employee participation.
It is important to conduct this research in small enterprises because, globally, the majority of people work for small businesses and suffer a significant amount of work-related injuries, illnesses, and fatalities as well as poor health [
6]. We find that small businesses are implementing a variety of TWH business strategies to protect and promote employee health [
7], but employees of small businesses report varying levels of their employers’ commitment to the TWH business strategies [
8]. There is a need to simultaneously characterize what small employers are doing, both in terms of business strategies as well as leadership and climate, to protect and promote their employees’ health. This information can inform the design and implementation of needed small business TWH interventions [
9].
According to the theory of social exchange, when organizations provide employees with resources to protect and promote their health, employees will be motivated to reciprocate by engaging in safety and health behaviors [
10]. These resources can take the form of business strategies as well as indicators of leadership and climate. We define leadership to be a commitment to safety and health via communication, role modeling, positive feedback, resource allocation, and accountability. While climate reflects employee perceptions that their organization is committed to their safety and health. Meta-analyses support the positive relationship between health and safety leadership, climate, and behavior [
4,
5]. However, there is little research that describes the relationship between health and safety business strategies and employee behavior [
8]. Each of these three types of resources - business strategies, leadership, and climate – contributes information about the work environment as it relates to TWH. Business strategies reflect information about the existence of policies and programs that protect and promote employee health, whereas ratings of leadership and climate provide us with an indication of whether the business strategies are implemented successfully. Employee engagement in worksite health and safety practices is critical to the success of any TWH program [
11]. However, an understanding of the characteristics of small businesses that elicit health and safety behaviors is limited.
The purpose of this study is to characterize small businesses by their organizations’ TWH approach -- business strategies, leadership, and climate; and to assess the relationship of these approaches to employee health and safety behaviors. Using latent profile analysis, we hypothesized that small business could be characterized by indicators of TWH business strategies as well as employee perceptions of leadership commitment safety, leadership commitment to health, safety climate, and health climate. Specifically, we hypothesized (H1) that there would be four profiles: 1) A beginner profile with the lowest indicator scores, 2) A business strategy-focused profile where scores on the TWH business strategy indicators were high but scores on climate and leadership indicators were low, 3) A culture-focused profile where scores on climate and leadership indicators were high but scores on TWH business strategy indicators were low, and 4) An advanced profile where scores on all indicators were high. The culture-focused profile was named as such because leadership and climate indicators have been associated with a culture of health and safety in prior literature [
12]. On the other hand, the business strategy profile was named as such because of its focus on TWH policies and programs. We also hypothesized (H2) that employees who worked for businesses with higher TWH business profile scores would report better safety and health behaviors than employees who worked for businesses with lower TWH business profiles scores.
Discussion
Businesses often report that they have difficulty meeting their engagement goals for their workplace safety and worker well-being programs. They often respond in a transactional way –adopting additional programs and policies. The present study demonstrates that employee participation in health and safety behaviors is greater when organizations display strong leadership commitment to employee health and safety and when they are perceived by employees as having climates supportive of health and safety practices. Our findings suggest that workers’ health and safety actions are strongest in those workplaces that have focused on the combination of not only its TWH policies and programs, but also on establishing leadership that establishes a climate that supports and encourages health and safety behaviors.
The results of the present study add to the occupational health and safety small business literature by identifying four ways in which small business address TWH. As we might expect, few small businesses have both the TWH business strategies and the leadership and climate to support the strategies. Indeed, prior research demonstrates that smaller businesses lag in their efforts to implement TWH policies and practices [
7]. However, about half of the businesses in our study either had stronger TWH business strategies or stronger leadership and climate (i.e., culture-focused). This suggests there is variation in small business approaches to TWH. These findings have significant implications for how we design small business TWH interventions.
As hypothesized, we found that employees working for businesses with advanced TWH practices reported better safety and health behaviors than did employees working for businesses with less advanced TWH practices. This is consistent with prior research demonstrating the relationship between safety and health leadership, climate, and employee behavior [
4,
5]. There is some evidence that safety management practices are associated with better safety behaviors and lower injury rates (e.g., [
26,
27]). Similarly, worksite wellness practices are associated with better employee engagement and health risk factors (e.g, [
28]). There is emerging TWH intervention research suggesting that a focus on policy and program development and implementation via management and leadership practices lead to changes in employee practices and lifestyle health risks (e.g., [
29]).
Employee engagement in TWH is critical to the success of any TWH initiative [
11,
30], given the priority that TWH frameworks place on workplace safety, it is encouraging to see that regardless of which TWH programs and policies are in place, engagement in safety behaviors is highest when businesses focus on their culture. Prior research focused on the relationships between leadership, climate, and behavior without including more context around TWH business strategies [
8]. Our study adds to this literature by supporting the primacy of leadership and climate in eliciting employee engagement. Businesses with a business strategy-focused profile with better scores on benchmarks and worse scores on leadership and climate elicited better employee health and safety behaviors than did businesses that were just beginning to develop their methods for TWH in the beginner profile with lowest benchmark, leadership and climate scores. However, given prior literature, it is not surprising to observe that organizations in the two business profiles that are focused on culture elicited the best employee health and safety behaviors [
4,
31].
Our findings are also similar to prior workplace health protection and promotion research using a latent profile analysis approach. Biswas et al. [
22] profiled businesses based on the co-occurrence of business health protection and promotion practices (e.g., safety audits and flexible work hours). They found that larger businesses (> 500 employees) were more likely to be in the highest co-occurrence profile than were small businesses (< 100 employees). We cannot directly compare our results to theirs as we did not have employers with more than 500 employees in our study, but we did find that, on average, the largest employers in our study fell into the profile with more TWH policies and programs (i.e., business strategy profile) and the smallest organizations fell into a profile with fewer TWH policies and programs (i.e., culture-focused profile). Weaver et al. [
21] characterized businesses using a workplace health promotion checklist and found that some businesses fell into a profile characterized by a supportive environment but little operational initiatives, which is similar to our culture-focused profile. Finally, we found that those businesses that fit the profiles with more positive leadership and climate for health and safety employed workers who reported better health and safety behaviors. Similarly, Klug et al. [
19] found that positive workplace healthy leadership profiles were related to self-rated health.
Future research
There are a number of important priorities for future research in this area. First, longitudinal data are needed to understand how TWH profiles in small businesses change over time. Additionally, this research can inform whether contextual factors such as age of business, size of business, industry, and geographical region influence change in profile. Second, in light of the COVID-19 pandemic, it would be informative to understand which profile(s) are associated with the best employee health outcomes during emergencies. We recently observed that employees’ self-reported well-being is highest in those small businesses which had stronger health and safety climates at the start of the COVID-19 pandemic [
32]. Thus, we might expect that businesses with a business culture-focused or advanced profile would elicit the best employee health outcomes during emergencies. Third, research is needed to understand how TWH interventions help small businesses adopt TWH practices and improve their profile. We hypothesize that TWH leadership training is an important intervention that helps small businesses achieve an advanced profile [
2]. In a study of 38 leaders from 23 small businesses, we found that a TWH leadership training program helped small business leaders develop their TWH leadership practices in the context of their business’s TWH strategy [
33]. Current work is being conducted to evaluate how this training can help small businesses improve their TWH profiles via our broader Small+Safe+Well study [
2]. Small businesses in that study are randomized to receive either an intervention that was intended to help them change their TWH policies and programs or that intervention plus a TWH leadership training. Our aim is to help the small business undergo organizational change by modifying TWH policies and programs, leadership, and climate, with the ultimate goal of helping its employees improve their safety, health and well-being.
Public health practice implications
Public health practitioners may use assessments such as those used in the present study to determine current TWH approaches in small businesses and identify ways in which to help them improve. Consistent with prior research on the paucity of protections for workforce safety and health promotion programs [
6,
7,
34], we observed that some businesses were at a
beginner stage with the lowest scores on all indicators of TWH. Our research adds to this literature by showing that some small businesses had employees reporting positive perceptions of safety and health leadership and climate (i.e., culture-focused). These small businesses may be at an advantage when it comes to developing and implementing a TWH business strategy because they already have a supportive environment [
35]. However, we hypothesize that without the commensurate TWH business strategies, these small businesses may find themselves in an
unsustainable situation over time where there are few methods to keep workers healthy and safe. In this case, the small business may only need assistance developing a TWH business strategy that can help them cope with changing threats to worker safety and health. On the other hand, we observed that some businesses have invested in TWH business strategies but without ensuring adequate employee perceived organizational commitment to health and safety. We hypothesize that they may find themselves in an
ineffective situation over time where methods to keep workers healthy and safe are rarely used in practice [
4,
31]. In this case, small businesses may benefit from TWH interventions that focus on leadership.
Strengths and weaknesses
Our study has a few strengths and weaknesses. A strength of this study is the variety of businesses from multiple industries and from both urban and rural settings represented in the study. We also had access to a unique data source with information from both the perspective of the business as well as the employee. Furthermore, the variables gather from both the Healthy Workplace Assessment and the Employee Health and Safety Culture survey have been previously evaluated for reliability and validity [
7,
8]. However, we did not have access to information that would describe the quality of TWH business strategies. Another limitation is the potential for misclassification of business into a profile. However, the average latent profile probabilities for most likely latent profile membership were high (> 0.90) indicating that the potential for misclassification is low. Finally, our cross-section data limits our ability to make causal claims about the relationship between the profiles and employee safety and health behaviors.
Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit
http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (
http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.