Assessing health promotion programming in small businesses.

Abstract: Most studies of worksite health promotion have examined health promotion in large businesses. However, most American workers are employed by small businesses (those with 2 to 500 employees). Thus, a Workplace Wellness Appraisal was developed to assess health promotion programming in small businesses and administered by telephone to 2, 000 small businesses in Southern California. Results indicate that among small businesses (1) the most common health promotion activities are safety-related (and therefore mandated by law); (2) the smallest businesses have less health promotion programming than larger ones, and yet (3) the smallest businesses report higher participation rates than larger ones. Results suggest that employees in small businesses are more likely to participate in health promotion programs than employees of large businesses, but they have only limited access to them. Thus, most American workers, being employed in small businesses, are an underserved population with regard to health promotion programming.

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Since 1985, there have been three national surveys conducted to characterize and quantify health promotion awareness and activities in worksites with 50 or more employees (Association for Worksite Health Promotion [AWHP], 1999; Fielding & Piserchia, 1989; U.S. Department of Health and Human Services [USDHHS], 1993). These surveys have found that more and more businesses are adopting health promotion programs. In fact, results of the most recent survey in 1999 indicated that 90% of worksites offer at least one health promotion activity (AWHP, 1999). Common health promotion activities include smoking cessation, weight management, nutrition, and exercise programs. Moreover, these studies have consistently found that company size was a prominent indicator of the quantity and type of health promotion activities offered. Worksites with over 750 employees consistently offered a much greater number of health promotion activities than smaller worksites. The smallest worksites in their survey, those with 50-99 employees, consistently offered fewer programs than the larger companies. However, these studies have not included companies with fewer than 50 employees. Although one study by the U.S. Centers for Disease Control and Prevention (Wilson et al., 1999) did examine smaller businesses and did find that businesses with 15-99 employees offer fewer health promotion programs than businesses with 100 employees or more, this study was designed to track HIV/AIDS activities in the workplace and did not assess health promotion programming in great detail. The large-scale studies of worksite health promotion have not included businesses with fewer than 50 employees. Thus, we cannot make assumptions about these very small businesses until we have systematically included them in our studies.

However, the data that we do have suggest that small businesses have fewer health promotion programs than larger ones. There appear to be several reasons for the lack of health promotion programming in smaller businesses, including: (1) small businesses rarely have an individual on staff with expertise in the design, development, and provision of health care services; (2) small businesses are less likely to provide health insurance coverage, so preventive programs are less likely to be offered; and (3) many small businesses feel overwhelmed by occupational safety and health legislation and are often resistant to develop health-related programs not mandated by law (Stokols, McMahan & Phillips, 2001; Donaldson, Gooler, & Weiss, 1998; Kathawala & Elmuti, 1994; California Senate Committee on Industrial Relations, 1992; Muchnick-Baku & Orrick, 1992; Wilcox, 1992).

The lack of health promotion programs in small businesses is particularly problematic because these firms employ most American workers. According to the U.S. Small Business Administration, small firms (those employing 2-500 employees) represented 99% of all employers in the U.S. in 1995 (USSBA, 1998). Thus, the employees of these businesses are greatly underserved in health promotion programming. A greater understanding of existing health promotion programs in small businesses is critical if health professionals expect to increase the number of health promotion programs in these businesses. Several questions pertaining to small businesses need to be addressed. First, what types of health promotion activities are most often administered in small businesses? Second, do very small businesses have fewer health promotion programs and activities than larger ones? And third, do very small businesses have more or less employee participation in health promotion activities than larger ones? These questions should be answered if health promotion professionals plan to better serve small businesses in the future.

To examine these issues, a workplace wellness appraisal for small businesses was developed. The Workplace Wellness Appraisal takes a comprehensive, holistic approach to worksite wellness and views workplaces as complex systems comprised of social and physical environmental conditions that influence the well-being of employees. Very few appraisals have been implemented to date that are truly comprehensive in scope (e.g., that combine individual lifestyle change, health risk appraisal, employee counseling and support groups, medical interventions, environmental enhancement, and health supportive facilities) (O'Donnell & Harris, 1994; Stokols, Pelletier, & Fielding, 1995; Wilson, Holman & Hammock, 1996). The Workplace Wellness Appraisal includes questions about awareness of health promotion, types of health promotion activities offered at the workplace, health benefits and claims history, compliance with occupational safety and health legislation, the healthfulness of physical facilities, the organization's structure and management style, employee attitudes and morale, and demographic information.

METHODS

PROCEDURE

The Workplace Wellness Appraisal was administered to small businesses in Los Angeles and Orange counties, California. The appraisal was conducted by Interviewing Services of America in Ventura, California, over a two month period. The survey company obtained a list of all eligible companies (those having 2-500 employees) listing their telephone numbers in the Yellow Pages telephone directory. The survey company was instructed to call as many companies on the list necessary to complete 2,000 appraisals. Interviewers requested to speak with the person responsible for workplace safety, health promotion, human resources, or personnel. Each appraisal took approximately 15 minutes. The interviewers spoke with 11,497 individuals, and 2000 of those agreed to be interviewed for a response rate of 17.4%. (Most of the individuals who declined to participate claimed that they did not have the time to participate. Time is a frequently-cited reason for businesses, particularly small businesses, not participating in research (Wells, Stokols, McMahan, & Clitheroe, 1997).)

Of the 2,000 appraisal respondents, 1,846 maintained that their company had 2-500 employees. Thirty-eight companies had only one employee, three companies reported that they had more than 500 employees, and 113 companies did not answer the question regarding number of employees, so these 154 companies were excluded from the analyses reported here.

In addition to the 2000 participants who completed the appraisal, 502 individuals said that they did not have the time to complete the full interview, but they did agree to answer a few brief questions designed to determine if there were any differences between people who responded to the full interview and those who declined the full interview. There were no significant differences between these companies based on size or type of industry.

PARTICIPANTS

The 1,846 businesses in the sample reflected a wide variety of industries, including manufacturing (25%), business or professional services (25%), retail/ wholesale trade (17%), and other (33%). About half of the employees in these companies were white (54%), 31% were Hispanic, 9% were Asian, 4% were African-American, and 3% were of another ethnicity. Most (87%) were employed full-time.

WORKPLACE WELLNESS APPRAISAL INSTRUMENT

The interview consisted of administering the Workplace Wellness Appraisal. The appraisal contains eight sections: health promotion awareness, health promotion activities offered by the business, health promotive company policies and procedures, company benefits, economic status of the company, organizational climate, company problems, and company demographic information.

The appraisal begins by assessing the respondents awareness of health promotion. Participants are asked to rate their awareness of (1) health promotion programs and activities, (2) health risks that their employees may be exposed to, and (3) the potential benefits to their company of implementing health promotion programs, using the response categories of "well informed," "somewhat informed," and "not well informed."

The second section assesses the number and type of health promotion programs and activities the company offers. Respondents are asked to respond "yes" or "no" when asked if their company offers any of 16 health promotion programs (e.g., a weight management program, a smoking cessation program, and a workplace violence prevention program). If they answer "yes" to any program, they are asked if "most," "some," or "few" employees participate. Using the same format, they are also asked about the presence of 10 health promotive facilities (e.g., indoor and outdoor exercise facilities, medical treatment facilities, adjustable furniture, and healthy foods provided in vending machines or the cafeteria).

The third section asks questions pertaining to health-related policies and procedures. Respondents are first asked to answer "yes" or "no" when asked whether their company has any of six health-related policies (e.g., safety, drug-free workplace). The appraisal then asks several questions to determine such things as whether or not the company has conducted a needs assessment of health promotion programs, has a written health promotion plan, monitors the effectiveness of their health promotion programs, communicates with employees about health and safety matters, includes employees in the planning of health promotion activities, and includes a statement about employee health in its mission statement.

The fourth section assesses the company's employee benefits. Respondents answer "yes" or "no" when asked if their company has any of six benefits such as a 401 (k) retirement plan, flextime schedules, and health insurance.

The fifth section assesses the company's economic status. It asks if the company's gross revenues are growing, remaining the same, or decreasing and if the company is making a profit. It was believed that the respondents, many of whom were managers, would be privy to this information.

The sixth section asks five questions pertaining to organizational climate. Participants are asked to assess the workplace facilities, the general health of employees, and employee morale on a four-point scale from "excellent" to "poor." They are then asked about the frequency of employee complaints about working conditions and violations of safety legislation. The seventh section assesses company problems. This section lists 17 company problems (e.g., employee turnover, injuries, illnesses, poor productivity, workplace violence, substance abuse) and asks participants to state whether each of these issues has been a "major problem," "minor problem," or "not a problem" for them during the last year.

The last section of the appraisal assesses company demographics. It asks about the type of company (e.g., manufacturing, retail), ownership of the company (corporation, sole proprietorship), number of employees, and ethnic make-up of the company.

RESULTS

DESCRIPTIVE STATISTICS

Health promotion Awareness. In terms of awareness of health promotion programs and activities, about one-third (35%) of respondents reported that they were well informed, but most (43%) reported that they were only somewhat informed. As for the kinds of health risks that their employees may be exposed to, most (69%) reported that they were well informed. When asked about the potential benefits of implementing health promotion programs, most (82%) said they were either well informed or somewhat informed. These results indicate that most small businesses are well informed about the health risks their employees face and the benefits of health promotion programs, but are only somewhat informed about the types of health promotion activities that are included in these programs.

Health Promotion Activities and Programs. Of the 1,846 small businesses analyzed, 84% had at least one health promotion program or activity. The most frequently reported programs and activities included: safe work practices training (67%), emergency and disaster training (52%), hazardous materials training (48%), first aid training (46%), an employee safety committee (46%), ergonomics training such as safe lifting (43%), and employee social activities (42%). Fewer companies reported having a violence prevention program (20%), a substance abuse program (20%), mental health counseling (18%), immunization programs (16%), stress management training (14%), a smoking cessation program (12%), a cholesterol or blood pressure screening program (10%), and a physical fitness program (10%). Some of the companies reported having screening programs for diseases such as cancer (8%), diet or nutrition programs (8%), and weight management programs (8%). These results indicate that the most common health promotion activities in small businesses are safety-related (i.e., safe work practices, emergency and disaster training, hazardous materials training, first aid training, and ergonomics), perhaps due to California's injury and illness prevention legislation which requires all companies with more than 10 employees to have these safety programs (Cal-OSHA, 1991). However, when these mandatory programs are omitted from the analyses, only 50.1% of the companies had at least one "traditional" health promotion program (e.g., fitness, nutrition, smoking cessation).

Health Promotive Facilities. The respondents were also asked about their company's health promotive facilities. Over one-half of the businesses reported having adjustable furniture (60%), and approximately half reported having an employee lounge (51%). Many also reported having an employee suggestion box (40%) and healthy food available on-site (26%). Lockers were provided in 26% of the workplaces, and showers were provided in 13%. Outdoor exercise facilities were available in 12% of the companies, and indoor exercise facilities were available in 6%. These finding suggest that most small businesses do not have many health promotive facilities, except adjustable furniture and an employee lounge for socializing.

Health Promotion Policies and Procedures. A majority of the participating businesses had health-related company policies. At least three-quarters of the companies reported having policies pertaining to safety (90%), substance abuse (83%), smoking (83%), sexual harassment (79%), and the Americans with Disabilities Act (75%). Almost one-half of the companies (46%) reported having a violence prevention policy. Over half regularly communicated with employees about health and safety matters (74%), had a management-level employee in charge of health promotion (70%), regularly monitored working conditions (65%), and included employees' family members in health promotion activities (57%). Less than half of the companies included employee health in their mission statement (44%) or involved employees in the planning of health promotion activities (42%). However, less than a third had a written health promotion plan (32%), monitored the effectiveness of their health promotion programs (30%), or allowed appropriate employees to telecommute (30%), and only 20% had conducted a health promotion needs assessment. These finding suggest that most small businesses have only required business policies but no more.

Health Promotive Benefits. The businesses were a bit more progressive with their company benefits. A majority of the businesses reported providing health insurance coverage to employees and dependents (78%). Flextime schedules were available in 59% of the companies, accumulation of vacation/personal time in 60%, education/training reimbursement in 55%, 401(k) programs in 40%, and off-site fitness facilities in only 15%.

Company's Economic Status. Approximately 83% of the businesses reported that they were making a profit. Fifty percent (50%) stated that their company's gross revenues were growing, whereas 38% stated they were about the same. These findings suggest that the small businesses in our sample were doing well economically.

Organizational Climate. Respondents seemed pleased with workplace quality, employee health, and employee morale. Ninety-two percent (92%) of the respondents reported that the quality of their workplaces was excellent or good, 95% reported that employees' health had been excellent or good during the past year, and 89% ranked their employees' morale as excellent or good. As for working conditions, 80% reported that employees had never or rarely complained, and only 3% stated that the company had been cited for violations.

Company problems. Despite the high levels of employee satisfaction, some respondents did report a few problems within their organizations. Several companies reported having problems with employee turnover (33%), lost time due to illnesses (30%), poor employee productivity (22%), poor work quality (19%), and lost time due to injuries or accidents (19%). Additionally, some respondents reported that within the past year they had experienced disability claims (20%), accidents requiring first-aid (20%), vehicular accidents (14%), lifting injuries (14%), and cumulative trauma disorders (7%). These findings suggest that the most common problems among small businesses are turnover, illness, and poor productivity.

Effect of Company Size on Health Promotion. In order to demonstrate the effect of company size on health promotion programming and activities, comparison analyses were performed by splitting company size into three categories: 2-14 employees, 15-99 employees, and 100-500 employees. The results indicated that company size was a strong predictor of the number of health promotion activities offered. Smaller companies offered significantly fewer health promotion activities than the larger companies in our sample, [C.sup.2]=197.43, df=8, p<.000. Company size was also a very strong predictor of the types of health promotion activities offered: Smaller companies were less likely than larger companies to offer every single health promotion activity listed on the survey (e.g., safe work practices training, fitness, smoking cessation, weight management) (See Table 1). Smaller companies were also less likely than larger companies to offer health promotive facilities (e.g., adjustable furniture, healthy food, fitness facilities, showers) and benefits (e.g., 401K plan, health insurance, education reimbursement) (see Table 2). With regard to health promotive policies and procedures, smaller companies were less likely than larger companies to have health promotive policies (e.g., a safety policy, a violence prevention policy, a sexual harassment policy) as well as some of the other hallmarks of health promotion programs (e.g., having a written health promotion plan, collecting information from employees on the types of programs to implement, assessing the effectiveness of the programs) (see Table 3).

However, smaller companies did report higher participation rates than larger companies did in six programming areas. Smaller companies, compared to larger companies, were more likely to report that most employees participated in weight management programs, [C.sup.2]=2.77, df=6, p<.05, violence prevention programs, [C.sup.2]= 15.12, df=6,p<.02, immunization programs, [C.sup.2]=13.33, df=6, p<.04, mental health programs, [C.sup.2]= 12.81, df=6, p<.05, ergonomics training programs, [C.sup.2] =16.79, df=6, p<.01, and first aid training, [C.sup.2]=27.28, df=6, p<.000.

DISCUSSION

The goal of this paper was to obtain a better understanding of health promotion programming in small businesses and to answer three questions. The first question asked what type of health promotion activities are most often administered in small businesses. The results of the Workplace Wellness Appraisal indicate that the most common health promotion activities in these businesses are safety-related (i.e., safe work practices, emergency and disaster training), perhaps due to California's injury and illness prevention legislation requiring all companies with more than 10 employees to have these safety programs (Cal-OSHA, 1991). However, when these mandatory programs are omitted from the analyses, only 50.1% of the companies have at least one "traditional" health promotion program (e.g., fitness, nutrition, smoking cessation). This appears to be consistent with the U.S. Centers for Disease Control and Prevention and the National HIV/AIDS survey (Wilson et al., 1999). Programs that were least often reported in small businesses were nutrition, weight management, and fitness. This is not surprising since the latest information on obesity indicates that 35% of employees are overweight by 20% or more (WELCOA, 1995).

The second research question asked, among small businesses, do smaller businesses have fewer health promotion programs and activities than larger ones. The results strongly suggest that the smallest businesses are significantly less likely to implement health promotion programs and to offer all types of health promotion activities, including nutrition, weight management, fitness, smoking cessation, stress management, screenings, safe work practices training, and first aid training. This study validated findings from earlier studies suggesting that larger companies offer more health promotion activities, health promotion facilities, employee health benefits, and health promotion policies than smaller companies (AWHP, 1999; Wilson et al., 1999; USDHHS 1993). Owners/managers of the smallest businesses were also less likely than the owners/managers of larger business to monitor the effectiveness of health promotion programs and activities.

The third research question asked if, among small businesses, the smallest businesses have significantly more or less employee participation in health promotion activities than larger businesses. Previous national surveys did not collect data on participation rates. Thus, a comparison of participation rates can only be made within our sample. This study found that the smallest businesses report greater participation rates in six programming areas: weight management, mental health, ergonomics, first-aid, violence prevention, and immunization programs. There axe a number of reasons why this may have occurred (Muchnick-Baku & Orrick, 1992). First, employees in smaller businesses are more likely to know their fellow employees and families, and this family-orientation may facilitate participation in health promotion activities. Second, smaller businesses tend to have less diversity among employees than do larger businesses, making it easier for them to tailor programs to suit the needs of their entire staff. Finally, support from top management is critical to the success of a workplace health promotion program, and in smaller businesses, top management is more accessible to employees and more involved in the day-to-day operations of the company.

This study is not without its limitations, particularly the low response rate. It is thought that the response rate was low because small businesses are frequently under-staffed and pressed for time. In fact, most of the 500 survey decliners reported that they did not have enough time to participate in the fifteen-minute interview. Wilson et al. (1999) sent postcards to small business owners prior to the survey alerting them of the upcoming telephone survey to increase participation rates. Future studies should include similar techniques to attract potentially vulnerable populations such as this one.

Despite the low response rate, the authors believe that this study has merit. This is one of the first studies to address worksite health promotion needs in very small companies (2-14 employees) which constitutes nearly 80% of U.S. private firms (USSBA, 2000). There is very little existing data describing health promotion in the small business sector, particularly among the very small businesses and businesses with fewer than 50 employees (Stokols, McMahan, & Phillips, 2001; Wilson et al, 1999; DeJoy & Southern, 1993; and Erfurt & Holtyn, 1991). In the future, large-scale studies of worksite health promotion should include small businesses in their samples.

This study also reveals that, among small businesses, the smallest businesses have fewer health promotion programs than larger ones, and the programs they have are mandated by law. At the same time, their participation rates are actually better than those of larger companies. This suggests that employees of small businesses are open to health promotion programs; they just have less access to them.

This is unfortunate given that small businesses have some advantages over larger businesses with regard to health promotion programming. Since small businesses employ fewer employees than larger businesses, they have fewer people to accommodate with their programming and perhaps fewer health issues to address. In addition, since there are fewer employees, less time and money are required to communicate with employees about health and safety issues. Moreover, since one of the keys to a successful health promotion program is management support and involvement, small businesses may have the advantage over larger businesses due to the accessibility of top management in smaller businesses: Employees in these businesses are more likely to know their bosses opinions about and support of health promotion programs than employees in larger businesses. Finally, small businesses tend to have a greater sense of community than larger businesses, which may translate into a supportive environment conducive for group participation in health promotion programs.

Unfortunately, the fact remains that small businesses have fewer health promotion programs and activities than larger ones. One theory is that smaller businesses have less organizational capacity (i.e., staff and financial resources) to develop and maintain health promotion programs (Price, 1998). However, small businesses do not have to be limited by financial constraints. There are several methods to incorporate health promotion activities and programs at no or low cost. Community sources such as non-profit agencies, service clubs, and local colleges and universities provide many free community services. Government agencies, industrial and professional groups, and various health care vendors can provide information, equipment, and supplies at little or no charge. Additionally, pooling resources with other small businesses can provide opportunities to promote health (UCIHPC, 1998; Donaldson & Klein, 1997). Further efforts should be made to educate small businesses owners about the variety of quick and inexpensive health promotion activities available through the community. This is especially important given the overwhelming number of American workers employed in small businesses. Targeting these businesses appears to be essential for improving the health of the U.S. population.

Table 1. Percentage of Companies Having Health
Promotion Programs by Size of Company

                                 Number of Employees

Type of Program                 2-14   15-99    100-500  Chi-Square

Ergonomics Training             30.0    46.6      64.3     94.97 *
First Aid Training              32.0    50.1      68.1    105.65 *
Hazardous Materials Training    34.0    52.7      67.5     96.34 *
Emergency Training              36.4    57.4      69.7    103.89 *
Safe Work Practices Training    52.4    71.5      84.1    102.29 *
Violence Prevention Training    12.7    20.3      36.7     64.61 *
Employee Safety Committee       24.8    51.9      77.8    230.64 *
Nutrition                        6.5     7.0      16.2     26.26 *
Weight Management                7.2     6.7      14.4     16.57 *
Fitness/Exercise                 7.5     9.2      20.2     33.64 *
Smoking Cessation                9.0    13.4      18.5     15.85 *
Stress Management                9.2    13.6      29.4     60.89 *
Mental Health Counseling        11.1    19.0      34.5     66.09 *
Substance Abuse                 12.7    21.1      33.9     51.98 *
Disease Screening                5.2     9.0      14.3     20.20 *
Cholesterol/BP Screening         8.7     8.9      20.6     32.02 *
Immunizations                    9.4    16.5      33.9     78.01 *

* p<.001
Table 2. Percentage of Companies Having Health
Promotive Facilities and Benefits by Size of Company

                             Number of Employees

Type of Facility          2-14   15-99    100-500  Chi-Square

Healthy Food              15.6    26.7      50.6    114.78 *
Indoor Exercise            5.5     5.3      11.9     15.62 *
Outdoor Exercise           6.6    13.7      17.9     28.72 *
Showers                    7.2    14.3      24.5     48.81 *
Employee Lounge           36.5    55.0      70.8     98.68 *
Lockers                   15.5    28.6      43.4     79.03 *
Suggestion Box            25.0    43.4      67.1    141.20 *
Adjustable Furniture      56.0    59.3      73.3     22.94 *

Type of Benefit

401 K Plan                25.8    41.6      66.4    126.75 *
Education Reimbursement   47.0    55.4      71.0     42.42 *
Health Insurance          64.2    83.7      93.3    124.50 *

* p<.001
Table 3. Percentage of Companies Having Health
Promotive Policies and Procedures by Size of Company

                                         Number of Employees

Type of Policy/Procedure               2-14  15-99  100-500  Chi-Square

Safety Policy                          81.9   93.3    97.2     70.92 *
Violence Prevention                    38.1   46.4    63.1     43.95 *
Drug Policy                            76.5   85.8    92.5     41.01 *
Sexual Harassment                      66.3   84.3    94.8    115.93 *
Americans with Disabilities Act        62.4   79.4    89.3     85.20 *
Manager Responsible for HP             59.5   74.1    84.2     65.46 *
Collecting Employee Input on HP        15.8   20.8    32.9     31.01 *
Written HP Plan                        25.9   35.7    42.4     26.30 *
Assessing Effectiveness of Program     21.4   34.8    46.5     58.85 *
Communicating with Employees           65.1   78.9    87.0     60.17 *
Including Health in Mission Statement  37.8   48.9    57.7     32.97 *

p<.001

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Shari McMahan, PhD Meredith Wells, PhD Daniel Stokols, PhD Kimari Phillips, MA H.C. Clitheroe, Jr., PhD

Shari McMahan, Ph.D., is with the Division of Kinesiology and Health Promotion at California State University Fullerton. Meredith Well, Ph.D., is with the Department of Psychology at Eastern Kentucky University. H.C. Clitheroe, Jr., Ph.D., is with the Health Promotion Center at the University of California, Irvine. Address all correspondence to Dr. McMahan at: Division of Kinesiology and Health Promotion; P.O. Box 6870; California State University Fullerton; Fullerton, CA 92834-6870; Phone: [phone]; FAX: [phone]; e-mail: [e-mail].