Objective: The aim of this study was to conduct a cross-sectional assessment of the adoption of Total Worker Health (TWH) policies and practices by business size and evaluate extent and alignment of their safety and health. Methods: We conducted an analysis of 382 businesses that completed the Health Links^™ Assessment. We measured organizational adoption of TWH across six benchmarks: organizational supports, workplace assessments, health policies and programs, safety, engagement, and evaluation. Results: Benchmark scores were significantly associated with business size. Larger businesses were more likely to score higher across each benchmark. Conclusion: Small businesses are implementing TWH in a variety of ways and the level of implementation differs by business size. Practical interventions as well as dissemination and implementation research should take business size into account to ensure that TWH is both effective and sustainable in meeting the needs of employees.

Total Worker Health^® (TWH) frameworks call for attention to organizational leadership in the implementation and effectiveness of TWH approaches. It is especially important to study this within in the small business environment where employees face significant health, safety, and well-being concerns and employers face barriers to addressing these concerns. The purpose of this study was to gain a better understanding of how small business leaders perceive employee health, safety, and well-being in the context of their own actions. We conducted semi-structured interviews with 18 small business senior leaders and used a qualitative coding approach to analyze the transcripts to determine the frequency with which leaders discussed each code. When we asked leaders about their leadership practices for health, safety, and well-being, leaders reflected upon their business (65%), themselves (28%), and their employees (7%). Leaders rarely discussed the ways in which they integrate health, safety, and well-being. The interviews demonstrate that small business leaders care about the health of their employees, but because of the perceived value to their business, not to employees or themselves. Thus, they may lack the knowledge and skills to be successful TWH leaders. The present study supports a need for continued small business TWH leadership research.

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.

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.

The COVID-19 pandemic created workplace challenges for employee safety and health, especially in small enterprises. We used linear mixed-effects regression to examine changes in health climate, safety climate, and worker well-being, prior to the pandemic and at two timepoints during it. We also examined whether employees at organizations that had received a TWH leadership development intervention prior to COVID-19 would better maintain pre-pandemic perceptions of climates and well-being. The final study cohort consisted of 261 employees from 31 organizations. No differences were observed in mean outcome scores between the leadership intervention groups at any of the survey timepoints. We combined intervention groups to examine the difference across timepoints. Perceptions of health and safety climates remained stable across all timepoints. However, employee well-being scores declined between the pre-pandemic period and subsequent COVID-19 timepoints. These findings suggest that while small organizations continued to be viewed as supporting employees’ health and safety over the course of the pandemic, well-being scores declined, indicating that other factors contributed to decreased well-being. The findings from this study have implications for small business leaders as they navigate the impact of the COVID-19 pandemic on the health, safety, and well-being on their organizations and employees.