*3.6. Negative Impacts of Employee Health Issues*

Figure 1 represents the weighted percentage of worksites that indicated specific employee health issues having a negative impact on business in 2016. Among health issues which employers noted as "very severely", "severely", or "moderately" having a negative impact on the worksite, stress (53%) was listed as the top issue. Obesity (34%) and lack of physical activity/exercise/fitness (33%) were the second and third most frequently cited health issues that negatively impacted business. When results were restricted to health issues that "very severely" impacted the worksite, injuries at the worksite (5%) was the most frequent health issue reported, followed by stress (4%) and alcohol/other drug habits (4%).

**Figure 1.** Percentage of Nebraska worksites that reported selected employee health issues negatively impacted business, 2016.

#### *3.7. Barriers in Implementing Workplace Health and Wellness Strategies*

Worksites indicated perceived barriers to implementing workplace health and wellness programs and policies (Figure 2). Differences in barriers were examined based on worksite size. Time constraints were the most reported barrier, regardless of worksite size. In 2016, more than half of all worksites reported time constraints as a barrier, which was lowest in small worksites (49%). Large worksites were least likely to identify staff to organize worksite health and wellness as a barrier (4%), while small worksites were least likely to identify lack of management support as a barrier (18%). More than half of large worksites reported lack of participation by high-risk employees as a barrier (56%), which was comparably lower than for small businesses (30%).

**Figure 2.** Weighted percentage of Nebraska worksites that indicated the following as barriers to implementing worksite health and wellness programs by worksite size, 2016.

#### **4. Discussion**

Due to the growing burden of chronic diseases on employee health and well-being, coupled with the cost of health care coverage, businesses are adopting a wide variety of workplace health promotion initiatives. A comprehensive workplace health program consists of essential components such as: Health education, supportive physical and social environments, integration of the worksite program into the organization's structure, linkage to related programs, and worksite screening programs [17,23]. At the same time, occupational health regulatory requirements compel employers to adopt employee safety policies aimed at injury and illness prevention. Studies highlight the important role of organizational capacity and workplace policies in the prevention of injury, illness, and chronic disease [18,24–26]. This study sought to learn more about the implementation of workplace health governance and planning strategies and organizational safety policies among employers in a largely rural state through a worksite survey.

When compared across survey years, we found an increase in the implementation of all the six workplace health planning and governance strategies measured. The comprehensive U.S. health care reform law was enacted in March 2010, which happened to be during the first year of our study. The Prevention and Public Health Fund (PPHF), under the ACA, includes a provision for creating employer-based wellness programs [11,27]. Peer-reviewed research on the effectiveness of the ACA's employer-based wellness programs is limited [28]. While we did not directly assess impact of the ACA's wellness incentives, the results of our study suggest an increase over time in the implementation of workplace health governance and planning strategies.

When results were combined over multiple study periods, we found adoption of workplace health governance and planning strategies among all worksites was relatively low (less than 20%) and varied widely across industry sectors. Higher adoption found in the 'Educational Services' sector was consistent with Hannon et al. who assessed workplace health capacity among mid-sized employers [29]. Comparably low implementation of governance and planning strategies was found among 'Other Services', 'Construction', and 'Transportation and Warehousing' industries. Studies have shown participation and availability of workplace health initiatives are generally lower among workers in blue-collar and low-wage industries [18,30,31].

Overall, the presence of selected organizational safety policies was higher than governance and planning strategies, a result consistent with similar studies [18,32]. The observed higher adoption of policies related to seatbelt use and cell phone/texting while driving in the 'Construction' and 'Transportation and Warehousing' sectors was expected considering these workers are more likely to engage in work-related travel. Among all worksites, 62.5% reported having a worksite safety committee, a similar result found in a survey among small businesses by McLellan et al. [18]. The presence of a safety committee and a return to work program was lower than expected in some sectors. For example, less than two-thirds of worksites in the 'Health Care and Social Assistance' sector reported having safety committees and return to work programs, despite the fact that these workers experience significant risk for occupational injuries [33].

The discordance between the adoption of governance, planning, and safety strategies and policies highlights the opportunity for integrating prevention programs at the organizational level and within specific sectors. Workers, especially in labor-intensive and blue-collar industries, face unique behavioral and occupational hazards and outcomes as evidenced by data from health behavior surveys and occupational injury surveillance [34–39]. For example, truck driving workers face environmental factors that both influence unhealthy eating patterns and excess weight gain and result in higher risks of occupational injuries and illnesses [40–42]. The combined health hazards and risks make workers in blue-collar worksites prime candidates for comprehensive programs which integrate injury prevention, employee safety, and worker well-being initiatives.

One approach for integrating health protection with health promotion is the TWH framework. Research supports the potential of integrated workplace approaches to improve worker health, safety, and well-being by addressing overlapping risk factors [43–45]. While evaluating the impacts of TWH

framework is an emerging field, several studies have shown that TWH interventions can effectively address injuries and chronic diseases in specific worker populations [46–50]. While the current study did not evaluate specific integrated TWH interventions or programs, in our 2016 survey we found that only 15.6% of worksites reported a coordinated program for occupational health and safety with health promotion (data not shown).

Our findings on the impact of employer's perceived health issues demonstrate a business case for TWH approaches. We found stress, obesity, physical activity, alcohol/drug use, and workplace injuries were the top five employee health issues reported by worksites which negatively affect business. These results highlight the complex and interconnected worker health dynamic which could be addressed with an integrated approach. Worksite stress, for example, is associated with negative health outcomes such as increased risk of cardiovascular disease and metabolic syndrome [51,52]. Evidence also supports the relationship between workplace injuries and chronic disease [36,53–55].

Our results regarding barriers suggest challenges in implementing workplace health initiatives can be attributed to both the employers and the employees, similar to other studies [14,25]. More than half of businesses stated that time constraints were a barrier to successful workplace health and wellness at their worksite. For these worksites, having a coordinator who is responsible for employee health promotion or a health promotion/wellness committee could help to provide a platform for employee engagement and collaboration to drive effective worksite health planning and implementation efforts.

Generally, small worksites were less likely to report barriers; no barrier was reported higher than 50% among small worksites. Worksite costs and time barriers were less likely to be reported among small worksites, which was a similar result in a survey among Australian workplaces [56]. There are many opportunities for workplace health and wellness programs in small businesses to be successful and well-accepted among employees. For example, the process of implementing new initiatives is comparatively less bureaucratic and easier to implement, a greater proportion of employees' preferences may be incorporated, and employees may have greater personal accountability [14].

There were several limitations to this study. Given the self-report nature of the worksite survey, this study was susceptible to selection bias. Large worksites were more likely to complete the survey compared to small and medium sized worksites, and these large worksites may be more likely to have certain workplace health or safety initiatives. Furthermore, nonresponse rates increased over time among large and small businesses which was unexplained. This nonresponse increase could account for the significant increase in trends observed in Table 2. To mitigate selection bias, reminders were sent to potential respondents during all three years of survey collection. Weighting was also performed to adjust for the effect of nonresponses across worksite size (Table S3).

The relationship between worksite size and industry sector should be considered when interpreting the results. Generally, certain industries like 'Construction' tend to be smaller establishments while industries such as 'Manufacturing' tend to be larger. This association held true between worksite size and industry sector in our sample (*p* < 0.0001) (Table S4). Additionally, surveys were addressed to either the business owner, manager, or human resource representative, but the worksite information collected may result in misclassification if the representative was not the most appropriate respondent. Lastly, the data represents the views of a single worksite, thus caution is warranted when interpreting our results since evidence suggests that employees' perceptions may vary from employers' [57].

Despite these limitations, the findings can be used to guide recommendations for future workplace health and safety promotion research and practice. To our knowledge, this is the first study to describe the adoption and trends of specific workplace health governance and planning strategies using multiple point-in-time surveys. The data also fill a critical gap which no recent, publicly available, and existing data on workplace health governance and planning strategies and organizational safety policies by detailed industry sector. Lastly, our study had a relatively large sample size, especially for just one state.

The scope of this study did not allow for assessing the employee utilization of workplace health programs, thus observational studies are needed to verify the validity of these survey results. Furthermore, employee outcome data as well as employees' perspectives need to be taken into

consideration. While disparities in uptake of workplace health initiatives have been observed in this study as well as others, further research is needed to examine how to better engage high risk and underserved worker populations [14,30]. The majority of small businesses in Nebraska are in rural settings; therefore, a follow-up study on the urban and rural differences in the adoption of workplace health and safety strategies is warranted.
