**1. Introduction**

Similar to many other high-income countries, Germany currently faces two trends that have a serious impact on its economy and workforce. First of all, the composition of the working population is shifting toward older age groups, which is a process that will probably be accompanied by an increase in the burden of non-communicable diseases among the workforce [1,2]. Secondly, many branches of the German economy are confronted with an acute shortage of skilled workers and qualified staff, which is a situation that has persisted for years, and recently deteriorated [3,4]. Against this background, stakeholders are increasingly recognizing activities that strengthen the workability and employability of the workforce and promote the good health of workers [2,5]. Thus, it comes as no surprise that during the last few decades, a strategy called 'workplace health management' (in German 'Betriebliches Gesundheitsmanagement') has gained popularity in Germany [6–8]. 'Workplace health management' is very similar to the 'Total Worker Health' approach in the USA [9–19]. The National Institute for Occupational Safety and Health (NIOSH) defined 'total worker health' as activities integrating protection from work-related safety and health hazards with the promotion of injury and illness prevention efforts in order to advance worker well-being [12,13]. The German 'workplace health management' approach pursues a similarly holistic strategy. It is commonly defined as the integration and management of all operational processes (in an enterprise) so as to create healthy working conditions and promote the health of its employees [5,20]. Workplace health management can be differentiated into four components or subcategories: (1) occupational health and safety measures, (2) management of the return to work process of employees who have been on long-term sickness absence (in short: 'reintegration management'), (3) workplace health promotion, and (4) a corresponding personnel development. In Germany, these components differ as to their legal status: whereas many occupational health and safety measures as well as some reintegration management activities are required by law, measures in the areas of workplace health promotion and personnel development are voluntary (cf., in greater detail below).

While the importance of comprehensive workplace health management in Germany seems to be commonly recognized in public discourse, a quite different question is whether and to what extent enterprises actually follow the concept in practice. From several surveys we know that in small and medium enterprises (with up to 250 employees, or—according to another common categorization—with up to 500 employees), workplace health management is often neglected. The ability or willingness to implement workplace health management measures seems to depend linearly on company size. The smaller the company, the less likely it is that a comprehensive workplace health management will be implemented [21–24]. Small enterprises with up to 50 employees seem to have implementation deficits even with regard to occupational health and safety measures that are required by law [25]. Thus, as to small and medium enterprises (SMEs), the situation in Germany seems to be comparable to the United States (USA) and other European countries [26,27].

In light of these former surveys we wanted to find out the current situation in a German region in which the social and economic environment for health-related measures is comparably good, i.e., clearly above average. If the results of such a survey show that the implementation of workplace health management measures is still as poor as previous surveys suggest, we may conclude and confirm that serious implementation problems persist also within an above-average social and economic environment. Thus, we designed a short survey of health-related measures in small, medium, and big enterprises in the county of Reutlingen (Landkreis Reutlingen). As far as socio-economic strength and population health is concerned, the County of Reutlingen is well above the German average. In 2015, e.g., the unemployment rate in the county was 3.7% (Germany: 6.4%), the average monthly household income per inhabitant amounted to 1946 €, i.e., about 2208 USD (Germany: 1787 €, i.e., about 2028 USD), and the gross domestic product per inhabitant was 38,400 €, i.e., about 43,574 USD (Germany: 36,900 €, i.e., about 41,872 USD) [28]. At the same time, the average life expectancy in the county was 82.69 years (Germany: 80.89 years). At the end of 2015, the county had 282,000 inhabitants. Furthermore, five out of 26 municipalities in the county have been certificated as 'healthy communities' because of their commitment to promote physical activity and population health.

In our survey, we addressed only companies that had a minimum size of 10 employees in craft enterprises or 20 employees respectively in non-craft enterprises (cf., further details in the next section). Craft enterprises are enterprises that do not produce industrial mass goods, but generally work to order or provide services on demand (such as carpenters, painters, etc.). As we know from previous studies that the implementation of health-related measures in micro enterprises is very poor or virtually non-existent [21–24], we concentrated—for economic reasons—on enterprises that had a certain minimum size. Thus, our focus on small, medium, and big enterprises (leaving aside micro, i.e., very small enterprises) and on the county of Reutlingen sets the framework for the following argument. If the degree of implementation of workplace health management measures in the companies we

surveyed is good or acceptable, we should not conclude that this is the same (or similar) on average in Germany. On the other hand, if the degree of implementation is poor even in the companies we surveyed, we can conclude that this probably also applies to the German average.

In this context, we will answer the following research questions (RQs):

