*3.3. Satisfaction with Implementation Status*

In case important—or even legally required—health-related measures are lacking, it is important to know whether and to what extent these companies are aware of this deficiency before planning any interventions.

In the present survey, company representatives generally tended to be more satisfied with the implementation of a given category of health-related measures the higher the implementation score of their company was in that category. Thus, correlation analyses showed that satisfaction—as measured by the four-point Likert scale—was positively associated with the implementation score value in the categories 'workplace health promotion' (Spearman's r = 0.34, *p* < 0.001), 'occupational health and

safety' (Spearman's r = 0.16, *p* = 0.022), 'personnel development' (Spearman's r = 0.21, *p* = 0.002), and 'reintegration management' (Spearman's r = 0.25, *p* < 0.001).

To get further hints on the above-mentioned awareness of company representatives, we furthermore checked how satisfied those company representatives were whose enterprises had a comparably low implementation score in a given category. We defined having a 'low implementation score' as belonging to the lowest quartile of the respective scores. In the category 'workplace health promotion', *n* = 81 companies (37.3%) belonged to the lowest implementation quartile, and in the category 'occupational health and safety', *n* = 62 (28.8%) companies belonged to the lowest implementation. In the category 'personnel development', *n* = 58 (26.7%) enterprises belonged to the lowest implementation quartile, while in 'reintegration management' this was true for *n* = 57 (26.8%) companies. Within each of these groups of enterprises with a comparably poor implementation of corresponding measures, a substantial proportion of company representatives were nevertheless satisfied (either 'rather satisfied' or 'very satisfied') with the implementation status (cf., in detail Table 5). With regard to the current situation in the domain 'workplace health promotion', *n* = 33 (40.7% of those companies that belonged to the lowest implementation score quartile) company representatives were satisfied. As to the domain 'occupational health and safety', *n* = 55 (88.7%) company representatives were satisfied in spite of their comparably poor implementation grade. As to 'personnel development', *n* = 39 (67.2%) company representatives were satisfied, despite the relatively poor implementation status of their companies, and regarding the category 'reintegration management', *n* = 25 (43.9%) of company representatives were satisfied, although they had a poor implementation record in this category. Thus, a substantial proportion—if not the majority—of 'under-performing' enterprises (those belonging to the lowest score quartile) seemed to be satisfied despite a comparably poor implementation.


**Table 5.** Satisfaction with implementation status in all enterprises vs. enterprises with poor implementation status (enterprises in the lowest implementation score quartile).

Explication of Table 5: For the sake of clarity, the response categories 'very dissatisfied' and 'rather dissatisfied' were combined to form the 'dissatisfied' category, while the response categories 'very satisfied' and 'rather satisfied' were combined to form the 'satisfied' category.

Turning to the association between satisfaction and the fulfillment of legally required measures in a given domain, the results were as follows (cf., Table 6). Among those companies that did not comply with all of the legal occupational health and safety requirements as assessed in this study (*n* = 155), 92.3% (*n* = 143) were satisfied with the current status of their company's occupational health and safety implementation. This proportion was nearly as high as within the group of company representatives whose companies fulfilled the listed legal requirements (96.2%). Correspondingly, there was no significant correlation between satisfaction (dichotomously grouped into 'satisfied' versus 'dissatisfied') and the fulfillment of legally required measures in that domain (Chi<sup>2</sup> test *p* = 0.383; Fisher's exact test *p* = 0.522). As to the category of 'reintegration management' (cf., Table 6), among those companies that did not comply with all of the listed legal requirements (*n* = 101), 53.5% (*n* = 54)

were satisfied with the current situation of their company's reintegration management implementation. As to this domain, there was a significant but low correlation between satisfaction (grouped into 'satisfied' versus 'dissatisfied') and the fulfillment of the legally prescribed measures (Spearman's r = 0.22; *p* = 0.002). Nevertheless, in both domains, a majority of respondents representing companies that did not fully comply with legal requirements were satisfied (either 'very' or 'rather satisfied'); as to the occupational health and safety domain, this majority seemed to be overwhelming (92.3%).


**Table 6.** Satisfaction with implementation status in the domains 'occupational health and safety' and 'reintegration management' according to compliance with legal requirements in a given domain.

Explication of Table 6: For the sake of clarity, the response categories 'very dissatisfied' and 'rather dissatisfied' were combined to form the 'dissatisfied' category, while the response categories 'very satisfied' and 'rather satisfied' were combined to form the 'satisfied' category.

#### **4. Discussion**

The aim of the study was to provide an assessment of the implementation (RQ 1 and RQ 2) and satisfaction with workplace health management activities (RQ 4) in enterprises in the economically very strong county of Reutlingen. In addition, relationships between company size and implementation (RQ 3) as well as between implementation and satisfaction were to be analyzed and discussed.

#### *4.1. Study Design, Questionnaire, Response Rate, and Data Quality*

We performed an almost complete cross-sectional survey where only enterprises with less than 10 (craft enterprises) or 20 employees (non-craft enterprises) were not included. Yet, due to the cross-sectional design, no causal relationships can be described.

The questionnaire items were developed to retrieve as many typical health-related measures as possible because of the wide range of measures in workplace health management. The respondents' low utilization of an offered blank text field for further possible "other measures" that had not been presented as listed items suggests that the lists were practically complete.

The response rate of the survey was 24.5%. The response rate is within the range of the common rates for studies of this type [42–44]. The non-responder analysis showed that the response rate was the highest in medium-sized companies, whereas it was lower in both small enterprises (with up to 100 employees) and big companies (with more than 500 employees). An average of less than 5% missing answers indicates a high data quality.

The study results show a large deficit regarding the compliance with legal requirements according to the participants' indications. Less than 25% of the responding enterprises indicated that their company fulfilled all of the listed legally required measures in the category 'occupational health and safety'; in the category 'reintegration management', about half of the surveyed companies (50.9%) indicated the implementation of all the legally required measures. These comparably low compliance

rates might be due to several shortcomings. First of all, companies might be not sufficiently informed about their obligations as employers with regard to all aspects of occupational health and safety (legally required since 1973 [37] and 1996 [35], but with major modifications concerning the defined need for occupational health physicians and occupational safety engineers in 2008 and 2011 [36]) and the implementation of reintegration management (legally required since 2001 [40]). Second, the people who indicated the status of the respective measures in the questionnaire might not have been aware of all the activities implemented in the enterprise. One reason for this could be that some of the activities that were surveyed might be implemented more or less in an implicit manner, but not be spoken of explicitly, especially if the occasion (i.e., an accident or work-related health complaint of an employee) is rather rare. Another reason could be that occupational health physicians, occupational safety engineers, and other experts are available and take care of the implementation without the management noticing much of it. Thus, the respective measures might well be implemented, but not known. Fourth, enterprises are not encouraged strongly enough to follow the legal requirements, as there is not enough compliance monitoring by the respective institutions in Germany (government and statutory accident insurances).

Particularly in the category 'reintegration management', small enterprises might not see the need for the implementation of methods of reintegration management, because they may not have needed it yet. Possibly in some small enterprises, individual occupational health and safety measures might be taken now and then according to need, but not on a regular basis [45], which would in part explain the low proportion of companies fulfilling all of the listed occupational health and safety measures. Yet, there is no satisfying explanation for only 29.1% to 85.0% of the study participants indicating the availability of an occupational health physician (cf., Table 2), other than the current shortage of occupational health physicians in Germany [46]. The availability of occupational safety engineers in only 63.0% of the small enterprises (10–50 employees) can well be explained by the regulation that the employer himself can participate in an occupational health and safety training offered by the statutory accident insurance with the consequence that usually no occupational safety engineer is necessary (so-called "Unternehmermodell"). The proportion of only 85.4% of enterprises indicating the availability of an occupational safety engineer in companies with 51–100 employees may either be related to the current lack of occupational safety engineers and other occupational health and safety experts in Germany [47] or due to underreporting, which may also explain the figures reported with regard to occupational health physicians.

Taking these aspects together, the lack of implementation, especially in the area of occupational health and safety, may be somewhat overestimated in this survey. However, the findings do point to the need for supportive measures for a better implementation of legally required measures in German enterprises. The same is true for some measures of workplace health promotion in the majority of enterprises, especially with regard to general, rather than work-related, health (median = 0, cf., Table 1).

Due to the positive correlation between company size and the implementation of the components of workplace health management, we may suppose that the real implementation in all of the companies in the county of Reutlingen is even lower than implied in our study, because very small enterprises—where implementation is generally poor [21–24]—did not participate in this survey. This assumption applies both to legally required measures and voluntary measures. Furthermore, it should be kept in mind that the county of Reutlingen is a German district with an above-average social and economic environment, as has been shown in the Introduction. Then, we have to assume that in other districts with less favorable economic conditions the situation is probably not better or even worse.

Although there is a positive correlation between satisfaction and implementation grade in the four categories, there is still a surprisingly high satisfaction in enterprises with poor implementation (cf., Tables 5 and 6). This might indicate that many measures, including those required by law, are not considered necessary (or are not perceived as being required by law). This result, as surprising as it is, needs to be taken into account before planning any interventions to improve the implementation of workplace health management measures.

The results of our study seem to show—once again—that the effectiveness of a top–down approach to the implementation of comprehensive health-related measures in enterprises is rather limited, at least in the context of Western, liberal–capitalist social systems. Even (or just?) in Germany, where there is a long tradition of occupational health and safety legislation, this seems evident. Perhaps a different, less top–down approach is more promising in contemporary Western social systems. The demonstration and publication of success stories of companies that have benefited economically from the implementation of comprehensive health management approaches and the dissemination of corresponding best practice models could possibly stimulate more willingness and motivation on the part of companies to adopt such approaches in the mid and long term.
