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Researchers from the Center for Health, Work & Environment (CHWE) at the Colorado School of Public Health have published a paper in the Journal of Occupational and Environmental Medicine studying the impact of Total Worker Health (TWH) advising in small- to medium-sized businesses. The study is one of the first to examine how TWH consultation impacts the way organizations adopt and improve workplace policies and practices for worker health and safety.

According to lead author and assistant professor at the Colorado School of Public Health, Dr. Lili Tenney, little is understood about how organizations, specifically small businesses, operationalize TWH. Tenney serves as the director of outreach and programs for CHWE. Tenney co-founded Health Links™ in 2013 as a public health practice initiative to help organizations improve worker health, safety, and well-being. “We designed Health Links as a program to reach organizations of all types, but really to help small and mid-sized businesses that lack the resources and attention they deserve,” said Tenney.

Reaching small employers through 1-on-1 advising

Small- to medium-sized businesses, which make up 47.1% of the U.S. workforce, often have limited resources, such as time, knowledge, and financing, to devote to employee health and safety efforts. Previous studies have found that safety consulting in small businesses and health promotion coaching in larger enterprises have been effective interventions. Yet, there are no studies evaluating the TWH model of consulting/advising on sustained, long-term adoption of organizational behaviors that promote worker health, safety and well-being.

The recent publication is based on a longitudinal study of a TWH intervention in 200 organizations completing the Health Links Healthy Workplace Assessment™ between October 2016 and December 2019. Organizations were offered consultation via telephonic and live web-based advising sessions. With theoretical frameworks, information is often disseminated either through written materials or online training even though these methods are difficult to inspire organizational change. CHWE’s researchers wondered if one-on-one conversations about TWH policies and programs could spark interest and action from employers.

Growth in key benchmarks

Through the group’s method of TWH advising, organizations’ assessment scores improved from baseline to the following year. Specifically, businesses that completed advising showed significant growth in their Healthy Workplace Assessment scores between their first and second year in the program. The scores indicate that these businesses improved their workplace health and safety programs in four key TWH benchmarks; organizational supports; collecting data to inform TWH priorities; health promotion efforts for stress management, nutrition, disease prevention, mental health; safety; and engagement.

While the purpose of the study was not to evaluate the effect of Health Links on TWH benchmark scores, it is worth noting that participating businesses demonstrated improvements in four out of the six benchmarks. The group anticipates conducting further research on the comprehensive effectiveness of Health Links on how organizations achieve and maintain TWH and also how policies and practices impact worker health and safety as a result.

“Because our employer advising is bidirectional, we’re able to take the science and evidence behind Total Worker Health and put it into practice in real-time, based on what the organizations we work with are able to accomplish,” says Health Links program manager and lead advisor David Shapiro. “We use motivational interviewing to build action plans with tangible next steps. This method is focused on feedback and results. Rather than a one-size-fits-all approach, we provide a customized experience to improving employee health, safety, and well-being.”

As the first study to evaluate a TWH advising intervention, the study highlights the difference in improvement among groups with varying levels of program engagement, which included completing assessments and participating in advising, over time. The more dedicated businesses performed better in their scores, signifying positive organizational change. Businesses with the largest TWH improvements were those that participated in advising.

Scaling Total Worker Health interventions

For researchers and occupational health and safety professionals looking to impact the total health of workers, this study provides a compelling case for advising. As the field of TWH grows, the future for scaling up TWH depends on identifying approaches that are effective in strengthening organizational support; leadership; health promotion for addressing stress, chronic disease, fatigue, and mental health; safety; employee engagement; and evaluation. Due to the diverse nature of small business organizations and their workforces, these approaches need to be flexible in identifying TWH strategies that meet the goals, values and needs of each. As understood in this study, consistent advising, paired with assessment, serves as a nimble, yet impactful approach to reaching this goal.

“Our results indicate that consulting businesses on TWH has a positive impact,” shares Dr. Tenney. “While there was a range of how businesses made changes after advising, in general, we saw that even the businesses that were already doing a lot still received some benefit. This supports our hypothesis that businesses committed to employee health and safety are seeking ways to improve—they just need some guidance.”


Written by Laura Veith, marketing and communications coordinator for the Center for Health, Work & Environment at the Colorado School of Public Health.