Health Education

Emerald Article: Workplace health promotion within small and medium-sized enterprises Ann Moore, Kader Parahoo, Paul Fleming

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To cite this document: Ann Moore, Kader Parahoo, Paul Fleming, (2010),"Workplace health promotion within small and medium-sized enterprises", Health Education, Vol. 110 Iss: 1 pp. 61 - 76 Permanent link to this document: http://dx.doi.org/10.1108/09654281011008753 Downloaded on: 13-11-2012 References: This document contains references to 28 other documents To copy this document: permissions@emeraldinsight.com

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Workplace health promotion within small and medium-sized enterprises

Ann Moore
Faculty of Life and Health Sciences, University of Ulster, Newtownabbey, UK

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Kader Parahoo
Institute of Nursing Research, University of Ulster, Coleraine, UK, and

Paul Fleming
Faculty of Life and Health Sciences, University of Ulster, Newtownabbey, UK
Abstract
Purpose The purpose of this study is to explore managers understanding of workplace health promotion (WHP) and experiences of WHP activity within small and medium-sized enterprises (SMEs) in a Health and Social Care Trust area of Northern Ireland. The paper aims to focus on engagement with activities within the context of prevention of ill-health and health protection, lifestyle issues and working culture and the environment as dened in the Luxembourg Declaration on WHP. Design/methodology/approach A Heideggerian interpretive phenomenological methodology is adopted, using in-depth telephone interviews with a purposive sample of 18 SME managers. Data are analysed using Benners strategy for data analysis. Findings Levels of awareness of WHP activity are revealed as a central theme and interpreted as high awareness activities, including the need to: preserve and protect employee health and safety, prevent ill-health and injury and promote employees quality of daily living, and low awareness activities, including the provision of training and development, human resource management and environmental considerations. Originality/value An Iceberg model, grounded in the data, draws attention to the limited awareness of what constitutes WHP activities and the untapped meaningfulness of organisational and environmental activities. Keywords Small to medium-sized enterprises, Workplace, Welfare, Health and safety requirements, Northern Ireland Paper type Research paper

Introduction Small and medium-sized enterprise (SME) managers are being encouraged by the European Union (European Network for Workplace Health Promotion, 2001b), UK (Department for Work and Pensions/Department of Health, 2008) and Northern Ireland (NI) public health policy (Department of Health, Social Services and Public Safety (DHSSPS), 2002; Health and Safety Executive for Northern Ireland (HSENI), 2003), to take the initiative in improving employee health. This is substantiated by: . the belief that the workplace provides an ideal setting to target individuals given the amount of time they spend there (Wynne, 1998);
The authors would like to thank the SME managers who kindly gave of their time to take part in the study and without whom this research would not have been possible.

Health Education Vol. 110 No. 1, 2010 pp. 61-76 q Emerald Group Publishing Limited 0965-4283 DOI 10.1108/09654281011008753

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the growing economic and social importance of SMEs (KPMG Consulting, 2002; ma la inen, 2007); Ha increasing levels of occupationally related ill-health and injury (European Network for Workplace Health Promotion, 2001b; KPMG Consulting, 2002; Department of Health, Department for Work and Pensions Dame Carol Black, 2008); and the view that workplace health promotion (WHP) activities can lead to improvements in SME efciency and competitiveness (European Network for Workplace Health Promotion, 2001a).

Despite these assertions, a lack of research exists on SME managers experiences of WHP activities in context. The majority of research conducted on WHP activities has taken place within larger organisations using quantitative outcome evaluation approaches (Wynne, 1998; European Network for Workplace Health Promotion, 2001b; ma la inen, 2007). The multi-faceted nature of SMEs, and associated access issues, Ha has limited conduct of methodologically sound research on this subject area (Bradshaw et al., 2001; Eakin et al., 2001; European Network for Workplace Health Promotion, 2001b; Stephens et al., 2004; Grifn et al., 2005; Antonelli et al., 2006). The Luxembourg Declaration (European Network for Workplace Health Promotion, 1997) outlines areas of WHP activity directed at improving an organisations working culture and environment, preventing the development of occupational diseases and addressing employee lifestyle issues. Within each area, the potential exists for prevention of ill-health, health protection and health education approaches to be taken, dependent upon targets for change and expected outcomes. Whilst this framework has offered stakeholders specic direction for the marketing and development of WHP activities, its translation into policy and practice across Europe has been patchy ma la inen, 2007). In order to develop effective programme planning methods for all (Ha areas of WHP activity, the reality that exists for SME managers needs to be fully explored. More specically, the meaning of managers experiences of WHP activities within the SME context needs to be understood. This study aimed to explore managers understanding of WHP and experiences of WHP activity within SMEs in a Health and Social Care Trust area of NI. This paper focuses on engagement with activities within the context of prevention of ill-health and health protection, lifestyle issues and working culture and the environment as dened in the Luxembourg Declaration on WHP (European Network for Workplace Health Promotion, 1997) using a Heideggerian interpretive phenomenological approach with a purposive sample of 18 SME managers. The study ndings will contribute to an understanding among strategists, practitioners and educationalists of what constitutes as WHP activity for the SME manager within the context of their workplace. In addition, the ndings will be useful in deciding how best to increase SME managers engagement with WHP activity, leading to collective benets for both employees and the SME business. Methods Given limited research within this area and SME access and recruitment issues (Bradshaw et al., 2001; Stephens et al., 2004; Grifn et al., 2005; Antonelli et al., 2006), maximising opportunities to gain meaningful data becomes important. Heideggers (1962) philosophical focus centres on describing the meanings of the

individuals Being-in-the-world and how these meanings inuence the choices they make (Lopez and Willis, 2004, p. 729) rather than looking for purely descriptive, narrative accounts of individuals perceived worlds. Adopting a Heideggerian interpretive phenomenological approach, therefore, offers a way to move beyond reductionist views of WHP activity to explore the unique meaning of SME managers experiences, interpreting their practical understanding of experiences within their situational context as the study unfolds. Sampling and recruitment Detailed consideration was given to problems encountered in previous studies accessing and recruiting SME managers (Bradshaw et al., 2001; Stephens et al., 2004; Grifn et al., 2005; Antonelli et al., 2006). To best enrich the meaningfulness of the data, both the sampling strategy and data collection methods were discussed with a group of stakeholders. This group consisted of two human resource managers, two health and safety ofcers, one trade union representative, two occupational health advisors, one representative from the Health Promotion Agency for NI, one health promotion commissioner and one health promotion manager. All had an expressed interest in WHP within SMEs. A sample of 249 SMEs were identied as fullling inclusive criteria: . a private sector SME, belonging to different business sectors; and . respondent for the SME holding a senior position, either: the owner, general manager, senior manager, human resources manager, health and safety manager, or designated person responsible for a number of these roles. The identied spokesperson was working at an organisational level, aware of management culture, with the power to make strategic business decisions. An invitation letter was sent to named managers outlining the nature of the study. A response form, provided with a stamped addressed envelope, offered the opportunity to participate in either a face-to-face or telephone interview. A total of 28 responses were received. From this sample, ve declined because of business priorities, two declined being interviewed requesting a questionnaire, one telephone number was unobtainable, and two telephone numbers rang without reply. Successful contact was established with 18 participants, although, on some occasions, interviewing appointments had to be re-arranged up to ve times because of managers business commitments. Each respondent requested a telephone interview as opposed to face-to-face contact. Data collection In-depth interviewing is considered the main method of data collection within interpretive phenomenological research as it is designed to reveal a deeper meaning (Polit and Beck, 2006). Within the Heideggerian philosophy, this form of interviewing is viewed by Johnson (2000) as a conversation that connects the researcher and the participant in such a way that the distance between the two diminishes (p. 141). However, account also needs to be taken that participants worlds cannot be completely understood and they may choose not to reveal everything about their experiences (Johnson, 2000). The achievement of rich data therefore becomes dependent upon the researchers experience and skills (Polit and Beck, 2006). The principal investigators previous experience of working with SME managers as an occupational health advisor

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accorded the advantage of being able to understand some terms and nuances participants used to describe their experiences. It also helped in building trust and establishing a sense of connectedness: both of which were essential to permeate and correctly visualise SME managers perspectives. Telephone interviewing In research terms, the telephone interview is simply dened as a strategy for obtaining data which allows interpersonal communication without face-to-face meeting (Carr and Worth, 2001, p. 512). Indeed, studies have found that telephone interviews held the added advantage over face-to-face interviews in reducing both interviewer effects and the tendency for socially desirable responses (Carr and Worth, 2001; Davis-Kirsch and Brandt, 2002). Other advantages have included, increasing the anonymity of the participants and providing greater personal safety for the researcher (Carr and Worth, 2001). Key benets have also been found to surround its cost effectiveness in terms of time, money and effort on behalf of both the researcher and the participant (Carr and Worth, 2001; Polit and Beck, 2006; Grifn et al., 2005). The value of telephone interviewing as a means to overcome difculties in accessing and recruiting hard to reach groups, such as SMEs, given managers time and resource constraints, has been noted (Bradshaw et al., 2001; Stephens et al., 2004; Grifn et al., 2005; Antonelli et al., 2006). For busy SME managers, who are often away from their premises travelling, with time at a premium, this form of interviewing offered the exibility for remote data collection, at a time and place more convenient for them. Concerns previously purported in terms of the difculties in establishing rapport in telephone interviews and inability to elicit visual cues to assist in interpretation of verbal responses (Davis-Kirsch and Brandt, 2002) were taken into account both during data collection and interpretive analysis phases. Interview guide An interview guide, developed from existing WHP and occupational health and safety literature (European Network for Workplace Health Promotion, 1997; Wynne, 1998; European Network for Workplace Health Promotion, 2001b; Bradshaw et al., 2001; ma la inen, 2007) and Stephens et al., 2004; Grifn et al., 2005; Antonelli et al., 2006; Ha the stakeholders groups viewpoints, was employed using an open-ended questioning technique. All interviews followed an iterative conversational format rather than take a chronologically ordered, and therefore researcher controlled, sequence. Data analysis Benners strategy for data analysis (Benner, 1994) was selected given its congruency with the hermeneutical methodological process of the Heideggerian approach and the studys philosophical underpinnings. This strategy revolves around three interrelated processes: identication of paradigm cases, thematic analysis and analysis of exemplars (Benner, 1994). An interpretive outline was formed from lines of enquiry, emerging both from the research objectives and themes rising from the data following thorough reading and re-reading of all the manually transcribed interviews together. Identied themes, capturing managers lived experiences of WHP, were then studied within each narrative account and within each context, searching for commonalities and differences. Interpretation was considered as a continual diffusive process of

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porous reection and discovery between each participant and that of the researcher until understanding was achieved. Measures to ensure rigour A framework specically designed for interpretive phenomenology by de Witt and Ploeg (2006) provided the basis for preserving the studys rigour. The framework includes consideration of ve expressions of rigour: balanced integration, openness (pertaining to the research process), concreteness, resonance and actualization (relating to the research outcome) (p. 224). Attention was given to maintaining balanced integration between the research area, the researchers skills and knowledge and the underpinning philosophical orientation of the interpretive phenomenology of Heidegger (1962). In interpreting the text, a conscious effort was made to ensure the ndings remained true to participants experiences and not biased to the researchers knowledge and experience. To preserve the expression of openness, attention was given during the research process to providing a detailed outline and rationale for each decision made, as well as details of the interviewers previous knowledge, skills and experience of workplace health. During the analysis phase, the texts were read and re-read a number of times against proposed interpretations. These were then presented to those participants who indicated their willingness to be contacted again, to see if interpretations reected a full everyday expression of their experiences. Participants conrmed that important information was retained, inaccurate assumptions were not made and their experiences were not overstated. The expression of concreteness centred upon situating the reader within the SME context in an attempt to link consideration of such experiences to the context of their own practice. In parallel, metaphorical expressions and artistic impressions were used to create an expression of resonance, offering a richness of interpretation to allow readers to more fully experience the multiple perspectives of SME managers and to help gain a sense of the SME experience. Actualization implies that full appreciation may not be achieved until readers are faced with similar circumstances, which may not occur until long after the study has been read. Participants were thus afforded an opportunity to clarify and verify the researchers interpretation of the data both during the interview and analysis stages, to ensure their views and experiences were appropriately represented. Ethical considerations The study was subject to review by the University of Ulsters Research Ethical Committee and carried out in accordance with the ethical principles outlined by Polit and Beck (2006), including: benecence; respect for human dignity and justice. Sensitive reassurance on behalf of the researcher was considered important in being able to convey a non-judgmental approach when gathering the information and in reassuring participants they were not being evaluated in terms of their implementation of WHP activity. Participant agreement was obtained for interviews to be recorded, data stored anonymously in locked les and made available only to the researchers involved. Results Findings revealed levels of awareness of WHP activity as the central theme, including high awareness activities and low awareness activities. Each activitys

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relevance was tightly bound to their understanding of WHP. High awareness activities identied by participants included: health and safety, lifestyle and occupational health. Collectively these addressed their concerns to: . preserve and protect employee health and safety; . prevent ill-health and injury; and . promote employees quality of daily living. Further probing revealed an additional three distinct WHP activities: provision of training and development, human resource management and environmental considerations. These low awareness activities revealed participants unforeseen attempts to directly and indirectly improve organisational management of employee health issues, and address community environmental concerns. High awareness activities The idiosyncratic nature of health issues faced by SMEs revealed varied experiences of WHP activities. Some shared similarity was perceived in preventing ill-health or injury through the provision of information on prevalent hazards and effective means of risk control. To transgress these controls were perceived as detrimental for employee health through injury or ill-health, and the organisation through loss of business:
They have a health and safety course [. . .] their hard hats [. . .] all of their equipment [. . .] have to wear the proper clothing. In the construction industry, they have to wear their bright overalls if theyre outside [. . .] can be seen easily [. . .] risk of them being injured is less [. . .] moving machinery [. . .] working on roofs. [. . .] must wear their equipment all the time [. . .] theyre told that. [. . .] Its our policy here that they have to wear them [. . .] We could lose a contract on the basis of it [. . .] (Manager of family-owned, small, rural, construction business).

Others felt WHP activities incorporated more traditional problem-oriented health education issues, including nutrition and exercise. This was based upon their experience of improvements in employee morale and expressed individual health:
We generally decide for ourselves what programmes to run with [. . .] step meter challenges [. . .] six a side for the men [. . .] a weight watcher morning [. . .] It has all gone well [. . .] provided a lot of interest and competition for everyone [. . .] It has lifted everyone [. . .] its a good diversion from work [. . .] People have said to us that they feel better within themselves (Manager of independently-owned, medium-sized, rural, engineering business).

Many participants, although not all, engaging with this type of lifestyle-related activity, came from organisations of between 100 and 250 employees. Responses seemed to indicate this engagement was synonymous with access to nancial and human resources not readily available to smaller organisations. Some participants had a clear idea as to what lifestyle-related activity should involve and were happy to determine and control these programmes themselves. Others, uncertain of what was involved, viewed such activity as being the province of external experts, such as an occupational health nurse. Such experts would either act as consultants or be employed directly by the business on a part-time basis. Much of this activity was based upon a negotiated arrangement

between the manager and service provider, centring on promotion of healthier lifestyles through the provision of health screening, smoking cessation, alcohol and drug awareness and diet and exercise events. One participant asserted lifestyle-related activities should not become the responsibility of the occupational health nurse or indeed health and safety personnel but rather sit within the realm of general health promotion provided by the statutory health services. From her experience, WHP activities concerned promoting an individuals personal health only and therefore should sit outside conventional workplace health and safety practice. This she considered to be more akin to occupational medicine:
In my experience its really about promoting various aspects of health whether it be cancer awareness, healthy living, exercise, anything like and doing that through the workplace [. . .] working with the local Health and Community Trusts [. . .] I wouldnt associate it with health and safety for example, nor would I associate it with occupational health [. . .] because they have a medical remit (Manager of independently-owned, medium-sized, rural, manufacturing business).

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Others reected upon how their experience to date led them to take a more conventional focus of occupational health: protecting individual employees health and providing specialist advice to managers on prevention of occupationally-related diseases and ill-health. This disparity in responses suggests that for some employers external support from occupational health providers and health promotion departments was identied as being necessary in the implementation process of WHP. Further, a lack of clarity exists not only on who the provider should be but on what their role should encompass. Even though many participants considered occupational health practice as being an important WHP activity, its function and value was not overtly clear to them. For others, becoming involved in what they perceived to be WHP activity was an even more uncertain process. Some viewed WHP activity as being solely related to personal health improvement on an individual basis and therefore did not consider any of activities they engaged with to be relevant, even though they reected upon engagement with activities considered as health promoting:
We dont have anything that is regarded as being directly related to health promotion. We do have an occupational health service that is bought in, twice a month. They do pre-employment assessments [. . .] musculoskeletal assessments, eyesight tests, blood pressure, etc. [. . .] ag up issues for us [. . .] absenteeism, and injuries sustained at work. Its not really used for promoting someones health. We dont focus on employees personal health. We concentrate on health and safety ok. We make sure they wear their PPE, comply with hand washing regulations [. . .] rst aid policies [. . .] a non-smoking policy [. . .] (Manager of independently-owned, medium-sized, rural, food processing business).

Low awareness activities: what lies beneath? Probing of participants experiences revealed further activities not perceived as relevant to WHP yet which promoted a positive organisational and community culture, and preserved the environment. Many participants spoke of their organisational management in terms of optimizing employee health potential and facilitating the smooth running of the business through training and development:

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I think that most organisations recognize that their workforce is their number one asset [. . .] there has to be an investiture [sic] in keeping people healthy, safe and fullled within their work environment. There are issues around optimizing peoples potential [. . .] giving them opportunities for training [. . .] For example, [. . .] rst aid courses, [. . .] how to reduce stress, [. . .] line management courses and career progression [. . .] Ive found these are all in the interests of the individual as much as the rm [. . .] but I never really thought of them in that way before (Manager of independently-owned, small, rural, residential nursing home).

Participants, with fewer than 50 employees, operating in rural areas, reected on a exible approach characterized in how they managed employees health issues, such as working patterns and sickness absence on a day-to-day basis. Given that many employees were known to them and lived locally, the way they directly managed employees was seen to be important in attending to, and respecting, employee health needs. As a consequence, of this approach, employees were found to be more supportive of each other and reliable and trustworthy for the business:
We have a very laissez-faire management no strict regime of you have to work this or you have to work that. We know many of these employees, they live close by [. . .] Most requests are looked upon favourably. People are exible about working shifts. Because of this sickness absence is not a difculty for us (Manager of family-owned, small, rural, residential nursing home).

Participants from medium sized organisations, also situated in rural areas, described having the added facility of human resource structures and access to occupational health services. This was experienced positively in being able to adopt a collaborative approach to organisational management, including sickness absence, terms and conditions of work, induction and exit interviews and appraisal and performance reviews:
From a HR point of view we have all the policies on sickness absence and leave [. . .] induction training and exit interviews [. . .] appraisal systems and performance reviews [. . .] training up-dates [. . .] I wouldnt have immediately thought of HR [. . .] being linked to [. . .] workplace health promotion [. . .] but I can see how that sits well (Manager of independently-owned, medium-sized, rural, engineering business).

From an environmental perspective, one participant from a family-run, medium-sized, rural, manufacturing business was eager to relay his experiences of how the successful introduction of a waste disposal system had a knock-on effect for the environmental health of the local community in terms of reducing pollution levels, and for the business in terms of saving money:
We are heavily into recycling [. . .] protects the local residents [. . .] from pollution [. . .] and indeed it saves (the business) money in the long-term.

Even though differences in the size of the organisation seemed to inuence the management approach taken, organisational and environmental activities were deemed by all participants to be important in improving employees overall health and well-being and the business itself. Whilst such activities were not mutually exclusive, and engagement with each had context-specic meanings, exploration of participants experiences at a deeper level uncovered a richer description of the meaningfulness of organisational and environmental activities for them. Though participants expressed a desire to improve workplace health for their employees, they seemed to lack awareness of the full potential of WHP activities to

allow them to do this condently. They therefore had no clear idea as to what the full nature or extent of their engagement with WHP activity might be. Organisational and environmental activities more fully embodied each participants approach to workplace health although not immediately perceptible as such. Discussion Despite recent strategic efforts to re-direct attention to the effects of environmental and ma la inen, 2007; Department for organisational factors on shaping employees health (Ha Work and Pensions/Department of Health, 2008), ndings suggest health and safety, and lifestyle approaches remain dominant (high awareness activities). Activities engaged in at organisational and environmental level (low awareness activities) only became perceptible as being relevant to improving workplace health through further probing. Based upon the ndings, the Iceberg principle (Figure 1) illustrates seven practical activities, identifying the perceived relevance and untapped meaningfulness of each activity to WHP. Metaphorically, the Iceberg depicts the focused attention on mainly legislative health and safety, occupational health and lifestyle-related activities and a lack of awareness of prospective effects of other activities, including employee training and development, human resource policies and procedures and environmental considerations. The depth of hiddenness shows the potential power and strength that exist for improvement in the marketing and development of WHP initiatives. High awareness activities Two levels of possible explanation exist for the main difference in participants experience of high awareness activities: legislative requirements and availability of resources. Since legislation requires managers by law to preserve employees health and safety through hazard identication and risk management, it stands to reason
WHP activities H&S policies & practices: Hazard identification Risk assessment of working processes & conditions Education & monitoring use of PPE Provision of first aid facilities Monitoring risk control effectiveness Lifestyle activities:Education & support regarding Diet; Exercise; Smoking cessation; Alcohol/ drug awareness Occupational health activities: Pre-employment assessment Health surveillance Sickness absence management Occasionally lifestyle health education provision

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Awareness of relevance of activity for employee health & the business

High

Sea level'

Provision of training & development: Self development (stress management; organisational management) First aid training

Human resource policies & procedures: Management of work terms & conditions Sickness absence management Provision of workplace accommodations Induction & exit interviews Appraisal & performance reviews

Environmental considerations: Waste disposal Air pollution

Low

Figure 1. Levels of awareness of WHP activity the Iceberg interpretation

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health and safety activities would dene managers practices. Axiomatically, at a resource level, those managers with the time, personnel and nancial latitude to devote to health and safety, occupational health and lifestyle-related activities are more likely to engage in their implementation. The concentration of efforts on preventing ill-health may extend from an historical positioning of workplace health within the traditions of health and safety and occupational medicine, with a single discipline emphasis on health assessment and control of hazards through health and safety measures (Wynne, 1998). At a political level, emphasis has been placed on actively persuading SME managers of the business ma la inen, 2007; benets to be gained from health and safety engagement (Ha Department of Health, Department for Work and Pensions Dame Carol Black, 2008; Department for Work and Pensions/Department of Health, 2008). Findings from this study revealed the intrinsic importance of health and safety activities for managers in maintaining customer condence in the business. This suggests managers may already be aware of the business benets from health and safety activity investment. Considering the competitive environment of SMEs, and lack of personnel and nancial resources (KPMG Consulting, 2002; Stephens et al., 2004; Grifn et al., 2005), increasing engagement with health and safety activities is therefore more likely to be dependent upon SMEs being provided with adequate funding than health and safety awareness-raising. Disparity among participants experiences of occupational health services role is consistent with the literature (Bradshaw et al., 2001; Eakin et al., 2001; Stephens et al., ma la inen, 2007). Findings support existing recommendations (Eakin et al., 2004; Ha 2001) for occupational health service providers and health promotion departments, to actively collaborate with each other to ensure SME managers are aware of the services they provide. On the basis of the ndings, providers also need to be cognisant that a blanket approach to service provision across all SMEs is likely to be ineffective given each SME not only has different needs but their manager may have different perspectives on what they consider appropriate for their business. The high prole of lifestyle-related activities, low implementation costs and a growth in consumerism, has encouraged its permeation as a health education strategy into a number of public health settings since the 1970s, including the workplace (Wynne, 1998). Increased interest in lifestyle-related activities has also been inuenced by an extension of occupational health services role to include optimization of employees health potential, as opposed to treatment and advice on health-risk management practices and disease management alone (Green and Kreuter, 1991). Consistent with the literature (European Network for Workplace Health Promotion, 2001b; Department of Health, Department for Work and Pensions Dame Carol Black, 2008), participants experiences of positive feedback from employees on lifestyle-related activities, and the availability of resources, emerged as being important. Given that service providers can only operate with managers permission, more attention needs to focus on marketing lifestyle-related activities which have proved successful in similar SME settings. Low awareness activities Under-estimation of the level of WHP activity engagement was signicant. Participants accounts showed health and safety, lifestyle and occupational health

activities were being complimented by the incorporation of health promotion concepts within organisational and environmental level policies and cultural practices. These contributed to promoting employees health and the business yet were not considered within the realm of WHP. This may be accounted for in two ways. First, although NIs strategic public health policy (DHSSPS, 2002) espouses the need for a determinants approach across all priority settings, including the workplace, the Long Term Workplace Halth Strategy for Northern Ireland (HSENI, 2003) continues to take a traditional health and safety and occupational health focus. It refers to WHP as a separate entity which is seen as a voluntary initiative of employers, targeting smoking, physical health, diet and alcohol/drug abuse. This is contrary to the vision encouraged within the Luxembourg Declaration (European Network for Workplace Health Promotion, 1997) which considers WHP to subsume health and safety, occupational health, lifestyle, organisational and environmental activities under the same umbrella. Consequently, not only are SME managers unaware of what constitutes as being WHP activities, but occupational health, health and safety and health promotion practitioners, are being encouraged in their work with businesses to promulgate a political view that WHP activities are principally concerned with lifestyle behaviour change. This political view differs from the new strategic vision for health and work in Britain recently advocated by Dame Carol Black (Department of Health, Department for Work and Pensions Dame Carol Black, 2008) which reinforces the importance of combining workplace health strategies directed at preventing ill-health, promoting health and well-being and encouraging individuals to make the most of their work potential. The moral, social and business case for this approach, outlined in the current national health, work and well-being initiative (Department for Work and Pensions/Department of Health, 2008), has stressed the need for collaborative involvement of all of the main stakeholders in the process for it to be a success. Lack of appropriately trained WHP specialists, and the need to provide suitable education and training programmes for political strategists and practitioners, has previously been stressed in the literature (Wynne, 1998; European Network for Workplace Health Promotion, 2001b). Second, limited evidence exists of organisational and environmental programmes effect on employees health and businesses (Shain and Kramer, 2004). Difculties have centred on: . quantifying outcome variables such as staff morale and corporate image; . establishing direct links between organisational level WHP programmes and the aforementioned variables; and . a predominance of quantitative studies, focussing purely upon nancial benets of sickness absence management and injury rate reduction (European Network for Workplace Health Promotion, 2004). This phenomenological study provides preliminary evidence of intangible business benets participants perceived from organisational and environmental activities, in improving employees loyalty to the company, respect for each other and for management, from showing an altruistic concern for the health of their employees. The ndings also draw attention to how these activities were experienced as directly improving customer and community condence in their businesses. The value of adopting a exible, accepting and laissez-faire approach to managing sickness absence and day-to-day working patterns rather than taking a strict documentary stance was considered particularly important for smaller businesses in

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rural areas. This was based upon their experience of local employees being more supportive of each other and loyal to the business. Stronger social support systems within smaller organisations have been associated with lower psycho-social risks for employees (Antonelli et al., 2006). Marketing the value of human resource activities with smaller business therefore may not require as high a priority as the provision of funding for training and development courses. Providing best practice examples of this informal management approach within smaller organisations may also offer better opportunities for SME managers to learn from local success. From an environmental perspective, the positive experience of introducing an environmentally friendly waste disposal system for businesses and local communities presents an added public health dimension to the Luxembourg WHP framework (European Network for Workplace Health Promotion, 1997). Given current concerns with the effects of global climate change, and an emphasis on resource efciency (Fudge, 2007), commitment to environmental protection within workplaces warrants stronger consideration within strategic WHP policies. SMEs role in minimising their consumption of natural resources and increasing their use of renewable resources is exemplied by their projected increased growth, both locally (NTC Economics, 2007) ma la inen, 2007). Further research is needed, however, to and across Europe (Ha determine what environmental health approach would be effective in motivating SME managers to engage in energy efciency processes. Epidemiological, behavioural, management and environmental diagnosis A modied version of Green and Kreuters (1991) health promotion programme planning model draws political strategists and practitioners attention to SME managers level of awareness of WHP activities (Table I). Consideration is also given to potential expected outcomes of improved quality of life for employees and the business from epidemiological, behavioural, management and environmental sets of activities. Within the epidemiological component, an exploration is made of activities likely to promote employee health, safety and wellbeing and prevent ill-health and injury in the workplace. These activities include: . health and safety policies and procedures, designed to improve employees working environment through health risk management; and . health and safety, and occupational health practices, designed to improve employees quality of working life through assessment of tness for work, advice on safe work practices, wearing of personal protective equipment and continued health monitoring. The behavioural diagnosis involves an assessment of activities thought to support or inuence employee change by: . improving individual lifestyles; . contributing to self development; and . improving life preserving skills, both inside and outside the workplace. In order to make a clear distinction between activities focused purely on internal business management and those with a wider public health impact, a management

Epidemiological diagnosis Environmental considerations: Waste disposal

Behavioural diagnosis

Management diagnosis

Environmental diagnosis Outcomes

Human resource policies and procedures: Management of terms and conditions of work Sickness absence management Provision of workplace accommodations Induction and exit interviews Appraisal and performance reviews Low level of awareness Low level of awareness Employee Improved quality of working life Improved quality of life in general Improved loyalty to the business

Working environment Lifestyle/occupational health H&S policies and procedures: activities: Hazard identication Education and support Risk assessment of working regarding: processes and conditions Diet; Monitoring of use of personal Exercise; protective equipment (PPE) Smoking cessation; Provision of rst aid facilities Alcohol/drug awareness Monitoring risk control effectiveness High level of awareness High level of awareness Employee behaviour Provision of training and H&S practices: Education on the use of PPE development: Self development (stress Provision of health and safety management; organisational up-date training management) First aid training Occupational health: Pre-employment assessment Low level of awareness Health surveillance

Business Legislative compliance Reduced sickness absence Reduced employee turnover Enhanced productivity Enhanced prots Enhanced customer, community, employee condence Improving public health by reducing levels of pollution

High level of awareness

Note: Italicised text represents low awareness WHP activities Source: Adapted from Green and Kreuter (1991)

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Table I. Epidemiological, behavioural, management and environmental diagnosis: levels of awareness of WHP activities and the expected outcomes in the SME context

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diagnostic component is incorporated at this point. Within this component, human resource policies and procedures are considered, which are beyond employees personal control yet have a direct and indirect effect on their working life and the smooth running of the business. Within the environmental diagnostic component, an assessment is made of those activities whose impacts extend beyond the workplace, and which hold the potential to improve business prot margins and public health in general. In terms of programme planning, a much wider variety of WHP activities can therefore be explored by political strategists and practitioners within SME settings. Limitations Limitations include the studys restricted focus on SME businesses within one geographical area. The experiences of WHP of these participants may be different than those of SME managers in other business sectors and/or geographical locations. Moreover, the provision of services and SME managers access to them may be different. Therefore, account needs to taken of the limited generalizability of the ndings to other SME settings. It is also important to acknowledge that the Luxembourg Declaration (European Network for Workplace Health Promotion, 1997) framework used to dene WHP activities in this study may not correspond with denitions used or approaches taken in other studies and therefore the ndings may differ. Furthermore, the present study did not allow for the exploration of employees perspectives of WHP activities, considered to be crucial in the development of effective WHP intervention strategies. Neither did it allow for strategists and practitioners perspectives of the difculties they face in engaging with SME managers and in encouraging them to undertake WHP activities. Given the importance of the views of employees, strategists and practitioners, an exploration of their experiences should be undertaken through further research studies, using the same conceptual framework, so that a more holistic understanding of WHP can be established and a fully co-ordinated approach can be taken to policy, practice, education and training. Another limitation relates to the use of telephone interviewing as opposed to face-to-face interviewing. Whilst participants did request this method of data collection when offered either face-to-face or telephone interviews as alternatives, and it was successful in gaining access to this hard to reach group, it could be argued that more meaningful data could have been obtained by observing the non-verbal communications of those being interviewed. Uncovering this level of hiddenness is particularly important in Heideggerian philosophy where the quality of the data is dependent upon achieving a sense of connection with the participant so that a deeper level of meaning can be revealed. Therefore, additional research using face-to-face interviews or focus groups where possible is needed to explore the ndings further. Conclusion Evidence from the study draws attention to the lack of awareness of the importance organisational and environmental activities play in addressing the wider determinants of workplace health within the SME context. Based upon the ndings, the proposed Iceberg model suggests that, when marketing WHP activities, strategists, practitioners and educationalists need to focus not only on legislative health and safety, occupational health and lifestyle activities, but also the benets both for SME

businesses and their employees from human resource policies and procedures, training and development and environmental practices. The untapped signicance of these activities suggests the need to move from the present focus on mainly legislative health and safety, occupational health and lifestyle-related activities, to bring to light the full potential of WHP for SMEs from organisational and environmental measures, many of which SMEs may already have in place.
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