Views of the workplace as a health promotion arena among managers of small companies

Abstract

Introduction:

Several studies have shown that workplace health promotion leads to better health, increased productivity, as well as reduced absenteeism and presenteeism among employees. The objective of this study was to describe how managers in small companies (10–19 employees) perceive their company as an arena for promoting employees’ health.

Method:

A sample of 10 managers (four women) was strategically selected. Semi-structured interviews were conducted with each person. Interviews were transcribed and analysed using qualitative content analysis. The analysis focused on both manifest and latent content.

Results:

Three main categories emerged from the analysis: the potential to promote employees’ health, responsibility as an employer and the need for external support. An arena for workplace health promotion is created when managers prioritise health at the workplace.

Conclusion:

Small companies often lack the knowledge and resources to manage health and safety problems and also have less access to occupational health services. This paper highlights the importance of the views of small company managers as resources for the development of health promotion.

Keywords

Health promotion small companies Sweden workplace

Introduction

In health education and public health, the workplace is assumed to be an important arena for promoting health (World Health Organization [WHO], 2010). Health promotion activities benefit employers and employees, as well as improve society in times of strain or health service reduction (Allen et al., 2012; Chu et al., 2000; Kuoppala et al., 2008a). However, health promotion activities in the workplace tend to be limited, mainly focusing at the individual level through health profile assessment and recommendations to stop smoking, decrease alcohol use and increase physical activity (Larsson et al., 2014; Shain and Kramer, 2004).

A more encompassing approach, called Workplace Health Promotion (WHP), has been defined as ‘the combined efforts of employers, employees as well as society in order to improve the health and well-being of people at work’ (Barbeau et al., 2006; European Network for Health Promotion [ENWHP], 2007). WHP has the potential to help to improve health, enhance the work ethic, deliver higher levels of productivity and reduce sick leave (Kuoppala et al., 2008a; Ljungblad et al., 2014; Mills et al., 2008; WHO, 2010). Regarding attending to work while sick (presenteeism), results are more mixed (Cancelliere et al., 2011; NICE, 2015; Robertson et al., 2012). Bustillos and Trigoso (2013) did not find any significant association between decreased presenteeism and access to health programmes in the workplace, whereas others have reported more positive effects (Cancelliere et al., 2011; Merrill et al., 2012; Sanchez and Ortiz, 2013). With regard to the future, however, WHP is increasingly important as the average age of the workforce increases (Eriksson et al., 2008).

A salutogenic approach to health promotion focuses primarily on health and resource factors (Antonovsky, 1996), in contrast to a pathogenic approach, where the focus is on risk factors for illness. A sense of coherence (SOC) is a part of a salutogenic approach and combines comprehensibility (predictability and understanding), manageability (resources and accessibility) and meaningfulness (personal commitment). An individual’s SOC score offers an indicator for well-being. Feldt et al. (2000) suggested that a good organisational climate in the workplace is the key to supporting an SOC, which influences the employee’s well-being at work. Togari and Yamazaki (2012) highlight the managers’ role in establishing a work environment that enhances SOC. Studies have shown that company leadership has an influence on employees’ health (Dellve et al., 2007; Hicks, 2011; Institute for Employment Studies, 2014; Kuoppala et al., 2008b; Larsson et al., 2009; Shain and Kramer, 2004). Managers’ commitment to and support for WHP are essential for employers’ well-being (Milner et al., 2015). A major challenge in implementing WHP programmes in the workplace is, however, the lack of motivation among managers, as many tend to dismiss the importance of WHP (Dellve et al., 2007; ENWHP, 2007; Kuoppala et al., 2008b; Whitehead, 2006).

The research reported here took place in a number of small private companies in a rural area of southwest Sweden. This setting was selected because small-to medium-sized enterprises are affected more by employees’ absence than larger firms and also because the managers of small companies have shown to lack knowledge of how to manage health issues among employees (Barbeau et al., 2004; Cocker et al., 2013). Studies have also shown that fewer small companies have WHP programmes compared to large companies (Hannon et al., 2012; McCoy et al., 2014). According to the European Commission (2003), a small company may be defined as having between 10 and 49 employees, while in this study, small companies were defined as having between 10 and 19 employees.

Objective

The principal objective of this study was to describe how the managers of small companies perceive their company as an arena for promoting the health of the employees.

Method

Participants and settings

Small businesses included in the study came from a list of all private companies registered in a rural area in southwest Sweden and having between 10 and 19 employees in the year 2010. Companies were classified by Swedish Standard Industrial Classification, which is based on the European Union’s (EU) recommended standard (Statistics Sweden, 2007). A strategic sample of 10 managers was selected taking gender, location and branch into account. Six men and four women from different locations and branches of industry were included (Table 1).

Table 1.

Managers (n = 10) employment contexts categorised according to the Swedish Standard Industrial Classification based on the EU’s recommended standard, SNI (Statistics Sweden, 2007).

Interview	Sex	Swedish Standard Industrial Classification, SNI
1	Male	Transport, storage and communication
2	Male	Real estate, renting and business activities
3	Male	Electricity, gas and water supply
4	Female	Hotels and restaurants
5	Male	Manufacturing
6	Male	Wholesale and retail trade; repair of motor vehicles, motorcycles and personal and household goods
7	Male	Financial, insurance sector
8	Female	Construction
9	Female	Hotels and restaurants
10	Female	Public administration and defence; compulsory social security

EU: European Union.

Data collection

Interviews were conducted by the first author (V.W.) in spring, 2011. Prior to data collection, a pilot interview was conducted to develop the questions for inclusion in the interview guide and to eliminate misconceptions and irrelevancies. The participants selected were personally contacted by telephone with information concerning the aims of the study and told that the obtained data would be treated confidentially. This initial contact was followed up by written information distributed via e-mail describing the aims and procedure of the study and to make it clear that participation was voluntary. Signed informed consent was then obtained from each participant. Interviews were conducted at a place and time chosen by the participants, mainly at participants’ workplace. All interviews lasted between 15 and 45 minutes and were recorded digitally and transcribed verbatim. Field notes were also taken during the interviews.

The interview guide included an initial question – What does health mean to you? – followed by a number of subsidiary questions: What does WHP mean to you? How do you perceive the concept of promoting health at your company? How do you perceive your role as a manager in the promotion of health at your company? How do you perceive collaboration between your company and other organisations in the promotion of health? What would you, as a manager, like to develop in the area of WHP? What kind of support do you need in order to promote health at your company? During the interviews, participants were encouraged to provide more detailed statements by responding to follow-up probes such as the following: What do you mean? In what way? Can you explain further?

Data analysis

Data analysis was conducted in line with Graneheim and Lundman’s (2004) guidelines for qualitative content analysis. Analysis focused on both the manifest and latent content of the interview text. Manifest content analysis identified the more obvious components of what was said, while latent content analysis sought to explore underlying meanings within the text.

The transcribed interviews were first read carefully several times to gain a comprehensive picture of the collected data. Following this, the interviews were re-read line by line, and statements concerning the workplace as an arena for health promotion – that is, words, sentences and paragraphs of the interview based on content and context – were marked. The statements were placed into meaningful units, condensed and then labelled with codes. All codes were grouped together based on similarities and dissimilarities into categories (Table 2). The categories were discussed and reflected upon several times, and after final consensus, the underlying meaning, which expresses the latent content of the categories, was formulated into a theme.

Table 2.

Example of the analytic process regarding how managers perceive their company as an arena for promoting employees’ health.

Condensed meaning unit	Code	Subcategory	Category	Theme
… of course the employees become more alert and positive and less ill, there is also the fellowship. You do something together, and in return it affects the work quality …	Improve work quality	Value for the company	Responsibility as an employer
… to be a leader is to set a good example for everyone …, as I said before … to show that you are a human … that you try … It’s just like everybody else, you would like to exercise more and eat healthier food and so on.	Lead by example	Influencing the psychosocial work environment	Potential to promote employees’ health	An arena for WHP is created when the managers prioritise health at the workplace
you have questions about work environment … and then you perhaps have questions about promoting health, eh … and then you need someone, who comes and help you to find activities …	Lack of ideas	Inspiration and knowledge	Need for external support

WHP: workplace health promotion.

Ethical considerations

Ethical regulations and guidelines enshrined in Swedish law (Ministry of Education and Research, 2003) and the ethical principles defined by the World Medical Association Declaration of Helsinki (WHO, 2001) were adhered to in this study. Managers provided their consent to participate both orally and in writing after being informed about the purpose and the content of the study. Managers were further reminded about their voluntary participation and that they could end the interview at any time without giving a reason. They were also guaranteed confidentiality.

Findings

An overarching theme appeared in the date in the form of the statement, ‘an arena for WHP is created when the managers prioritised health at the workplace’. Overall, managers were aware of the workplace as a prospective area for health promotion. However, findings showed that managers wished to add to the definition and shape the arena in such a way that it would be in the interest of the company’s profit, and they felt they needed some extra support from organisations outside the company. Three categories (potential to promote employees’ health, responsibility as an employer and need for external support) and six subcategories representing the manifest content were identified (Figure 1).

Figure 1.

How managers in small companies (10–19 employees) perceive their company as an arena for promoting employees’ health.

Potential to promote employees’ health

Health was viewed by managers as a concept comprising both physical and psychological well-being. Managers were aware that they had the potential to promote health among their employees by positive influences on the psychosocial workplace environment.

Influencing the psychosocial work environment

Participants were aware that they influenced norms and culture in the workplace and that they were in a position to influence the psychosocial dimensions of the workplace environment. Participants indicated that in creating a positive psychosocial work environment, it was important to ensure that everyone in the company is valued equally and that everyone has the possibility to speak out and feel appreciated. Other factors deemed important in the creation of a positive psychosocial workplace environment included ensuring that employees were encouraged not to be afraid to discuss problems when they arise:

… If you think more about the psychosocial work environment … I am trying to work for an open and warm atmosphere at the workplace, where it’s okay for the employees to talk about the fact that they might not be feeling very well today because such and such has happened. It should feel natural to be able to open up in front of your colleagues … (Interview 4, female manager)

The key to good leadership, according to participants, lies in being sensitive to negative emotions or ill health in the workplace, as well as attempting to find solutions to the problems that arise. Managers expressed that fellowship and collegiality were of significance in regard to psychosocial health in the workplace and felt it was important to take part in activities outside work that could bring members of a group closer together.

Creating the conditions for good health

Employees were viewed by managers as having a major responsibility for ensuring their own health by reflective thinking on health in their daily lives. Some doubt was expressed as to whether or not an employer could influence employees’ body weight and lifestyle choices such as smoking:

… You can’t stop people from smoking … We don’t forbid it. It is up to the individual. It is their choice … (Interview 1, male manager)

The managers saw it as important to encourage employees to adopt healthy lifestyles, and that by promoting health in the workplace, they could create the conditions for them to do so. By offering physical activities, for example, they were also creating conditions for good psychological well-being for their employees:

… well, it is good to encourage employees to keep fit and companies can do so by providing opportunities such as giving out gym cards or memberships to various activities and so on … (Interview 7, male manager)

Setting a good example was seen as important when it came to motivating employees to adopt a healthy lifestyle. Participants indicated that it was advantageous if they were physically active themselves and participated in wellness activities:

… If I challenged my employees by saying ‘I’m off to run a half marathon and I want you all to join me’, quite a lot of them would do it, I think. In many ways, you’re a sort of role model … (Interview 3, male manager)

Actions to prevent hazards in the workplace (e.g. the provision of fire safety information, building evacuation practice, training in cardiopulmonary rescue [CPR]) were perceived as a natural part of the work of a manager. These activities include creating safety awareness among the employees so that they need not worry about risks in the workplace.

Responsibility as an employer

Participants felt that promoting health was meaningful and beneficial for the company. Beyond this, managers felt that promoting health was a part of their leadership role, that is, by organising and structuring work at the company well, they were able to influence employees’ health.

Value for the company

The workplace was seen as an arena for health promotion and was generally perceived to provide the opportunity to reduce employees’ sickness absence. Managers viewed sick leave as an indicator of health:

… It is very important because the whole company depends on the employees’ wellbeing … Without our employees we are simply not a company … so it is obvious … (Interview 8, female manager)

Improving the health of employees was also perceived as increasing the quality of the employees’ work. Participants who had experience of working with health promotion felt that if employees had a sense of solidarity and enjoyed their work, they became more committed. This in turn benefitted the company and its image because employees who enjoy their work project a positive image to the company’s clients:

… partly so that people (i.e. employees) have fun at work and partly because it produces other good results. It means that they (employees) feel good and business goes well … (Interview 4, female manager)

Organising and structuring work

The company’s organisation and structure were felt to contribute to the health of the employees. Straightforward communication increased a sense of security among employees, and consistency and careful planning helped to create a feeling of community. Clear roles and a division of responsibility within the organisation were other items seen as contributing to improved employee health:

… When we expanded the company, we missed (out some) vital parts in the organisation’s job descriptions and similar, which has caused some problems [later] and contributed to much harder work in the long run … (Interview 3, male manager)

Most managers saw it as part of their leadership role to promote health and arrange health promotion activities:

… It’s all about giving support and pushing forward to ensure that the health promotion programme develops … That is, create time and space in our calendar for the programme. It is all about the company being behind the promotion of the activities … (Interview 7, male manager)

However, some found it difficult to identify and implement activities and make employees aware of them once they were implemented. Developmental dialogue with employees was considered to be a good way to follow up the employees’ opinions of the health promotion activities.

Value of external support

The participants expressed a need for external support to perceive their workplace as an arena for health promotion. They stated that they needed inspiration and knowledge as well as collaboration with other parties outside the company.

Inspiration and knowledge

Managers were aware that, at times, they did not have enough knowledge about health and ideas for health promotion activities in the workplace:

… The fact is that you know so little. I don’t know enough about what can be done. Maybe there’s something that’s really easy to implement, but I don’t know about it. I think there are a lot of people like me who just don’t have enough knowledge in this area … (Interview 9, female manager)

Participants indicated that support might include receiving information about what kinds of activities can be done to promote health in the workplace and what the cost of implementing such activities would be. They compared the lack of information on this issue to other workplace matters such as work environment issues, where support and information were more easily accessible:

… The Regional Folkhälsomyndigheten¹ or other organisations could push the work further a bit and also remind people (i.e. employees) about its importance … They could help in setting up the activities … in exactly the same way as in work environment issues … (Interview 5, male manager)

Managers were interested in learning about activities that are suitable for everyone, as, for example, some participants had experienced resistance from older employees when it came to participation in certain physical activities. Interviewees expressed the need for easily accessible sources of support that do not take too much time from other work-related tasks. They felt that there was a certain sense of security in being able to share ideas with someone who was trusted, as health is a complicated and multi-faceted issue:

… It’s pretty lonely work; working as a boss, you’re often quite vulnerable and isolated. If you don’t have a companion, you don’t really have anyone to bounce ideas around with … (Interview 8, female manager)

Need for collaboration

Managers viewed the local occupational health services (OHS) as valuable as they provided access to relevant sources of support when it came to preventive and rehabilitative activities. Furthermore, managers viewed OHS as having the knowledge of who they could contact for help and support. Participants considered that OHS should be organised as a part of the regular public health service, as the prices currently charged for activities were unrealistic:

… I think it is a bad thing about the occupational health services. It should not be a profit-driven company … It should be included in ordinary health care service, though more tailored towards businesses … (Interview 5, male manager)

Managers said that collaboration with other companies to exchange ideas and gain inspiration would be a valuable way of gaining and sharing knowledge. They suggested that it could be useful to join forces so that resources and expertise can be shared.

Discussion

When the managers of small companies in Sweden were given the opportunity to describe their perceptions of WHP, their responses consisted of what should or might be included in such a practice, rather than what it was about. Managers seemed to understand that they had the potential to promote employees’ health. However, their main justification for prioritising health promotion in the workplace was that it would be beneficial to the company.

Managers were largely aware of their impact on the psychosocial environment at the workplace and consequently their employees’ health. Some managers had also experienced WHP leading to job satisfaction and solidarity, which in turn created committed and motivated employees that strengthened the company’s brand. This aligns with findings from studies conducted by Whitehead (2006) that came to similar conclusions.

Managers also considered themselves as strong opinion-builders, for example, by providing a good example and how they were aware of that they had the opportunity to create positive attitudes among employees regarding health promotion. This finding supports previous research that states that leadership is important when it comes to using the workplace to prioritise health (Dellve et al., 2007; Kuoppala et al., 2008b). In the presence of good leadership, a healthy workplace environment with a supportive atmosphere increases employees’ well-being (Kalimo et al., 2003; Volanen et al., 2004).

In this study, good health was seen as linked to having a healthy lifestyle such as eating healthy food. Health promotion was seen by managers as providing the opportunity to participate in physical activities, as well as having free fruit and massage available at the workplace. This finding is in line with findings from other studies in which WHP is often construed in terms of opportunities to participate in prevention activities at the individual level (Larsson et al., 2014; Shain and Kramer, 2004). However, according to ENWHP (2007), a combination of both prevention and promotion is likely to be more useful in improving health in the workplace; more information concerning factors contributing to good health may strengthen ways of influencing employee health and creating a healthy work environment. Managers also expressed the need for external support for their work in the form of instances and examples as well as collaboration with other organisations beyond their own company. Ito et al. (2006) have suggested that WHP should draw on local examples from small companies and focus on low-cost, general initiatives.

Interviewed managers in this study regard sick leave as an indicator of health and ill health, and according to Angelöw (2002), pessimistic health indicators may label an organisation and its employees negatively. However, research has also shown that presenteeism may also be used as an indicator for health and ill health (Leineweber et al., 2012). Evidence suggests that people who go to work while ill pose a more costly problem for the employer than absenteeism is (NICE, 2015). Because of this, instead of indicators of ill health, new indicators derived from a salutogenic perspective may be needed in order to more fully understand the workplace as an arena for health promotion (Lydell et al., 2011).

Some limitations of the study should be noted. In qualitative research, there are few established criteria for sample size. In this study, strategic selection and maximum variation were used with respect to gender and branches, respectively. Broader sampling which included a greater number of participants may have better reflected the profile of managers in small companies.

In conclusion, further studies are needed concerning WHP in developing it at small companies. Furthermore, education and support are needed for managers at small companies in order to implement WHP successfully.

Footnotes

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

Notes

References

Allen

Lewis

Tagliaferro

(2012) Cost-effectiveness of health risk reduction after lifestyle education in the small workplace. Preventing Chronic Disease 9(11): 110169.

Angelöw

(2002) Healthier Work: To Develop an Attractive, Healthy and Well-Functioning Workplace. Lund: Studentlitteratur.

Antonovsky

(1996) The salutogenic model as a theory to guide health promotion. Health Promotion International 11(1): 11–18.

Barbeau

Calderon

Hartman

. (2006) Results of a union-based smoking cessation intervention for apprentice iron workers (United States). Cancer Causes and Control 17(1): 53–61.

Barbeau

Roelfs

Youngstrom

. (2004) Assessment of occupational safety and health programs in small businesses. American Journal of Industrial Medicine 45(4): 371–379.

Bustillos

Trigoso

(2013) Access to health programs at the workplace and the reduction of work presenteeism: A population-based cross-sectional study. Journal of Occupational and Environmental Medicine 55(11): 1318–1322.

Cancelliere

Cassidy

Ammendolia

. (2011) Are workplace health promotion programs effective at improving presenteeism in workers? A systematic review and best evidence synthesis of the literature. BMC Public Health 26(11): 395.

Chu

Breucker

Harris

. (2000) Health-promoting workplaces – International settings development. International Health Promotion 15(2): 155–167.

Cocker

Venn

Sanderson

(2013) Psychological distress and related work attendance among small-to-medium enterprise owner/managers. International Journal of Environment Research Public Health 10(10): 5062–5082.

10.

Dellve

Skagert

Vilhelmsson

(2007) Leadership in workplace health promotion projects: 1- and 2-year effects on long-term work attendance. European Journal of Public Health 17(5): 471–476.

11.

Eriksson

Jansson

Haglund

. (2008) Leadership, organization and health at work: A case study of a Swedish industrial company. Health Promotion International 23(2): 127–133.

12.

European Commission (2003) Commission recommendation of 6 May 2003 concerning the definition of micro, small and medium-sized enterprises. Official Journal of the European Union 124(37): 36–41.

13.

European Network for Health Promotion (ENWHP) (2007) Luxembourg declaration on work place health promotion in the European Union. Available at: http://www.enwhp.org/fileadmin/rs-dokumente/dateien/Luxembourg_Declaration.pdf (accessed 11 April 2016).

14.

Feldt

Kinnunen

Mauno

(2000) A mediational model of sense of coherence in the work context: A one-year follow-up study. Journal of Organizational Behavior 21(4): 461–476.

15.

Graneheim

Lundman

(2004) Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today 24(2): 105–112.

16.

Hannon

Garson

Harris

. (2012) Workplace health promotion implementation, readiness, and capacity among midsize employers in low-wage industries: A national survey. Journal of Occupational and Environmental Medicine 54(11): 1337–1343.

17.

Hicks

(2011) Leader communication styles and organizational health. Health Care Management 30(1): 86–91.

18.

Institute for Employment Studies (2014) Workplace policy and management practices to improve the health and wellbeing of employees. Evidence review 3. Available at: http://www.nice.org.uk/guidance/ng13/evidence/evidence-review-3-67231263 (accessed 6 October 2015).

19.

Ito

Sakai

Kogi

(2006) Development of interactive workplace improvement programs in collaboration with trade associations of small-scale industries. Industrial Health 44(1): 83–86.

20.

Kalimo

Pahkin

Toppinen-Tanner

(2003) Staying well or burning out at work: Work characteristics and personal resources as long-term predictors. Work & Stress 17(2): 109–122.

21.

Kuoppala

Lamminpää

Husman

(2008a) Work health promotion, job well-being, and sickness absences – A systematic review and meta-analysis. Journal of Occupational and Environmental Medicine 50(11): 1216–1227.

22.

Kuoppala

Lamminpää

Liira

. (2008b) Leadership, job well-being, and health effects – A systematic review and a meta-analysis. Journal of Occupational Environmental Medicine 50(8): 904–915.

23.

Larsson

Vinberg

(2009) To control with health: From statistics to strategy. Work 32(1): 49–57.

24.

Larsson

Ljungblad

Sandmark

. (2014) Workplace health promotion and employee health in Swedish municipal social care organizations. Journal of Public Health 22: 235–244.

25.

Leineweber

Westerlund

Hagberg

. (2012) Sickness presenteeism is more than an alternative to sickness absence: Results from the population-based SLOSH study. International Archives of Occupational and Environmental Health 85: 905–914.

26.

Ljungblad

Granström

Dellve

. (2014) Workplace health promotion and working conditions as determinants of employee health. International Journal of Workplace Health Management 7(2): 89–104.

27.

Lydell

Marklund

Baigi

. (2011) Return or no return – Psychosocial factors related to sick leave in persons with musculoskeletal disorders: A prospective study. Disability and Rehabilitation 33(8): 661–666.

28.

McCoy

Stinson

Scott

. (2014) Health promotion in small business: A systematic review of factors influencing adoption and effectiveness of worksite wellness programs. Journal of Occupational and Environmental Medicine 56(6): 579–587.

29.

Merrill

Aldana

Pope

.; Hero Research Study Subcommittee (2012) Presenteeism according to healthy behaviors, physical health, and work environment. Population Health Management 15(5): 293–301.

30.

Mills

Kessler

Cooper

. (2008) Impact of a health promotion program on employee health risks and work productivity. American Journal of Health Promotion 22(1): 45–53.

31.

Milner

Greyling

Goetzel

. (2015) The relationship between leadership support, workplace health promotion and employee wellbeing in South Africa. Health Promotion International 30(3): 514–522.

32.

Ministry of Education and Research (2003) The act concerning the ethical review of research involving humans (SFS 2003:460). Available at: http://www.codex.uu.se/en/manniska5.shtml (accessed 1 April 2014).

33.

NICE (2015) Workplace policy and management practice to improve the health and wellbeing of employees. Available at: www.nice.org.uk/guidance/ng13 (accessed 20 October 2015).

34.

Robertson

Leach

Doerner

. (2012) Poor health but not absent: Prevalence, predictors, and outcomes of presenteeism. Journal of Occupational and Environmental Medicine 54(11): 1344–1349.

35.

Sanchez

Ortiz

36.

Shain

Kramer

(2004) Health promotion in the workplace: Framing the concept; reviewing the evidence. Journal of Occupational and Environmental Medicine 61(7): 643–648.

37.

Statistics Sweden (2007) Search for industry code, (SNI). Available at: http://www.sni2007.scb.se/snisokeng.asp (accessed 19 June 2013).

38.

Togari

Yamazaki

(2012) A causal relationship between sense of coherence and psycho-social work environment: From one-year follow-up data among Japanese young adult workers. Global Health Promotion 19(1): 32–42.

39.

Volanen

Lahelma

Silventoinen

. (2004) Factors contributing to sense of coherence among men and women. European Journal of Public Health 14(3): 322–330.

40.

Whitehead

(2006) Workplace health promotion: The role and responsibility of health care managers. Journal of Nursing Management 14(1): 59–68.

41.

World Health Organization (WHO) (2001) World medical association declaration of Helsinki – Ethical principles for medical research involving human subjects. Bulletin of the World Health Organization 79(4): 373–374.

42.

World Health Organization (WHO) (2010) Workplace health promotion. Available at: http://www.who.int/occupational_health/topics/workplace/en/index1.html (accessed 19 June 2013).