Integrating Safety and Health Promotion in Workplaces: A Scoping Review of Facilitators,Barriers,and Recommendations

Abstract

Background

Growing evidence supports the integration and coordination of occupational health and safety and workplace health promotion activities instead of these coexisting as siloed efforts. Identifying implementation challenges and how these can be overcome is an important step to achieving truly integrated worker health efforts. We conducted a scoping review to identify the barriers and facilitators to integrated worker health approaches and described recommendations for implementing these efforts.

Method

Peer-reviewed articles and gray literature from 2008 to 2019 were searched from the following electronic databases: EMBASE, Ovid Medline, PsycINFO, and ABI/INFORM. References from relevant articles and key informant suggestions also were collected. Data were extracted from documents if they focused on the occupational health and safety and health promotion of workers and described outcomes associated with integrated worker health approaches or outlined considerations relevant to the implementation of these approaches.

Results

Fifty-one documents met the inclusion criteria and were reviewed. Barriers and facilitators to implementing integrated worker health approaches were found at the extraorganizational, organizational, worker, and program levels, with limited resource availability the most reported barrier and support from leadership the most reported facilitator. Ten broad recommendations were identified and highlighted gaining leadership support, demonstrating leadership commitment, developing worker-centric approaches, and building capacity for workers.

Conclusion

In reviewing the literature, we found clear and consistent recommendations relevant for integrated worker health approaches. Further research is needed to better understand how these recommendations apply to diverse workforces and organizations with varied resources.

Keywords

scoping review workers occupational safety health promotion workplace

A growing body of literature is supportive of integrated worker health approaches (Anger et al., 2015; Feltner et al., 2016a; Joss et al., 2017) and are described as “the coordination of goals and activities between the occupational health and safety and the health promotion functions of organizations” (Punnett et al., 2020, p. 227). It is common practice for organizations to manage occupational health and safety programs and policies separately from health promotion programs that emphasize health education and individual behavior change to achieve goals such as weight loss, smoking cessation, and chronic disease screening (Hannon et al., 2012; Rongen et al., 2013). The core idea of an integrated approach is to coordinate occupational health and safety and health promotion activities in ways that both constructs coexist, each informing and influencing one another, instead of existing as siloed efforts (Punnett et al., 2020). Empirical evidence, while still emerging, provides support for integrated worker health approaches compared with more traditional “nonintegrated” approaches in contributing to higher rates of worker participation for both safety and health promotion efforts (Cooklin et al., 2013; LaMontagne et al., 2004; Sorensen et al., 2002; Sorensen et al., 2005), reductions in occupational injury and disability rates (Lustig & Weisfeld, 2014; McLellan, Williams, et al., 2017), and reduced health care and societal costs (Mellor & Webster, 2013). Integration further facilitates better use of limited resources, with internal collaboration across multiple departments potentially leading to improved processes and outputs, and an enhanced work climate (Hunt et al., 2005). Furthermore, integrated worker health approaches may deliver improved health outcomes in workplace sectors that are more challenging for health promotion strategies to target, for example, shift workers and blue-collar workers (Cooklin et al., 2013; Joss et al., 2017).

The integrated worker health approach has gained momentum in many countries (Feltner et al., 2016a) and is widely endorsed by international health and labor agencies (International Labour Organization, 2012; Schill & Chosewood, 2013; World Health Organization, 2010). However, despite increasing evidence supporting integrated worker health approaches, program implementation continues to be challenging, with varied success (Punnett et al., 2020; Sorensen et al., 1996). Some reviews of the literature have offered insight into the benefits of interventional strategies (Anger et al., 2015; Cooklin et al., 2013; Feltner et al., 2016a; Hudson et al., 2019). However, there is little available guidance on potential implementation hurdles and solutions to challenges. Identifying implementation hurdles and how challenges can be overcome is an important step to drive implementation practices in the field (Punnett et al., 2020; Tamers et al., 2018). The objectives of this scoping review were to (1) identify the barriers and facilitators to integrated worker health approaches and (2) describe evidence-based recommendations for implementing integrated worker health approaches.

Method

This scoping review was guided by a framework developed by Arksey and O’Malley (2005) and recommendations made by Levac et al. (2010). The following five-step process was followed: (1) identify the research question, (2) identify relevant documents, (3) choose documents based on criteria for inclusion and exclusion (document selection), (4) list data organized by themes and major issues (charting the data), and (5) group, summarize, and report the results to draft a summary description (data synthesis).

Identify Relevant Documents

Both peer-reviewed articles and gray literature were systematically searched, and a combination of both types was screened as relevant documents. The search strategy was designed in consultation with a research librarian, and details of the key search terms are described in Supplemental Appendix Table 1. The following electronic databases were searched to identify documents for inclusion: EMBASE, Ovid Medline, PsycINFO, and ABI/INFORM. The search was limited to publications dated between January 2008 and February 11, 2019 (the past 10 years) to ensure the literature was current and relevant. The reference lists of relevant documents were manually searched for additional documents. We identified gray literature (guides, periodicals, book chapters, tool kits) from the ABI/INFORM database, which stores business-related documents available from unpublished sources (e.g., news content, press releases, business flyers, country- and industry-focused reports), and from the researchers’ own knowledge of the literature (e.g., existing guidance on integrated worker health approaches for organizations). We also contacted six key informants with knowledge of workplace safety and health promotion initiatives (i.e., health and safety professionals, wellness consultants, academics) to identify any additional documents (e.g., reports, policy documents, guidebooks, presentation slides). Five of the key informants were Canadian and one from the United States and were already known to members of the research team. Only English-language articles were retrieved (some included papers from international sources and printed in English).

Charting the Data

Four reviewers (AB, MB, DVE, and HJ) developed a data charting form to collect information on document characteristics (geographic location, design, industry sector, number of participants, and job titles), and results (ways documents defined an integrated worker health approach, reported health outcomes, any methodological and/or conceptual/theoretical processes that informed the approach, enablers and barriers, and recommendations provided for addressing the barriers and gaps reported by the authors). The data charting form was piloted by each of the reviewers on four exemplary documents that were unanimously identified as clearly meeting the inclusion criteria. After this pilot exercise, the final data charting form was completed for each of the included full-text documents by the four reviewers. Responses were reviewed at the final stage by a single reviewer (AB).

Data Synthesis

The characteristics of the documents (e.g., geographic origin, intervention approach, worker and workplace characteristics) were tabulated. A narrative synthesis was conducted by two researchers (AB and MB). Data were collected from empirical articles, literature review articles, theoretical/conceptual articles, methodological articles, and gray literature. Data were charted broadly under the following categories: facilitators, barriers, and recommendations. When possible, data within the categories were further organized by organizational level (e.g., extraorganizational factors, organizational factors, etc.) and summarized. The narrative synthesis was completed using NVIVO qualitative data analysis software (QSR International, 2012).

Results

Search Results

Figure 1 describes the selection of included peer-reviewed and gray literature documents. Fifty-one documents were eligible for inclusion (31 peer-reviewed and 20 gray literature).

Figure 1

PRISMA Flow Chart of Document Selection

Document Characteristics

Table 1 provides an overview of the document characteristics. Thirty-nine documents (76%) originated from the United States, four (8%) documents from Australia, two (4%) from India, and one (2%) each from Norway, Spain, Sweden, the United Kingdom, Ireland, and from the World Health Organization. Fourteen documents (24%) described the development of methods and theoretical frameworks, 10 (17%) were case studies, eight (14%) were existing guidelines or tool kits, seven (12%) described randomized controlled trials, five (8%) were evaluations of interventions, four (7%) were reviews, while the rest of the articles included summary documents, reports, observational studies, and unpublished presentations.

Table 1

Characteristics of Reviewed Documents

Author (year)	Country	Document type	Other characteristics
Agency for Healthcare Research and Quality (2016)	United States	Summary documents, reports, unpublished presentations	Health outcomes: Smoking cessation, promoting a healthy diet, increasing physical activity/reducing sedentary behavior
Apostolopoulos et al. (2014)	United States	Methods/theoretical framework	Strategies aimed at trucking industry workers
Baron et al. (2014)	United States	Methods/theoretical framework	Organizational practices aimed at low-income workers
The California Commission on Health and Safety and Workers’ Compensation (2009)	United States	Summary documents, reports, unpublished presentations
Campo (2016)	United States	Summary documents, reports, unpublished presentations
Carr et al. (2016)	United States	Randomized control trial	Health outcomes: Prevention of musculoskeletal disorders, increasing physical activity/reducing sedentary behavior
CDC Workplace Health Resource Center (2018)	United States	Case study	Case study of the American Cast Iron Pipe Company
Center for Promotion of Health in the New England Workplace (2019)	United States	Methods/theoretical framework	Readiness and resource self-assessment checklist
Chang (2017)	United States	Summary documents, reports, unpublished presentations
Commission on Health and Safety and Workers’ Compensation (2010)	United States	Guidelines/tool kits
Cooklin et al. (2013)	Australia	Review	Health outcomes: Prevention of musculoskeletal disorders, smoking cessation, promoting a healthy diet, stress management
Dennerlein (2018)	United States	Summary documents, reports, unpublished presentations	Health outcomes: Prevention of musculoskeletal disorders, smoking cessation, increasing physical activity/reducing sedentary behavior
Dony and Smith (2017)	United States	Case study	Case study of nine participant organizations
Feltner et al. (2016a)	United States	Review	Health outcomes: Prevention of musculoskeletal disorders, smoking cessation, promoting a healthy diet, stress management, improving health and safety awareness
Feltner et al. (2016b)	Spain (among other countries reviewed)	Case study	Health outcomes: Prevention of musculoskeletal disorders, smoking cessation, promoting a healthy diet, increasing physical activity/reducing sedentary behavior
Ghaziri et al. (2017)	United States	Methods/theoretical framework	Learnings aimed for correctional worker health
Goetzel et al. (2008)	United States	Summary documents, reports, unpublished presentations
Gunther et al. (2019)	United States	Summary documents, reports, unpublished presentations	Case study of Merck
Health and Productivity Institute of Australia (2015)	Australia	Guidelines/tool kits
Henning et al. (2009)	United States	Methods/theoretical framework	Participatory ergonomics focus
Henning et al. (2013)	United States	Methods/theoretical framework	Participatory ergonomics focus
International Labour Office (2012)	United States	Guidelines/tool kits	Health outcome: Smoking cessation, promoting a healthy diet, stress management
Joss et al. (2017)	Australia	Case study
LaMontagne et al. (2017)	Australia	Randomized control trial	Health outcome: Mental health
Loeppke et al. (2013)	United States	Summary documents, reports, unpublished presentations	Focus on aging workforce
Lustig and Weisfeld (2014)	United States	Guidelines/tool kits
McLellan et al. (2012)	United States	Guidelines/tool kits
McLellan, Moore, et al. (2017)	United States	Guidelines/tool kits
McLellan, Williams, et al. (2017)	United States	Guidelines/tool kits
Mellor and Webster (2013)	United Kingdom	Case study	Case study of a large organization
Nelson et al. (2015)	United States	Case study	Leadership perspectives from small- to medium-sized businesses
Nobrega et al. (2017)	United States	Randomized control trial	Health outcome: Prevention of musculoskeletal disorders
Parkinson (2018)	United States	Review
Peters et al. (2018)	United States	Randomized control trial	Commercial construction site setting.Health outcomes: Prevention of musculoskeletal disorders, smoking cessation, promoting a healthy diet, increasing physical activity/reducing sedentary behavior
Pronk (2013)	United States	Guidelines/tool kits
Punnett et al. (2009)	United States	Methods/theoretical framework
Punnett et al. (2013)	United States	Methods/theoretical framework	Health outcome: Prevention of musculoskeletal disorders
Robertson et al. (2013)	United States	Methods/theoretical framework
Rohlman et al. (2018)	United States	Case study	Focus on small businesses
Sorensen (2016a)	United States	Methods/theoretical framework
Sorensen (2016b)	United States	Evaluation	Health outcomes: Prevention of musculoskeletal disorders, promoting a healthy diet, increasing physical activity/reducing sedentary behavior, improving health and safety awareness
Sorensen et al. (2017)	India	Randomized control trial	Health outcome: Smoking cessation
Sorensen et al. (2018a)	United States	Methods/theoretical framework
Sorensen et al. (2018b)	United States	Guidelines/tool kits
Tetrick (2008)	United States	Methods/theoretical framework
Thakur et al. (2012)	India	Evaluation	Health outcomes: Prevention of musculoskeletal disorders, smoking cessation, promoting a healthy diet, increasing physical activity/reducing sedentary behavior, stress management
Tveito (2009)	Norway	Randomized control trial	Health outcomes: Prevention of musculoskeletal disorders, increasing physical activity/reducing sedentary behavior, stress management
von Thiele Schwarz (2015)	Sweden	Summary documents, reports, unpublished presentations
Watkins et al. (2018)	United States	Case study	Case study of a rural workplace
World Health Organization (2010)	Nonspecific	Guidelines/tool kits
Wynne (2016)	Ireland	Summary documents, reports, unpublished presentations

The most frequently mentioned health outcomes in interventional studies were the following: the prevention of musculoskeletal disorders (10 studies, 20%), smoking cessation (nine studies, 18%), promoting a healthy diet (eight studies, 16%), increasing physical activity/reducing sedentary behavior (eight studies, 16%), stress management (five studies, 10%), and improving health and safety awareness (two studies, 4%). Additional details of the individual documents are available on request.

Worksite and Worker Characteristics

The manufacturing sector was the most frequently reported industrial setting (n = 19, 39%), followed by health care (n = 17, 29%), public services and government (n = 6, 10%), and transportation and equipment operation (n = 5, 9%). Eleven (19%) documents did not mention any specific industry sector. Thirty-five (59%) documents described large worksites (500 or more employees) and eight (14%) described medium-size worksites. Seven documents (12%) reported the proportion of men and women sampled, with these all from intervention studies. No studies reported the relevance of findings in relation to gender differences. Furthermore, there was no information reported on age-related or sociodemographic differences in facilitators, barriers, and recommendations for integrated worker health approaches.

There was considerable overlap in the findings from peer-reviewed and gray literature sources in the barriers, facilitators, and recommendations for implementation of integrated worker health approaches. The majority of gray literature that met study selection criteria highlighted findings from the peer-reviewed literature.

Barriers and Facilitators

Barriers and facilitators to implementing integrated worker health approaches were categorized as (1) extraorganizational factors (relates to macro-level factors outside the workplace, e.g., unions, government, and the wider community), (2) organization factors (relates to leadership and management perspectives, organizational policies and culture), (3) worker factors (relates to individual worker factors such as a worker health literacy and willingness and flexibility to participate in programs), and (4) programs/implementation characteristics (relates to the specific characteristics and the design of the integrated worker health program). Details are presented in Table 2. Documents were primarily organizational case studies or described the perspectives of employers, while worker perspectives were reported least frequently.

Table 2

Barriers and Facilitators to Implementing Integrated Worker Health Approaches

Level	Barriers to integrated worker health approaches	Facilitators to integrated worker health approaches
Extraorganizational	Fear of violating collective agreements	Union support
	Financial and psychological stresses from underemployment or when jobs are temporary or low wage	Collaboration and partnerships with external stakeholders
	Limiting policies: Zoning laws, budget cuts, and labor policies
	Limited capability of subcontractors to assist in changing working conditions
Organization	Company downsizing and high staff turnover	Support from senior leadership and management
	Difficulty getting functional managers to agree on a unified strategy	Organization has a culture of health and well-being
		Organization is open to change and innovation
	Lack of management/leadership support	Advocacy by senior leadership, middle managers, and worksite health promotion practitioners
	Limited resources (finances, time)	Adequate and allocated budgets and resources
	Target-driven work culture	Safety and health goals align with business plan and mission statement
	Top-down decision-making culture	Existing policies, programs, practices focused on flexible and supportive working conditions
	Lack of effective communication
	Failure to convince leadership of benefits
	Poor fit with company culture and mission
	Change-resistant managerial culture
	Poor existing occupational health and safety infrastructure
	Diverse organization and workforce with multiple individual sites and departments
	Uncooperative management and staff. Supervisors refusing to permit employees to participate in programs during workday
Worker	Privacy concerns	Workplace champions
	Productivity and work demands	Employee awareness, openness to behavior change strategies, or perceived need or benefit from program
	Voluntary nature of approach
	Unpredictable work schedules
	Poor worker participation and engagement
	Workplace’s safety situation not adequately addressed
	Distrust in management’s efforts in protecting their health and safety
	Retribution from employer for unhealthy behaviors
	Attitudes and knowledge level
	Fear of participating in strategies focused on mental health issues
	Lack of a strong workplace champion
Programs	Lack of expertise to evaluate/assess program requirements and effectiveness	Existing joint worker–management advisory board
	Lack of implementation capacity	Existing health promotion practices
	Long design process
	Difficulty scheduling and completing project activities
	Lack of effective communication
	Difficulty protecting confidentiality in small worksites

Extraorganizational barriers were identified from organizational case studies and documents describing the development of conceptual frameworks. It was reported that underemployment in the labor market or when jobs were mostly low wage or temporary could potentially create financial and psychological stresses for workers; which in turn may affect their ability, interest, or motivation to participate in workplace programs (Baron et al., 2014; Punnett et al., 2009). Employer perspectives described zoning laws, economic budget cuts, and labor policies as well as employer concerns about repercussions for potentially violating collective agreements with unions as barriers to developing plans for integrated programs (Baron et al., 2014; Dony & Smith, 2017; Gunther et al., 2019).

Organizational barriers were reported from the perspective of organizational practices, senior leadership, workers, and managers of varying roles (Baron et al., 2014; Gunther et al., 2019; Joss et al., 2017; LaMontagne et al., 2017; Mellor & Webster, 2013; Nelson et al., 2015; Nobrega et al., 2017; Parkinson, 2018; Pronk, 2013; Rohlman et al., 2018; Sorensen et al., 2017; Sorensen et al., 2018; Sorensen, McLellan, et al., 2016; Thakur et al., 2012; Wynne, 2016). Barriers were also reported from the perspective of program implementors and practitioners (The California Commission on Health and Safety and Workers’ Compensation, 2009; Commission on Health and Safety and Workers’ Compensation, 2010; Cooklin et al., 2013; Lustig & Weisfeld, 2014; Watkins et al., 2018). A lack of support from management and senior leadership was the most frequently reported barrier (Baron et al., 2014; Gunther et al., 2019; Lustig & Weisfeld, 2014; Nelson et al., 2015; Nobrega et al., 2017; Peters et al., 2018; Rohlman et al., 2018; Sorensen et al., 2017; Sorensen, Nagler, et al., 2016). It was also noted that failing to convince senior leadership of the benefits of an integrated approach in terms of a return on investment and value of the investment could dissuade interest in implementation that is especially the case when management and staff are uncooperative on changing existing work plans (The California Commission on Health and Safety and Workers’ Compensation, 2009; Dony & Smith, 2017; Lustig & Weisfeld, 2014; Nelson et al., 2015; Wynne, 2016). Organizations with a highly bureaucratic decision and approval process with top-down decision making, and a corporate mission statement that did not prioritize the health and well-being of workers were reported to impede buy-in for integrated worker health approaches (Baron et al., 2014; The California Commission on Health and Safety and Workers’ Compensation, 2009; Lustig & Weisfeld, 2014; Nelson et al., 2015; Nobrega et al., 2017; Punnett et al., 2009; Punnett et al., 2013; Sorensen et al., 2017). The limited availability of financial resources and perceived time available were also notable barriers, particularly for small organizations (Baron et al., 2014; Gunther et al., 2019; Lustig & Weisfeld, 2014; Nelson et al., 2015; Nobrega et al., 2017; Peters et al., 2018; Rohlman et al., 2018; Sorensen et al., 2017; Sorensen, McLellan, et al., 2016). The downsizing of staff, layoffs, and retirements made it difficult for organizations to commit to new ideas or consider investing in extra training for existing staff (Agency for Healthcare Research and Quality, 2016; Gunther et al., 2019; LaMontagne et al., 2017; Lustig & Weisfeld, 2014; Nobrega et al., 2017). Another notable challenge was coordinating an integrated approach in large organizations with multiple departments and diverse staff with differences in safety and well-being needs, cooperativeness, and available infrastructure (Cooklin et al., 2013; Joss et al., 2017; Mellor & Webster, 2013). A lack of a focused and targeted organizational communication strategy could also hinder buy-in and participation from workers (Nelson et al., 2015; Peters et al., 2018; Robertson et al., 2013; Sorensen et al., 2017; Wynne, 2016).

Worker-level barriers were mostly reported from organizational case studies and actual worker perspectives were quite limited (Baron et al., 2014; The California Commission on Health and Safety and Workers’ Compensation, 2009; Cooklin et al., 2013; Joss et al., 2017; Lustig & Weisfeld, 2014; Nelson et al., 2015; Punnett et al., 2009; Rohlman et al., 2018; Sorensen et al., 2017; Watkins et al., 2018; Wynne, 2016). Poor participation and engagement from workers were the most commonly cited barriers for the implementation and continuation of integrated worker health approaches, which was thought to be affected by workers having poor knowledge of healthy behaviors and a low motivation to change their existing behaviors (Cooklin et al., 2013; Joss et al., 2017; LaMontagne et al., 2017; Lustig & Weisfeld, 2014; Nelson et al., 2015; Punnett et al., 2009; Rohlman et al., 2018; Sorensen et al., 2017; Watkins et al., 2018; Wynne, 2016). Privacy concerns regarding employer interference with perceived nonwork-related health behaviors, cynicism, and distrust in the true intentions of the employer were commonly noted barriers to worker buy-in (Baron et al., 2014; The California Commission on Health and Safety and Workers’ Compensation, 2009; LaMontagne et al., 2017; Lustig & Weisfeld, 2014; Nelson et al., 2015). Workers facing high physical and psychological work demands often perceived inadequate time for participating in integrated worker health approaches or felt that this was of low priority (LaMontagne et al., 2017; Peters et al., 2018; Sorensen et al., 2017; Sorensen, Nagler, et al., 2016; Watkins et al., 2018). Another barrier reported was the absence of a person in the organization to champion the benefits of an integrated worker health approach or if this person was unable to motivate workers to buy in to the approach (LaMontagne et al., 2017; Wynne, 2016).

Program/implementation barriers were from the perspectives of leadership, organizational case studies, and workers (Joss et al., 2017; LaMontagne et al., 2017; Mellor & Webster, 2013; Nelson et al., 2015; Nobrega et al., 2017; Rohlman et al., 2018; Sorensen et al., 2017; Sorensen et al., 2018; Wynne, 2016). Some documents reported that senior leadership had a lack of capacity to implement an integrated worker health approach or had insufficient expertise to evaluate or assess the effectiveness of a program once it was implemented (Joss et al., 2017; Lustig & Weisfeld, 2014; Mellor & Webster, 2013; Nelson et al., 2015; Sorensen et al., 2017; Wynne, 2016). Spending a lot of time in the planning and design stage and difficulty for workers to schedule and complete program activities also could hinder timely implementation (LaMontagne et al., 2017; Nobrega et al., 2017; Wynne, 2016). For small organizations, it was noted that it could be especially difficult to protect participant confidentiality when measuring the progress of an integrated worker health program (Rohlman et al., 2018).

Extraorganizational facilitators were reported from a mix of worker and employer perspectives in literature reviews (Apostolopoulos et al., 2014; Campo, 2016; Feltner et al., 2016a; Lustig & Weisfeld, 2014). It was reported that organizations receiving support from unions for integrated approaches were important contextual facilitators (Campo, 2016; Feltner et al., 2016a). Organizations having an existing relationship with others in the community, researchers, and health organizations also were reported to facilitate the transfer of evidence, experience, and expertise that an organization may be lacking (Apostolopoulos et al., 2014; Campo, 2016; Lustig & Weisfeld, 2014).

Organizational facilitators were identified from organizational case studies and the perspective of senior leadership and management. From the perspectives of organizations and leadership, having their support was the most reported facilitator for attaining organization buy-in (Agency for Healthcare Research and Quality, 2016; Apostolopoulos et al., 2014; Campo, 2016; Center for Promotion of Health in the New England Workplace, 2019; Commission on Health and Safety and Workers’ Compensation, 2010; Cooklin et al., 2013; Feltner et al., 2016b; Goetzel et al., 2008; Health and Productivity Institute of Australia, 2015; Henning et al., 2009; Henning et al., 2013; International Labour Office, 2012; Joss et al., 2017; Lustig & Weisfeld, 2014; McLellan et al., 2012; Mellor & Webster, 2013; Nelson et al., 2015; Rohlman et al., 2018; Sorensen, 2018; Sorensen et al., 2017; Sorensen et al., 2018; Sorensen, McLellan, et al., 2016; Tetrick, 2008; World Health Organization, 2010). Organizations supporting a culture of health through a working environment that valued, provided, and promoted healthy choices both explicitly and in their everyday behaviors also was viewed as advantageous (Apostolopoulos et al., 2014; Baron et al., 2014; Chang, 2017; Cooklin et al., 2013; Goetzel et al., 2008; Health and Productivity Institute of Australia, 2015; Lustig & Weisfeld, 2014; McLellan et al., 2012; McLellan et al., 2017; Mellor & Webster, 2013; Nelson et al., 2015; Parkinson, 2018; Tetrick, 2008; Thakur et al., 2012; Watkins et al., 2018). Similarly, organizations with existing policies, programs, and practices focused on flexible and supportive working conditions and that had a business and mission statement closely aligned with goals to protect and promote the health of their workers were viewed as more supportive of integrated worker health approaches (Baron et al., 2014; The California Commission on Health and Safety and Workers’ Compensation, 2009; Chang, 2017; Cooklin et al., 2013; Ghaziri et al., 2017; International Labour Office, 2012; Mellor & Webster, 2013; Sorensen et al., 2018). Support from middle management was found to be key to developing relationships with employees, supervisors, and leaders at all levels. Case study findings suggested that middle managers who had a good rapport with implementers were more likely to allow their employees to participate in wellness programs (CDC Workplace Health Resource Center, 2018; Goetzel et al., 2008). Having sufficient resources and budgets also was reported as helpful to support the case for an integrated approach, although it was acknowledged that this was not always possible (Apostolopoulos et al., 2014; Campo, 2016; Center for Promotion of Health in the New England Workplace, 2019; Cooklin et al., 2013; Feltner et al., 2016a; Ghaziri et al., 2017; Goetzel et al., 2008).

Worker facilitating factors were from the perspective of workers, employers, organizational case studies, and consultations between experts and practitioners (Center for Promotion of Health in the New England Workplace, 2019; Cooklin et al., 2013; Goetzel et al., 2008; Joss et al., 2017; LaMontagne et al., 2017; Lustig & Weisfeld, 2014). Having workforce “champions” that recognized the need or benefit of an integrated approach and having employees open to changing their unhealthy behaviors were viewed as important to facilitating employee buy-in (Center for Promotion of Health in the New England Workplace, 2019; Cooklin et al., 2013; Goetzel et al., 2008; Joss et al., 2017; LaMontagne et al., 2017; Lustig & Weisfeld, 2014).

Program facilitators were reported from the perspective of workers and employers (Dennerlein, 2018; Feltner et al., 2016a; Sorensen et al., 2017). Organizations with existing health promotion practices were seen as more amenable to and as having the resources in place to extend their activities toward integrated worker health approaches (Dennerlein, 2018; Sorensen et al., 2017). Last, it was reported by one study that some organizations with existing joint worker–management decision making enabled swift organizational and worker needs assessment and buy-in (Feltner et al., 2016a).

Recommendations

Table 3 outlines 10 recommendations from the literature for organizations wanting to overcome barriers to implementing an integrated worker health approach. Most frequently reported was considering the needs of workers for any implemented strategy and involving them in the design, planning, and implementation. It was also suggested that multiple strategies with different levels of influence and methods of delivery could be effective in reaching workers with different health literacy levels (Apostolopoulos et al., 2014; Campo, 2016; Feltner et al., 2016a, 2016b; Gomez-Recasens et al., 2018; Henning et al., 2013; Joss et al., 2017; Lustig & Weisfeld, 2014; Nelson et al., 2015; Parkinson, 2018; Punnett et al., 2009; Robertson et al., 2013; Rohlman et al., 2018; Sorensen, 2018; Sorensen et al., 2018; Sorensen, McLellan, et al., 2016; von Thiele Schwarz et al., 2015). To gain leadership support, it was recommended to build a case for the integrated approach in consideration of leadership concerns, underpinned by scientific evidence of the benefits and how the approach could provide a return on investment (Feltner et al., 2016a, 2016b; Henning et al., 2009; LaMontagne et al., 2017; McLellan, Moore, et al., 2017; Rohlman et al., 2018; Sorensen et al., 2018). Workers could be supported by other stakeholders in an organization (e.g., leadership, health, and safety representatives) to plan and implement an intervention as part of a healthy workplace committee. It was also suggested that any gaps in knowledge and understanding in a healthy workplace committee could be complemented with input from external groups (e.g., unions, wellness consultants, and insurance groups; Apostolopoulos et al., 2014; Feltner et al., 2016a, 2016b; Henning et al., 2013; Lustig & Weisfeld, 2014; Mellor & Webster, 2013; Sorensen, 2018; Thakur et al., 2012). Building capacity for workers to make healthy decisions and participate in programs was frequently reported, via the provision of flexible working conditions, incentives and rewards, workforce “champions,” and tailored strategies that meet the needs and preferences of different workers (Baron et al., 2014; Carr et al., 2016; Feltner et al., 2016b; Henning et al., 2013; Joss et al., 2017; Lustig & Weisfeld, 2014; McLellan, Moore, et al., 2017; Nelson et al., 2015; Peters et al., 2018; Punnett et al., 2009; Rohlman et al., 2018; Sorensen et al., 2017; Sorensen, McLellan, et al., 2016; von Thiele Schwarz et al., 2015). To evaluate the effectiveness of programs, piloting a small-scale version of the strategy was seen as a cost-efficient way to develop a proof-of-concept and fine-tune the approach for wider scale-up. It was also acknowledged that expecting immediate successes was not realistic. Instead, recognizing successes in intermediate measures (e.g., increased worker participation, positive feedback) could convince leadership for continued support, with a view that the integrated approach is an iterative process of continual improvement (Dony & Smith, 2017; Gunther et al., 2019; Henning et al., 2009; Henning et al., 2013; Lustig & Weisfeld, 2014; Robertson et al., 2013; Thakur et al., 2012).

Table 3

Recommendations for Implementing Integrated Worker Health Programs

Recommendation	Description
Legislation, policies, and incentives protect and promote worker health	• Develop industry benchmarks for organizational implementation of health, safety, and well-being standards.• Support the accreditation of compliant organizations. An annual recertification can support continued improvements.
Gain leadership support	• If you do not get leadership support at first, make sure you understand their concerns—it will help build a stronger case going forward.• Build a business case through a review of the literature, review of key programs based on those that support a comprehensive health, safety, and well-being effort.• A business case should also identify how the integrated worker health approach can provide a return on investment.
Demonstrate leadership commitment	• Demonstrate leadership commitment to worker safety and health at all levels of the organization.• Align objectives of integrated worker health practices with organizations’ current practices and also with the interests and goals of the workforce.
Needs assessment and worker-centered approach to program implementation	• Understand the needs and concerns of workers and get their feedback (e.g., through focus groups and surveys) on setting priorities for what strategies to focus on.• Involve workers, in the design, planning, and implementation of the interventions.• Consider multicomponent interventions with multiple levels of influence or multiple methods of delivery to reach different workers (e.g., workers with low literacy skills).
Establish a healthy workplace committee	• Establish a committee of stakeholders across the organization, including workers, managers, representatives from health and safety and human resources departments, with the responsibility to plan and implement the intervention.• Consider input from external groups such as unions, nonprofit groups, wellness consultants, and insurance groups to provide program oversight and guidance.• Create realistic timelines and expectations for members of the committee.
Identify and utilize workforce “champions”	• If leadership is not already on board with an integrated approach, the champion can present a business case to convince them. Once top leadership buys in, the champion sustains commitment by continually seeking input and support.• The champion may also build collaboration among supervisors, manage employees responsible for implementation, and communicate with various stakeholders about the integrated approach and its results.
Create awareness and provide training	• Provide widespread training across the organization for management/supervisors and workers.• Coordinated and regular communication among the implementation team and communicating difficult issues to management can help sustain the program, facilitate consensus and team building.• Communication strategies should be easily understandable and developed in discussion with workers.
Build capacity for workers to make healthy decisions and being flexible to participate in integrated efforts	• Provide supportive and flexible working conditions to enable workers to participate in the integrated approach. Examples can include flexibility in scheduling, providing different program sessions, locating the program in multiple locations of a large organization.• Consider program delivery that is tailored to meet the needs and preferences of employees, for example, multiple modes of delivery, online versus paper reporting, lunch-and-learns versus online resources.• Consider using incentives and rewards for worker participation.
Develop privacy measures	• Take steps to protect the confidentiality of worker information.• A solution to this problem might be to hire an independent contractor for health risk assessments with privacy assured; the employer does not get individual data, only aggregate data.
Evaluate the program	• Consider piloting a small-scale version of the approach, modify it with the approach based on the findings, and then scale it up for wider implementation.• To improve measuring of outcomes, instead of calculating return on investment and organizations, consider focusing on aggregate measures, for example, increased participation, positive worker feedback, and health measures for blood pressure, weight, and body mass index to see if workers’ health is improving.• Collection of process and outcome measures is crucial, and it is likely that some adaptation of the intervention will be needed. An iterative cycle for refining interventions is essential to any continuous improvement process, and this process promotes organizational learning on how to protect and promote employee health and safety in the face of changing demands and the evolution of the workplace.• Recognize successes and make sure all stakeholders are aware of it and continue to provide support.

Discussion

This scoping review identified and described existing barriers, facilitators, and recommendations to implementing integrated worker health approaches. These findings add to the literature on health promotion in the workplace and represent a comprehensive in-depth overview of a broad subject area with a relatively large number of both academic and gray literature documents reviewed. A particular strength of this review was that it sought and described the elements of implementation. The breadth of concepts identified point to the complexity of the issues raised and how they need to be addressed at all levels of the organization. Implementers and researchers can use the findings as a roadmap to develop practices, policies, and interventions to better implement integrated worker health approaches in organizations.

The majority of evidence in this review originated from the United States, which reflects a focus on English-language studies and also perhaps efforts by the National Institute of Occupational Safety and Health to promote research activities in its Total Worker Health program (Schill & Chosewood, 2013). More studies are needed to understand whether integrated worker health approaches are feasible in other countries with different labor markets and policy situations than the United States. This review also found that available guidance was broadly relevant or specific to organizations in the industrial, health care, or public service industries. Yet studies show that organizations with a unionized workforce and in the entertainment or electrical/utilities sectors were likely to have more resources and a culture of health to be able to promote an integrated worker health approach (Biswas et al., 2018; Tremblay et al., 2013). Broadening the evidence base can help identify additional considerations that are relevant for different industries and organizations and expand the limited scope of existing case study evidence from mostly vanguard employers.

Successfully integrating occupational health and safety with health promotion is complex and not only is dependent on the coordination of goals and activities of separate programs and policies but also requires a consideration of multiple factors at the extraorganizational, organizational, worker, and programmatic levels. It was unclear from the reviewed documents on which recommendations to undertake early on or later in the process of implementation and the time and resources required. In the absence of specific guidance on timing and resources required, certain recommendations can be undertaken for different situations. An organization or practitioner seeking to implement an integrated worker health approach might face difficulty doing so if there are budgetary constraints or if organizations have limited capability to change their existing work conditions and policies (Baron et al., 2014; Nelson et al., 2015; Nobrega et al., 2017). When an organization is capable of supporting integrated policies and practices, leadership support may be helpful in launching efforts and driving success (Lustig & Weisfeld, 2014; Nelson et al., 2015). Yet having the capacity to fully implement integrated approaches in an organization requires careful consideration of other downstream factors. It has been recommended that integrated worker health approaches focus on continual improvement based on an incremental and cyclical process of development, implementation, and review, rather than a prescriptive linear one (Joss et al., 2017; McLellan, Moore, et al., 2017). When the extraorganizational environment (e.g., policies and legislation) is not supportive of organizational changes at the moment, other recommendations such as building a business case, understanding worker needs, and identifying workplace champions can be emphasized (Feltner et al., 2016a; Goetzel et al., 2008; Gunther et al., 2019). When there is leadership support and buy-in, the initial goals for a program may focus on short-term benefits such as increasing worker participation and satisfaction (Peters et al., 2018; Punnett et al., 2009). Subsequent incremental program goals may aim toward key integrated approach outcomes such as improving the health, safety, and productivity of workers resulting in organizational outcomes such as greater return on investment (Feltner et al., 2016a; Gunther et al., 2019). Although identifying the barriers and facilitators outlined in this scoping review may not be feasible for all organizations, targeting some aspects of the listed recommendations as relevant to needs and resources can be a useful starting point when planning for integrated worker health approaches.

In comparison with organizational case studies and perspectives from leadership and researchers, this review found few documents that examined the views of workers themselves. Similarly, while the documents revealed implementation factors specific to certain occupations and industries, there was little reported in terms of considerations of gender, age, and sociodemographic differences. There is evidence from the workplace health promotion literature that minority workers, younger workers, and workers with lower education and family income are less likely to participate in health promotion activities (Tsai et al., 2019). Furthermore, male and female differences have been noted for work exposures and the risk of injury from work exposures (Smith, Ibrahim-Dost, et al., 2013; Vermeulen & Mustard, 2000). Women might be harder to reach for workplace interventions given that they are less likely to have their safety concerns taken seriously (Breslin et al., 2007) or might perceive less time to participate because of dual roles at work and home (Smith et al., 2013; Strazdins et al., 2004). Accordingly, an understanding of how workplace interventions are relevant to different workers is important as it cannot be assumed that recommendations apply uniformly across all workers. The majority of studies (35 studies) also described large worksites, with fewer studies examining medium (eight studies) and large (nine studies) worksites. Reaching small- and midsize employers for integrated worker health approaches can be more challenging (Harris et al., 2014; McLellan, Williams, et al., 2017; Rohlman et al., 2018) but is needed. In addition, efforts to translate the best practices of large employers into models that can be adopted by smaller employers have been generally lacking (Loeppke et al., 2013).

These recommendations should be considered with acknowledgment of the following limitations. First, the recommendations in this review should be considered more generally when considering the implementation of integrated worker health approaches. Specific integrated programming guidance was not possible due to the wide heterogeneity across the various contexts and settings outlined in the available evidence, the range of health outcomes, and worker populations. The search strategy was restricted to English articles from the past 10 years. As such, the findings might not be truly representative of global integrated worker health efforts, or some of the early approaches to the integration of occupational health and safety and health promotion programs. Another limitation is that this scoping review did not have a quality assessment stage of the documents in the review. Quality evaluation of studies is difficult to conduct in scoping reviews due to the large variety of literature (peer-review and gray), study designs, research approaches, and, in this case, a rapidly emerging area under study (Arksey & O’Malley, 2005). This study, therefore, emphasizes the breadth of information provided within the available literature rather than depth in a high-quality-based document selection.

Implications for Practice and Research

This review indicated consistent barriers, facilitators, and recommendations as relevant to the implementation of integrated worker health approaches. Recommendations such as gaining leadership buy-in, using a worker-centric approach to program implementation, communicating clearly to all stakeholders, building capacity for workers to make healthy decisions, addressing privacy concerns, and evaluating the program with a focus on continual improvement were all viewed as important considerations. An integrated worker health approach acknowledges that common work-related illnesses and injuries are often multifactorial in origin, including both work-related and nonwork-related factors. Given the ongoing increase in attention to integrated worker health approaches as a more effective approach to workplace health promotion, there has been an emergence of diverse research and real-world implementations that might prove difficult to navigate. Further research is needed to better understand how these recommendations apply to the diverse workforce and organizations with limited resources. Moreover, future research could be directed toward testing and quantifying the recommendations identified in this study so as to advance an understanding of the pathway to successful integrated worker health initiatives, programs, and policies. This would help improve the capacity of workplaces wanting to effectively implement healthy changes and generate information that more clearly explicates the drivers of this type of change in the workplace.

Supplemental Material

sj-docx-1-hpp-10.1177_15248399211028154 – Supplemental material for Integrating Safety and Health Promotion in Workplaces: A Scoping Review of Facilitators, Barriers, and Recommendations

Supplemental material, sj-docx-1-hpp-10.1177_15248399211028154 for Integrating Safety and Health Promotion in Workplaces: A Scoping Review of Facilitators, Barriers, and Recommendations by Aviroop Biswas, Momtaz Begum, Dwayne Van Eerd, Heather Johnston, Peter M. Smith and Monique A. M. Gignac in Health Promotion Practice

Footnotes

Authors’ Note:

We thank Maggie Tiong (research librarian) and Joanna Liu (library technician) for developing the scoping review search strategy and supporting the data collection process. We also thank Albana Çanga for assistance with editing the references and preparing the article for journal submission. The research was funded by the Government of Alberta Occupational Health and Safety Futures—Research Funding Program; Grant No. 095244774. The study was performed at the Institute for Work & Health. Research ethics approval was obtained for this study as part of a larger research project from the Health Sciences Research Ethics Board at the University of Toronto; Protocol No.: 00036727

ORCID iD

Aviroop Biswas

Supplemental Material

Supplemental material for this article is available online at .

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