Bigger Companies Score Higher on Total Worker Health Implementation

Compared to small and "micro" businesses, larger companies have made more progress toward introducing the Total Worker Health (TWH) approach to worker health and safety, reports the August Journal of Occupational and Environmental Medicine.

"Our results indicate a need for intervention research that specifically targets microbusinesses and small businesses, especially in light of the outsized health and safety risks encountered in these sectors of the economy," write Liliana Tenney, MPH, and colleagues of Colorado School of Public Health, University of Colorado, Aurora.

The Total Worker Health® approach seeks to integrate traditional occupational safety and health approaches with injury and illness prevention efforts to advance worker well-being. Using an assessment developed for their Health Links™ mentoring program, the researchers analyzed TWH implementation at 382 companies—ranging from large businesses with more than 200 employees to microbusinesses with 2 to 10 employees.
While there was room for improvement in all groups, larger companies scored higher on the Health Links assessment. Out of a total possible score of 100, average score was 63 for large companies, 47 for medium and small companies, and 33 for microbusinesses.

Larger businesses were likely to score higher on all six benchmarks included in the assessment, indicating "a more systematic and comprehensive approach to addressing health promotion and safety." Smaller companies—especially microbusinesses—were less likely to have organizational supports, methods for assessing employee needs and interests, or integrated health and safety strategies. Smaller businesses were more likely to say their health and safety efforts were motivated by a desire to improve employee health, morale, productivity, and retention.

Most previous studies of TWH implementation have focused on large companies—despite the fact that employees of small businesses have higher rates of occupational fatalities, illnesses, and injuries, among other health risks. The new study is one of the first to look at comprehensive policies and strategies for TWH in small and microbusinesses.

The results show that TWH adoption and approaches vary by business size, reflecting different patterns of organizational behavior. Ms. Tenney and colleagues conclude, "Our results indicate a need for intervention research that targets small businesses, notably to better understand how TWH is effectively implemented."
About the Author
Ms. Tenney may be contacted for interviews at
ACOEM (, an international society of more than 4,000 occupational physicians and other health care professionals, provides leadership to promote optimal health and safety of workers, workplaces, and environments.
About the Journal of Occupational and Environmental Medicine
The Journal of Occupational and Environmental Medicine ( is the official journal of the American College of Occupational and Environmental Medicine. Edited to serve as a guide for physicians, nurses, and researchers, the clinically oriented research articles are an excellent source for new ideas, concepts, techniques, and procedures that can be readily applied in the industrial or commercial employment setting.


Tenney L, Fan W, Dally M, et al. Health Links Assessment of Total Worker Health® practices as indicators of organizational behavior in small businessJ Occup Environ Med. 2019;61(8):623-34.