In our study, we met the 3 proposed objectives: 1) improved the capacity of small workplaces to participate in the HealthLinks program, 2) implemented HealthLinks with on-site support from a respected community partner, and 3) evaluated attitudes about HealthLinks program components. Guidelines to aid employers in adopting WHP programs are available (17
); other researchers have identified characteristics that make WHP programs sustainable (18
). The HealthLinks program for small workplaces is potentially sustainable over time.
Sustainable WHP programs target high-risk populations, involve upper management buy-in, increase program accessibility, offer incentives, and increase health awareness through effective communication (18
). HealthLinks exhibited these key elements of sustainable WHP programs for small workplaces.
We effectively targeted high-risk populations (a community with elevated rates of obesity and tobacco use). Most workplaces selected the Quit Line promotional posters, and almost half participated in the intensive physical activity program, thus showing the importance of tobacco use and weight management to the targeted workplaces. In addition, employers appeared to support HealthLinks; they rated the HealthLinks resources and services as useful, relevant, and appealing.
HealthLinks increased workers' access to AFL, with almost half of workplaces participating in the program. The high level of participation is likely attributable to the support provided by the ACS-GWD interventionist and Mason County Department of Health personnel who helped to identify incentives, managed competitive teams, and coordinated the program at workplaces. Our results demonstrate the importance of offering small workplaces hands-on support to improve workers' participation in health promotion programs, thus increasing employers' capacity to engage their workers. Without support and a champion to help promote AFL, many small workplaces may not have had the capacity to implement AFL.
HealthLinks also helped employers promote the free Quit Line through on-site postings, thus enhancing access to a tobacco use cessation program. Research has shown that although most large and small workplaces rank smoking cession as a priority, only 2% offer cessation benefits (19
) and less than 10% of small workplaces offer cessation programming (7
). Like other researchers (20
), we found that workplaces did not offer tobacco use cessation benefits; however, after HealthLinks, approximately two-thirds of employers promoted the state Quit Line through posters and other print materials, and 26% received information about instituting tobacco ban policies. These are encouraging results for small workplaces. The results demonstrate the willingness of employers in small workplaces to address cessation through policy and programs when they are offered resources.
Improving workers' health education through effective communication is a key element of sustainable WHP programs (21
) and enhances the sustainability of these programs. In our study, employers showed a high likelihood of implementing various communication strategies to improve workers' health awareness. Improved health communication was most likely due to the availability of ready-to-use materials and regular distribution of a health-based e-newsletter, making it easier for employers to offer up-to-date health information. With ACS's assistance, we helped employers establish a communication system that used diverse distribution channels (posters, e-newsletters, fightcancer.org website, Lunch and Learn health education sessions) and offered health information covering multiple topics, with the intention that the workplaces would be able to sustain health awareness among their workers after the intervention ended.
This study has several strengths. The first is that we intervened in a community with elevated smoking and obesity rates. Second, we collected both process and outcome-level data, with process-level data corroborating outcome-level results. Finally, we collaborated with a known and respected community partner, ACS, which set in motion a community-based partnership that strengthened the recruitment and intervention-delivery processes and helped to sustain the relationships with the workplaces.
The study also has several limitations. We did not collect worker-level data, and this limits our understanding of how the HealthLinks program affected workers' health behaviors and attitude. Second, our study used a preintervention and postintervention analysis without using a comparison group; however, our results demonstrated the feasibility of implementing WHP programs in small and low-wage workplaces and may potentially pave the way for future randomized controlled trials using the model of working with community partners and offering enhanced support.
Employers in small and low-wage workplaces can improve their workers' health through evidence-based WHP best practices targeting specific modifiable health risk behaviors. The keys to working with small workplaces include making the WHP program easy to implement, collaborating with a respected community partner, and offering free resources and hands-on support. By targeting high-risk communities, obtaining employer buy-in, making the health programs accessible, and effectively communicating information to workers about health and wellness, WHP programs such as HealthLinks have the potential to be sustained over time. A recent report emphasized the need to disseminate "real-life" successful, WHP programs (21
). Our study showcased a WHP program tailored to small and low-wage workplaces that increased employers' implementation of evidence-based best practices. Furthermore, we targeted and reached small workplaces with workers at high risk for obesity and tobacco use.