10 Lessons Learned From a Multi-Year Total Worker Health Study of Small Businesses

Posted on by Natalie Schwatka, PhD; Liliana Tenney, DrPH MPH; Miranda Dally, MS; Carol Brown, PhD; & Lee Newman, MD MA


Over half of Americans are employed in small businesses. Small employers face unique challenges and often do not offer the same level of safety protections or health promotion activities found in larger organizations. However, there is evidence that small businesses are committed to addressing employee well-being, but they may lack the necessary resources and infrastructure to provide for it. (1). Senior-level decision-makers in small businesses are especially important in driving these efforts. Thus, there is a great need to design and test Total Worker Health®  interventions that reach senior-level decision-makers in these settings (2, 3). The Small+Safe+Well study was a 5-year (2016-2021) intervention study on small businesses, defined as those consisting of fewer than 500 employees. Researchers at the Center for Health, Work, & Environment (the Center), a NIOSH Center of Excellence for Total Worker Health (TWH), conducted the study (4). The study aimed to improve the health and safety climate of small businesses by changing leadership behaviors and implementing TWH workplace policies, programs, and practices.

Businesses participating in the study enrolled in Health LinksTM, a mentoring program that provides TWH-related assessment, advising, and certification. The researchers randomly assigned businesses to participate in a TWH leadership development program which included ten hours of leadership assessment, in-person training, and support transferring what they learned in the in-person training to their business over four months. Researchers administered business- and employee-level assessments annually. Ultimately, the Center enrolled 132 small businesses. Of those businesses, 97 (73%) of them completed their baseline business-level Health Links assessment and a total of 2,785 employees completed surveys.

The following are ten lessons learned from the Small+Safe+Well study to inform future TWH research and practice:

 1. Recruit small businesses for TWH research through trusted intermediaries

The Center followed recommendations to engage small businesses via intermediaries (5). They leveraged existing small business engagement platform, Health Links (1), as well as partnerships with local community organizations including local public health agencies, chambers of commerce, and business groups.

2. Caring for employees drives motivation and participation

Employees are more internally motivated to participate in TWH initiatives under working conditions where they feel that their employer cares for their health and safety. This internal motivation can drive their engagement even without the incentives that employers commonly use to drive participation (6).

3. A TWH business strategy signals that employee health matters

Businesses implement a variety of TWH business strategies, with some offering similar safety, health, and well-being policies and programs and others offering differing levels (1). For example, some may focus heavily on their safety program and offer few health benefits other than providing insurance. However, businesses that offer more TWH policies and programs have workers who are more likely to report that their employer cares for their health and safety than businesses that offer fewer TWH policies and programs (7).

4. Leadership support matters for creating a culture that supports employee health, safety, and well-being

Employees who report that organizational leadership is committed to their health and safety report more favorable perceptions of their business’ safety and health climates and greater engagement in their business’ TWH policies and programs (8).

5. Better together – Small businesses should pair a TWH business strategy with leadership support and a culture of health and safety for maximum impact

Small businesses need a business strategy for how they are going to implement TWH approaches—but in addition, their leadership needs to show daily support of this strategy. This signals to employees that their health and safety is valued and strengthens the organization’s safety and health climates. The combination of a TWH business strategy and leadership support brings together the best employee engagement in TWH policies and programs. However, only 9% of small businesses in the study did this, suggesting there is a need for methods to help small businesses integrate the TWH approach into their business (9).

6. Retaining small businesses and their employees for TWH intervention studies is a challenge

In multi-year studies, it is important to consider ways to maintain a balance between research participation demands and a small business’ resources and capacity to participate. Despite substantial efforts to maintain relationships with the enrolled businesses, the study retained about 37% of businesses for our longitudinal studies. If researchers and practitioners wish to engage owners and other senior leaders of small businesses, they need to consider the minimum effective dose of leadership intervention that aligns with the leaders’ capacity to engage.

7. Leadership behaviors can improve after participating in a TWH leadership development program

The 60 small business leaders that enrolled and completed the TWH leadership development program reported a 10% improvement, on average, in their TWH leadership practices (10). However, this potentially came at a cost as many of the leaders reported increased work-related stress. This could indicate that leaders faced some challenges when integrating TWH approaches into their business.

During coaching sessions, several leaders mentioned challenges such as staffing shortages and competing business priorities. The Center found that one potential way to mitigate this may be through sharing leadership roles for implementation of TWH policies and practices. Many leaders attended the program with someone else in their organization who was responsible for health and safety. They appreciated the opportunity to collaborate on the TWH related goals for their organization. Future TWH leadership development intervention research should seek to build leadership through team-based approaches.

8. Consultation services can enhance workplace TWH policies and programs

 After participating in Health Links for one year, businesses reported an 11% increase in the TWH policies and programs offered to support their employees’ health, safety, and well-being (11). Our research suggests that this may be due, in part, to the TWH consultation they received (12).

9. The impact of a TWH organizational and leadership intervention signals improvements in employee safety and health in some cases, but not all

The ultimate test of a TWH intervention is its ability to improve the health, safety, and well-being of workers. Researchers completed a pilot study of 25 small businesses that completed one year of the Health Links program before participating in the TWH leadership development program. Researchers observed positive (but non-significant) changes in employee perceptions that their organization cared for their health and safety (i.e., safety climate and health climate) (11). However, researchers also completed a randomized control trial evaluation of the TWH leadership development program where Health Links participation served as the only control. Researchers did not observe positive changes in any indicators of employee-reported safety leadership and health leadership practices, safety climate and health climate, safety behaviors and health behaviors, and well-being. Retention factors described in #6 above and the COVID-19 pandemic described in #10 below likely influenced these findings.

10. Employers with strong safety and health climates were better prepared for responding to COVID-19

The COVID-19 pandemic began as the Center was starting its final TWH leadership development cohorts. The disruption prohibited some of the small businesses from participating in the leadership intervention and limited the center’s ability to finish collecting follow-up data needed to evaluate the intervention. However, the pandemic presented a unique opportunity to examine the impact of a global pandemic on small business health and safety culture and employee well-being. In May 2020, the Center learned, perhaps not so surprisingly, that employees who worked for small businesses with strong safety and health climates reported better well-being (13). However, over time as the pandemic lingered, employees reported a decline in their well-being (14). The Center’s research supports the consideration of TWH approaches during emergency planning and the potential of TWH strategies in building a foundation that supports a culture of health and safety.


These findings show that small businesses with both a business strategy that uses TWH approaches and leadership to support it are poised to advance the well-being of their workers. This study demonstrates that this should be done by helping small businesses assess their current TWH business strategy and culture and by mentoring them as they work towards improving upon this strategy and culture. The study demonstrates the value and challenge of focusing on small business leaders in this effort.


Natalie Schwatka, PhD; Liliana Tenney, DrPH MPH; Miranda Dally, MS; Carol Brown, PhD; & Lee Newman, MD MA are with the Center for Health, Work & Environment at the Colorado School of Public Health, University of Colorado Anschutz Medical Campus.

The Center for Health, Work & Environment is an academic center within the Colorado School of Public Health. The Center is one of 10 NIOSH-funded Centers of Excellence for Total Worker Health®. The Colorado School of Public Health also houses the Mountain & Plains Education and Research Center (MAP ERC), one of 18 centers of its kind supported by the National Institute for Occupational Safety and Health (NIOSH). ​

This blog is part of a series highlighting extramural research funded by NIOSH through the Office of Extramural Programs.

Total Worker Health® is a registered trademark of the U.S. Department of Health and Human Services (HHS).



Health Links

Total Worker Health® Leadership Programs



 Tenney L, Fan W, Dally M, Scott J, Haan M, Rivera K, et al. Health Links™ assessment of Total Worker Health practices as indicators of organizational behavior in small business. Journal of Occupational & Environmental Medicine. 2019;61(8):623-34.

  1. Tenney L, Newman L. Total Worker Health approaches in small to medium-sized enterprises. In: Hudson H, Nigam J, Sauter S, Chosewood L, Schill A, Howard J, editors. Total Worker Health: American Psychological Association; 2019.
  2. Thompson J, Schwatka N, Tenney L, Newman L. Total Worker Health: A Small Business Leader Perspective. International Journal of Environmental Research and Public Health. 2018;15(11).
  3. Schwatka NV, Tenney L, Dally MJ, Scott J, Brown CE, Weitzenkamp D, et al. Small business Total Worker Health: A conceptual and methodological approach to facilitating organizational change. Occup Health Sci. 2018;2(1):25-41.
  4. Sinclair R, Cunningham T, Schulte P. A model for occupational safety and health intervention diffusion to small businesses. American Journal of Industrial Medicine. 2013;56(12):1442-51.
  5. Schwatka N, Sinclair R, Fan W, Dally M, Shore E, Brown C, et al. How does Organizational Climate Motivate Employee Safe and Healthy Behavior in Small Business? A Self Determination Theory Perspective. Journal of Environmental and Occupational Medicine. 2020;62(5):350-8.
  6. Schwatka N, Dally M, Tenney L, Shore E, Brown CE, Newman LS. Total Worker Health Leadership and Business Strategies Are Related to Safety and Health Climates in Small Business. Int J Environ Res Public Health. 2020;17(6).
  7. Shore E, Schwatka N, Dally M, Brown C, Tenney L, Newman L. Small business employees perceptions of leadership are associated with safety and health climates and their own behaviors. Journal of Environmental and Occupational Medicine. 2020;62(2):156-62.
  8. Schwatka N, Dally M, Shore E, Dexter L, Tenney L, Brown C, et al. Profiles of Total Worker Health® in United States small businesses. BMC Public Health. 2021;21.
  9. Schwatka N, Brown C, Tenney L, Scott J, Shore E, Dally M, et al. Evaluation of a Total Worker Health leadership development program for small business. Occupational Health Science. 2021;5:163–88.
  10. Shore E, Tenney L, Schwatka N, Dally M, Dexter L, Brown C, et al. A pilot study of changes in Total Worker Health® policies and programs and associated changes in safety and health climates in small business. AJIM. 2021;64(12):1045-52.
  11. Tenney L, Dexter L, Shapiro DC, Dally M, Brown CE, Schwatka NV, et al. Impact of Advising on Total Worker Health Implementation. J Occup Environ Med. 2021.
  12. Brown CE, Schwatka N, Dexter L, Dally M, Shore E, Tenney L, et al. The Importance of Small Business Safety and Health Climates during COVID-19. J Occup Environ Med. 2021;63(81-88).
  13. Brown CE, Dexter L, Schwatka NV, Dally M, Tenney L, Shore E, et al. Total Worker Health® and Small Business Employee Perceptions of Health Climate, Safety Climate, and Well-Being during COVID-19. International Journal of Environmental Research and Public Health. 2021;18(18).
Posted on by Natalie Schwatka, PhD; Liliana Tenney, DrPH MPH; Miranda Dally, MS; Carol Brown, PhD; & Lee Newman, MD MA

2 comments on “10 Lessons Learned From a Multi-Year Total Worker Health Study of Small Businesses”

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    Small businesses have several crisis situations over the past two years, including cyberattacks, labor shortages, The Great Resignation and Covid. In response to the challenges posed by the pandemic, many companies made important decisions about their budgets, spending priorities, resources and strategies.

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Page last reviewed: February 18, 2022
Page last updated: February 18, 2022