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Quantitative Research
Results of the Workplace Health in America Survey
Laura A. Linnan, ScD1, Laurie Cluff, PhD2, Jason E. Lang, MPH, MS3, Michael Penne, MPH4, and Maija S. Leff, MPH1
Abstract
Purpose: To provide a nationally representative snapshot of workplace health promotion (WHP) and protection practices among United States worksites.
Design: Cross-sectional, self-report Workplace Health in America (WHA) Survey between November 2016 and September 2017.
Setting: National.
Participants: Random sample of US worksites with �10 employees, stratified by region, size, and North American Industrial Classification System sector.
Measures: Workplace health promotion programs, program administration, evidence-based strategies, health screenings, disease management, incentives, work–life policies, implementation barriers, and occupational safety and health (OSH).
Analysis: Descriptive statistics, t tests, and logistic regression.
Results: Among eligible worksites, 10.1% (n ¼ 3109) responded, 2843 retained in final sample, and 46.1% offered some type of WHP program. The proportion of comparable worksites with comprehensive programs (as defined in Healthy People 2010) rose from 6.9% in 2004 to 17.1% in 2017 (P < .001). Occupational safety and health programs were more prevalent than WHP programs, and 83.5% of all worksites had an individual responsible for employee safety, while only 72.2% of those with a WHP program had an individual responsible for it. Smaller worksites were less likely than larger to offer most programs.
Conclusion: The prevalence of WHP programs has increased but remains low across most health programs; few worksites have comprehensive programs. Smaller worksites have persistent deficits and require targeted approaches; integrated OSH and WHP efforts may help. Ongoing monitoring using the WHA Survey benchmarks OSH and WHP in US worksites, updates estimates from previous surveys, and identifies gaps in research and practice.
Keywords workplace health promotion, occupational safety and health, work–life balance, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, cross-sectional survey, surveys and questionnaires, public health surveil- lance, employer surveys
Purpose
The workplace remains an important place for supporting and
promoting health and safety, given the fact that more than 60% of US adults are employed and spend a majority of their daily
waking hours at work.1 Over the past 3 decades, the US federal
government has sponsored 4 different surveys (1985, 1992,
1999, and 2004) to assess the extent to which employers offer
workplace health promotion (WHP) programs, policies, and
practices.2-5 These data have typically been evaluated by work-
site size and industry and sometimes by geographic region. The
benefits of conducting national employer surveys include mon-
itoring worksite-based programming growth over time,
1 Department of Health Behavior, UNC Gillings School of Global Public Health,
Chapel Hill, NC, USA 2 Social Policy, Health, & Economics Research Unit, RTI International, Holly
Springs, NC, USA 3 National Center for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta, GA, USA 4 Behavioral Statistics Program, RTI International, Holly Springs, NC, USA
Corresponding Author:
Jason E. Lang, Division of Population Health, Centers for Disease Control and
Prevention, National Center for Chronic Disease Prevention and Health
Promotion, 4770 Buford Highway NE, MS S107-6, Atlanta, GA 30341, USA.
Email: [email protected]
American Journal of Health Promotion 2019, Vol. 33(5) 652-665 ª The Author(s) 2019 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0890117119842047 journals.sagepub.com/home/ahp
understanding trends and emerging issues, identifying gaps in
the utilization of evidence-based programs, policies and prac-
tices across the country, and linking outcomes and progress to
national health priorities such as Healthy People. This article
will describe results of the 2017 Workplace Health in America
(WHA) Survey, the most recent nationally representative sur-
vey of employers sponsored by the US Centers for Disease
Control and Prevention (CDC); it will also compare changes
in key items from the 2004 government survey.5
Several other national surveys of employers have been con-
ducted in recent years, but they have not represented all types
of employers. In 2012, the RAND Workplace Wellness Pro-
grams Study6 surveyed public and private employers with 50þ employees but did not survey smaller employers (eg, less than
50 employees which represent a large proportion of US busi-
nesses). The Harris Poll Neilson Survey7 (fielded in 2015) was
a nationally representative survey of for-profit businesses with
50þ employees. This survey was unique in that it gathered both
employer and employee feedback. The Staying@Work Willis
Towers Watson Survey8 (fielded in 2015) focused on large
employers, only sampling those with 1000þ employees. The
annual Kaiser Employer Health Benefits Survey9 surveys only
nonfederal public and private employers with 3þ workers that
offer health benefits to their employees; thus, results do include
employers of all sizes but only those that offer employees
health benefits.
DeJoy et al10 noted that previous surveys failed to capture
information on the quality and effectiveness of WHP programs.
The WHA Survey takes some small but important steps in this
regard by adding questions to assess which evidence-based
strategies were offered, who managed the program, and esti-
mates of employee participation for each type of health pro-
gram offered. However, detailed or objective measures of
program quality and effectiveness (eg, direct links between
programming and employee health) may be better assessed
through site visits, archival employer records, and/or other
employee surveys linked to employer data.
DeJoy and colleagues10 also recommended that future sur-
veys strive to create systematic processes for collecting, main-
taining, and comparing data sets. The WHA Survey has created
a platform to enable easy access to the survey instrument, the
data set, and an online dashboard presenting key outcomes as
part of its overall dissemination efforts (https://www.cdc.gov/
workplacehealthpromotion/data-surveillance/index.html). We
believe the 2017 WHA Survey documentation and publicly
available data can serve as an important link to the past and
bridge to future planning and benchmarking of WHP and pro-
tection activities.
Methods
Survey Development
A full listing of all expert contributors to the survey planning
and development process is found at https://www.cdc.gov/
workplacehealthpromotion/data-surveillance/index.html.
A national Steering Committee including experts in workplace
health and safety guided the survey development process.
A Data User Group provided input on what types of data
employers and other key stakeholders would find most valu-
able. A Survey Development Team made up of CDC subject
matter experts, RTI International, the University of North Car-
olina at Chapel Hill, and several national experts in workplace
survey design created domains, reviewed a data dictionary of
items from 16 employer surveys, conducted cognitive inter-
views, and pilot tested the final draft version of the instrument
before it was launched. RTI’s institutional review board
exempted the survey (study #0214531) because the subject of
data collection was the worksite, not a human subject. The
instrument was designed to move the field forward by addres-
sing rapidly evolving practices or emerging issues such as
sleep, Total Worker Health® (TWH), and work–life benefits
and to allow for comparisons with past surveys and more tra-
ditional program elements. For example, the WHA Survey
reports on the 5 key elements of a “comprehensive” program,
which was first measured in the 2004 national survey.
To reduce respondent burden, we included 204 items deemed
most critical to the survey’s objectives in the “core” section of
the survey and 41 other items in a “supplemental” section
that followed the core section. All survey respondents were
invited to complete both the core and the supplemental
section. A copy of the final survey instrument is available at
https://www.cdc.gov/workplacehealthpromotion/data-
surveillance/index.html.
Design and Sample
The WHA Survey gathered information from a cross-sectional,
nationally representative sample of US worksites. The sample
was drawn from the Dun & Bradstreet (D&B) database of 2.5
million private and public employers in the United States with at
least 10 employees. Like previous national surveys, we included
specific worksites rather than the companies to which the work-
sites belonged. We selected worksites using a stratified simple
random sample design, where the primary strata were 10 multi-
state regions plus an additional stratum containing all hospital
worksites. The hospital worksites were assigned to their own
primary stratum to ensure a sufficient sample size. Within each
CDC region stratum, we further stratified by worksite size (10-
24 employees, 25-49 employees, 50-99 employees, 100-249
employees, 250-499 employees, 500-749 employees, 750-999
employees, and 1000 employees or more) and 7 combined
industry groups based on the North American Industry Classifi-
cation System sectors (see Table 1 for groups). We selected the
number of worksites per size and industry group based on pro-
portional allocation to the population of worksites.
Data Collection Procedures
Trained interviewers contacted each sampled worksite by tele-
phone to recruit the individual who was “most knowledgeable
about employee health and safety at the worksite.” Interviewers
Linnan et al. 653
also confirmed each worksite met eligibility criteria of having
at least 10 employees and being in operation for least
12 months. Respondents had the choice of completing the
survey using 1 of 3 modes: the web (86.6%), telephone inter-
view (8.6%), and mailed paper survey (4.9%). The survey
took about 40 minutes to complete. The data collection pro-
tocol included reminder e-mails to worksites that requested,
but did not complete, the web survey and follow-up phone
calls to all worksites that had not completed the survey. To
improve response to the survey, we also e-mailed postcards,
alerting worksites that we would be contacting them to com-
plete the survey. We also offered respondents free access to
expert webinars on how to implement low-cost health promo-
tion programs at work as an incentive.
Measures
We used previous items from the 2004 survey and 15 other
national workplace-related surveys (See Supplemental Data 1:
Reference surveys reviewed to help develop the WHA Survey).
Key measures included presence of WHP programs, evidence-
based strategies, health screenings, disease management
programs, incentives, work–life policies, barriers to health
promotion program implementation, and occupational safety
and health. Consistent with the 2004 national survey,
“comprehensive” health promotion programs were defined as
those that incorporated all of the 5 key elements outlined in
Healthy People 2010: (1) health education programs, (2) sup-
portive social and physical work environment, (3) integration
of the program into the organization’s structure, (4) linkage to
related programs such as employee assistance programs
(EAPs), and (5) health screening with appropriate follow-up
and education.11 Most WHA Survey items were dichotomous
(eg, “Did you offer any programs to address physical activity
for your employees?”), and the remaining items had multiple
categorical response options to elicit more detailed informa-
tion. For example, a question asking about the percentage of
employees that participated in physical activity programs in the
past 12 months had 4 response options: “1%-25%, 26%-50%,
51%-75%, or more than 75%.”
Analysis
Data management and prevalence estimation (including var-
iances) were conducted with a combination of SAS (V9.4) and
SUDAAN (V11.0.1). We computed analysis weights as the
inverse of selection probabilities, adjusted for both nonre-
sponse and coverage. The weights reflect the D&B total num-
ber of worksites in each region, size, and industry category,
representing approximately 2.5 million worksites. Variances
were estimated using first-order Taylor series approximations
of deviations of estimates to expected values, accounting for
stratification and unequal weighting. Estimates for each mea-
sure included weighted population totals, means/percentages,
standard errors, and 95% confidence intervals. We excluded
respondents with missing or nondeterminant (eg, don’t know,
refused) item data from analyses with that particular item. We
used the standard t test to determine statistically significant
differences comparing estimates between worksite size or
industry groups. When reporting differences based on size,
“largest worksites” refer to those with 500 or more employees
and “smallest worksites” are those with 10 to 24 employees.
We used multivariable logistic regression to assess worksite
characteristics associated with the presence of a comprehensive
health promotion program. Levels of statistical significance
were set at P < .05. Only worksites with health promotion
programs were asked about the topics and types of programs,
health screenings, and disease management services they
offered. Conservatively, worksites reporting no health promo-
tion program were also coded as not having any specific type
Table 1. Unweighted Sample Frequencies and Percentages for Size, Industry, and Regional Categories.
Unweighted Frequencies
Unweighted Percentages
Total Sample 2843 100.0 Size based on number of employees
10-24 1175 41.3 25-49 655 23.0 50-99 365 12.8 100-249 263 9.3 250-499 131 4.6 500þ 254 8.9
Industry Category 1: Agriculture, Forestry, Fishing; Mining;
Utilities; Construction; Manufacturing
525 18.5
2: Wholesale/Retail Trade; Transportation; Warehousing
311 10.9
3: Arts, Entertainment, Recreation; Accommodations and Food Service; Other Services
433 15.2
4: Information; Finance; Insurance; Real Estate and Leasing; Professional, Scientific, Technical Services; Management; Administration Support; Waste Management
429 15.1
5: Education Services; Health Care & Social Assistance
551 19.4
6: Local, State and Federal Public Administration
256 9.0
7: Hospitals 338 11.9 CDC Region
1: CT, ME, MA, NH, RI, VT 215 7.6 2: NJ, NY 166 5.8 3: DE, DC, MD, PA, VA, WV 251 8.8 4: AL, FL, GA, KY, MS, NC, SC, TN 340 12.0 5: IL, IN, MI, MN, OH, WI 322 11.3 6: AR, LA, NM, OK, TX 273 9.6 7: IA, KS, MO, NE 413 14.5 8: CO, MT, ND, SD, UT, WY 311 10.9 9: AZ, CA, HI, NV 216 7.6 10: AK, ID, OR, WA 336 11.8
Abbreviation: CDC, Centers for Disease Control and Prevention.
654 American Journal of Health Promotion 33(5)
of health promotion, screening, or disease management pro-
gram or service.
Results
Sample Description
We sampled 35,584 worksites and eliminated 4721 as ineligi-
ble, most commonly because they had fewer than 10 employ-
ees. A total of 3109 worksites completed some portion of the
survey (10.1% of the eligible cases using AAPOR RR method 2
for the calculation). For the final sample, we retained 2843
cases that met completion criteria of answering the item about
having a health promotion program or answering at least 50% of the survey items. Table 1 presents the unweighted sample
worksites in each of the size, industry, and regional categories.
The largest percentage of worksites (41.3%) was in the smallest
size category (10-24 employees), followed by 23.0% of the
sample in the 25 to 49 employee size category. Among 2843
complete cases, 1255 also completed the supplemental survey
and did not significantly differ from the overall sample on size,
industry, region, or presence of health promotion program. The
largest percentage of respondents reported they were affiliated
with human resources or benefits (32.4%), while 6.3% reported
being the worksite’s office manager/administrator and 5.9% reported being the general manager. For full-time employees,
39.1% of worksites offered full payment of health insurance
premiums, 45.6% offered partial payment, and 79.6% offered
family health insurance coverage. Larger worksites were more
likely to offer health insurance benefits overall.
The remainder of the results section describes how health
promotion programs were administered and supported, fol-
lowed by the type of health promotion programming offered,
health screenings and disease management programming
offered, specific health promoting environmental supports and
policies (including work–life policies) in place, and occupa-
tional safety and health practices conducted. We conclude with
results for comprehensive health promotion programs and a
comparison of the 2017 WHA results with the 2004 WHP
survey results. As space permitted, results appear in tables and
are reported in the text for items with categorical answers or
with meaningful industry group differences. The survey instru-
ment, datafile, and the national, industry group, size group, and
regional group estimates for most variables are available at
https://www.cdc.gov/workplacehealthpromotion/data-surveil
lance/index.html
Administration and Support of Health Programming
Overall, almost half of all worksites offered some type of
health promotion or wellness program (46.1%; Table 2). Sig-
nificantly lower percentages of worksites in the 2 smallest size
categories offered programs compared to worksites in the 4
larger size categories (P < .001). Public administration and
hospital industry groups were significantly more likely than
worksites from the other 5 industry groups to offer health
programs (P < .001). Program experience varied among work-
sites with a health promotion program: 10.1% had programs in
place for less than 1 year, 20.6% for 1 to 2 years, 32.9% 3 to 5
years, 16.5% 6 to 9 years, and 19.8% 10 years or more. Among
worksites with a health promotion program, 46.1% agreed that
their organization includes references to employee health in the
mission statement or business objectives; this was true espe-
cially among the largest worksites (61.6% of sites with 500þ employees) compared to smaller worksites (44.6% of sites with
25-49 employees).
Most worksites with health promotion programs had at least
1 person assigned responsibility for the program (72.2%). A
majority of worksites with a health promotion program
reported it was primarily managed by their own employees
(62.3%), compared to programs managed by vendors (21.5%)
or programs managed by health insurance providers (16.2%).
Moreover, 41.0% of worksites with programs had no wellness
or safety committee, 21.2% had separate health promotion and
safety committees, 17.5% had a combined health promotion
and safety committee, 12.5% had just a safety committee, and
7.9% had just a health promotion committee.
Among worksites with a health promotion program, the
annual budget available to spend on health promotion programs
varied: 35.6% reported having no annual budget; 11.0% had
<$1000; 11.5% had $1000 to $5000; 13.5% had $5001 to
$20 000; and 28.4% had more than $20 000. Most of the work-
sites with a program reported planning to spend about the same
amount in the coming year (79.4%), 17.5% planned to spend
more, and 3.1% planned to spend less.
Regardless of size or industry type, most worksites with
health programs agreed that senior leadership (84.2%) and
middle management (83.4%) were visibly committed to
employee health and safe work environments. More than half
(58.9%) of the worksites with programs had an annual health
promotion plan. Of those with plans, a majority (65.3%)
endorsed having measurable objectives, 88.8% included com-
munication strategies to promote and market the program to
employees, and 77.8% reported there was clear responsibility
for implementing components.
Among worksites with programs, 53.3% used data to help
decide what to offer and 50.2% used data to evaluate their
program. While nearly all (98.3%) of the worksites that used
data to evaluate their program used employee participation
data, other highly endorsed sources of data included employee
program feedback (89.7%), changes in employee health risk
behaviors (78.1%), health-care claims costs (73.1%), worker
compensation claims (60.7%), and return on investment
(57.2%). We assessed the use of health risk assessments
(HRAs) by all worksites in the sample (not just among those
with health promotion programs). Overall, while 25.5% of the
worksites had offered an HRA in the past 12 months (Table 2),
there were significant differences by size as 21.6% of worksites
with 10 to 24 employees offered an HRA compared to 52.0% of
worksites with 250 to 499 and 68.7% of worksites with 500 or
more employees (P < .001).
Linnan et al. 655
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(2 8 .6
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)
A b b re
vi at
io n : C
I, co
n fid
en ce
in te
rv al
. a W
e su
p p re
ss ed
es ti m
at es
w it h
a sa
m p le
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an 5 0
o r
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la ti ve
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d ar
d er
ro r
ab o ve
3 0 %
.
656
About half (53.0%) of the worksites with programs offered
incentives. The largest worksites were more likely to offer
incentives (78.0%) than any of the smaller size worksites. The
most common type of incentives offered were gifts or prizes
(offered by 64.4% of those offering incentives), cash (53.1%),
and premium discounts (52.6%). Of those offering incentives,
82.3% offered incentives tied to program participation, 30.6% tied to achieving a health standard, and 30.8% tied to both
participation and achieving a health standard. When asked how
effective they considered the incentives they used, less than
half (48.1%) reported the incentives were “somewhat
effective” for achieving intended outcomes, 34.2% rated their
incentives as “effective,” 11.2% rated them as “extremely
effective,” while 6.5% rated them as “not at all effective.”
All worksites were asked about 12 potential barriers or chal-
lenges to offering health promotion programs; we report the
most challenging here. Cost was rated as challenging or
extremely challenging by 57.5% of all worksites, followed by
competing business demands (41.7%), lack of employee inter-
est (37.5%), lack of experienced staff (32.9%), lack of physical
space (30.4%), and demonstrating program results (24.7%).
Reviewing the 2 most commonly endorsed challenges in more
depth, we found there were no significant differences on ratings
of cost or competing business demands based on worksite size.
And, no differences on the cost barrier existed between work-
sites with a health promotion program (56.7%) versus those not
offering a health promotion program (58.4%). However, work-
sites with a health promotion program were slightly more likely
(45.4%) than those without a program (39.4%) to rate compet-
ing business demands as challenging or extremely challenging.
Health Promotion Programming
We assessed the prevalence of 9 categories of health topics and
related evidence-based strategies. Larger worksites were more
likely than smaller worksites to offer nearly all types of health
programs (Table 2). Physical activity programs (offered by
28.5% of all worksites) and nutrition programs (offered by
23.1% of all worksites) were the 2 most prevalent, so we report
on them in more detail, including information about the type of
programs offered, who offered the program, and an estimate of
employee participation. These data are available for all 7 addi-
tional health topics.
Among those offering physical activity programs, 57.9% offered a combination of informational and skill-building pro-
grams, nearly a third offered information only, and 12.9% offered skill-building only. Over a third (37.6%) reported their
physical activity programs were offered mostly by the
employer, 11.9% by the health plan, 8.1% by a vendor, and
42.4% by combination of employer, health plan, or vendor.
About half (49.2%) estimated that 1% to 25% of the employees
participated in the physical activity program during the past 12
months, 35.1% estimated 26% to 50% participated, and 15.8% estimated more than half of the employees participated.
For nutrition programs, 52.5% offered information and skill-
building, 43.0% offered information only, and 4.6% offered
skill-building only. About a third (32.5%) were offered mostly
by the employer, 11.1% by the health plan, 13.0% by a vendor,
and 43.4% by combined efforts of the employer, health plan, or
a vendor. Half estimated that 1% to 25% of employees parti-
cipated during the past year, 20.4% estimated 26% to 50% participated, and 28.9% estimated that more than 50% of
employees participated.
For most other health promotion topics, at least half of the
worksites offered information only, with most of the others
offering a combination of information and skill-building. Across
all health promotion topics, employers or a combination of the
employer, health plan, and vendor were most likely to be offer-
ing programs. Respondents’ estimates of employee participation
for other types of programs were concentrated mostly at 1% to
25%, with the exception of musculoskeletal disorders, where
39.6% estimated having 1% to 25% employee participation and
44.4% estimated having over 75% employee participation.
For each health topic, we assessed the extent to which spe-
cific evidence-based strategies consistent with the CDC Com-
munity Guide and/or the CDC Worksite Health ScoreCard12,13
were offered. For example, 15.3% of all worksites reported
offering self-management programs with advice on physical
activity, and 8.8% of all worksites offered physical fitness
assessments and follow-up counseling. Regarding evidence-
based strategies for tobacco cessation, approximately 17.5% of all worksites provided insurance coverage for tobacco ces-
sation medications, 15.9% provided free or subsidized cessa-
tion counseling, 12.3% referred users to a tobacco cessation
telephone quit line, and 7.5% helped remove barriers to acces-
sing cessation treatments, like copayments and prior authoriza-
tion requirements.
Health-Related Screenings and Disease Management Programs
Respondents were asked whether they had offered health
screenings to employees in the past 12 months. The most pre-
valent screenings offered were blood pressure (22.5% of all
worksites offered this), blood cholesterol (19.7%), diabetes/
prediabetes (19.0%), and obesity (18.2%; Table 2).
Respondents were also asked whether disease management
programs were provided, including programs offered by the
employer, health plan, or a third-party vendor. The most preva-
lent types of disease management programs offered were for
hypertension (19.7% of all worksites offered this), diabetes or
prediabetes (19.5%), blood cholesterol (18.9%), and obesity
(18.6%; Table 2). For all types of screenings and for each disease
management topic, large worksites were more likely than small
worksites to offer programs. The most common approach to
disease management was providing information (e.g., brochures,
newsletters), with fewer than half of those with disease manage-
ment programs offering one-on-one counseling and/or
follow-up. Nearly a third (29.8%) of all worksites made flu shots
available to employees (22.4% of all worksites offered these on-
site), and the percentage offering flu shots ranged from 23.3% among smallest worksites to 87.5% of the largest worksites.
Linnan et al. 657
Environmental Supports and Policies
A health-supportive work environment includes policies, phys-
ical/structural changes, and benefits. Overall, larger worksites
were more likely than smaller sites to offer a wide array of
environmental supports and policies (Table 3). For example,
16.3% of all worksites had some type of environmental
support for physical activity (eg, trails/tracks, bike racks,
showers, and changing rooms) and 8.2% offered employees
paid time to be physically active. Just over 40% provided
food preparation and storage facilities for employees, 16.2% had an on-site cafeteria or snack bar, and 10.1% had a
written policy making healthier food and beverages avail-
able during meetings where food is served (Table 3).
Among worksites with food available for purchase on-site,
26.4% had a policy in place to make healthier choices avail-
able. Over 30% of all worksites had a written policy to
restrict smoking, 28.9% of worksites displayed signs includ-
ing no smoking signs, and 19.4% had a policy banning all
tobacco use at the worksite.
For disease management, making a blood pressure–moni-
toring device available for employees to use at work was not
very common (4.8% of all worksites offered this), but the larg-
est worksites were most likely to offer this on-site (22.0%;
Table 3). On-site health clinics, available at just 7.6% of all
worksites, were also most common in the largest sites (39.5%).
Work–Life Benefits and Policies
Table 3 presents estimates related to work–life benefits and
policies. Fewer than half of all worksites (45.1%) offered
EAPs, 31.7% for employees and their families, and 13.4% for employees only. Most worksites (55.3%) offered flexible
work schedules, and 35.8% allowed employees to work
from home. The largest worksites (69.8%) were more likely
than smaller worksites to allow employees to work from
home. Only 27.1% of worksites helped employees cover
childcare costs through direct reimbursement or flexible
spending accounts. However, most (76.5%) worksites
allowed unpaid parental leave, and 42.8% offered paid fam-
ily leave for new parents.
Occupational Safety and Health
Overall, 83.5% of all worksites reported having at least 1 per-
son responsible for employee safety (Table 3), and 33.4% among those reported that this person was also responsible for
promoting health or wellness. Overall, 69.4% of all worksites
have a written injury and illness prevention program, while
about 91% of worksites with more than 250 employees have
a program (Table 3). Most worksites (69.8%) report that efforts
to protect and promote worker health included improved work
design and work environment, along with worker education.
The following training topics were identified as most useful to
people responsible for employee health and safety at their
worksites: best practices for employee safety and health
promotion (75.5%); laws, regulations, and standards related
to employee health and safety (55.6%); conducting health and
safety risk assessments (53.2%); and program planning, imple-
mentation, and evaluation (45.9%).
Comprehensive Health Promotion Programs
Each of the 5 specific elements of a comprehensive health
promotion program were present in less than 50% of worksites:
supportive social and physical environments (47.8% of all
worksites reported this), linkages to related programs
(46.0%), health education programs (33.7%), integration of the
program into the organization’s structure (28.4%), and health
screenings with appropriate follow-up and education (26.6%;
Table 3). Overall, 11.8% of worksites offered all 5 key ele-
ments of a comprehensive WHP program. Larger worksites
(250+ employees) were both more likely to report having any
1 of the 5 elements, as well as more likely to report having all 5
key elements, as compared to smaller worksites. Worksites in
the hospital industry (35.7%) were more likely to have a com-
prehensive program than any other industry group.
The 2004 national survey identified several factors that were
found to be independent predictors of having a comprehensive
health promotion program: employer size, experience with
offering a comprehensive program, industry sector, having a
responsible person, and a budget.5 Among all 2017 respon-
dents, we did a similar analysis and have summarized both the
unadjusted and the adjusted models (Table 4). Similar to 2004,
in the unadjusted model, we found that all of these factors were
significant independent predictors of having a comprehensive
program. In the adjusted model, after controlling for all other
variables, worksites with a person assigned responsibility for
the health promotion program had 8.14 times the odds of hav-
ing a comprehensive program (P < .001), worksites with an
annual budget had 6.99 times the odds (P < .001), and sites with
more than 5 years of health program experience had 3.08 times
the odds of having a comprehensive program (P < .001). Only
the 50- to 99-size employer group had lower odds of offering a
comprehensive program compared to the reference category
when controlling for all other model variables (P ¼ .004); the
industry group that included arts, entertainment, recreation,
accommodations and food service had significantly greater
odds of offering a comprehensive program compared to the
reference group (P ¼ .030).
Changes in Comprehensive Programming: 2004 to 2017
To make appropriate comparisons between the previous (2004)
and 2017 survey results, we adjusted the 2017 sample by
removing public administration worksites and those with less
than 50 employees. Once the sample was adjusted, we found a
significantly higher percentage of worksites had any 1 of the 5
comprehensive health promotion program elements in 2017
compared to 2004, and more than twice as many had all 5
elements in 2017 compared to 2004 (17.1% vs 6.9%,
P < .001; Table 5). Significantly higher percentages of
658 American Journal of Health Promotion 33(5)
T a b
le 3 .
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(8 5 .2
-9 5 .7
) 9 3 .9
(8 5 .5
-9 7 .5
) 9 3 .9
(8 7 .9
-9 7 .0
) W
ri tt
en in
ju ry
an d
ill n es
s p re
ve n ti o n
p ro
gr am
6 9 .4
(6 6 .9
-7 1 .8
) 6 3 .6
(6 0 .0
-6 7 .1
) 7 7 .1
(7 2 .7
-8 1 .0
) 7 7 .7
(7 0 .3
-8 3 .7
) 7 0 .9
(6 1 .9
-7 8 .5
) 9 0 .6
(8 0 .3
-9 5 .8
) 9 1 .1
(8 3 .4
-9 5 .5
) O
n -s
it e
h ea
lt h
cl in
ic 7 .6
(6 .3
-9 .1
) 7 .8
(6 .0
-1 0 .1
) 4 .0
(2 .4
-6 .7
) 6 .6
(3 .9
-1 0 .9
) 1 2 .2
(7 .6
-1 8 .8
) 2 0 .6
(1 2 .2
-3 2 .6
) 3 9 .5
(3 0 .6
-4 9 .2
) W
o rk
– lif
e E A
P fo
r em
p lo
ye es
an d
fa m
ili es
3 1 .7
(2 9 .2
-3 4 .2
) 2 5 .4
(2 2 .2
-2 8 .9
) 3 0 .8
(2 6 .3
-3 5 .7
) 4 1 .7
(3 4 .2
-4 9 .6
) 5 5 .4
(4 5 .3
-6 5 .0
) 6 2 .5
(4 9 .1
-7 4 .2
) 7 3 .6
(6 4 .7
-8 1 .0
) Fl
ex ib
le w
o rk
sc h ed
u le
s 5 5 .3
(5 2 .7
-5 7 .8
) 5 9 .0
(5 5 .5
-6 2 .4
) 5 1 .0
(4 6 .1
-5 5 .8
) 4 7 .6
(4 0 .2
-5 5 .2
) 5 0 .2
(4 0 .6
-5 9 .7
) 5 5 .7
(4 2 .7
-6 7 .9
) 6 8 .1
(5 9 .5
-7 5 .6
) A
llo w
w o rk
in g
fr o m
h o m
e 3 5 .8
(3 3 .4
-3 8 .3
) 3 5 .2
(3 1 .9
-3 8 .7
) 3 4 .0
(2 9 .9
-3 8 .4
) 3 6 .3
(2 8 .8
-4 4 .5
) 4 0 .2
(3 1 .2
-4 9 .8
) 4 4 .5
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-5 8 .0
) 6 9 .8
(6 0 .9
-7 7 .4
) D
is ab
ili ty
le av
e/ d is
ab ili
ty in
su ra
n ce
6 9 .6
(6 7 .3
-7 1 .9
) 6 3 .7
(6 0 .2
-6 7 .1
) 7 0 .2
(6 5 .5
-7 4 .5
) 8 3 .4
(7 8 .5
-8 7 .4
) 8 3 .9
(7 5 .5
-8 9 .8
) 9 3 .9
(8 1 .7
-9 8 .1
) 9 7 .1
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-9 9 .1
) P ai
d n ew
p ar
en t
le av
e 4 2 .8
(4 0 .2
-4 5 .3
) 4 1 .2
(3 7 .6
-4 4 .9
) 3 9 .6
(3 5 .0
-4 4 .4
) 4 6 .0
(3 9 .2
-5 3 .0
) 5 3 .5
(4 3 .8
-6 2 .8
) 5 0 .1
(3 7 .9
-6 2 .4
) 7 6 .4
(6 8 .0
-8 3 .1
) U
n p ai
d p ar
en ta
l le
av e
7 6 .5
(7 4 .1
-7 8 .7
) 7 0 .3
(6 6 .8
-7 3 .7
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(7 5 .7
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(7 9 .2
-8 9 .4
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(2 2 .8
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(3 3 .9
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(4 6 .8
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(6 2 .0
-7 8 .8
) O
n -/
o ff -s
it e
ch ild
ca re
6 .0
(5 .0
-7 .2
) 5 .7
(4 .3
-7 .5
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-8 .9
) 6 .2
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-1 0 .1
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p p re
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Su p p re
ss ed
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(1 2 .9
-2 7 .7
) C
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p re
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si ve
p ro
gr am
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en ts
Su p p o rt
iv e
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al an
d p h ys
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ro n m
en t
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(4 5 .3
-5 0 .3
) 4 4 .9
(4 1 .5
-4 8 .5
) 4 6 .4
(4 1 .7
-5 1 .1
) 4 8 .8
(4 1 .8
-5 5 .9
) 6 4 .0
(5 5 .1
-7 2 .0
) 7 5 .8
(6 5 .4
-8 3 .8
) 8 4 .2
(7 6 .7
-8 9 .6
) Li
n ka
ge to
re la
te d
p ro
gr am
s 4 6 .0
(4 3 .5
-4 8 .4
) 3 7 .8
(3 4 .4
-4 1 .3
) 4 5 .4
(4 0 .6
-5 0 .2
) 5 9 .3
(5 2 .1
-6 6 .1
) 7 7 .3
(6 8 .9
-8 4 .0
) 8 3 .8
(7 4 .9
-9 0 .0
) 9 2 .6
(8 5 .5
-9 6 .4
) H
ea lt h
ed u ca
ti o n
p ro
gr am
s 3 3 .7
(3 1 .5
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-3 5 .5
) 4 3 .9
(3 7 .4
-5 0 .7
) 5 0 .9
(4 2 .7
-5 9 .1
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) 7 9 .6
(7 2 .1
-8 5 .5
) In
te gr
at io
n 2 8 .4
(2 6 .2
-3 0 .8
) 2 4 .1
(2 1 .2
-2 7 .4
) 2 7 .6
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-3 2 .3
) 3 5 .8
(2 9 .0
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-7 4 .9
) 7 7 .4
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-8 4 .0
) H
ea lt h
sc re
en in
gs 2 6 .6
(2 4 .5
-2 8 .9
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-2 5 .9
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-3 7 .3
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(3 9 .8
-5 6 .6
) 6 2 .9
(5 0 .3
-7 3 .9
) 6 3 .4
(5 4 .5
-7 1 .4
) A
ll 5
el em
en ts
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(1 0 .4
-1 3 .4
) 1 1 .0
(9 .1
-1 3 .3
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(6 .1
-1 1 .2
) 1 2 .2
(8 .7
-1 6 .7
) 2 1 .3
(1 5 .5
-2 8 .6
) 3 3 .6
(2 3 .2
-4 5 .9
) 3 9 .5
(3 1 .8
-4 7 .8
)
A b b re
vi at
io n s:
C I,
co n fid
en ce
in te
rv al
; E A
P , em
p lo
ye e
as si
st an
ce p ro
gr am
. a W
e su
p p re
ss ed
es ti m
at es
w it h
a sa
m p le
si ze
o f le
ss th
an 5 0
o r
a re
la ti ve
st an
d ar
d er
ro r
ab o ve
3 0 %
.
659
Table 4. Relative Odds of Providing a Comprehensive Health Promotion Program by Worksite Characteristics: Among All 2017 Survey Respondents.
Unadjusted Odds Ratio (95% Confidence Interval) P Value
Adjusted Odds Ratio (95% Confidence Interval) P Value
Person assigned responsible 19.49 (12.68-29.95) <.001 8.14 (4.11-16.11) <.001 Annual budget 38.18 (23.66-61.61) <.001 6.99 (4.03-12.13) <.001 Health program experience > 5 years 8.35 (6.04-11.54) <.001 3.08 (1.93-4.91) <.001 Size
10-24 (ref) 1.00 1.00 25-49 0.73 (0.49-1.09) .127 0.63 (0.33-1.22) .174 50-99 1.13 (0.73-1.72) .589 0.34 (0.16-0.70) .004 100-249 2.20 (1.41-3.43) .001 0.89 (0.46-1.71) .718 250-499 4.10 (2.36-7.13) <.001 1.50 (0.58-3.87) .398 500þ 5.30 (3.56-7.87) <.001 1.77 (0.82-3.84) .145
Industry Ag/Forest/Fish/Mining/Util/Const/Manf (ref) 1.00 1.00 Wholesale/Retail, Transp/Wareh 1.66 (1.04-2.64) .034 1.69 (0.81-3.52) .159 Arts/Entertain/Rec/Accom and Food 1.39 (0.87-2.23) .166 2.38 (1.09-5.19) .030 Info/Finance/Insur/Real Est/Prof, Scientific 0.65 (0.39-1.08) .097 0.40 (0.15-1.11) .079 Educ Srvcs/Hlth Care & Soc Assist 1.12 (0.70-1.80) .630 0.95 (0.41-2.19) .910 Local/State/Fed Public Admin 2.53 (1.63-3.92) <.001 1.45 (0.69-3.03) .328 Hospitals 5.22 (3.53-7.71) <.001 1.71 (0.80-3.68) .167
Estimates in bold are significant.
Table 5. Comparing Selected 2004 and 2017 Estimates.
2004, % (95% CI) 2017, % (95% CI) P Value 2017-2004, % Absolute
Difference (95% CI)
Comprehensive program elements Supportive social and physical environment 29.2 (24.7-35.0) 56.0 (50.6-61.4) <.001 26.1 (18.7-33.5) Linkage to related programs 41.3 (35.7-46.7) 65.3 (59.9-70.6) <.001 24.0 (16.4-31.6) Health education 26.2 (21.5-30.8) 48.3 (43.2-53.3) <.001 22.1 (15.3-28.9) Integration 28.6 (23.4-33.7) 38.8 (33.2-44.3) .009 10.2 (2.6-17.8) Health screenings 23.5 (18.7-28.3) 38.4 (33.5-43.3) <.001 14.9 (8.0-21.8) All 5 elements 6.9 (3.9-10.0) 17.1 (13.7-20.6) <.001 10.2 (5.6-14.8)
Programs Physical activity 19.6 (15.5-23.7) 41.1 (35.5-46.7) <.001 21.5 (14.6-28.4) Nutrition 22.7 (18.2-27.2) 34.5 (29.1-40.0) .001 11.8 (4.7-18.9) Stress 24.9 (20.1-29.9) 29.3 (23.8-34.8) .242 4.4 (�3.0-11.8) Tobacco 18.6 (14.5-22.5) 28.5 (23.5-33.4) .002 9.9 (3.5-16.3) Weight management 21.4 (16.9-25.9) 29.8 (24.7-34.8) .015 8.4 (1.6-15.2) Employee assistance program 44.7 (39.3-50.1) 62.5 (52.2-72.7) <.001 17.8 (8.0-27.6)
Screenings Blood pressure 36.4 (31.0-41.7) 34.0 (29.0-39.0) .523 2.4 (�5.0-9.8) Cholesterol 29.4 (24.5-34.4) 29.9 (25.1-34.6) .886 0.5 (�6.4-7.4) Diabetes 27.4 (22.5-32.3) 29.5 (24.9-34.2) .542 2.1 (�4.7-8.9)
Disease management Hypertension 22.9 (18.1-27.6) 27.9 (22.8-33.1) .197 5.0 (�2.6-12.6) Diabetes 25.0 (20.1-29.8) 27.0 (22.0-32.0) .612 2.0 (�5.7-9.7) Obesity 16.4 (12.2-20.5) 26.0 (21.0-31.0) <.001 9.6 (5.4-13.8) Cancer 22.5 (17.7-27.8) 22.1 (17.2-27.0) .906 0.4 (�6.2-7.0) Depression 20.5 (16.1-24.9) 23.5 (18.6-28.4) .180 3.0 (�1.4-7.4) High-risk pregnancy 18.6 (14.2-22.9) 14.2 (10.4-18.0) .048 4.4 (0.0-8.8) Asthma 19.1 (14.8-23.4) 16.8 (12.7-20.9) .292 2.3 (�2.0-6.6)
Abbreviation: CI, confidence interval. Estimates in bold are significant at P < .05.
660 American Journal of Health Promotion 33(5)
worksites in 2017 offered physical activity (P < .001), nutrition
(P ¼ .001), tobacco (P ¼ .002), weight management (P ¼ .015), and EAPs (P < .001), compared to worksites in 2004.
The percentages of worksites offering the 3 most common
types of health screenings (eg, blood pressure, cholesterol, and
diabetes) were not very different from 2004 to 2017. There
were few changes in the percentages of worksites offering
disease management programs between 2004 and 2017. While
the percentage offering obesity management programs signif-
icantly increased from 16.4% in 2004 to 26.0% in 2017
(P < .001), the percentage offering high-risk pregnancy man-
agement programs decreased from 18.6% in 2004 to 14.2% in
2017 (P ¼ .048).
Discussion
Over a decade has passed since the 2004 federally funded
national survey of WHP programs was conducted. Like the
previous surveys, the current survey offers a snapshot in time
of the status of workplace health and safety among a nationally
representative sample of worksites. However, we also had an
opportunity to monitor progress on a core set of items that were
comparable to the 2004 survey. Specifically, after adjusting to
create comparable samples (eg, excluding worksites with less
than 50 employees and those in public administration), 2017
results indicate that for all health program areas (eg, physical
activity, nutrition, tobacco cessation) except for stress, there
were significant increases reported between 2004 and 2017.
While this is encouraging, it is critically important to realize
that less than half of responding workplaces overall (46%)
report offering any health programming, and less than one-
third of responding worksites offered each of the health topics
we queried them about. In part, this is not surprising since the
WHA Survey sample had a bigger proportion of smaller work-
sites that tend to have fewer programs. These results are similar
to the RAND Workplace Wellness Programs Study,6 where
51% of responding workplaces offered any wellness programs,
and among workplaces with programs, nutrition/weight, smok-
ing, and fitness programs were most common. Also like the
WHA Survey, in all cases, larger workplaces offered more
programming than did smaller workplaces. Clearly, work must
be done to convince employers that it makes good business
sense to offer health programming and/or incentivize them to
offer a healthy work environment for their employees.
What have we learned about why employers choose not to
offer these programs? In the WHA Survey, all responding
employers, including those who reported they did not offer any
type of health programming, were asked to rate the extent to
which different potential barriers might prevent them from
offering health programming for their employees. “Cost” was
rated as challenging by the greatest number of respondents, but
there were few differences by size of workplace, sector, or even
whether a health program was in place (or not). It can be
difficult to ascertain through surveys why employers do not
offer health programming. This is an area that warrants
additional research, potentially through structured interviews
or focus groups with different types and sizes of employers.
Surprisingly, while the WHA Survey results revealed health
programming increased slightly between 2004 and 2017, there
were no significant differences in health screening programs or
disease management programs during that time period with 2
exceptions. Obesity programming significantly increased,
likely because of the widely acknowledged epidemic of obesity
among US adults; high-risk pregnancy programming experi-
enced a significant decrease, despite the high rates of maternal
mortality in the United States. We must be cautious when
comparing these results to other recent national employer sur-
veys because most did not include employers with less than 50
employees, and most were not a nationally representative sam-
ple. However, within specific employer size categories, we do
observe some similar results. For example, the Kaiser Survey,9
among employers that offer health benefits, found that 62% of
large employers (200þ employees) offered an HRA and 67% offered weight loss programs. This is comparable to the finding
for large employers in the WHA Survey, where 69% of large
employers (500þ employees) offered an HRA and 66% offered
weight loss programs.
Beyond considering single health programs, which may be
limited in reach and impact, the 2017 WHA Survey documen-
ted that 11.8% of all worksites reported offering all 5 key
elements of a “comprehensive” health program. After adjusting
the sample to allow for comparisons between 2004 and 2017, it
is encouraging that 17.1% of worksites (vs 6.9% in 2004)
reported having all 5 key elements of a comprehensive pro-
gram. There were statistically significant differences over those
13 years in all 5 of the key elements. Positive and statistically
significant gains were made both in the individual health pro-
grams and in the 5 key elements that comprise a comprehensive
program. Thus, we observed important increases in the propor-
tion of worksites with a comprehensive program as well as for a
number of specific health topics. However, we cannot lose
sight of the fact that fewer than 1 in 5 workplaces are offering
a comprehensive health promotion program. Although few
comparisons are available, the 2015 Harris Poll Nielsen Survey
of for-profit businesses with 50þ employees found that just
13.3% offered a similarly defined comprehensive health pro-
gram.7 We acknowledge that refining the measurement of a
“comprehensive” program may be helpful. Nevertheless, given
that fewer than 20% of employers overall have offered a health
promotion program that integrates health, safety, and benefits;
provides administrative support; offers evidence-based health
programming; provides screening programs with adequate edu-
cation and follow-up; and creates an environment and policies
that support health, it is clear that more work must be done to
understand how and why employers decide to invest in these
practices and how to best facilitate the adoption of these efforts.
Similar to 2004 survey results, we learned that employers
with a responsible person assigned to provide WHP had signif-
icantly greater odds of having a comprehensive program, con-
trolling for all other variables in the model. Similarly,
worksites with an annual budget for health promotion or
Linnan et al. 661
experience having a program in place for at least 5 years also
had significantly greater odds of having a comprehensive pro-
gram. Taken together, these results were quite similar to pre-
dictors of having a comprehensive program reported in 2004
and reinforce the importance of having dedicated staff, budget,
and some experience if the goal is to offer a comprehensive
worksite-based health promotion program, which is most likely
to yield the best employee health and safety outcomes.5
Consistent with results from all previous national surveys,2-5
and recent employer surveys,6-9 in 2017, we observed that
smaller worksites are less likely to offer any type of health
program, policy, environmental support, or a host of other
employee benefits and resources. This finding has persisted
over the past 3 decades. While some progress has been made
among small employers, this represents a gap that should be
addressed. The WHA Survey results suggest that smaller work-
sites are likely to offer safety-related programming, but we
recognize this may be true because they are regulated by the
Occupational Safety and Health Administration. While several
promising interventions have emerged for small employers,14-16
a clear disparity in access to health programming exists for the
59 million Americans who work in small businesses.17 Also
consistent with previous national surveys, few differences by
industry sector emerged with the exception of hospitals and
worksites in the public administration sector that were generally
more likely to offer health programming or policies than were
other industry groups. Future research should clarify why these
types of workplaces are more likely to offer health programming
and determine whether there are best practices that might be
shared across sectors.
New to the 2017 WHA survey was that for each health topic
offered we asked follow-up questions, including an estimate of
employee participation, the type of program management
(ie, internal/external), and an inventory of a much broader set
of evidence-based strategies than previous surveys. Questions
about evidence-based strategies included those assessing
whether worksites were employing policies, systems, or envi-
ronmental interventions. Over the last decade, national health
priorities have increasingly incorporated policies, systems, and
environmental (PSE) approaches into public health programs
as a means of initiating and sustaining healthy behavior
change,18 including the design of workplace health pro-
grams.19-22 Policies, systems, and environmental approaches
target the whole population and, when combined with tradi-
tional individually focused education and skill-building inter-
ventions, provide additional access and opportunity to achieve
successful behavior change. However, evidence suggests5,7,23
and the 2017 national survey results revealed that PSEs are
often less prevalent when compared to individual-level inter-
ventions. It is important to note that results on PSEs may be
underestimated because worksites that reported no health pro-
motion programming (54% of all worksites) were skipped
out of the questions on environmental supports and policies
and assumed to have a “no” response to these questions. Yet
we can certainly envision that worksites who report having
no program in place might have a walking trail or cafeteria
with healthy foods choices; our findings therefore are con-
servative estimates.
Employee participation in nearly all types of programs was
estimated to be less than 25%. An exception was programming
for musculoskeletal injury, back pain, and arthritis. Higher
participation in these programs, we suspect, could be attributed
to worksites requiring employees to participate in back injury
prevention programs. Few other national surveys have asked
about employee participation. Exceptions include the RAND
Workplace Wellness Programs Study,6 where the majority of
employers reported less than 20% participation for most pro-
gramming, and the Staying@Work Willis Towers Watson sur-
vey,8 where participation was around 50% for HRAs and
biometric screenings, but generally less than 10% for other
health programming. Thus, employee participation remains rel-
atively low in most health programs, which represents a limit
on the potential impact of workplace health programming.
Strategies to increase employee participation should consider
factors beyond employee motivation by establishing realistic
participation outcomes and by addressing access, cost, program
design, and supervisor support.24 Moreover, if designers do not
engage employees in the development of programs, they may
be creating interventions that do not meet the real needs and
interests of their intended audiences. We agree with the recent
commentary by Sherman25 who clarifies the importance of
employee engagement and the need to address social deter-
minants of health as a fundamental premise of program design
and implementation. By doing this well, employee participa-
tion in relevant programing within a healthy and safe work-
place may increase, and the long-term impact of health
programming may improve.
The WHA Survey results revealed important insights about
the use of evaluation assessments, administration of worksite
health programming, governance structures, and incentives.
Fifty percent of our respondents with programs reported their
worksite used data to evaluate program success. However,
follow-up questions about evaluation revealed that worksites
doing evaluation were more likely to collect process metrics
such as employee participation (98.3% of those doing evalua-
tion) or employee feedback (89.7%), whereas complex evalua-
tion activities such as calculating return on investment were
rarer (only 57.2% of those doing evaluation reported this). This
is in line with findings from other national surveys, where
activities such as measuring employee satisfaction and partic-
ipation were more common than measuring health outcomes or
return on investment.6,9 The authors of the 2015 Willis Towers
Watson Staying@Work survey noted that “While there’s
plenty of utilization data—77% of employers measure program
participation rates—only 46% measure the impact of the pro-
grams on participants’ health, and even fewer (31%) measure
the effects on productivity. As a result, leaders struggle to build
compelling cases for strengthening their offerings or adding
new ones—or, in some cases, even for maintaining them.”8(p13)
Interestingly, only one-quarter of WHA respondents identified
“demonstrating program results” (eg, doing evaluation) as
“challenging” or “extremely challenging” to their ability to
662 American Journal of Health Promotion 33(5)
offer health promotion programs. One interpretation of these
findings is that many respondents view process evaluation
activities as sufficient to support their worksite’s health promo-
tion programming. However, more detailed analyses (eg, by
size, comprehensive vs noncomprehensive program, and cur-
rent evaluation activities) are needed to understand the unique
needs of different types of worksites as it pertains to building
capacity for evaluation.
With regard to program administration, 72.2% of worksites
with health promotion programming had a designated individ-
ual with responsibility for health programming, and 83.5% of
all worksites had a designated individual responsible for
employee safety. We observed important variation in the types
of health or safety committees responding worksites had in
place, including 41.0% of worksites with programs that had
no employee wellness committee at all. Full engagement of
employees in planning and implementing workplace health and
safety programming has been demonstrated to build ownership,
trust, and can help sustain programming over time.26
Results revealed that more than half of worksites with pro-
grams reported offering incentives. However, almost half of
those offering incentives (48.1%) characterized them as only
somewhat effective at achieving their intended outcomes, and
6.5% said they were not effective at all. Literature on the
impact of incentives is still nascent,27 but while incentives can
increase participation in completing HRAs and other health
programs, long-term effectiveness is mixed, and mismatches
between the type of incentive and the expected outcome may
reduce overall effectiveness.
WHA Survey results also indicate that more worksites are
doing occupational safety and health programming and training
than are doing health promotion programming. This is notable
in light of NIOSH’s TWH®28 initiative, which seeks to inte-
grate health protection and health promotion to advance worker
well-being. Because many employers have safety professionals
and safety programs in place, training programs to build health
promotion onto these efforts is a promising strategy for creating
a healthy work environment. NIOSH has supported Centers of
Excellence for TWH (https://www.cdc.gov/niosh/twh/cen-
ters.html) as well as a national network of TWH affiliates
(https://www.cdc.gov/niosh/twh/affiliate.html) to advance
research, practice, and training on integrated safety and health
programing. The WHA Survey revealed training priorities of
interest to worksites and should help affiliates and Centers
clarify topics and methods that will best meet these training
needs. Since knowledgeable and dedicated staff is crucial to
having a comprehensive health program and staff will need
training on how to best do integrated health promotion and
health protection/safety programming, results provide some
useful guidance for addressing training needs.
Strengths of the WHA Survey include the extensive and
engaged survey development process that involved a Data
User Group, expert input, cognitive interviewing, and pilot
testing. Additionally, this survey created a sample that could
be analyzed by CDC geographic region, worksite size, and
industry sector, which is consistent with previous national
surveys but also added new health topic domains, detailed
information about each health topic offered, and additional
questions on administration of health and safety program-
ming. While we had a supplementary questionnaire, there
were no differential responses between this group and the
respondents to the primary questionnaire, which gives us
greater confidence in our results.
Limitations of the survey include a low overall response
rate, despite a rigorous protocol29 that followed best practices
in survey methodology. This response rate is consistent with
the growing trend that survey response rates have diminished,
especially among employer surveys. In the early 2000s, cross-
sectional household surveys saw response rates drop by as
much as 2 percentage points annually.30 The response rate
(telephone) of the 2004 National Worksite Health Promotion
SO WHAT?
What Is Already Known on This Topic?
Several national employer surveys have been conducted in recent years, but they have not represented all types of employers
What Does This Article Add?
Some progress has been made in workplace health promotion among US worksites; more worksites are offering health promotion programs, including compre- hensive programs. Yet, fewer than 1 of 5 worksites offer comprehensive health promotion programs. Physical activity and nutrition programs are the most prevalent, yet <30% of all employers offer them.
Small employers (which represent over 98% of all employers) consistently offer fewer health programs, services, or policies.
What Are the Implications for Health Promotion Practice or Research?
Regular, repeated surveys of employers to assess WHP and OSH programming would improve benchmarking and give both practitioners and researchers an opportu- nity to identify gaps in research and practice and monitor progress over time. Linking employee-level data to employers would provide additional, useful information to monitor impact of WHP, OSH, and integrated health programming efforts.
Employers are more likely to offer safety than health programming, especially among smaller employers. Inte- grated workplace safety and health programs like those endorsed by the NIOSH Total Worker Health® initiative may represent a promising approach for improving efforts to increase the prevalence and impact of work- place safety and health for employees in all sizes and types of workplaces.
Linnan et al. 663
Survey was 59.7%.5 More recently, the RAND Workplace
Wellness Programs survey had a response rate of 19%,6 the
Kaiser Employer Health Benefits Survey had a 17% response
rate among first-time respondents,9 and the Employee Total
Health Management survey (fielded with Iowa employers in
2012) had a response rate of 21.5%.31 We conducted a non-
response bias analysis for known characteristics (size, industry,
and region) of responding and nonresponding worksites and
found no systematic differences. If the survey outcomes of
interest are related to other, unknown characteristics, there is
potential for bias. For example, we cannot be certain whether
worksites with health promotion programs or interest in health
promotion were more likely to respond. The WHA Survey
sample was drawn to be proportionally allocated across size
and industry strata within each CDC region, and final analysis
weights accounted for nonresponse and matched the frame-
based distribution of eligible US worksites by region, size, and
industry. Another limitation is that despite a standardized pro-
tocol, we cannot be sure we interviewed the most informed
person on workplace health and safety at any given location.
Finally, survey results are based on self-report from employers.
There was no independent verification of responses to reduce
concerns of social desirability bias nor was it possible to get
employee data to complement employer data. Future surveys
would benefit from employee-level data like the Harris Poll
Nielsen Survey.7
Results of the WHA Survey will be widely disseminated. A
public datafile and dashboard through the CDC Workplace
Health Promotion website (https://www.cdc.gov/workplace
healthpromotion/data-surveillance/index.html) will make these
data publicly available. We believe this is an important strength
of the survey and hope the national, industry, employer size,
and regional-level estimates will be used to benchmark local,
state, regional, and national objectives around workplace
health and safety programming. Current and accurate data are
also essential to identify needs and set priorities for research
and practice; therefore, repeat administrations of the national
survey on a regular interval would establish longitudinal data
and allow for trend comparisons over time. Thirteen years
between administrations hinders the progress that we can make
in research and practice to strengthen both worker and work-
place health.
Authors’ Note
The findings and conclusions in this article are those of the authors and
do not necessarily represent the official position of the Centers for
Disease Control and Prevention.
Acknowledgments
With gratitude to the WHA National Steering Committee, Data User
Group, and WHA Survey Development Group for your insights and
expertise that shaped the development of the WHA survey. Thank you
to all participating worksite representatives for your time and contri-
bution to advancing knowledge about US workers and worksites.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: This work
was supported by the CDC National Center for Chronic Disease Pre-
vention and Health Promotion as a project by RTI International, sub-
contract to University of North Carolina at Chapel Hill [contract
number GS-10F-0097L/200-2014-F-60862].
ORCID iD
Maija S. Leff https://orcid.org/0000-0002-2127-7565
Supplemental Material
Supplemental material for this article is available online.
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