The Emerald Research Register for this journal is available at The current issue and full text archive

xt archive of this journal is available at

www.emeraldinsight.com/researchregister www.emeraldinsight.com/0965-4283.htm

HE
105,2 Health at work in small and
medium sized enterprises
Issues of engagement
126
Barbara L. Griffin, Nicky Hall and Nigel Watson
University of Sunderland, Sunderland, UK
Received October 2003
Accepted May 2004

Abstract
Purpose – This paper aims to explore a health at work initiative (“Fair Chance at Work”) for small
and medium sized enterprises (SMEs) and identify opportunities for improving engagement of
businesses in such activities.
Design/methodology/approach – A case study approach is used
Findings – Two problems are identified - engagement and participation. A model of engagement
incorporating aspects of Prochaska and DiClemente’s transtheoretical model of behaviour change is
proposed based on findings from the case study and existing literature. It is concluded that improving
the engagement of SMEs requires a greater understanding of their current needs, perceptions and
attitudes towards health at work. Schemes such as the Teaching Companies Scheme could be useful in
testing the model.
Research limitations/implications – The Teaching Companies Scheme could be useful in testing
the model.
Practical implications – These findings may inform the development of health promotion projects
to SMEs using an applied model behaviour change.
Originality/value – This paper is useful to health promotion workers when developing projects in
SMEs.
Keywords Health and safety, Small to medium-sized enterprises, Employee participation,
United Kingdom
Paper type Case study

Introduction
Context and aims of this paper
This paper draws on a health at work project, “Fair Chance at Work” (FCAW) that
targeted small and medium-sized enterprises (SMEs) in the North East of England.
FCAW was a sub-regional project initiated by three health promotion departments in
Tyne and Wear. It was specifically developed to incorporate recommendations of best
practice including a multidisciplinary perspective, a flexible approach, targeting the
individual needs of SMEs and offering a range of support and available resources in
relation to health initiatives. Nevertheless, FCAW failed to recruit more than a handful
of SMEs, some of which were already committed in some way to health promotion in
the work place. Therefore, this paper explores lessons that can be learnt from the
Health Education
Vol. 105 No. 2, 2005 The authors wish to thank all the participants who took part in the telephone questionnaire and
pp. 126-141 the “Fair Chance at Work” co-ordinator from the Newcastle and North Tyneside Health
q Emerald Group Publishing Limited
0965-4283
promotion department. Thanks are also due to the advice from Soumen Sengupta, Kevin Paton
DOI 10.1108/09654280510584571 and the reviewers of this paper.
problems encountered, what is achievable in this area and the overall value of such Health at work in
projects. A case study approach is used, which draws on the project’s rationale, current SMEs
literature, and comments from the participating SMEs. This paper contributes data on
the range of broader health at work activities taking place within SMEs in the UK
rather than focusing specifically upon health and safety.

Health at work in SMEs 127

Existing research on health promotion initiatives in SMEs is limited in both the health
and the business literature. Moreover, most investigations into determinants of low
participation in health promotion programmes are concerned with low levels of
employee participation. Worksite engagement level, meaning the number of
organisations that participate, and associated participation issues have received
little attention (Linnan et al., 2001). Much of the literature that is available originates
from Canada or the USA and may not be specifically applicable to the UK. The
situation in North America is not directly comparable to the one in the UK because the
employer is much more likely to be closely involved with health insurance provision
than is the case in the UK. They are interested in employee assistance programmes
(EAPs) because this can reduce their insurance costs. Additionally, making
comparisons between research studies involving small businesses is problematic
due to inconsistent definitions of SMEs (Harms-Ringdahl et al., 2000). Nonetheless, the
Small Business Service defines an SME as a business with less than 250 staff, with
small businesses having less that 50 and medium-sized having from 50 to 249
employees (Small Business Service, 2001). It has been estimated that they provide
employment for over 74.5 million people and are responsible for around two thirds of
total employment in the UK. According to Hillary (2000), SMEs contribute to 90 per
cent of the gross national product in Europe. The Confederation of British Industry
(2001)) estimated that there were 3.7 million SMEs in the UK at the start of 1999. The
majority of these (98 per cent) had less than 50 employees.
In general, larger businesses are much more likely to offer a range of health
promotion programmes than smaller businesses. The Health Education Authority
(HEA) survey, Health Promotion in the Workplace (see Gee et al., 1997) showed that
only 18 per cent of companies with less than 25 employees had initiated 2 or more
health related programmes compared to 74 per cent of companies with over 500
employees. It was concluded that the number of programmes tends to increase with
workplace size; however, this data relates to lifestyle health promotion programmes
only (Gee et al., 1997).
In the USA, Wilson et al. (1999) found that the most common programmes for
worksites with 15-99 employees were those related to occupational safety and health,
back injury prevention and Coronary Pulmonary Resuscitation (CPR). Small worksites
offered health insurance to their employees at a rate only slightly lower than that of
large work-sites (Wilson et al., 1999). In Canada, Ashley et al. (1997) found that small
workplace workers were least knowledgeable about smoking restrictions, reported
fewer restrictions and were least willing to intervene in co-workers smoking. Data from
Eakin and Weir’s (1995) survey of health promotion in Canadian small businesses
suggest that health promotion programmes draw on a segmented rather than holistic
view of health. They called for an integration of lifestyle and occupational approaches
to workplace health.
HE In the UK, the need for a multidisciplinary approach to health at work, including
105,2 health and safety, health promotion and occupational health professionals is
highlighted by Houston et al. (1999). The authors point to the existence of core areas
common to both health promotion and health and safety, for example, alcohol, drugs
and smoking. In recent years, there has been an increased emphasis within public
health strategies on partnership working and inter-professional collaboration to
128 improve the delivery of public health and health promotion actions (Markwell and
Speller, 2001). Partnership working is an important aspect of the Government’s White
Paper, Saving Lives: Our Healthier Nation (Department of Health, 1999) and is an
essential part of reducing inequalities in health. The Health and Safety Commission’s
(2000) Small Firms Strategy aims to “make small firms healthier and safer for those
who work in them and for others affected by their activities” (Health and Safety
Commission, 2000 p. 1). This involves close partnerships with local authorities,
employers, trade unions and business partnerships (Health and Safety Commission,
2000). Nevertheless, Houston et al. (1999) states that:
It would appear that where lifestyle issues are affiliated to legislation there is a higher level of
implementation by company management. . .little emphasis is placed upon those health
promotion issues without legislative commitment but which could contribute to the overall
well-being of individuals and thus enhance the wellness of the workplace (Houston et al.,
1999, p. 108).
This indicates that SMEs’ engagement with health promotion issues is low. Moreover,
SMEs often struggle to comply with even basic health and safety requirements (Lamm,
1997; Health and Safety Executive (1998); Dugdill et al., 2000; Tait and Walker, 2000a).
Furthermore, evidence suggests that risks to the health of people working in some of
these businesses are greater (Harms-Ringdahl et al., 2000; Tait and Walker, 2000a).

SMEs – “Hard to reach”

The failure of SMEs to tackle health at work issues and to engage in health at work
initiatives has been explained in relation to a range of organisational and cultural
factors. For instance, Eakin and Weir (1995) describe SMEs as hard to reach because
“a) they lack the resources and the motivation to deal with health issues and b) there
are few organisational mechanisms for communicating with them, that is they are less
likely to have links with trade unions or trade associations” (Eakin and Weir, 1995,
p.109). SMEs tend to be predominantly private companies and owner managed. They
have flatter management structures than most large companies and unlike them have
few, if any, in-house human resource or occupational health departments (Vassie et al.,
2000; Confederation of British Industry, 2001). Health promotion specialists (HPSs)
might expect these organisations to have a greater need for assistance and support in
understanding and developing health at work. The government recognises this in the
National Health Service (NHS) Plan (Department of Health, 2000a). The NHS is aiming
to improve partnerships with private sector employers by offering a range of services
such as advice, information, and pre-employment health checks as well as occupational
health services under the NHS Plus scheme (Department of Health, 2000b).
As well as organisational determinants, another barrier may be the perceived lack
of evidence of the benefits of health at work interventions. For instance, the costs of ill
health in the workplace are often quoted as an incentive for implementing health
promotion (Gee et al., 1997). Nevertheless, the perception of the economic benefits of
health promotion interventions in the UK is not measured and formal cost benefit or Health at work in
cost effectiveness studies are rare (Gee et al., 1997; Springett and Dugdill, 1999). SMEs
Yet another difficulty is, no doubt, that today’s business environment is becoming
increasingly competitive. This seems to be particularly so within Tyne and Wear
where the average survival rates for businesses are lower than both the North East and
the UK overall (Tyne and Wear Economic Assessment, 2001). Companies need to be
able to respond to the ever-increasing pace of change and keeping up with technology 129
and regulation takes an increasing amount of management time (Vassie et al., 2000;
Confederation of British Industry, 2001). The competitive environment for SMEs
extends beyond the market and into the successful recruitment and retention of
talented staff. In this context, Michaels et al. (2001) draw attention to the so called war
for talent. They suggest that the most important business resource will be talent and
that companies will compete to attract and keep the brightest and most able staff. In
this context there may be an opportunity for companies to use EAPs as part of their
overall HR strategy. In the UK, this has been a feature of the public sector, where less
autonomy over local pay arrangements has encouraged the development of employee
support programmes aimed at retaining staff and becoming employers of choice. This
context may provide an incentive for SMEs to look at the ways in which health
promotion programmes could assist them in the war for talent.
Despite the difficulties facing SMEs, attitudes to health at work in SMEs have been
reported to be positive (Vassie and Cox, 1998, Harms-Ringdahl et al., 2000). Thomas
and Sadler (1995, p. 421) concludes that SMEs are “enthusiastic about occupational
health issues in principle rather than practice”. Furthermore, Dugdill et al. (2000)
suggests that small business will take up health and safety support if it is offered in an
appropriate way, at an affordable cost and is relevant to the immediate needs of the
business.

Methods
This section will outline the rationale behind the choice of a case study approach that is
qualitative and draws on an interpretative paradigm.
Bowling (2002) argues that case studies are valuable for exploratory research where
generating hypotheses is a key feature. The single case study contributes to the
understanding of a wider situation, although the material is not necessarily
generalisable. The FCAW project was thought to be especially relevant for a case
study approach as the implementers had attempted to incorporate good practice from
the literature available; however, the response rate was particularly low when
compared to other studies. This offered an opportunity to learn from those aspects that
appeared to have been unsuccessful and propose a framework that would assist in
analysing the reasons for the low uptake. Therefore, FCAW was regarded as a
bounded project and drawing on Stake (2000) is an instrumental case study because
this approach provides insight into an issue and advances understanding.
The researchers explored the problems and processes involved in engaging and
maintaining active support from SMEs involved in the FCAW project. In order to
achieve this, data was collected from the following sources: the project manager,
documentation, and participating employers. The majority of data was collected
during the evaluation of the project by the authors during 2001. This included: the
background to the project, historical account of the recruitment/engagement onto the
HE project (qualitative and quantitative), project documentation and correspondence to
105,2 SMEs, statistics on participants including participation by district, business activity
and size, stated health at work needs, telephone interview with participating and
non-participating employers who agreed to take up services offered. The telephone
interview included questions on the attraction of the project, benefits and barriers to
participation and satisfaction with FCAW.
130 Through the case study approach the particular and general features of the FCAW
project are examined, many aspects of which are specific to FCAW and in particular to
the Northeast region. Nevertheless, the authors believe that this case study also offers
insight into future engagement of SMEs in workplace health promotion projects in
other areas. Stake (2000 p. 437)) provides a taxonomy of issues that facilitate the
undertaking of a particular case study. This taxonomy provides the structure for the
study drawing on the following areas:
.
the nature of the case;
.
the case’s historical background;
.
the physical setting;
. the wider issues including the economic, political and legal contexts;
.
comparison with other case studies in order to recognise the case; and
.
informants about the case.

Results
Aim of this section
The aim of this section is to draw on Stake’s (2000) instrumental case study taxonomy
in order to describe the FCAW project, processes that took place and aspects of the
evaluation. We then outline lessons that can be learnt from the experiences of FCAW
and, finally, discuss the implications in relation to engaging SMEs in health at work
initiatives.

The nature of the case and historical background

This section provides a detailed description of the nature and the background to the
FCAW project.
FCAW was part of the Tyne and Wear “Health @ Work” Initiative, a cross-district
partnership to tackle the causes of ill health by implementing a health promoting
strategy in the workplace setting. The Tyne & Wear “Health @ Work” Award was a
major element of the initiative (Griffin et al., 2002). The health promotion departments
of Newcastle and North Tyneside, Gateshead and South Tyneside and Sunderland
worked intensively with SMEs to identify barriers in building health at work into
corporate culture because it was felt that SMEs were not engaging in other aspects of
the initiative. Links to other organisations and access to additional resources such as
health and safety advice provided a focus for the project. Funding was provided by a
grant from the Tyne and Wear Health Action Zone (HAZ). The co-ordinator from the
Tyne and Wear “Health @ Work” Award was appointed project manager for FCAW
and took an active role in all aspects of project implementation. A HPS from each of the
three Health Authority districts recruited and invited participants to information
meetings within the districts including: the local chamber of commerce, a business link
advisor, an economic development officer, an environmental health officer and the Health at work in
regional HAZ co-ordinator. Backing from sources seen as credible to SMEs was felt to SMEs
be important. Letters endorsed by a range of organisations and flyers were sent to 480
SMEs. Correspondence focused on the opportunity for SMEs to take advantage of free
services to promote health at work according to their needs. Two districts targeted
businesses in areas of public health special action. The other focused on retail and
hotels, a business area that typically attracts low rates of pay, in order to target SMEs 131
with employees from lower socio-economic backgrounds. Only four organisations
responded to the mailshots. Due to the low recruitment, each HPS subsequently
worked with their local chamber of commerce to contact members. Hosting two
meetings and posting more letters resulted in 13 additional commitments. This seems
to confirm the view that personal contact and word of mouth strategies are likely to be
more effective in marketing “unsought” (i.e. where no existing need is perceived) goods
or services (Tait and Walker, 2000a).
Of a total of 17 respondents, only 15 organisations finally agreed to participate.
Organisations actively involved in FCAW covered a total of 672 employees and a range
of business activities from the region. These included manufacturing, retail/wholesale,
financial and business services, and catering/hotels. Ten of the organisations had less
than 50 employees; the remaining five had less than 250 employees.
HPSs visited all 15 organisations and helped to identify possible health priorities
based on a verbal audit. All were recommended to consult with their staff to identify
key areas of interest. All 15 gave a verbal commitment to the project. Participants
agreed that a seminar format based on identified needs with half-day seminars would
be acceptable. A seminar programme was put together based on the stated needs of the
organisations, consisting of nine half-day seminars over the period of July 2000 to
March 2001. These seminars were also made available to the wider group of
organisations known to health promotion departments, increasing cost effectiveness
and the opportunities for networking. Consultancy and small grants were offered to
assist organisations with their chosen health at work priorities. Partnerships with
other organisations such as the local chamber of commerce, environmental health
departments and occupational health services occurred at all levels of the planning and
implementation of the project. This allowed FCAW to link in with other local health
initiatives such as: the “Health @ Work” Award (Griffin et al., 2002), Back Awareness
in Tyne and Wear (2001), smoking cessation and mental health campaigns.
All the services were offered free of charge and emphasis was placed on meeting the
individual needs of each organisation. HPSs invested time to ensure that those
recruited participated fully in the project. Each organisation was visited and offered
ongoing support and contact with a nominated HPS. The Project Manager maintained
regular contact and sent reminders for each of the seminars including requests for
feedback on the appropriateness of the seminar format of the project. Despite a
re-launch in September 2000, ongoing correspondence (November 2000, January and
March 2001) and publicity for each seminar in the form of flyers, faxbacks and
follow-up phone calls, six of the 15 organisations attended none of the seminars nor
took up the offer of consultancy or grants. The initial response rate to the project was
2.7 per cent. This fell to 1.6 per cent since some organisations subsequently made no
attempt to attend seminars or take up consultancy.
HE The physical setting
105,2 The physical setting of the case study was the health promotion units and the SMEs in
the Tyne and Wear region in the North East of England. By targeting small
organisations in Tyne and Wear, FCAW aimed to address some of the health needs of
the working population of one of the most deprived regions in the country. 48 of the 113
wards in Tyne and Wear have been identified as having the poorest health records in
132 the UK (Tyne and Wear Health action Zone, 1999). There is higher unemployment than
the rest of the country and the average weekly earnings of those in work is about 91 per
cent of the national average (Tyne and Wear Economic Assessment, 2001). It was
decided to specifically target SMEs as these companies typically have little existing
resources to develop health at work, are less likely to offer existing health promotion
programmes (Gee et al., 1997) and often struggle to comply with health and safety
requirements (Lamm, 1997; Health and Safety Executive, 1998; Dugdill et al., 2000; Tait
and Walker, 2000a).

The wider issues including the economic, political and legal contexts
The wider context of this case study includes elements previously mentioned in the
introduction, such as the number of people employed in SMEs, SMEs as hard to reach
organisations, the aim of the NHS to improve partnerships with the private sector, the
legal issues related to health and safety at work and reducing inequalities in health.
The White Paper, Saving Lives: Our Healthier Nation (Department of Health, 1999)
identifies the workplace as a key setting for improving health and reducing
inequalities. The Healthy Workplace Initiative, jointly sponsored by the Department of
Health and the Health and Safety Executive, aims to establish health at work as an
integral part of workplace culture, benefiting employers, employees and the local
communities that provide the workforce (Department of Health, 2001). It has been
recognised that the needs of SMEs are not always taken into account (Vassie and Cox,
1998; Tait and Walker, 2000b; Griffin et al., 2002) and one of the aims of FCAW was to
redress this balance and assist SMEs in accessing help. Daykin and Doyal (1999)
suggest health promotion in workplaces aims to broaden the remit of work-related
illness interventions; however, in addressing lifestyle and behaviour issues, there can
be a reduction in attention paid to hazards in the workplace because of the individual
focus rather than a focus on the setting. FCAW attempted to address these issues.

Informants about the case

This section will include some of the qualitative responses typical of the employers
who took part in FCAW to indicate the benefits and barriers of FCAW. Information
was gathered from telephone interviews with active participants in FCAW and those
who offered their commitment but failed to participate (non-active). Other informants
in the case study include the project manager and the HPSs with a responsibility for
health in the workplace.
Benefits, barriers and opportunities. Participants reported a high level of satisfaction
with the project. The most frequently reported benefits were consultancy and training,
focus of health and safety and an increased awareness of health at work issues.
Comments on the project being useful included: “The way things have changed since
the first contact”, “Focus on what we need to do, not alone in this work.”, “Transformed
our views on health issues”. Active and inactive participants recognised the value of
the ongoing support and facilitation from the health promotion departments. Different Health at work in
levels of support required by different organisations helped to maintain momentum SMEs
within the organisations that actively participated. The contact with health promotion
departments led to: “A review of where we were, recruit a safety officer ‘Fair Chance at
Work’ gave the impetus for this action”, “Someone to come and do an audit on health
and risk assessment”.
The initial audit, the health survey, and the seminars provided access to networks 133
as well as information. “Risk assessment” was the best attended seminar as well as the
most common issue for grants and consultancy. Attendance at the seminars provided,
in some instances, staff development opportunities and an improved involvement with
management. The issues raised by the participating organisations indicate the
potential benefits of partnerships between health promotion and SMEs.
The dominant difficulties in taking part for organisations included, not
surprisingly, aspects of time, staffing problems and other pressing priorities: “No
time to spend on the project”, “It has been a very difficult year”. “Pushed to time-scales.
We are here to make money sometimes other time-scales more important”, “Cannot get
cover to come to meetings, lack of time, other business priorities”. The difficulties
reported by non-active organisations were similar to those who were active. One
non-active respondent stated “personal issues reduce action I can take with staff, lack
of interest from staff”. Reference to personal issues demonstrates an awareness of the
sensitivity of the content of health at work. Implementation of health related issues
required co-operation between groups of people in one organisation but in another
organisation there was “difficulty in getting people together to discuss the
organisation’s skills”.

Discussion
It is clear that FCAW failed to attract more than a handful of SMEs, despite
endorsement from credible sources, the offer of free multidisciplinary services,
including health and safety, and support tailored to individual needs. Given that the
greatest problems encountered were both initial engagement and the retention of
companies, we now want to consider these difficulties in the light of the current
literature and then to propose an alternative model of engagement.

Focus of project and perception of needs

According to the principles of social marketing, consumers must perceive they have a
genuine problem and that the product is offering a good solution to the problem
(Weinreich, 1999). Basic health and safety support was identified as the most important
health priority for small businesses during a detailed consultation with local small
businesses, as part of the initial development of the SAS project (Dugdill et al., 2000,
p. 159). This was offered within FCAW along with the opportunity of choosing
individual priorities. Nonetheless, the FCAW promotional literature included this
within a general base drawing on a wider workplace health programme incorporating
personal lifestyle issues, legislation and hazards at work. Arguably, there is a
recognition of the value of integrating all three in the literature available (Houston et al.,
1999); however, our argument here is that general health issues may obscure more
specific aspects available within the project. Employers, especially SMEs with limited
resources and lack of specialist personnel, are more likely to perceive an immediate
HE problem in complying and understanding health, safety and welfare regulation. They
105,2 may be unclear as to what a holistic view of health at work may entail, so will be
unlikely to perceive themselves as having a problem achieving it.
The main aim of FCAW was to provide an introduction to health at work; however,
in order for companies to participate, they have to perceive a need for such an
introduction, and they also need to view FCAW as an appropriate solution to their
134 problem. They may not accept that participating in FCAW would achieve any real
improvement in the “health” of their workforce or that of the region. Additionally, they
may not perceive this activity as part of the responsibility of an SME especially
without legislative requirement or direct benefit. The main attraction to the SAS
project was the offer of a free health and safety starter pack which was taken up by 94
per cent of respondents (Dugdill et al., 2000). This demonstrates where a common
perceived need seems to lie.

Shared values and understanding: health promotion and SMEs

Those organisations able to maintain active involvement in FCAW recognised the
benefits and were satisfied with the project as a whole. One explanation may be that
those who could see the benefits of the project at the initial stages, and already shared
similar values to those of the health promotion staff in regards to health at work, were
most likely to participate in the first place. The same underlying principle seems to
apply across a range of what are often perceived as “non-essential” activities when
working with SMEs, such as training and staff development. For instance, after
evaluating the European Social Fund objective 4 programme, Devins and Johnson
(2002) concluded that SMEs most likely to take part in training were those who already
had some form of commitment to training and development and needed resources and
support to develop this further. This may apply equally as well to health at work
initiatives. Similarly, Smith and Whittaker (1998) identified a need to research the level
of awareness of opportunities available to SMEs for developing their staff, their
attitudes towards the variety of initiatives and the degree of take up. They concluded
that SMEs are unsure about the value of training in general as well as being unclear
about potential benefits to business performance. Indeed, evidence supporting the
impact on business effectiveness of both staff development and health at work
initiatives tends to be inconclusive and can be problematic to measure (Gee et al., 1997;
Smith and Whittaker, 1998; Devins and Johnson, 2002).

Proposed model of engagement

In order to explain the above-mentioned issues in more detail, the following section will
look at the engagement process in terms of Prochaska and DiClemente’s (1984)
transtheoretical model of behaviour change. The original model was developed to
explain individual health behaviour in relation to smoking and includes five stages of
behaviour change. First, pre-contemplation, meaning that an individual was not
actively thinking about the health issue. Second, contemplation, meaning the
individual was thinking about the health issue. Third, preparation, meaning that the
individual intends to engage in a change of behaviour or behaviours. Fourth, action
meaning, engaging in the appropriate health behaviour or behaviours. Fifth,
maintenance meaning, an individual continuing with the new health behaviour or
behaviours. Other theoretical constructs also form part of the model. For example, it
has been proposed that there are ten experiential and behavioural processes of change Health at work in
which people use when changing behaviour and these are used differentially at each SMEs
stage of change (Perz et al., 1996). Additionally, constructs such as self-efficacy and the
perceived benefits and disadvantages of changing the behaviour are also proposed to
affect stage transitions. Although not without criticism (see Sutton, 2000), the
transtheoretical model, along with other stage models, have seen an increase in
popularity over the past decade within the fields of health psychology and health 135
promotion. These models all share the view that behaviour change is a dynamic
process involving movement through a sequence of distinct stages. Individuals can
move back and forth between stages before achieving long-term behaviour change.
The transtheoretical model has been used by health promoters to identify the most
appropriate intervention required at different stages to enhance successful behaviour
change in individuals. The model has been applied to other health related individual
behaviours as diverse as pregnancy and Sexually Transmitted Diseases prevention
(e.g. Horowitz, 2003), exercise behaviour (e.g. Cropley et al., 2003) and mammography
adoption (e.g. Lauver et al., 2003).
We want to explain how far the transtheoretical model can be adapted to explain a
complex range of health behaviours at an organisation level, to provide a useful
starting point in trying to ascertain why the response to FCAW was so low and how to
address the problem in the future. Extending this model to an organisational level
provides the opportunity to imply, at least on a theoretical basis, a range of possible
explanations as to why businesses were not attracted or failed to participate in FCAW.
First, SMEs may have already been in the action or maintenance stages and were
already doing all they could to become a healthy workplace. In which case, although
they may have had positive attitudes to health at work and possessed the structural
and/or cultural aspects necessary to enable activities of this sort to take place, FCAW
would not have be seen as offering an acceptable solution to their needs. They may, for
example, be receiving assistance from alternative sources. Second, in contrast, SMEs
may have been in a pre-contemplation phase with regard to health at work. This stage
is characterised by a “lack of awareness of the problem (behaviour) or the lack of desire
to change” (Perz et al., 1996, p.462). The failure of FCAW in engaging SMEs could
therefore be explained as a misplaced assumption of shared values and general
understanding. Finally, it could be argued that SMEs in the preparation or action
stages would be most likely to respond to these sorts of initiatives. The former stage is
typified by “a growing awareness of the problem and potential solutions and where the
change in intention becomes more proximal” (Perz et al., 1996, p.462) and the latter by
more observable behavioural changes. The findings from Dugdill et al. (2000) would
suggest that the health and safety starter pack offered and taken up by 94 per cent of
respondents enabled the SMEs already in the preparation stage to move to the action
stage. The model also provides a useful way to understand those SMEs who were
attracted to FCAW and yet who subsequently failed to maintain their participation
despite reporting the same barriers as those who actively participated. The stages of
change have been illustrated as a spiral whereby individuals may cycle and recycle
before achieving long-term behaviour change. This may also be applicable at an
organisational level. Figure 1 illustrates the proposed model of engagement.
A theoretical model of engaging SMEs in health at work projects is therefore
proposed based on lessons learnt from the FCAW project and related literature. It
HE
105,2

136

Figure 1.
Proposed model of
engaging SMEs in health
at work projects

incorporates aspects of communication theory (Macdonald, 1992), whereby the source,

target, type and medium of any communication is an important factor in its
effectiveness, Prochaska and DiClemente’s (1984) transtheoretical model and social
marketing (Weinreich, 1999). In line with Tait and Walker (2000a), it is perhaps not
solely a question of what is on offer, but also how it is packaged and marketed. Their
paper discusses the benefits of applying principles of marketing to address the
apparent reluctance of SMEs to take up the opportunity of using health and safety
consultants. They propose strategies useful for creating a perceived need for otherwise
“unsought” goods or services and reducing levels of high risk often associated with
purchasing services of this kind. As discussed earlier, for example, the use of personal
contact and word of mouth is seen as effective in marketing this type of service. Using
aspects of the transtheoretical model, our argument takes this a step further and
proposes that different strategies could be used to market health at work to SMEs at
different stages of the contemplation process. Therefore, it is suggested that for every
stage, the appropriateness of the product, price, credible source, medium and type of
communication will differ. In order to increase levels of engagement, these all need to Health at work in
be considered before promotional material for health at work initiatives is developed. SMEs
For instance, there might be a need to provide material that raises awareness of health
at work issues for organisations in the pre-contemplative stage whereas more specific
promotional material on health legislation might be required for those who are
preparing to engage in health at work projects.
Furthermore, the influence that external sources can have on SME attitudes and 137
readiness to take on such projects is not to be underestimated. Factors at the national,
regional and local levels originating from a variety of sources such as government,
business, and local media can all have such an effect. Social, environmental and even
personal factors will also have a role to play in whether a small business shows interest
in a health at work initiative. From a social marketing point of view, accurate market
research is the key to successful marketing of a product or, in this case, a project and
awareness of the attitudes to health at work within a particular company would be an
advantage. The planning and preparation stages are more important than the actual
engagement process itself, including increasing familiarity with the subject via as
many different means as possible.
The model illustrates the proposed focus specific to each stage to enable successful
transition to other stages. The model also highlights the change in awareness of
perceived costs and benefits and shared understanding and values across the stages as
well as the likelihood of cultural and structural aspects being in place to support health
at work activities.

Engagement
The engagement rate with the FCAW project was low; however, this is a common
problem working with SMEs (Houston et al., 1999; Vassie and Cox, 1998;
Harms-Ringdahl et al., 2000). Additionally, this may reflect issues surrounding the
economic climate specific to Tyne and Wear. On the other hand, other UK studies on a
similar theme, Thomas and Sadler (1995), Houston et al. (1999), Dugdill et al. (2000) had
higher response rates of 33 per cent, 31 per cent and 20.5 per cent respectively. It is
because of the particularly low engagement rate with FCAW, despite attempts at
implementing best practice, that FCAW offers the opportunity to identify lessons to be
learnt from this failure. Furthermore, those projects with high participation rates and
successful programs are most likely to be published in the literature. This may provide
an unbalanced view of the difficulties faced by such projects as there is no data
available to identify their rate of failure or success. This following section covers a
discussion of what is achievable and the implications on resources.

What is achievable?
Participation in any initiative that involves a “longer term” vision and that has real or
perceived resource implications may be problematic for SMEs. Similar government
initiatives in skills development (Chaston et al., 1999) are analogous and will contribute
an insight on engagement. Similarities with health at work programs include findings
that situational factors such as lack of time, resources and management support have
been found to reduce levels of engagement (Stockols et al., 2001), they offer unclear
benefits of participation and employers as well as employees seem to be unsure of their
value (Smith and Whittaker, 1998; Chaston et al., 1999).
HE Furthermore, the notion of free services is not always accurate. For instance, there
105,2 are many perceived indirect costs such as the amount of management time needed for
continued involvement in a free service (Biondi et al., 2000). The evaluation of the
European Social Fund objective 4 programme concluded that while training
interventions positively contributed to the establishment of HR practices and were
perceived by managers to have met the needs of the SME, the majority of SMEs
138 participating were already involved in training (Devins and Johnson, 2002). Attracting
those who do not already value the initiative will always be more problematic as
indicated by our model of engagement.
Nevertheless, health at work initiatives seem to be advantageous in that certain
aspects are covered by legislation. This may provide a useful tool in attracting SMEs;
however, SMEs have particular requirements and differ substantially in terms of
cultural and structural aspects. Applying methods from large firms is unlikely to be
appropriate. Engaging SMEs in health at work initiatives requires health professionals
to seek a more in-depth understanding of individual contexts and priorities than is
currently being achieved (Marlow, 1998; Champoux and Brun, 2003).

Resource implications
The use of finite resources in promoting health at work in SMEs faces similar
quandaries to other areas such as training. The actual impact on business effectiveness
is problematic to measure and the evidence inconclusive. There are policy decisions to
be made in favour of supporting those already committed or increasing awareness in
those with no commitment (Devins and Johnson, 2002). Are the costs of carrying out
such programmes justified from the perspective of health professionals as well as the
SMEs themselves? The satisfaction and benefits reported by the employers in the
FCAW program would seem to indicate that health at work initiatives can increase
awareness and improve health practices in SMEs. The actual value of these reported
benefits needs to be evaluated not only in terms of short term financial costs / benefits
but also in terms of longer term actual or potential health outcomes.
Further research is required, first, to ascertain the current perceived needs and
attitudes of SMEs to health at work, and second, to assess what action is likely to be
most beneficial taking into account the stage of engagement of each company.

Conclusion
The previous sections described FCAW using a case study approach in order to
illustrate the main problems encountered when engaging SMEs and maintaining
participation. Our conclusion is that the proposed model of engaging SMEs in health at
work activities based on findings from the literature, the transtheoretical model of
behaviour change, communication theory and aspects of social marketing could
increase levels of engagement with SMEs. Nonetheless, making any conclusions from
the existing SME literature is problematic for a number of reasons. For example, one
cannot make assumptions about the nature of the SME, and business type and sector
are not always taken into account (Marlow, 1998). Additionally, studies that have failed
to recruit are rarely reported, whilst those who have are likely to have participants who
are already committed or have prior awareness of the area.
More in-depth knowledge about the attitudes, values and existing health at work
activities in SMEs is needed. This could be achieved with schemes such as the TCS
where we plan to test our model of engagement. Problems in operational stage Health at work in
definitions and measurement of change need to be overcome as with any research SMEs
based on the transtheoretical model (Sutton, 2000).
The benefits and cost effectiveness, financial and otherwise, of such initiatives need
to be more formally assessed. More collaboration between the various agencies and the
SMEs themselves may prove to be mutually beneficial in this area. Findings from
FCAW suggest that SMEs identify a range of benefits and that these need to be 139
included in developing and evaluating further health at work schemes targeting this
area. It may be precisely the reasons why SMEs find engaging and participating in
these initiatives difficult, which make it important that they receive the support to do
so. Finally, raising awareness is likely to be an important outcome in its own right.

References
Ashley, M.J., Eakin, J., Bull, S. and Pederson, L. (1997), “Smoking control in the workplace: is
workplace size related to restrictions and programs?”, Journal of Occupational and
Environmental Medicine, Vol. 39 No. 9, pp. 866-73.
Back Awareness in Tyne and Wear (2001), Final Report, BAIT, Tyne and Wear Health
Promotion Department, Sunderland.
Biondi, V., Frey, M. and Iraldo, F. (2000), “Environmental management systems and SMEs”,
Greener Management International, No. 29, Spring, p. 55.
Bowling, A. (2002), Research Methods in Health, 2nd ed., Open University Press, Buckingham.
Confederation of British Industry (2001), Facing the Future: Report Analysing the Business
Environment for SMEs, CBE SME Council, London, available at: www.cbi.org.uk/
pdf/SME_council.pdf (accessed 2001).
Champoux, D. and Brun, J.P. (2003), “Occupational health and safety management in small size
enterprizes: an overview of the situation and avenues for intervention and research”,
Safety Science, Vol. 41 No. 4, pp. 301-18.
Chaston, I., Badger, B. and Sadler-Smith, E. (1999), “Organisational learning: research issues and
application in SME sector firms”, International Journal of Entrepreneurial Behaviour and
Research, Vol. 5 No. 4, pp. 191-203.
Cropley, M., Ayers, S. and Nokes, L. (2003), “People don’t exercise because they can’t think of
reasons to exercise: an examination of causal reasoning within the transtheoretical model”,
Psychology Health and Medicine, Vol. 8 No. 4, pp. 409-14.
Daykin, N. and Doyal, L. (Eds) (1999), Health and Work: Critical Perspectives, Macmillan,
Houndsmills.
Department of Health (1999), Saving Lives: Our Healthier Nation, The Stationery Office, London.
Department of Health (2000a), National Health Service Plan, HMSO, London.
Department of Health (2000b), National Health Service Plus Scheme, HMSO, London.
Department of Health (2001), Workplace Initiative, available at: www.signupweb.net/About
_initiative/new_text.asp (accessed 2 May 2001).
Devins, D. and Johnson, S. (2002), “Engaging SME managers and employees in training: lessons
from an evaluation of the ESF Objective 4 Programme in Great Britain”, Education þ
Training, Vol. 44 No. 8/9, pp. 370-7.
Dugdill, L., Kavanagh, C., Barlow, J., Nevin, I. and Platt, G. (2000), “The development and uptake
of health and safety interventions – aimed at small businesses”, Health Education Journal,
Vol. 59, pp. 157-65.
HE Eakin, J.M. and Weir, N. (1995), “Canadian approaches to the promotion of health in small
businesses”, Canadian Journal of Public Health, Vol. 86 No. 2, pp. 109-13.
105,2
Gee, D., Hunt, R. and Sayers, M. (1997), Health Update: Workplace Health, Health Education
Authority, London.
Griffin, B.L., Hall, N.J. and Watson, N. (2002), “Towards sustainable and flexible health
promotion at work: summary of evaluation findings from the Tyne and Wear ‘Health @
140 Work’ award”, Health Education Journal, Vol. 61 No. 3, pp. 259-71.
Harms-Ringdahl, L., Jansson, T. and Malmén, Y. (2000), “Safety, health and environment in small
process plants-results from a European study”, Journal of Safety Research, Vol. 31 No. 2,
pp. 71-80.
Health and Safety Commission (2000), Small Firms Strategy, HSC, London.
Health and Safety Executive (1998), Health and Safety Executive Key Fact Sheet on Rates of
Injury within Small and Large Manufacturing Workplaces, HSE, London.
Hillary, R. (2000), Small and Medium Enterprises and the Environment, Greenleaf Publishing,
London.
Horowitz, S.M. (2003), “Applying the trastheoretical model to pregnancy and STD prevention: a
review of the literature”, American Journal of Health Promotion, Vol. 17 No. 5, pp. 304-28.
Houston, K.M., Atkinson, R.G., Macdonald, E.B. and O’Connor, M.E. (1999), “A multi-disciplinary
approach to assessing health promotion, occupational health and health and safety in the
workplace”, International Journal of Health Promotion and Education, Vol. 37 No. 3,
pp. 101-9.
Lamm, F. (1997), “Small business and occupational health and safety advisors”, Safety Science,
Vol. 25 No. 1-3, pp. 153-61.
Lauver, D.R., Henriques, J.B., Settersten, L. and Bumann, M.C. (2003), “Psychosocial variables,
external barriers and stage of mammography adoption”, Health Psychology, Vol. 22 No. 6,
pp. 649-53.
Linnan, L.A., Sorenson, G., Colditz, G., Klar, N. and Emmons, K.M. (2001), “Using theory to
understand the multiple determinants of low participation in worksite health promotion
programs”, Health Education and Behaviour, Vol. 28 No. 5, pp. 591-607.
Macdonald, G. (1992), “Communication theory and health promotion”, in Bunton, R. and
Macdonald, G. (Eds), Health Promotion, Disciplines and Diversity, Routledge, London.
Markwell, S. and Speller, V. (2001), “Partnership working and interprofessional collaboration:
policy and practice”, in Scriven, A. and Orme, J. (Eds), Health Promotion, Professional
Perspectives, Palgrave, Basingstoke.
Marlow, S. (1998), “So much opportunity-so little take up: the use of training in smaller firms”,
Journal of Small Business Enterprise Development, Vol. 5 No. 1, pp. 38-48.
Michaels, E., Handfield-Jones, H. and Axelrod, B. (Eds) (2001), The War for Talent, Harvard
Business School Press, Boston, MA.
Perz, C.A., DiClemente, C.C. and Corbonari, J.P. (1996), “Doing the right thing at the right time?
The interaction of stages and processes of change in successful smoking cessation”, Health
Psychology, Vol. 15 No. 6, pp. 462-8.
Prochaska, J.O. and DiClemente, C.C. (1984), The Transtheoretical Approach: Crossing
Traditional Boundaries of Change, Irwin, Homewood, IL.
Small Business Service (2001), available at: www.sbs.gov.uk/ (accessed 2 May, 2001).
Smith, A. and Whittaker, J. (1998), “Management development in SMEs: what needs to be done?”,
Journal of Small Business and Enterprise Development, Vol. 5 No. 2, pp. 176-85.
Springett, J. and Dugdill, L. (1999), Health Promotion Programmes and Policies in the Workplace: Health at work in
A New Challenge for Evaluation, European Health Promotion Series, No. 7, WHO Regional
Office for Europe, Copenhagen. SMEs
Stake, R.E. (2000), “Case studies”, in Denzin, N.K. and Lincoln, Y.S. (Eds), Handbook of
Qualitative Research, Sage, London.
Stokols, D., McMahan, S., Clitheroe, H.C. and Wells, M. (2001), “Enhancing corporate compliance
with worksite safety and health legislation”, Journal of Safety Research, Vol. 32, pp. 441-63. 141
Sutton, S. (2000), “A critical review of the transtheoretical model applied to smoking cessation”,
in Norman, P., Abraham, C. and Conner, M. (Eds), Understanding and Changing Health
Behaviour – From Health Beliefs to Self-regulation, Harwood Academic Publishers,
Amsterdam.
Tait, R. and Walker, D. (2000a), “Marketing health and safety management expertise to small
enterprises”, Safety Science, Vol. 36, pp. 95-110.
Tait, R. and Walker, D. (2000b), “Motivating the workforce: the value of external health and
safety awards”, Journal of Safety Research, Vol. 31 No. 4, pp. 243-51.
Thomas, M. and Sadler, S. (1995), “Health at work: a survey of attitudes, activities and needs of
businesses in inner Birmingham”, Health Education Journal, Vol. 54, pp. 421-9.
Tyne and Wear Economic Assessment (2001), available at: www.tyne-wear-research.gov.uk/
twri/default.htm
Tyne and Wear Health Action Zone (1999), Key Facts about Tyne and Wear Health Action Zone,
available at: www.haz.co.uk/contents/facts.htm
Vassie, L. and Cox, S. (1998), “Small and medium size enterprises (SME) interest in voluntary
certification schemes for health and safety management: preliminary results”, Safety
Science, Vol. 29, pp. 67-73.
Vassie, L., Tomàs, J.M. and Oliver, A. (2000), “Health and safety management in UK and Spanish
SMEs: a comparative study”, Journal of Safety Research, Vol. 31 No. 1, pp. 35-43.
Weinreich, N.K. (1999), Hands-on Social Marketing: A Step-by-Step Guide, Sage Publications,
London.
Wilson, M.G., de Joy, D.M., Jorgensen, C.M. and Crump, C.J. (1999), “Health promotion programs
in small work-sites: results of a national survey”, American Journal of Health Promotion,
Vol. 13 No. 6, pp. 358-65.