Understanding Small Enterprises: 

Proceedings from the 2017 Conference

Centers for Disease Control

and Prevention

National Institute for Occupational 

Safety and Health
This page intentionally left blank.
Understanding Small Enterprises: 

Proceedings from the 2017 Conference

Thomas Cunningham, Paul Schulte, Brenda Jacklitsch, Garrett Burnett,

Lee Newman, Carol Brown, and Michelle Haan, Editors

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health
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ii Understanding Small Enterprises: Proceedings from the 2017 Conference 

This document is in the public domain and may be freely copied or reprinted

Disclaimer

These Proceedings do not constitute endorsement of the views expressed or recommendations by the National Institute for Occupational Safety and Health (NIOSH). 

The opinions and conclusions expressed in the articles are those of each author and 

not necessarily those of NIOSH. All authors were provided the opportunity to review, 

update and correct statements attributed to them in these Proceedings. All conference 

presenters were given the opportunity to review and correct statements attributed to 

them in this report.

Recommendations are not statements of NIOSH policy or of any agency or individual 

involved. They are intended to be used in advancing the knowledge needed for improving the safety and health of workers in small businesses. 

Ordering Information

To receive documents or other information about occupational safety and health topics, 

contact NIOSH at

Telephone: 1-800-CDC-INFO (1-800-232-4636) 

TTY: 1-888-232-6348 

Email: cdcinfo@cdc.gov

or visit the NIOSH website at www.cdc.gov/niosh.

For a monthly update on news at NIOSH, subscribe to NIOSH eNews by visiting 

www.cdc.gov/niosh/eNews.

Suggested Citation

NIOSH [2018]. Understanding small enterprises: proceedings from the 2017 conference. 

Cunningham T, Schulte P, Jacklitsch B, Burnett G, Newman L, Brown C, Haan M, eds. 

Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease 

Control and Prevention, National Institute for Occupational Safety and Health, DHHS 

(NIOSH) Publication No. 2019-108

DOI: https://doi.org/10.26616/NIOSHPUB2019108

DHHS (NIOSH) Publication No. 2019-108

October 2018
Understanding Small Enterprises: Proceedings from the 2017 Conference iii

Foreword 

The majority of the U.S. and global workforce works in firms with fewer than 250 employees, and these firms have a disproportionate share of all occupational injuries and 

illnesses. Consequently, there is a need for continued focus on small and medium-sized 

enterprises. The periodic conferences held under the auspices of the Understanding 

Small Enterprises (USE) collaboration serve to illustrate that focus. USE is a voluntary, 

international collaborative focused on addressing the occupational safety and health of 

workers in small enterprises.

The National Institute for Occupational Safety and Health (NIOSH) and the Center for 

Health, Work and Environment (CHWE) at the Colorado School of Public Health hosted 

the fourth international Understanding Small Enterprises (USE) Conference in Denver, 

Colorado, on October 25–27, 2017. This event represented a culmination of two decades of the NIOSH small business occupational safety and health research agenda and 

an opportunity to generate new ideas through collaboration with world experts, entrepreneurs, and small business leaders who are creating safe and healthy workplaces.

NIOSH, CHWE, and USE organized this conference because we know workers in small 

businesses are injured and killed on the job at a higher rate than workers in larger 

businesses. Over the years, NIOSH has expanded the research focus from identifying 

small businesses in high-risk sectors to understanding how community networks affect 

worker safety and health. Small businesses often have limited resources, and efforts 

must be adapted and solutions created that are accessible in these economic situations. 

Although these organizations are small, they can make a big impact on the well-being of 

the people they employ.

Small business leaders, researchers, safety and health professionals, and all those who 

share an interest in creating safe and healthy small workplaces are encouraged to continue the conversation to move worker well-being and sustainable business health from 

ideas to achievable reality.

John Howard, M.D. 

Director 

National Institute for Occupational 

 Safety and Health 

Centers for Disease Control and Prevention 
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Understanding Small Enterprises: Proceedings from the 2017 Conference v

Contents

Foreword . .

Introduction . .

Acknowledgments .

Occupational Health and Safety Vulnerability in Canadian Small Enterprises .

The Critical Success Factors for Eco-Industrial Park Projects in Thailand: 

A Case Study of Saha Group Industrial Park, Sriracha, Thailand . 

Occupational Health and Safety Practices in a Small Metal Mechanic 

Company in Piura, Peru . 

Coordination Between Stakeholders to Improve Risk Prevention in 

Micro and Small Enterprises (MSEs): Case Studies in Transport and 

Construction Programs . 

Reducing Exposure to Harmful Dust by Implementing a Culture of Prevention 

in the Demolition Sector . 

Examination of Corporate Social Responsibility and Sustainability Indicators 

in Small Brazilian Metallurgical Enterprises . 

Vocational Colleges: Unique Opportunities to Enhance Safety and Health in 

Small Businesses—Findings from the Technical Education Curricula for 

Health and Safety (TECHS) Study . 

Assessment of Psychosocial Policies in Small and Medium-Sized Enterprises . 

Use of IDEWE’s General Prevention System (iGPS) to Implement and 

Manage Occupational Safety, Health, and Well-Being in Small Enterprises . 

Working Successfully with Small Business Owners: Results and Lessons from

the Collision Auto Repair Safety Study (CARSS) . 

Occupational Health Nurse as an Alternative Resource in a Small-Scale 

Enterprise in Japan . 

Applying Fundamentals of Total Worker Health® Approaches: Essential 

Elements for Advancing Worker Safety, Health, and Well-being . 

Total Worker Health in Childcare Centers: Preliminary Results from a 

Community-based Model . 

Correlation between Weekly Exercise Duration & Light Duty and Lost 

Time: A Cross-Sectional Analysis of an Occupational Working Population . 

Assessment of the Relevance and Impact of Promoting Marketable Skills for 

the Informal Sector in Addis Ababa, Ethiopia . 

Overlapping Vulnerabilities and Immigrant Safety Training in Small 

Construction Firms . 

Improved Safety Tools for Small Enterprises through Lean Start-up and 

Design Thinking . 
vi Understanding Small Enterprises: Proceedings from the 2017 Conference 

Aging Workforce Issues in Small Businesses: Preliminary Findings . .

Conference Participants . .

Conference Agenda . .

Poster Presentations . .
Understanding Small Enterprises: Proceedings from the 2017 Conference vii

Introduction

Focus on Safety and Health in Small Businesses

Given the disproportionate burden of occupational injuries, illnesses, and fatalities 

experienced by small businesses in the United States and worldwide, small business 

occupational safety and health (OSH) is of increasing concern to the National Institute 

for Occupational Safety and Health (NIOSH). Although researchers in public health 

have addressed multiple OSH issues, the very large group of academics and researchers 

specializing in the area of OSH has not been very active in the area of small business 

OSH. The USE 2017 conference brought together experts in the area of small business 

OSH and researchers from public health to build connections and to move forward a 

research agenda for small business OSH.

This conference represents the leading thinkers in the small business OSH research 

community from around the world. The conference is relatively new, having convened 

three times since 2009, but it has already had a significant impact in moving the OSH 

community to focus on small businesses. The conference aims to enhance the work 

environment for people within small firms.

What do we mean by small?

A “small” business is defined in many ways. The U.S. Small Business Administration 

considers 99.7% of all U.S. firms to be small businesses, with fewer than 500 employees. 

If we narrow the distinction further, then just over one-third of the U.S. workforce is 

employed by businesses with fewer than 100 employees. For discussions of workplace 

safety and health and for research purposes, the NIOSH Small Business Assistance 

Program considers small businesses as those having fewer than 50 employees. NIOSH 

researchers have also found that other than number of employees, it is important to 

consider factors such as age of the business, structure of the ownership, and availability 

of resources for workplace safety and health.

We know that in many cases, businesses are starting smaller and staying smaller. Given 

that small businesses often lack safety and health professionals, the need is increasing 

for simple, inexpensive ways to ensure safe and healthful working conditions (e.g., Total 

Worker Health and safety apps for employers). Tools that work for small businesses—

designed for convenience and ease of use—help everyone. Small business needs can 

drive safety solutions to cost less and to be more effective.

While NIOSH continues to lead a research agenda focused on small business safety and 

health needs, we recognize that no single organization can effectively reach the millions 

of small businesses that could benefit from assistance. That is why we have expanded 

our research agenda to include a specific focus on understanding the role of intermediaries. Intermediaries might be organizations already engaging small businesses in 

occupational safety and health assistance, looking for new ways to engage small firms, 

or already well-connected to a small business network. The range of intermediaries 

includes suppliers of goods and services (equipment/material suppliers, insurance companies, legal and financial advisors, health providers), membership organizations (trade 

associations, chambers of commerce), education organizations (community colleges, 
viii Understanding Small Enterprises: Proceedings from the 2017 Conference 

vocational schools), and government agencies. Several of the presenters at the 2017 

USE conference are making great advances in this line of research, both as investigators 

studying ways to improve OSH among small businesses and as intermediaries sharing 

their stories of success with helping small employers and their workforces.

USE is the premiere small business occupational safety and health conference and 

provides a forum where researchers and other national and world leaders in the study 

of worker health convene to discuss ways to prevent workplace illnesses and injuries 

among small business employees. It provides a forum for critical reviews, discussions, 

collaborations, and education on issues of occupational exposures and their human 

health effects.

The 2017 program was a stimulating mixture of talks, discussion sessions, posters, and 

mini-symposia with contributors from all over the world, with a forward-looking emphasis on addressing challenges for occupational epidemiology in the 21st century. Holding 

this world-renowned conference in the United States (for the first time) provided an excellent opportunity for U.S. researchers and small business stakeholders to participate 

with and engage in significant ways with their global peers. 

USE Conference History 

The different foci of the three previous Understanding Small Enterprises (USE) conferences reflect a progression in the study of managing safety in small and medium-sized 

enterprises (SMEs). The first Understanding Small Enterprises Conference (USE 2009) 

took place in October 2009 in Elsinore (Helsingør), Denmark. This initial conference 

focused on “understanding the issues (for practice).” The second conference (USE 

2013) took place in February 2013 in Nelson, New Zealand, hosted by Massey University and AUT University. USE 2013 focused on “putting understanding into action.” The 

2013 conference also yielded two special journal issues, focused on small business OSH. 

These were the Safety Science Special Issue: Managing Safety in Small and Medium 

Enterprises (https://www.sciencedirect.com/journal/safety-science/vol/71/part/PC) 

and International Journal of Small Enterprise Research Special Issue: Understanding 

Small Enterprises: Healthy Lives in Healthy Businesses (https://www.tandfonline.com/

toc/rser20/21/2). The third meeting, USE 2015: A Healthy Working Life in a Healthy 

Business, was held in October 2015 in Groningen, The Netherlands. The three main 

subthemes were healthy and safe working environments at SMEs, health organizations 

as small businesses, and SMEs in a networked society. The specific topics addressed at 

each of the previous conferences, as well as the 2017 conference, are available on the 

conference website, www.useconference.com.

USE 2017, Denver, USA

The overall aim of the most recent USE conference was to enhance both the work 

environment for people within small firms and the business performance of small firms. 

This opportunity significantly contributed to advancing the NIOSH Small Business 

Assistance Program strategic goal to reduce injuries and illnesses in smaller businesses 

by better understanding intermediary organizations (their structure, operations, and 

networks) and by better understanding the work environment of smaller enterprises. 

Several of the keynote presentations and other selected papers from the conference 

have been published in a dedicated issue of the Annals of Work Exposures and Health

[2018;62(S1), doi: 10.1093/annweh/wxy061]. This issue includes topics ranging from 
Understanding Small Enterprises: Proceedings from the 2017 Conference ix

suggestions for an overall OSH communication research strategy for reaching small employers to specific presentations of research findings from implementation of worksite 

health interventions with small employers and investigating the facilitators and barriers 

to effective interventions with small employers. Additional papers from the conference 

are published in these proceedings.

The papers included in this volume follow the various topic areas of the conference 

sessions: impact of business size; occupational safety and health in small industrial 

settings; prevention in high-risk industries; tools, resources, and systems for small 

enterprises; health services for small enterprises; Total Worker Health in small enterprises; informal economy; vulnerable workers; and workplace health and safety in 

construction. The variety of the conference presentations and discussions is illustrated 

by the variety of topics included here, from eco-industrial park projects in Thailand to 

childcare centers in the United States. Small businesses and the research aimed at finding 

better ways to help them are diverse and span across the globe. 
x Understanding Small Enterprises: Proceedings from the 2017 Conference 

Acknowledgments

The convening of the Understanding Small Enterprises Conference in Denver, Colorado, 

was supported by the Small Business Assistance Program of the National Institute for 

Occupational Safety and Health (NIOSH) and its host, the Center for Health, Work & 

Environment at the Colorado School of Public Health. We greatly appreciate the many 

contributors to the conference planning and production. The core conference committee included Avery Artman, Carol Brown, Garrett Burnett, Thomas Cunningham, 

Michelle Haan, Brenda Jacklitsch, Lee Newman, Paul Schulte, and Liliana Tenney. Conference planning committee members included Lisa Brosseau, Chia-Chia Chang, Peter 

Hasle, Dennis Hudson, Heidi Hudson, Stephen Legg, Harm van Lieshout, Hans Jørgen 

Limborg, Bruce Lundegren, Kirsten Olsen, David Parker, Diane Rohlman, and Scott 

Schneider. The conference was sponsored by the American Society of Safety Professionals, Axion Health, Pinnacol Assurance, the Colorado Office of Economic Development & International Trade, Colorado State University, the International Commission 

on Occupational Health, and the International Social Security Association.

We also thank those who presented at the conference and all who engaged in the 

thoughtful discussions.

Cover design, graphics, and layout were provided by Vanessa Williams and Nikki Romero 

(NIOSH). Seleen Collins (NIOSH) provided editing assistance. 
Understanding Small Enterprises: Proceedings from the 2017 Conference 1

Occupational Health and Safety Vulnerability in 

Canadian Small Enterprises

C.A. Mustard1,2; A.M. Lay1; P.M. Smith1,2,3

1Institute for Work & Health, Toronto, Canada

2Dalla Lana School of Public Health, University of Toronto, Toronto, Canada

3School of Public Health and Preventive Medicine, Monash University, 

Melbourne, Australia

Abstract

Objective: Occupational health and safety (OHS) vulnerability is often defined by 

demographic characteristics, such as young, new, or immigrant workers. We describe 

a novel conceptual approach to defining OHS vulnerability, on the basis of four characteristics of the enterprise: (1) workers’ exposure to OHS hazards, combined with (2) 

the adequacy of OHS policies and practices, (3) workers’ awareness of their rights and 

responsibilities, and (4) workers’ perceptions of empowerment to participate in injury prevention. We estimate the extent to which differences in the risk of work injury 

among workers in small and large enterprises can be accounted for by differences in 

OHS vulnerability associated with workplace size. 

Methods: We used a subset of respondents to a 27-item questionnaire administered 

to 1,835 working adults in the Canadian provinces of Ontario and British Columbia 

who worked in small (n = 505) or large (n = 525) enterprises. The survey instrument 

contained 9 items on OHS hazard exposure, 7 on organizational policies and practices, 6 on awareness, and 5 on empowerment. Survey respondents also self-reported the 

12-month incidence of work injury requiring time off work and/or medical attention. 

Results: Exposure to one or more of nine OHS hazards was reported by 49% of the overall sample. Inadequate organizational policies and procedures were reported by 42% 

of the sample, inadequate awareness of rights and responsibilities by 22%, and inadequate empowerment by 34%. Relative to workers in large enterprises (>500 employees), 

respondents in organizations with 5 to 19 employees reported a higher prevalence of 

hazard exposure, a higher incidence of work-related injury and illness, and a higher 

exposure to inadequate policies and procedures. Adjustment for these differences in the 

adequacy of workplace policies and procedures accounted for the higher work injury 

incidence observed among employees in small workplaces. 

Conclusion: This study recruited respondents from a wide range of occupational categories, employment relationships, and workplace sizes. Applying an approach to measuring 

three distinct categories of OHS vulnerability has highlighted important areas of priority 

focus for strengthening worker health protection in small enterprises.
2 Understanding Small Enterprises: Proceedings from the 2017 Conference 

Introduction

Workplace injury and illness are responsible for a significant share of sickness and 

disability burdens in working-age populations. Among working-age adults, approximately 20% of traumatic injuries requiring medical care are caused by work exposures 

[Chambers et al. 2015]. The direct and indirect costs of fatal and non-fatal occupational 

injuries and illnesses in the United States are estimated to exceed $250 billion annually 

[Leigh 2011]. In the North American economy, small businesses with fewer than 100 

workers employ approximately 50% of the total private-sector labor force and have 

well-described challenges in protecting the health of their workers [Breslin et al. 2010]. 

There is longstanding recognition that smaller enterprises face unique challenges in 

complying with regulatory standards concerning worker health protection. The unique 

characteristics of small enterprises include a limited knowledge of occupational health 

and safety (OHS) regulatory standards, generally weak or non-existent organizational policies and procedures concerning OHS practices, and a tendency to perceive the 

management of workplace health and safety risks to be the responsibility of individual 

employees [Breslin et al. 2010]. 

Here we apply a novel approach to measuring OHS vulnerability to describe differences 

between the smaller and largest employers in workplace characteristics that shape individual workers’ risk of injury [Smith et al. 2015]. This approach contrasts with much 

previous research that has focused on demographic or occupational characteristics to 

identify vulnerability, such as young workers [Breslin and Smith 2005], new workers 

[Breslin and Smith 2006], workers in temporary employment [Quinlan 2001], recent 

immigrants [Premji and Smith 2013; Smith and Mustard 2010], and those in high-hazard industries [Dembe et al. 2004]. The approach we describe focuses on the role of 

workplace characteristics in determining the vulnerability of individual workers to the 

risk of injury or illness. The measurement method collects information reported by 

individual workers on four dimensions of OHS vulnerability: (1) exposure to workplace 

hazards; (2) workplace safety policies and procedures; (3) workers’ awareness of health 

and safety-related rights and responsibilities; and (4) workers’ empowerment to act to 

protect themselves and colleagues. The premise of this framework is that vulnerability 

arises from exposure to on-the-job hazards in conjunction with inadequate access to 

resources (policies and procedures, awareness, or empowerment) to mitigate the effects 

of these risks.

In previous work, we reported a higher incidence of injury requiring medical attention and/or days off work among employees who were exposed to workplace hazards 

and who reported poor access to protective policies and procedures, poor awareness 

of workplace rights and responsibilities, or low empowerment to act to make their 

workplace safer [Lay 2017]. Previous work has also shown higher hazard exposure and 

weaker protective policies and procedures among employees in smaller enterprises than 

in medium and large enterprises [Lay 2016]. The objective of this study was to determine the degree to which the elevated hazard exposure in smaller enterprises was associated with a higher risk of work injury and to estimate the extent to which a difference 

in injury risk could be accounted for by workplace differences in protective policies and 

procedures, awareness of workplace rights and responsibilities, and perceived empowerment to act to make the workplace safer. 
Understanding Small Enterprises: Proceedings from the 2017 Conference 3

Methods

Data for this study were collected through a cross-sectional survey in April and November 2015 from a sample of working adults (18 years or older) employed at least 15 

hours a week at firms with five or more workers in British Columbia and Ontario, Canada. The majority of participants were recruited by a commercial survey provider from 

a panel of 90,000 Canadian households who had agreed to participate in surveys “from 

time to time.” In this report, we compare worker respondents in the smallest enterprises (5–19 employees: n = 505) to worker respondents in the largest enterprises (greater 

than 500 employees: n = 525). 

Outcome Measure: Workplace Injury or Illness

This report focuses on respondents’ self-reported frequency of work-related injury 

or illness in the past 12 months. Participants were considered to have experienced a 

work-related physical injury if they responded “yes” to this question: “In the past 12 

months, have you sustained a physical injury or illness due to your work?” 

Exposure Measures: OHS Vulnerability

Exposure to OHS vulnerability was assessed with a 27-item questionnaire. A full account 

of the development of the tool can be found elsewhere [Smith et al. 2015]. Survey participants responded to statements related to four dimensions of OHS vulnerability: their 

self-reported exposure to workplace hazards, the existence of protective policies and 

procedures in the workplace, their awareness of workplace rights and responsibilities, and 

their sense of empowerment to protect themselves in the workplace. The questions used 

to measure each of these dimensions are listed in Table 1. 

Workers were defined as vulnerable if they reported weekly exposure to one or more 

workplace hazards and they indicated inadequate access to at least one type of resource to mitigate the exposure risk (workplace policies and procedures, awareness, or 

empowerment). We defined three specific types of vulnerability: policy and procedure 

vulnerability (exposure to hazards and inadequate policies and procedures), awareness 

vulnerability (exposure to hazards and inadequate awareness), and empowerment vulnerability (exposure to hazards and inadequate empowerment). 

Respondents were classified as having inadequate access to a specific mitigating resource (policies and procedures, awareness, or empowerment) when they disagreed or 

strongly disagreed with at least one of the related statements. The adequacy of policy 

and procedure resources was evaluated with statements such as “There is an active and 

effective health and safety committee and/or safety representative” and “Incidents and 

accidents are investigated quickly in order to improve workplace health and safety.” 

Awareness was measured by statements about knowledge of worker rights and responsibilities in relation to health and safety, awareness of how to perform job tasks in a 

safe manner, and knowledge of how to contribute to safety and health in the workplace. 

Finally, empowerment was measured through five questions related to whether individuals feel free to voice concerns about health and safety issues and whether workers 

would act to correct an unsafe situation.

For each measure of OHS vulnerability (overall vulnerability, policy and procedure 

vulnerability, awareness vulnerability, and empowerment vulnerability), we classified 
4 Understanding Small Enterprises: Proceedings from the 2017 Conference 

participants into four categories, according to those who were exposed to (1) no hazards and had adequate mitigation resources (considered the least vulnerable); (2) no 

workplace hazards but had inadequate access to mitigation resources; (3) workplace 

hazards and had adequate mitigation resources; and (4) workplace hazards and insufficient mitigation resources (considered the most vulnerable). 

Covariates

Socio-demographic variables included in the multivariate analysis were gender (male or 

female), age (<35, 35–44, 45–54, or 55 years and older), and industry of employment 

(nine categories).

Analysis

Descriptive statistics contrasted the prevalence of hazard exposure and the 12-month 

prevalence of physical work injury between employees of small and large enterprises. 

These prevalence estimates were stratified by the adequacy of mitigation resources. 

Multivariate logistic regression models estimated the crude and adjusted risk of work injury among employees of small enterprises compared to large enterprises. Multivariate 

models adjusted for age, gender, industry, and the adequacy of policies and procedures, 

OHS awareness, and empowerment. 

Results

Exposure to OHS hazards was reported by 49% of the analytic sub-sample. Self-reported 

hazard exposure was higher among workers in small enterprises (56.9%) versus large 

organizations (40.8%) (Table 2). 

Inadequate organizational policies and procedures were reported by 42% of respondents, inadequate awareness of rights and responsibilities was reported by 22%, and 

inadequate empowerment was reported by 34% (Table 2). Relative to those in large enterprises (500 or more employees), respondents in organizations with 5 to 19 employees had a higher prevalence of vulnerability due to inadequate policies and procedures 

(33.7% versus 17.8%). Smaller differences were observed in the prevalence of inadequate awareness vulnerability and inadequate empowerment vulnerability between 

larger and smaller employers.

Relative to respondents in large enterprises, respondents in smaller enterprises reported a 

higher 12-month incidence of work-related physical injury (18.4% versus 12.7%) (Table 

3). In both large and small enterprises, the risk of work injury was strongly graded by 

hazard exposure and the adequacy of mitigation measures. For example, among respondents reporting adequate OHS policies and procedures in their workplace and no hazard exposure, the 12-month incidence of injury requiring medical attention was 5.4% 

in small enterprises and 5.3% in large enterprises. In contrast, the 12-month incidence 

of injury requiring medical attention among respondents reporting exposure to hazards 

and inadequate workplace OHS policies and procedures was 31.2% in small enterprises 

and 31.1% in large enterprises. 

In multivariate analysis, the crude relative risk of work injury among employees in small 

enterprises was 1.44 (95% confidence interval: 1.08–1.93) (Table 4). Adjustment for 

age, gender, and industry did not attenuate this risk. In a regression model additionally 
Understanding Small Enterprises: Proceedings from the 2017 Conference 5

adjusting for the adequacy of OHS policies and procedures, awareness, and empowerment, the relative risk observed for workers in small enterprises was no longer statistically significant, with the large majority of the relative risk accounted for by weaker 

OHS policies and procedures in small enterprises. Descriptive and analytic estimates 

were weighted to match the age, gender and provincial labour market distributions. 

Discussion 

The objective of this study was to estimate the extent to which differences in the risk 

of work injury among workers in small and large enterprises can be accounted for by 

differences in OHS vulnerability. Consistent with previous literature on OHS risk identification and control in relation to employer size, workers in small enterprises reported 

higher hazard exposure and weaker workplace OHS policies and procedures than did 

workers in larger enterprises. In multivariate analysis, the higher risk of work injury 

reported by workers in small enterprises was accounted for by differences in the adequacy of workplace OHS policies and procedures. 

We acknowledge the following limitations to this study. The cross-sectional design 

cannot exclude the possibility of reverse causation, whereby a respondent who has experienced a workplace injury adopts a more critical assessment of one or more dimensions of workplace vulnerability. The study sample may also be affected by recall bias, 

in that those reporting recent injuries provide a more careful appraisal of workplace 

conditions than non-injured counterparts. Our study also had a relatively low response rate. Among the strengths of this study is its use of a large sample that includes 

respondents from a broad cross-section of occupations and industries. Additionally, 

whereas previous studies have examined the impact of workplace hazards and concepts of organizational climate on injury [Leitao and Greiner 2016; Smith et al. 2006], 

this is one of the first to formally test the influence of these factors on risk of injury 

relative to employer size. 

This study recruited respondents from a wide range of occupational categories, employment relationships, and workplace sizes. Applying an approach to measuring three distinct categories of OHS vulnerability has highlighted important areas of priority focus 

for strengthening worker health protection in small enterprises.

Acknowledgments

This work was supported through a Canadian Institutes of Health Research (CIHR) Population Health Intervention Research Operating Grant (#201409GIR). Peter Smith is 

supported by a Research Chair in Gender, Work, & Health from CIHR (#201210CGW).

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Understanding Small Enterprises: Proceedings from the 2017 Conference 7

Table 1. Questions Used to Measure Four Dimensions of 

Occupational Health and Safety Vulnerability 

Hazards: How often do you ...

1. Have to manually lift, carry, or push items heavier than 20 kg at least ten times a day?

2. Have to do repetitive movements with your hands or wrists (packing, sorting, assembling, cleaning,

 pulling, pushing, typing) for at least three hours during the day?

3. Have to perform work tasks or use work methods that you are not familiar with?

4. Interact with hazardous substances such as chemicals, flammable liquids, and gases?

5. Have to work in a bent, twisted, or awkward posture?

6. Work at a height that is 2 meters or more above the ground or floor?

7. Work in noise levels that are so high that you have to raise your voice when talking to people less 

 than one meter away?

8. Have you been bullied or harassed at work?

9. Have to stand for more than two hours in a row?

Policies and Procedures: At my workplace...

1. Everyone receives the necessary workplace health and safety training when starting a job, changing 

 jobs, or using new techniques.

2. There is regular communication between employees and management about safety issues.

3. Systems are in place to identify, prevent, and deal with hazards at work.

4. Workplace health and safety are considered to be at least as important as production and quality.

5. There is an active and effective health and safety committee and/or health and safety representative.

6. Incidents and accidents are investigated quickly in order to improve workplace health and safety.

7. Communication about workplace health and safety procedures is done in a way I can understand.

Awareness: At my workplace...

1. I am clear about my rights and responsibilities in relation to workplace health and safety.

2. I am clear about my employer’s rights and responsibilities in relation to workplace health and safety.

3. I know how to perform my job in a safe manner.

4. If I became aware of a health or safety hazard at my workplace, I know who (at my workplace) I 

 would report it to.

5. I have the knowledge to assist in responding to any health and safety concerns at my workplace.

6. I know what the necessary precautions are that I should take while doing my job.

Empowerment: At my workplace...

1. I feel free to voice concerns or make suggestions about workplace health and safety at my job.

2. If I notice a workplace hazard, I would point it out to management.

3. I know that I can stop work if I think something is unsafe, and management will not give me a hard time.

4. If my work environment was unsafe I would not say anything and hope that the situation eventually 

 improves. (*reverse scored)

5. I have enough time to complete my work tasks safety.
8 Understanding Small Enterprises: Proceedings from the 2017 Conference 

Table 2. Prevalence of Hazard Exposure and Adequacy of 

Mitigation Resources at Small vs Large Employers

Dimension

Small employers: 5–19 

workers (n = 505)

Large employers: >500 

workers (n = 520) P value for test for 

difference (small vs 

Strata n Column % Strata n Column % large employers)

Policies/Procedures

Adequate; no hazard 126 24.9 227 43.7 <0.001

Inadequate; no hazard 92 18.2 80 15.5

Adequate; hazard 117 23.2 120 23.0

Inadequate; hazard 170 33.7 93 17.8

Awareness

Adequate; no hazard 172 34.2 258 49.6 <0.001

Inadequate; no hazard 45 8.9 50 9.6

Adequate; hazard 216 42.8 151 29.1

Inadequate; hazard 72 14.1 61 11.7

Empowerment

Adequate; no hazard 168 33.4 233 44.9 <0.001

Inadequate; no hazard 49 9.7 74 14.3

Adequate; hazard 169 33.5 105 20.1

Inadequate; hazard 118 23.4 108 20.7

Overall

Adequate; no hazard 102 20.2 164 31.6 <0.001

Inadequate; no hazard 115 22.9 144 27.6

Adequate; hazard 85 16.8 75 14.4

Inadequate; hazard 203 40.2 137 26.4
Understanding Small Enterprises: Proceedings from the 2017 Conference 9

Table 3. Prevalence of Physical Injury, in Past 12 Months: Small vs Large Employers

Dimension

Small employers: 

5–19 workers (n = 505)

Large employers: 

>500 workers (n = 520) P value for test for 

difference (small vs 

Strata n Column % Strata n Column % large employers)

Policies/Procedures

Adequate; no hazard 126 24.9 227 43.7 <0.001

Inadequate; no hazard 92 18.2 80 15.5

Adequate; hazard 117 23.2 120 23.0

Inadequate; hazard 170 33.7 93 17.8

Awareness

Adequate; no hazard 172 34.2 258 49.6 <0.001

Inadequate; no hazard 45 8.9 50 9.6

Adequate; hazard 216 42.8 151 29.1

Inadequate; hazard 72 14.1 61 11.7

Empowerment 

Adequate; no hazard 168 33.4 233 44.9 <0.001

Inadequate; no hazard 49 9.7 74 14.3

Adequate; hazard 169 33.5 105 20.1

Inadequate; hazard 118 23.4 108 20.7

Overall

Adequate; no hazard 102 20.2 164 31.6 <0.001

Inadequate; no hazard 115 22.9 144 27.6

Adequate; hazard 85 16.8 75 14.4

Inadequate; hazard 203 40.2 137 26.4
10 Understanding Small Enterprises: Proceedings from the 2017 Conference 

Table 4. Crude and Adjusted Relative Risk of Being Physically Injured 

in the Last 12 Months: Small vs Large Employers

Size of 

Employer

Model 1 Model 2

Model 3

Adjusted for 

Policies and 

Procedures 

Vulnerability

Model 3

Adjusted for 

Awareness 

Vulnerability

Model 3

Adjusted for 

Empowerment 

Vulnerability

Model 3

Fully Adjusted

RR 95%CI RR 95%CI RR 95%CI RR 95%CI RR 95%CI RR 95%CI

Small: 5–19 

Employees

1.44 1.08, 

1.93

1.39 1.04, 

1.86

1.12 0.84, 

1.48

1.37 1.02, 

1.82

1.33 1.00, 

1.75

1.22 0.92, 

1.60

Large: 500+ 

Employees

ref. ref. ref. ref. ref. ref.

Model 1: crude.

Model 2: adjusted for age, gender, and industry.

Model 3: further adjusted for Policies and Procedures vulnerability, Awareness vulnerability, and Empowerment vulnerability. 

CI = confidence interval; RR = relative risk.
Understanding Small Enterprises: Proceedings from the 2017 Conference 11

The Critical Success Factors for Eco-Industrial Park 

Projects in Thailand: A Case Study of Saha Group 

Industrial Park, Sriracha, Thailand

Kultida Bunjongsiri1,2,3; Sunil Herat1; Tri Dung Phung2; Cordia Chu2

1Griffith School of Engineering, Griffith University, Australia

2Centre for Environment and Population Health, Griffith University, Australia

3School of Health Science, Sukhothai Thammathirat Open University, Nonthaburi, 

Thailand

Introduction

Large industrial parks have had a significant impact on communities and on people’s 

health. Although industrialization brings wealth and development to a country’s economy, it also brings many problems, and one of these is industrial pollution. 

The current environmental problems in Thailand also have been created by the development of industry. To manipulate industrial pollution, however, industrial ecologists 

have introduced the concept of eco-industrial parks (EIPs) [Lowe et al. 1995]. EIPs are 

distinguished from industrial parks in their focus on ecological sustainability. Thai society has undergone significant changes and developments with important implications 

for issues of workplace health, and it is focusing on the significant health care needs of 

workers and their communities. Problems emerging from these considerations are the 

continuous restructuring and reorientation of occupational health services to meet the 

challenges created by the changing nature of working life and the environment [World 

Health Organization 2002].

Eco-industrial development in Thailand has been implemented by the Industrial Estate 

Authority of Thailand and Department of Industrial Works since its launch in 2000. 

Nevertheless, they have limited experience in evaluation of EIP initiatives. One major 

issue in the planning and development of EIPs in Thailand is that they are narrowly 

defined as companies “utilising each other’s wastes or [exchanging] by-products.” This 

approach is not practical for achieving the full benefits of an EIP developed according to 

a more systemic definition [Indigo Development ND].

Thailand needs to build capacity for using industrial waste. Illegal dumping is common, and 

illegal dumpsites are often not discovered until nearby soil and groundwater are found 

to be contaminated. Industrial waste disposal must be monitored, and policy compliance should be encouraged by improving accessibility to waste collection and treatment 

equipment. The private sector and local communities are potential partners for improving 

waste management across many waste streams, but such cooperation has not been emphasized by governmental policies. However, the country’s responses to the need for cooperation show that overarching and wide-ranging issues affecting many waste streams must be 

addressed [Global Partnership on Waste Management ND]. 
12 Understanding Small Enterprises: Proceedings from the 2017 Conference 

This research explores the future development of EIP projects in Thailand by focusing on the critical success factors for implementation of the EIP concept in a potential 

industrial park. The researchers selected the Saha Group Industrial Park, in Sriracha, 

as the case study. Of the pilot projects launched by the Thailand Department of Industrial Works in 2012, Saha Group Industrial Park is one of seven potential industrial park 

zones that plan to develop into EIPs. 

Methods

Our research focused on identifying the factors critical to the success of IEP projects in 

Thailand, on the basis of data from firms located in Saha Group Industrial Park, Sriracha. Data were collected mainly by field site investigations from May to September 

2014 [Bunjongsiri 2017]. This article presents only selected results of the data collection, from occupational health and safety (OHS) personnel at factories there. The data 

collection tool was a survey questionnaire to gather information on OHS management 

at each factory. The survey was sent to the factories by the parent company. Out of 65 

factories, 44 responded by having the safety officer or person in charge of OHS fill in 

the form. The indicators (questions) cover implementation of OHS management in any 

business and were pretested before the survey was conducted. The survey tool consisted of five parts: 

Part 1: General data comprising factory and personnel data

Part 2: Health and safety data such as occupational health–supporting activities 

Part 3: Knowledge of EIPs with regard to EIP regulations

Part 4: Opinions about EIP management with regard to EIP regulations (based on a 

Likert 5-point scale) 

Part 5: Problems, obstacles, and suggestions for implementation of an EIP in 

the park. 

To exemplify EIP management in companies operating in the case study area, secondary data were gathered to describe industrial park practices and operations. Then, 

factory officials were surveyed to evaluate critical success factors for EIP projects established in Thailand through industrial ecology methods. 

In addition, observations and in-depth interviews with officials of industrial park businesses were used to identify the problems, barriers, and needs associated with the 

critical success of EIPs in Thailand, along with EIP regulation. The interviewed officials 

included one industrial park manager, two industrial park safety officers, three specialists, one local politician, and two officers of the Industrial Estate Authority of Thailand 

and Department of Industrial Works. The in-depth interview was used to gather specific 

data for identifying opportunities to improve OHS in the prototype EIP, from the point 

of view of professionals and decision makers. 

Moreover, the workers from the industrial park factories were invited to participate 

in focus group discussions. Three groups of six to eight employees participated voluntarily. The participants came from each factory or enterprise group in the industrial 

park. The main issue of discussion was participation of industrial park workers in 

eco-industrial issues. 
Understanding Small Enterprises: Proceedings from the 2017 Conference 13

Therefore, we used mixed methods to gain complementary views about the same 

phenomenon. The methods were mainly qualitative, but quantitative methods complemented and enlarged the qualitative methods. This combination allowed a comprehensive collection and analysis of data. Furthermore, specific findings were explored 

through structured interviews, in-depth interviews, a questionnaire survey, and focus 

group discussions with different stakeholders in the factories, as well as through direct 

observation and relevant document review.

Results

Mainstreaming EIPs into the country’s national strategy is vital for their success and 

continuity, similar to Thailand’s circular economy. EIPs should be integrated into national development planning processes to link them to national plans, budgets, sector 

strategies, and local-level implementation within the wider stakeholder community. 

This would allow the government to use EIPs as one of the mechanisms to achieve 

economic growth and sustainable industrial development. Although there is a good 

indication that Thailand is moving toward industrial ecology, the conceptualization 

of EIPs still focuses strictly on only a few factors, such as by-product exchange and 

waste management, leaving out the other factors. Unfortunately, no action plan has 

followed the declaration to set up the conditions required to create EIPs in Thailand. 

The main findings and discussions of this research with regard to different levels are 

summarized next. 

Industrial Park level

Following the industrial park’s document review, in 2012, Saha Group Industrial Park 

began implementing the development-analysis guidelines issued in accordance with 

the Eco Industrial Town Project launched by the Department of Industrial Works. The 

first project, named “Green Factory,” involved only 18 firms; participation was voluntary. The objective of this project was to enhance the environmental sustainability of 

Thai industry such that all concerned parties were involved [Sahapatana Inter-Holding 

Public Company Limited 2014]. Focus group discussions and brainstorming activities 

involving all stakeholders were conducted to analyze the project goals. An area-based 

working group was set up to implement the EIP plan within a 5-year period (2012–

2017). Following the first stage in 2012, many activities were planned but delayed until 

government funding support came through. 

Ideally, the industrial stakeholders will drive the entire process. Although an eco-center 

has been set up to serve as central management for the whole park, the eco-center’s activities have not yet been as effective as expected. In addition, the level of participation 

has been low, with most firms and community members ignoring project activities. Full 

collaboration is needed from all involved in the area—its factories, communities, public 

organizations, and academic institutions—to monitor and support the move toward 

sustainable industrial ecology. 

Government level

Although the government agencies, Industrial Estate Authority of Thailand and Department of Industrial Works, have worked since 2000 to carry out their important mission 

of developing EIPs, they have focused on environmental dimensions such as waste 
14 Understanding Small Enterprises: Proceedings from the 2017 Conference 

exchange and water/wastewater management. Indeed, at present no EIPs in Thailand 

follow all the principles of industrial ecology. From the in-depth interviews, we derived 

data on the barriers and challenges in EIP implementation in the industrial park. These 

interview informants were from different organizational backgrounds, and their responses formed the themes and sub-themes listed in Table 1. 

Table 1. Barriers and challenges for success in implementing EIP projects

Main Factors Sub-factors

Policy and political 

challenges

• Unclear criteria/measures to guide implementation

• Shortage of specialists in understanding EIPs

• Lack of funding support

• Previous narrow focus on waste management

Industrial park and 

personal challenges

• Weak cooperation between firms and the industrial 

 park management

• Need for guidance from government (policy) and 

 experts (advice)

• Lack of funding support

• Firms ignoring the intention of the EIP

Community/local 

government agencies’ 

challenges

• Weak cooperation between community and 

 EIP management

• Difficulty in determining leader in communities 

• Weak sense of responsibility among local government for

 running projects

Technical and knowledge 

challenges

• Limited dissemination of knowledge

• Lack of technical services

• Lack of support for training/education

Discussion 

Most of the Thai factories focus mainly on manufacturing benefits rather than environmental improvements. Hence, the factory owners regard any environmental work as a 

burden to their business, not as a source of potential benefit. The success of EIPs depends 

heavily on support from the government and local administration as well as the local 

community. Coordination and working together with different sectors is a principle of 

the implementation of EIPs. Even with a strong desire to enhance environmental performance, the progress of EIPs in Thailand still has a long way to go. In addition, academic 

institutions have an important duty to assist the system by improving research-based 

knowledge and capacity building. Although many studies are done each year, few have an 

impact on national policy or lead to improvements in the country’s EIPs.

Acknowledgments

The authors thank Griffith University, Office of Educational Affairs, Royal Thai Embassy, and Sukhothai Thammathirat Open University for their generosity in funding this 
Understanding Small Enterprises: Proceedings from the 2017 Conference 15

study. The authors also gratefully thank Sahapatana Inter-holding Public Limited Company for their great support throughout the field study. Thanks also go to the Center 

for Health, Work & Environment, Colorado School of Public Health, for the Conference 

Scholarship to join the wonderful conference in Denver. 

References

Bunjongsiri K [2017]. The utility of health and safety performance to examine the eco - industrial parks development: a case study of Saha Group Industrial Park, Sriracha, Thailand. PhD 

thesis. Queensland, Australia: Griffith School of Engineering, Griffith University.

Global Partnership on Waste Management [ND]. Global Partnership on Waste Management, 

http://web.unep.org/gpwm/.

Indigo Development [ND]. Eco-industrial parks (EIP), http://www.indigodev.com/Ecoparks.html.

Lowe EA, Moran SR, Holmes DB [1998]. Eco-industrial parks: a handbook for local development 

teams. Oakland, CA: Indigo Development; revised edition available at http://indigodev.com/

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Understanding Small Enterprises: Proceedings from the 2017 Conference 17

Occupational Health and Safety Practices in a Small 

Metal Mechanic Company in Piura, Peru

Norvil Antonio Mera Chu

Universidad de Piura (Perú)

Introduction

Participatory programs for occupational risk reduction, adapted to the particular reality of each enterprise, are becoming more important in small workplaces in developing 

countries such as Peru. The current legislation on occupational health and safety in 

Peru is more focused on occupational exposure in big companies, however. 

In some small enterprises, workers have significant, high-risk occupational exposure. 

These companies provide services in mining, construction, and oil, work which increases the probability of accidents and diseases. Most of them are looking for suppliers 

aligned with their occupational health and safety systems.

Methods

This case report describes research in a small metal mechanic company where an occupational safety and health (OSH) system was implemented and improved during the 

past 3 years, with positive results. 

The study was of the economic indicators of expenses and income of the small company, related to OSH activities such as conducting training programs, involving workers 

in safety inspections, performing medical examinations for workers, and performing 

internal audits to the system. 

The study included analysis of the impact of the system on the frequency of accidents 

and illnesses in workers, on absenteeism, on labor inspections, on competitions organized by big companies seeking suppliers, and on other factors. The instrument used 

was a data collection sheet.

Results and Discussion

In 2014, the small metal mechanic company had 15 workers (2 administrative, 13 technical workers) and provided services to big companies in the agro-industrial, metallurgic, 

and civil construction sectors; some of them had high OSH standards and some not so 

high. Because of accidents leading to partial and temporary disability in their clients’ 

work environments, the small company started to lose some contracts. 

The small company hired an advisory team to implement the OSH system and training program for workers, involving employees and employers. The implementation 
18 Understanding Small Enterprises: Proceedings from the 2017 Conference 

included elements such as Politics in OSH, Hazard Identification and Risk Assessment, 

Risk Maps, Preventive Activity Planning, and OSH Records and Statistics. The training 

program included monthly participatory sessions with workers, to identify and discuss 

risky conditions and behaviors. The most important risk factors were mechanical, 

locative, ergonomic, and chemical. Some of the working conditions that increased the 

probability of accidents and illness were machines in bad status with no maintenance 

program; inadequate storage and manipulation of chemical products; disorder in the 

company’s facilities; and inadequate removal of chips and other waste.

During the first year of implementation, workers registered 14 accidents leading to 

temporary and partial disability and only 6 incidents (or, as they are called in Peru, “almost-accidents”). In relation to absenteeism due to job accidents, 360 man-hours were 

recorded. Because of these events, two of the small company’s most important clients 

asked the company to homologate their OSH system.

During the second year, the advisory team worked on OSH system homologation and 

for the rest of the time provided OSH support, holding participatory activities with the 

employees and employers. The OSH plan of the small company for this second year included medical examinations for workers; scheduled and unplanned safety inspections; 

acquisition of better elements of personal protection; machine maintenance and removal of unused machines; management of solid and hazardous waste; accident reporting 

and causality investigation; and elaboration of safe working procedures. Also, the OSH 

training programs and conversations with workers about OSH occurrences were held 

more frequently (every 15 days). 

During the second year of implementation of the OSH plan, workers registered 12 

accidents leading to temporary and partial disability and 20 incidents (higher than the 

previous year); 5 of the accidents occurred in the small company’s own work environment, and 7 occurred in a client’s work environment. In relation to absenteeism related 

to job accidents, 280 man-hours (lower than the previous year) were recorded. At that 

time, their current clients were satisfied with the small company’s OSH system change 

and asked it to renew the OSH system homologation. 

For the third year of implementation, because of the improvements seen in the previous years’ results, the small company hired the advisory team to work for the entire 

year on holding more frequent OSH activities each month and to prepare for any government labor inspections. 

During the third year, other big companies with high OSH standards who had never 

hired the small company before started to ask for its services. Workers registered 11 accidents leading to temporary and partial disability and 30 incidents; both of these totals 

were better than in previous years. In relation to absenteeism due to job accidents, 230 

man-hours (lower than in the previous year) were recorded. Also, some post-graduate 

course instructors at regional universities asked to visit the small company and assessed its OSH system, giving it very satisfactory results.

The investment in OSH (Table 1) during years 1, 2, and 3 was $44,800 USD, $48,280 

USD, and $58,220 USD. The most important investment during the 3 years was in the 

advisory team services and OSH training programs for workers. Even with that investment, the income (annual sales) increased every year: $184,848 USD, $175,757 USD, 

and $188,650 USD in years 1, 2, and 3.
Understanding Small Enterprises: Proceedings from the 2017 Conference 19

Table 1. Investment in OSH during the 3 study years

Income

($US)

Investment in OSH

($US)

Year

Annual 

sales

Advisory 

team

Elements 

of personal 

protection

Machine 

maintenance

Management of 

solid and 

hazardous 

waste

Training 

program 

in OSH

Medical 

examinations of 

workers

1 184,848 9,600 2,400 8,200 6,000 15,000 3,600

2 175,757 15,000 2,960 9,680 4,800 12,000 3,840

3 188,650 24,000 3,600 9,800 8,500 8,000 4,320

Total 549,255 48,600 8,960 27,680 19,300 35,000 11,760

Conclusion

The study findings suggest the following conclusions:

• It was a good investment to implement and improve the OSH system in this small 

metal mechanic company.

• It is necessary to implement studies for assessing the effect of OSH systems in 

other small enterprises in developing countries.

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48(2):185–196.
20 Understanding Small Enterprises: Proceedings from the 2017 Conference 

Hasle P, Kines P, Andersen LP [2009]. Small enterprise owners’ accident causation attribution 

and prevention. Saf Sci 47(1):9–19. 

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[2016]. Occupational safety and health measures in micro-scale enterprises (MSEs) in Shiraz, 

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Understanding Small Enterprises: Proceedings from the 2017 Conference 21

Coordination Between Stakeholders to Improve Risk 

Prevention in Micro and Small Enterprises (MSEs): 

Case Studies in Transport and Construction Programs

S. Caroly1; D. Gaudin1; P. Laine2; M. Malenfer2

1The Action Plan for Business Growth and Transformation (PACTE)

2The French National Institute for Research and Safety (INRS)

Introduction

Our aim is to describe the coordination between occupational safety and health (OSH) 

advisors and professional organizations, in order to develop good practices in risk prevention in micro and small enterprises (MSEs). We explore a major factor: the role of coordination of stakeholders in supporting the creation of prevention programs in MSEs.

The following factors have been identified as barriers to OSH in MSEs [EU-OSHA 2016].

• OSH is not a priority; the business market is of higher importance for the 

owner-manager, who has rather a reactive attitude toward occupational risks.

• There is a gap between MSEs and prevention stakeholders; few companies are visited by labor inspectors, few occupational health services are consulted for OSH 

advice, and support comes from private services.

• There is a lack of resources; enforcing OSH legislation is difficult because of a lack 

of time and internal skills.

• Few initiatives to prevent psycho-social risks are realized.

Our question is how to improve the capacity of owner-managers in MSEs to prevent 

occupational risks. The theoretical framework considers the following factors:

• OSH practices according to the sector and its specific risks

• The coordination of different stakeholders in a network

• The creation of programs that take into account the needs of the professional branch.

Methods

This study related to the French context is part of Work Package 3 (WP3) of the SESAME research, which is financed by the European Agency for Safety and Health at Work 

(EU-OSHA) and involves nine different European member states: United Kingdom, 

Belgium, Denmark, Italy, Germany, France, Estonia, Romania, and Sweden. During the 

3 years of 2014–2017, this SESAME research aimed to improve OSH management in 

MSEs by providing evidence-based support, identifying good practices, and increasing 

knowledge about the determinants of these identified good practices. This study was 
22 Understanding Small Enterprises: Proceedings from the 2017 Conference 

split into four work packages, focusing on different issues related to MSEs and risk prevention: a literature review (WP1); the existing good practices in OSH (WP2); the OSH 

program strategies and policies targeting MSEs in each country (WP3); and recommendations (WP4).

In France, in WP3, two networks were compared with regard to their different OSH 

intermediaries, which developed risk prevention actions in MSEs. Before choosing these 

two networks in road transport of goods and in construction, we made an inventory 

and selected among several programs with good practices (4). For each of them, we did 

collective interviews (2) with the leader of each national program and individual interviews with different stakeholders of the programs (4). We also obtained data about the 

targets (population, types of actions) and assessments of the programs.

In the construction sector, we completed 4 MSE interviews (including 1 owner-manager and 1 employee of each) and a short visit of the companies. This data collection 

was performed during WP2. For both the road transport and construction programs, we 

wrote two case studies (2), linked with the themes of the SESAME project, which will 

be part of more global analyses and a comparison between different countries (WP4).

We also held discussion groups during a dialogue workshop [Gustavsen and Engelstad 

1986], bringing together different stakeholders of these programs. All identified stakeholders related to three defined sectors (road transport, construction, and restauration), which include a large number of MSEs, were invited to a 1-day workshop. OSH 

advisors and professional organizations had a strong interest in participating, but 

convincing worker and employer representatives and OSH regulators to participate 

was more difficult. The dialogue workshop was designed as a two-phased discussion. 

The first discussion centered on sector of activity and roles, practices, incentives, and 

obstacles in OSH preventive activities in MSEs. The second was between peers about 

strategies and needs in OSH activities in MSEs for each stakeholder group: regulatory 

organizations and various external non-institutional stakeholders (which we called intermediaries, like professional organizations, chambers of commerce and industry, and 

social partners).

In each group discussion of the dialogue workshop, notes were taken by a facilitator 

and a moderator, who then shortly discussed the insights in order to highlight the main 

relevant findings. At the plenary discussion, each moderator presented to all participants the findings from each discussion group, and the participants were allowed to 

comment on the summaries. Following the workshop day, each facilitator made a final 

document from the notes taken, which was verified and completed by the moderators. 

On the basis of these data, the researchers wrote a final summary about the entire dialogue workshop (minutes of discussions in the dialogue workshop). The partners of the 

French National Institute for Research and Safety (INRS) provided comments on this 

before using it for writing the final national report. The discussion groups, the plenary 

discussion, and the additional interviews were recorded.

Results

The French Government and the National Health Insurance Fund for Salaried Workers 

(CNAMTS) defined four priorities for OSH actions, and these priorities were deployed 
Understanding Small Enterprises: Proceedings from the 2017 Conference 23

in 13 programs (2014–2017). Among the latter, we chose two national programs with 

the aim of creating OSH tools related to the needs of MSEs, in both the road transport 

and construction sectors. The following programs were selected as examples because 

their actions were supporting companies in multiple ways and targeting several specific 

points related to the sector of activity. We also considered their innovative character, 

the possibility of obtaining evaluations and further details about them, the involvement 

of various prevention stakeholders, and their relevance to the effectiveness of the prevention system.

Example 1: Road Transport Sector Program

The road transport sector program is characterized by a combination of methods. 

These various methods aim to expand the ways to reach MSEs to improve prevention, 

such as with the following features.

• The Online interactive Risk Assessment tool (OiRA), an e-tool, allows for sectoral 

risk assessments for MSEs; this OiRA tool was adapted to the French road transport sector by the INRS.

• Two French Synergie toolkits (Synergie pédagogie and Synergie accueil) aimed at 

welcoming new workers in firms as well as learners in vocational training (during 

practices) also provide an introduction to OSH. The French Government, the 

INRS, the CNAMTS, and the Regional Health Insurance Funds (CARSATs), were 

involved in this preventive project.

• OPCA T&S1 advisors undergo ongoing training on prevention. 

• Financial aid is available for companies that purchase specific equipment, such as 

a truck trailer adapted to prevent falls from a height.

• The MavImplant tool provides advice for designing work environments for particular situations, such as loading/unloading docks. 

• An awareness campaign educates owner-managers about specific risks and their 

legal obligations to face them.

This program required the coordination of various types of partners to reach the targeted companies: a training organization (OPCA T&S), national and regional OSH 

stakeholders (INRS, CNAMTS, CARSATs, and occupational health services), and equipment manufacturers.

An interesting point is that tools (OiRA and Synergie) were adapted to specific MSEs’ 

needs in the road transport sector. They focused on specific risks related to their occupational activites and were easy to use, free, and accessible online.

Example 2: Construction Sector Program

The construction sector program is characterized by a central platform for distribution 

of easy-to-use tools and information, designed for employers who have little time and 

resources for OSH. This platform is the Institute for Research and Innovation in Health 

and Safety at Work (IRIS-ST), founded by two professional organizations (the Confederation of Crafts and Small Construction Companies [CAPEB] and the National Union of 

1

The OPCA Transports & Services is a public not-for-profit organization in the road transport sector that collects financial contributions from companies and organizes training.
24 Understanding Small Enterprises: Proceedings from the 2017 Conference 

Craftsmen of Public Works and Landscape [CNATP]) to reduce accidents and improve 

OSH conditions in construction.

The IRIS-ST collaborates with various prevention organizations: a professional organization specializing in prevention (the French Professional Agency for Risk Prevention 

in Building and Civil Engineering, or OPPBTP), two national prevention stakeholders 

(Social Security and INRS). Equipment manufacturers are also involved in the program.

The kind of support offered includes the following:

• Advice about equipment for safety at work

• Information about risk exposure by profession

• Tools to make a risk assessment and documents explaining legal obligations related to prevention

• Information about safety training, with an online survey that assists each company in identifying mandatory training

• Financial support for purchasing materials or equipment.

The main point is that all these actions were focused on the specific needs of the construction companies. The information, tools, training courses, and financial support were 

promoted by the professional organization. The tools for risk assessment and prevention 

were adapted to the target group and the working conditions in construction. The information on the website and the app (smartphone application) was simple, short, and effective, which is necessary considering that the work is mainly done at temporal workplaces 

with little time available for OSH. Finally, the information was free for companies.

Suggestions produced by stakeholders during the dialogue workshop

Road transport

Training must be further developed in several dimensions: initial, continuous, and 

specialized. The message about risk prevention should reach the priority targets, like 

companies with a high number of accidents at work (temporary workers included), and 

should convince owner-managers that risk prevention is a profitable investment (improving both performance and health in the company). Coordination between stakeholders must be improved (with harmonization of the agreements and more information about the actions made by each stakeholder). A risk prevention leader, attached to 

a unique prevention organization, could be appointed for creating links between several 

MSEs and this central OSH stakeholder.

Construction

Trainings for future owner-managers and workers must be improved, and a culture of 

risk prevention in the construction sector should be developed. Adaptation of tools 

according to the trades is relevant and should be continued. Better informing new MSEs 

on the roles and functions of the various stakeholders is suggested. There is a need to 

write into regional contracts for resources (CPOM) the distribution of concerted actions between the stakeholders. Construction companies that are rigorously engaged in 

improving risk prevention should be encouraged with award labels. Finally, the French 

codification of risks should be simplified (NAF, codes related to the French activities).
Understanding Small Enterprises: Proceedings from the 2017 Conference 25

Discussion 

In both sectors (construction and road transport), the networks of stakeholders and the 

various methods used in the programs allow the promotion of advice among MSEs, most 

of the time given by professional partners. This contribution of the intermediaries is 

a key factor to developing OSH practices in companies. When the MSE has a question 

about health and safety at work, it contacts the intermediaries for help or advice. 

Cooperation between professional organizations and OSH advisors is necessary to 

develop a proactive OSH approach. Having a better network of different stakeholders 

can improve the efficiency of prevention in MSEs. However, this collective work among 

various stakeholders depends on sharing operative and common references about OSH 

and MSEs. One favorable comment from the dialogue workshop was that “it’s the first 

time everyone is together around the same table.” We must continue to promote meetings between stakeholders in order to coordinate their actions in MSEs.

Globally, the capacity of owner-managers to develop an OSH approach in their MSEs 

relies on their awareness of risks, their experience with implementing OSH measures, 

and the public policies (financial support to acquire equipment, obligation of risk assessment). Furthermore, the required written risk assessment determines the dynamics 

of MSEs in risk prevention. All stakeholders, both institutional and intermediary, agree 

that owner-managers often have difficulties in identifying the roles and functions of 

the stakeholders surrounding them. The diversity of support for prevention communications and the redundancy of multiple stakeholders’ actions do not help simplify 

owner-managers’ understanding of prevention devices, useful contacts, and adaptation 

of tools to their needs. The networks and programs we studied in both sectors (construction and road transport) show us that many stakeholders take several actions in 

OSH prevention according to their specific missions. However, these initiatives do not 

take into account collective strategies, such as for better coordination of actions with 

partnership agreements. These systems remain complex for MSEs. Networks between 

institutional stakeholders and intermediaries can answer the specific needs of MSEs, 

according to their professional branch, with tools appropriate for risk prevention. We 

need to be able to better identify, support, and pilot these networks.

References

EU-OSHA [2016]. Contexts and arrangements for occupational safety and health in micro and 

small enterprises in the EU-SESAME projects. Bilbao: European Agency for Safety and Health 

at Work.

Gustavsen B, Engelstad PH [1986]. The design of conferences and the evolving role of democratic dialogue in changing working life. Hum Rel 39(2):101–116.
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Understanding Small Enterprises: Proceedings from the 2017 Conference 27

Reducing Exposure to Harmful Dust by Implementing 

a Culture of Prevention in the Demolition Sector

Hans Jørgen Limborg1; Sisse Gron2

1Team Working Life and Roskilde University, Denmark

2Menzies Centre for Health Policy, The University of Sydney

Introduction

For the past 40 years we have had knowledge of what causes silicosis. We have also 

known what measures are necessary to prevent this serious occupational disease. Simultaneously, Denmark has developed a strategy for regulation of occupational health 

and safety (OHS), based on legislation, tripartite agreements, control and inspection, 

information, research, and occasionally economic incentives. Nevertheless, silicosis 

prevails as a major health risk. It seems that knowledge concerning silicosis has not 

been sufficiently translated to reach where it is needed in workplaces. One of the industries most affected is the demolition industry [Omland et al. 2014]. 

The aim of the project presented here was to assess how knowledge and prevention 

strategies can be transferred from regulation, research, and practice to the culture 

among workers on demolition sites. 

The project integrated the following: health research that has documented the high risk 

of dust exposure in the demolition sector and high prevalence of chronic obstructive 

pulmonary disease [Mølgaard et al, 2013; Omland et al. 2014; NEPSI 2014; Bergdahl 

et al. 2004; Deurssen et al. 2014; Vestbo et al. 1990]; research on prevention culture, 

employee involvement, and strategies for reaching small and medium-size enterprises 

(SMEs) [Kines et al. 2013; Hasle et al. 2006; Hale and Hovden 1998]; and research on 

the importance of networks as a means of regulating OHS [Limborg and Grøn 2015; 

Ellenbecker 1996; Hopkins and Hale 2009].

The basic idea was to partner with the key agents in the sector (management and OHS 

professionals) to develop a tool that would enable the workplace/site manager to embed 

a prevention culture leading to reductions in dust exposure. The tool was based on the 

Safety Observer App (http://www.arbejdsmiljoforskning.dk/da/projekter/safetyobserver), 

a planning and auditing system, but was paired with training and a series of workshops 

to develop a prevention system for the industry. The research question was thus: Can 

the prevention culture in the demolition industry be improved by introducing the Safety Observer App in OHS programs?

Demolition Work

The Demolition Sector in Denmark consists mostly of SMEs and has within a decade 

changed from a hazardous, polluting, unregulated, “Wild West” sector to one with high 

standards of environmental protection. However, health hazards from dust exposure 
28 Understanding Small Enterprises: Proceedings from the 2017 Conference 

containing silica are still prevalent and are not as well regulated in work practices as 

chemical risks are. This fact is a consequence of very strict regulation on handling of 

chemicals such as asbestos, paint containing lead, PVA, plastics, etc. The costs for sanitation of buildings before demolition are high, and the owner or the one who acquires 

the demolition task must pay these costs. This is basically the background for the economic growth of the demolition sector. 

The demolition sector in Denmark has, following this development, been segregated 

into what the sector itself refers to as “the good guys and the bad guys.” The “good guy” 

companies are organized in a section of the Danish Construction Association. These 

companies are the ones that benefit from regulation and have an interest in separating 

themselves form the other companies. The “bad guys” are foreign-owned companies 

hiring labor from Eastern Europe; from time to time they provide hired workers for the 

“good guys.”

The demolition section in the Danish Construction Association consists of 15 companies, which have on average 25 to 200 employees. In the year 2000, this group of companies joined efforts in establishing an educational program, known as Skilled Demolisher. 

They received public funding for the training program and agreed that all would provide 

at least 2 to 3 workers for the course each year to sustain it [Limborg and Gron 2015].

There are several different tasks in demolition work: 

• Sanitation (removal of toxic and environmentally unfriendly substances)

• Stripping 

• Machine operation

• Manual ground labor.

Traditions for protection and prevention vary among the worker groups who complete 

these tasks. The sanitation workers and machine operators are in general well protected 

and have access to air-supply masks and other relevant protective equipment, as the costs 

can be transferred to customers. Because the stripping teams and the manual ground 

workers do not have the same opportunities, these groups were the focus of this project.

Methods

The research project was designed in partnership with the Sector and the Danish Construction Association, with the aim to develop a tool that enhances planning and auditing of a new prevention culture in relation to dust exposure. The tool was developed by 

integrating experiences and results from safety culture projects within safety research 

[Kines 2001; Kines et al. 2011]; research on health consequences of exposure to dust 

containing silica [Sauvé et al. 2013]; and inspiration from a similar tool developed for 

accident prevention by the Pete Kines group [Kines et al. 2010 and Kines et al. 2011].

The tool was developed, tested, and evaluated in eight companies during 2016 and 2017; 

in three of the companies, two study cases were performed. The tool comprises a guide to 

developing a plan for a specific demolition job, with a focus on the dust-producing activities, equipment, etc., which are transferred to an audit tool developed as an application 

(app). The app can be used on various platforms such as IPad and Android phones. The 
Understanding Small Enterprises: Proceedings from the 2017 Conference 29

audit is performed by the local foreman/site manager and/or in-house OHS professionals. In the research project the results of the tool were evaluated. Results were assessed 

as changes in prevention strategies and workplace culture, documented through both a 

questionnaire answered by foremen and demolition workers and qualitative interviews 

performed with foremen and OHS professionals.

The results from the 11 cases were analyzed and used to develop a final version of the 

tool, consisting of four different elements:

• Instructions on how to develop a dust prevention plan and set up the app (which 

is specific for each single assignment). The plan is organized by factors that prove 

important to dust exposure: a) the physical layout of the site, b) the technology in 

use, c) the competence and training of the employees, d) the steps related to the 

specific tasks that will be done, and e) information related to availability and use 

of personal protective equipment available.

• Instructions on how to set up the app and how to use it, in a brief video-based 

training manual (to be found on YouTube). Using the app for safety rounds is 

meant as a task for the site manager. It is based only on observation and therefore 

takes little time.

• A guide for risk assessment of problems that are documented by the safety 

rounds; this is a job for the OHS professionals

• A general information section about dust and the health risks of silica exposure, 

to be used for training of all employees.
30 Understanding Small Enterprises: Proceedings from the 2017 Conference 

Figure 1. A picture of the app 

Preliminary findings from the qualitative interviews have shown differences in motivation among the involved partners with regard to developing and using the tool. 

• Managers find the tool relevant for reducing cost competition for OHS and to put 

the cost of health and safety on the customers. 

• The OHS professionals see the tool as another instrument for them to develop 

their positions. 

• The foremen and site managers find it an easy way to comply with regulation and 

provide necessary control. 

• The most difficult task is to make sure all workers follow the safety plan. The fact 

that employees in many companies are Polish or Romanian and don’t speak Danish adds to the complexity of enforcing safety plans.

Each employee assigned to the specific project where the tool was tested completed a 

questionnaire about dust prevention. The questionnaire was developed by the National 

Centre for the Working Environment of Denmark. It was translated into English, Polish, 

and Romanian and completed onsite before the tool was tested. 

The results from the quantitative data reveal that the demolition workers are aware 

of possible health risks associated with exposure to dust, but nevertheless there are 
Understanding Small Enterprises: Proceedings from the 2017 Conference 31

severe barriers in their motivation to the use of dust prevention equipment. First, it is 

of course crucial that the right equipment is available, and second, that employees use 

it. They often find the equipment uncomfortable to use and find work tasks takes too 

long when wearing equipment. 

Figure 2. The expected outcome, the gained outcome, and the obstacles to reaching it.

Figure 2 illustrates the expected outcome of the project and what proved possible to 

achieve, as well as barriers to full implementation that were uncovered through the 

evaluation. Management was formally interested in the prevention tool if they could 

transfer any costs for OHS to the customer; for this, the documentation given by the 

app was considered promising. However, cost competition is still hard, and OHS costs 

are often the first to be cut out in a tender. The group that benefitted the most were the 

OHS professionals. They found the tool very relevant, although an obstacle for this motivation was that the OHS professionals very often changed jobs and a new one had to 

be trained. The site managers found the tool very useful if they realized that it was an 

easy way to satisfy the management and OHS professionals. Finally, we learned that to 

encourage workers to maintain a safety culture, it is important to implement an ongoing flow of information and discussion about the health risks of silica dust. The diseases 

at risk are not likely to occur until the reach the age of above 50. 

In the qualitative interviews, it was uncovered that the reluctance to use personal protective equipment was often linked to excessive heat while wearing the equipment but 

also vanity. We also found that tasks such as handling waste and cleaning old buildings 

create the highest levels of dust exposure, and employees are rarely using protective 

equipment during these tasks. 

Discussion 

The developed tool was found to be applicable in all 11 cases, and all the relevant 

stakeholders expressed motivation to use it. OHS professionals and site managers find 
32 Understanding Small Enterprises: Proceedings from the 2017 Conference 

the tool easy to use and have adopted it for further projects. We have not documented 

changes in the level of dust, but the awareness of the risk and the means of prevention 

have increased among OHS professionals, site managers, and workers. However, there 

are several impediments to developing and maintaining a preventive practice in the 

sector as a whole:

• The relevant technical prevention equipment is not always available.

• Comfortable, effective dust masks are hard to find. 

• There is a hierarchy in dust exposure; the most exposed are the least 

protected.

{ Sanitation workers (asbestos, PCB, etc.) are fully protected.

{ Machine operators are protected by cabin ventilation. 

{ Manual site workers are exposed but often outdoors.

{ Demolishers are highly exposed at specific operations and tasks.

• Tasks such as handling waste, transporting waste, and cleaning old buildings cause 

the highest exposure but are considered less important.

Conclusion

For further development and application of the tool, it will be necessary to address 

the hierarchy of “intrinsic motivation” [Deci and Ryan 2012] among the different 

stakeholders, to create general interest in using and disseminating knowledge of 

the tool. 

In summary:

• Companies/managers included dust prevention in strategic plans in order to utilize regulation to transfer costs to the customers.

• OHS professionals found that the Audit tool is very relevant and applicable, 

but the network collaboration with other OHS professionals provided added 

value to them.

• Site managers found the audit tool easy to use (smart phone or tablet use was not 

a problem) and an easy way to please the project manager, but their ability to 

provide relevant equipment at the relevant time was restricted.

• Employees proved to have general knowledge that dust is harmful, but little 

knowledge about health risks, effects of prevention, and long-term consequences.

References and Resources

Bergdahl IA, Torén K, Eriksson K, Hedlund U, Nilsson T, Flodin R, Jarvholm B [2004]. Increased 

mortality in COPD among construction workers exposed to inorganic dust. Eur Respir J 

23(3):402–406. 

Deci EL, Ryan RM [2012]). Motivation, personality, and development within embedded social 

contexts: an overview of self-determination theory. In: Ryan RM, editor. Oxford handbook of 

human motivation. Oxford, UK: Oxford University Press.

Deurssen E, Anjoeka P, Spaan S, Goede H, Tielemans E, Heederik D, Meijster T [2014]. Quartz 

and respirable dust in the Dutch construction industry: a baseline exposure assessment as part 

of a multidimensional intervention approach. Ann Occup Hyg 58(6):724–738.
Understanding Small Enterprises: Proceedings from the 2017 Conference 33

Ellenbecker MJ. [1996]. Engineering controls as an intervention to reduce worker exposure. Am 

J Ind Med 29(4):303–307.

Hale AR, Hovden J [1998]. Management and culture: the third age of safety. A review of approaches to organizational aspects of safety, health and environment. In: Feyer A-M, Williamson A, editors. Occupational injury: risk, prevention and intervention. London: Taylor & 

Francis Ltd. 

Hasle P, Limborg HJ [2006]. A review of the literature on preventive occupational health and 

safety activities in small enterprises. Ind Health 44(1):6–12.

Hasle P, Limborg HJ, Kallehave T, Klitgaard C, Andersen TR [2012]. Working environment in 

small firms: responses from owner-managers. Int Small Bus J 30(6):622–639.

Hopkins A, Hale AR [2009]. Special issue on process safety indicators. Saf Sci 47(4):459.

Kines P, Andersen lP, Spangenberg S, Mikkelsen KL, Dyneborg J, Zohar D [2010]. 

Improving construction site safety through leader-based verbal safety communication. J Saf Res 

41(5):399–406. 

Kines P, Lappalainen J, Mikkelsen KL, Pousette A, Tharaldsen J, Tómasson K, Törner M [2011]. 

Nordic Safety Climate Questionnaire (NOSACQ-50): a new tool for measuring occupational 

safety climate. Int J Ind Ergo 41(5):634─646.

Kines P, Andersen D, Andersen LP, Nielsen K, Pedersen L [2013]. Improving safety in small enterprises through an integrated safety management intervention. J Saf Res 44:87–95.

Laitinen H, Päivärinta K [2010]. A new-generation safety contest in the construction industry: a 

long-term evaluation of a real-life intervention. Saf Sci 48(5):680–686.

Limborg HJ, Grøn S [2015]. Netværket som virkemiddel: Afsluttende rapport fra INVINE 

projektet i CAVI.

Limborg HJ, Kines P, Kabel A (2018). Styr på støvet: Udvikling og implementering af en forebyggelseskultur i nedrivningsbranchen. TeamArbejdsliv, København, Danmark..

Mikkelsen KL, Spangenberg S, Kines P [2010]. Safety walkarounds predict injury risks and reduce injury rates in the construction industry. Am J Ind Med 53:601–607.

Mølgaard EF, Hannerz H, Tüchsen F, Brauer C, Kirkeskov L [2013]. Chronic lower respiratory diseases among demolition and cement workers: a population-based register study. BMJ 

3(1):e001938.

NEPSI [2014]. Good practice guide on workers health protection through the good handling and 

use of crystalline silica and products containing it. European Network for Silica, http://www.

nepsi.eu/agreement-good-practice-guide/agreement.aspx.

Omland O, Würtz ET, Aasen TB, Blanc P, Brisman J, Miller MR, Pedersen OF, Schlünssen V, 

Sigsgaard T, Ulrik CS, Viskum S [2014]. Occupational chronic obstructive pulmonary disease: 

a systematic literature review. Scan J Work Environ Health 40(1):19–35.

Sauvé JF, Beaudry C, Begin D, Dion C, Gerin M, Lavoue J [2013]. Silica exposure during construction activities: statistical modelling of task based measurements from the literature. Ann 

Occup Hyg 57(4):432–443. 

Seixas N [2013]. A multilevel intervention to control crystalline silica exposure. Project application. 

Spangenberg S [2009]. An injury risk model for large construction projects. Risk Manag 

11(2):111–134.

Vestbo J, Rasmussen FV [1990]. Long-term exposure to cement dust and later hospitalization due to respiratory disease. Int Arch Occup Environ Health 62(3):217–220.
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Understanding Small Enterprises: Proceedings from the 2017 Conference 35

Examination of Corporate Social Responsibility 

and Sustainability Indicators in Small Brazilian 

Metallurgical Enterprises

Paulo Roberto Alves Pereira; Jessé Bergamini Furlan

UNIFAE – Centro Universitário das Faculdades Associadas de Ensino

FMPFM – Faculdade Municipal Professor Franco Montoro

Introduction

Corporate Social Responsibility (CSR) has been the aim of wide discussion among enterprises, the academic community, and other stakeholders because of its importance 

to conscious, sustainable business management. Some questions to be answered by 

the studies on CSR and Sustainability Practices (SPs) are related to enterprises’ size, 

business maturity level, effective level of practice formalization and implementation, 

and the people who benefit from the implemented practices. Despite significant studies, there is still a gap in knowledge related to monitoring and controlling CSR and SPs 

and their real impacts on society. To fill this gap, in 2014 the Institute Ethos developed 

Ethos Indicators for Sustainable and Responsible Businesses, a model which incorporates management practices with a simultaneous focus on CSR and SPs. 

In this context, the main aim of this study was mapping CSR and SPs incorporated in 

the business management of four small enterprises (less than 100 employees). These 

enterprises are in the metallurgical segment of cutting and mechanical conformation 

of metals, in the region of São João da Boa Vista (SJBV), São Paulo State, Brazil. This 

study is classified as applied research, with a quantitative approach, through the application of an auto-declared questionnaire from the Ethos Indicators for Sustainable and 

Responsible Businesses model.

The results showed that the enterprises have proactive behavior for some Ethos indicators. They are in the initial maturity level of SP implementation, in compliance with the 

present legislation and the Ethos Institute’s diagnosis report classification. The results 

also indicated that enterprise managers are interested in improving existing CSR and 

SPs, but the knowledge gap and insufficient human and economic resources prevent 

effective implementation of SPs.

Corporate Social Responsibility and Sustainable Development

The CSR strategic approach becomes more crucial day by day for enterprises’ competitiveness [EuroCommerce 2011]. CSR demands commitment and dialogue between the 

enterprises and stakeholders. CSR permits the enterprises to anticipate their actions in 

functioning despite constant changes in society’s needs and market fluctuations. The 

interaction with stakeholders provides solidity in enterprises’ actions, improves risk 

management, and stimulates innovation by the sharing of experiences. Moreover, by 
36 Understanding Small Enterprises: Proceedings from the 2017 Conference 

being socially responsible, enterprises can improve their reputations and inspire greater 

confidence from stakeholders [Pinheiro 2012]. CSR allows the enterprises to reduce 

costs and encourages the search for efficiency in use of resources (reductions in energy 

and water consumption; loss elimination and recuperation of valuable sub-products; 

increases in raw materials availability).

Therefore, enterprises who intend to participate in and contribute to sustainable development need to incorporate in their practices the concept of economic, social, and 

environmental equity. This means that CSR should be adopted by enterprises as a tool 

to achieve a sustainable development level in their businesses [Barbieri 2012].

The terms CSR and SD are frequently used indistinctively [Pinheiro 2012]. They are 

intrinsically related one to another, but they are distinct concepts. The concept of sustainable development was disseminated by The Brundtland Report, Our Common Future, in 1987 by the World Commission on Environment and Development–United 

Nations. It was characterized as “development that meets the needs of the present 

without compromising the ability of future generations to meet their own needs.” This 

definition considers simultaneously the social, environmental, and economic aspects of 

development. However, the core of CSR is organizations and the impact of their decisions that contribute to SD. From the fusion of social responsibility and sustainable development emerges the concept of sustainable enterprise, which represents a new way 

of business to satisfy the demands of new challenges imposed by society [Willard 2006].

The principles used to correlate these two concepts were based on the “triple bottom line 

(3Ps)” model: People, Planet, and Profit [Elkington 1997]. This model established that an 

enterprise should be evaluated according to social, economic, and environmental dimensions [Barbieri 2012]. Once CSR is supported by the 3Ps, a successful performance on the 

three dimensions is supposed to assure solid business sustainability [Marrewijk 2003].

The perspective of the 3Ps model is that enterprises could reach business equilibrium 

and simultaneously satisfy the social, economic, and environmental demands that emanate from stakeholders. However, according to Cambridge Leadership Development Ltd. 

[2013], “triple bottom line accounting and related frameworks fail to emphasize the 

foundations of sustainable prosperity in continuous and competitive entrepreneurship 

and innovation.” It suggests that, to reach enterprise-related progress in individuals’ 

lives and their communities, it is necessary to exhibit adaptive innovation and a successful implementation of new combinations related to all aspects of sustainable prosperity. It proposes that the “quadruple bottom line (4Ps)” model—People, Profit, Planet, 

and Progress—is capable of providing the basis for a more comprehensive framework 

for developing measures of sustainable prosperity.

Lawler [2012] affirms that organizations need to focus on quadruple, not triple, bottom line performance standards. He corroborates that it is necessary to perform well 

in financial, environment, and social terms, as well as treatment of employees. He adds 

that in the past, it was completely unrealistic to expect organizations to perform well 

in the 4Ps. Indeed, it was not practical to measure their performances, but times have 

changed. With the development of new metrics and computers with enormous data analytic capacity, it is easier to measure enterprises’ performance in the 4Ps. “Of course, 

measuring quadruple bottom line performance is just the first step to getting organizations to perform in a sustainable way,” Lawler [2012] notes. 
Understanding Small Enterprises: Proceedings from the 2017 Conference 37

In the structure of the Ethos Indicators for Sustainable and Responsible Business model, it is possible to identify all elements of the 4Ps model. Because the Ethos model was 

meant to support enterprises during the process of incorporating CSR and SPs in their 

businesses, the model was chosen for this study, which focused on small enterprises 

in the metallurgical segment of cutting and mechanical conformation of metals in the 

region of SJBV, São Paulo State, Brazil. 

Methods

There are important organizations working worldwide to create CSR evaluation instruments, taking into account the present challenges faced by society [Pinto and Leitão 

2006]. These organizations socialize knowledge on CSR. They support the control of 

CSR actions and maintain the quality of enterprises’ social, environmental, economic, 

and progress performance. They provide instruments to ease enterprises’ task of defining their values, beliefs, and policies, in addition to communicating their performances and management practices with transparency and commitment to stakeholders. 

Therefore, among these organizations, Institute Ethos was chosen for data compilation 

and analysis in this study. Its actions focus on multiple areas: Environmental, Human 

Rights, Integrity, Sustainable Management, Economy, and Support. 

The “Ethos Indicators for Sustainable and Responsible Business” model was developed 

from a convergence of different initiatives, with an emphasis on ABNT 26000 Social 

Responsibility–2004 and the G4 guidelines for Sustainable Reports from the Global 

Reporting Initiative–GRI 2002 [Ethos 2014]. This model is subdivided into dimensions, 

themes, and sub-themes, inside a preformatted category named Essential. This category 

is composed of 24 indicators and brings relevant questions to enterprises with the perspective of different stakeholders. It represents the “minimal agenda” of CSR and SPs.

The Essential category questionnaire offers enterprises the possibility of self-evaluation 

in level of maturity. It means that, for each indicator, an enterprise can be self-evaluated 

in five different maturity levels: 

• 1st: Compliance with present legislation when applicable, and/or treats the theme

 superficially.

• 2nd: Develops initiatives and implements current practices of CSR and sustainability.

• 3rd: Adopts formalized policies and programs to promote its values.

• 4th: Measures the benefits of its management and considers them to take actions

 and manage risks.

• 5th: Passes by transformation and innovation processes to create values and promote

 updated practices.

This study was basic in that its intention was not to solve a specific problem related to 

the involved enterprises but instead to generate knowledge on CSR practices and the 

Ethos Indicators as an important tool for enterprises. 

The method was defined as applied research with a quantitative approach and with 

exploratory and descriptive objectives. The sampling criteria were that enterprises were 

located in the region of SJBV (encompassing 16 cities); had no more than 100 employees; 
38 Understanding Small Enterprises: Proceedings from the 2017 Conference 

were in the metallurgical segment of cutting and mechanical conformation of metals; 

and agreed to participate in the research. Only 7 enterprises met all the criteria and 

were formally invited to participate in the research; unfortunately, just 4 enterprises 

accepted the invitation, and the other 3 declined (they alleged a lack of access to information, due to organizational restructuring and shifting in business).

Quantitative data collection by means of a survey (self-evaluation questionnaire of 

Ethos Indicators for Sustainable and Responsible Business) occurred in November 

2015. The questionnaires were filled out by the four enterprises with researcher supervision and then were sent to Institute Ethos, which was responsible for the data compilation. 

The enterprise scores referring to general performance were calculated by Institute 

Ethos. The points were distributed for each indicator inside each sub-theme. The calculation process was executed according to an algorithm that involved three steps: pruning, distribution, and aggregation (explained at the Ethos site). 

The Institute produced an exclusive diagnosis report for each enterprise, assuring full 

confidentiality and secrecy during this process. Only the researcher and Ethos workers 

involved in the compilation process had full access to all reports.

Institute Ethos did not create any performance index for CSR and SPs. Therefore, its 

work does not enable measuring or classifying enterprises in terms of CSR and SPs. 

However, the purpose was to provide a model for self-evaluation and reflection, learning, and motivation for developing with regard to identified issues. Therefore, with the 

aid from Institute Ethos, a conceptual index was developed for this study and future 

use: the Performance Index in CSR and Sustainability. It can be seen at the bottom of 

Charts 1, 2, and 3.

Results

This section presents the results obtained for the four enterprises that participated in 

this research, in comparison with the results (average and best scores) of 34 similar 

enterprises in the southeast region and metallurgical segment that participated in the 

2015 cycle. They were distributed in four different categories: In depth – 17; Wide – 4; 

Essential – 5; and Basic – 8.

Charts 1, 2, and 3 compare the results of the four enterprises’ individual performances 

with the average score of the five enterprises, in the Essential category. The results are 

also compared to the benchmark score, which was selected from the best results found 

in the Ethos database, cycle 2015, based on the 34 medium-sized southeast region enterprises in the metallurgical segment and different categories. 

The results shown in Charts 1 and 2 indicate that only one indicator from the dimension Governance and Management, theme Organizational Governance, received a score 

of 4.4 (Satisfactory performance) in CSR and SPs. All the other indicators in Dimension 

or Dimension/Theme scored an Insufficient or Bad performance.
Understanding Small Enterprises: Proceedings from the 2017 Conference 39

Chart 1: Enterprises’ Scores by Dimensions X Average and Best Scores

Source: Adapted from Ethos Database, 2015.
40 Understanding Small Enterprises: Proceedings from the 2017 Conference 

Chart 2: Enterprises’ Scores by Dimensions/Themes X Average and Best Scores

Source: Adapted from Ethos Database, 2015.

The most part of the average score calculated for the five similar enterprises from the 

same Essential category is situated in the Insufficient scale. The analysis of the Best Score in 

Charts 1 and 2 shows some scores from 4.4 to 5.8, indicating Satisfactory performance; only 

one score of 6.0, indicating Good performance; and the remaining scores of Insufficient, in 

terms of performance in CSR and SPs. Four scores of Good performances were identified in 

Chart 3 in different subthemes. No scores of Excellent performance are seen in Charts 1 to 3. 

In general, the results ratify the supposition of initial maturity level of the enterprises 

that were the object of this study. Moreover, the results indicate that all the companies 

participating in this research and even the ones used as benchmarks have much work 

to do and are far from achieving the status of Excellent in CSR and SPs, with regard to 

most of the Ethos Indicators.
Understanding Small Enterprises: Proceedings from the 2017 Conference 41

Chart 3: Enterprises’ Scores by Subthemes X Average and Best Scores

Source: Adapted from Ethos Database, 2015.

Discussion

The main aim of this study was mapping CSR and SPs of four enterprises in the metallurgical segment of cutting and mechanical conformation of metals, in the region of 

SJBV, and comparing the results with those in the Ethos database. The research results 

permit us to conclude that the proposed objective was achieved successfully. 

The enterprises’ poor performance results, described in Charts 1 to 3, can be explained 

by (1) unfamiliarity with and difficulties in understanding and implementing CSR and 

SPs to meet the Ethos Indicators; (2) the need to realign the Mission, Vision, Values, and 

Objectives to include new CSR and SP perspectives; (3) the gap in using Ethos Indicators 
42 Understanding Small Enterprises: Proceedings from the 2017 Conference 

to support the improvement of existing SPs and to implement new ones (which would 

demand commitment, dedication, and minimal financial support); (4) the absence of 

alternatives to improve CSR and SP performance as gradual implementation of ISO 

14,000, ISO 18,000, and ISO 26,000 (at least in a self-applied way); and (5) insufficient 

human and economic resources, affecting the effective implementation of CSR and SPs.

In view of the results, this study brings to the enterprises, Institute Ethos, and the 

academic community the following contributions. (1) The four participating enterprises 

have proactive behavior for some Ethos indicators. (2) They are in the initial maturity 

level of SP implementation, basically in compliance with the present legislation, according to the Ethos Institute’s diagnosis report classification. (3) They still have a long way 

to go in the search for excellence in CSR and SPs, according to the Ethos Indicators. (4) 

Despite the efforts of Institute Ethos in launching a model for micro and small enterprises, it was clear that the participating enterprises in this study had serious difficulties in understanding and implementing practices in compliance with Ethos Indicators, 

whether at the level of dimension, theme, or sub-theme. (5) Because the Ethos model is 

still complex for micro and small enterprises, Institute Ethos should consider stratifying 

this model by industrial and commercial activity branches, once they have established 

different specificities; this could help micro and small enterprises better understand 

and implement CSR and SPs. (6) The Ethos model has made undeniable contributions 

to enterprises, but dissemination of this model to micro and small enterprises in SJBV 

and other regions must be intensified to promote excellence in CSR and SPs. (7) A 

scoring scale should be proposed to evaluate enterprises’ performance in CSR and SPs. 

(8) An update with information on the Ethos Indicators for Sustainable and Responsible 

Business model would be helpful for application to metallurgical enterprises in cutting 

and mechanical conformation of metals. (9) Future in-depth research on CSR and SPs, 

including micro and small enterprises in different sectors of activity and using different 

models, such as GRI, is suggested.

References

ABNT (Associação Brasileira de Normas Técnicas) [2010]. ABNT NBR ISO 26000:2010. Rio de 

Janeiro: Diretrizes de responsabilidade social. 

Aligleri LM [2011]. A adoção de ferramentas de gestão para a sustentabilidade e a sua relação com 

os princípios ecológicos nas empresas. Doctoral dissertation, Universidade de São Paulo, Brazil.

Barbieri JC [2012]. Resp. Social Empresarial e Empresa Sustentável. SP, Saraiva.

Cambridge Leadership Development [2013]. Quadruple bottom line for sustainable prosperity, http://

cambridgeleadershipdevelopment.com/quadruple-bottom-line-for-sustainable-prosperity/. 

Cruz FJA, Cabral ACA, Pessoa MNM, Santos SM [2012]. Relações entre responsabilidade social 

interna comprometimento organizacional: um estudo em empresas prestadoras de serviços. 

Ver Bras Adm Cient 3(3):163–182.

Elkington J [2012]. Canibais com Garfo e Faca. São Paulo: Makron Books. 

Fundação Sistema Estadual De Análise De Dados—SEADE [ND]. Disponível em http:// https://

www.seade.gov.br/produtos/midia/spdemografico/popmunrsexo.pdf. Acesso em 03 de março 

de 2017.

EU Commission [2011]. A renewed EU strategy 2011-14 for Corporate Social Responsibility. 

Brussels: European Commission.

Global Reporting Initiative [2006]. Diretrizes para Relatórios de Sustentabilidade. Amsterdam, 

2002, http://www.globalreporting.org/guidelines/translations.asp. 
Understanding Small Enterprises: Proceedings from the 2017 Conference 43

Hitchcock D, Willard M [2006]. The business guide to sustainability: practical strategies and 

tools for organizations. London: Earthscan.

Hood J [1998]. Do corporations have social responsibilities? The Freeman 48(1):680─684. 

Instituto Brasiliero De Geografia E Estatística—IBGE [ND]. Disponível em http://www.ibge.gov.

br. Acesso em 03 de março de 2017.

Instituto Ethos De Empresas E Responsabilidade Social [2014]. Indicadores Ethos para Negócios 

Sustentáveis e Responsáveis Disponível, www.ethos.org.br/indicadores. 

Lawler III EE [2014]. The quadruple bottom line: its time has come, https://www.forbes.com/

sites/edwardlawler/2014/05/07/the-quadruple-bottom-line-its-time-has-come/#6111c26f6012.

Marrewijk MV [2003]. Concepts and definitions of CSR and corporate sustainability: between 

agency and communion. J Bus Ethics 44(2-3):95–105.

Maximiano ACA [2006]. Introdução à Administração. São Paulo: Atlas.

De Melo Neto FP, Froes C [2001]. Gestão da Responsabilidade Social Corporativa: O Caso Brasileiro. Rio de Janeiro: Qualitymark.

Napoleão R, Neto AC, Lima GS, Gonçalves P, Almeida T [2014]. Responsabilidade Social Empresarial e Gestão de Pessoas: a perspectiva dos trabalhadores de uma empresa pública. Contextus-Rev 

Contemporânea de Economia e Gestão 12(2):38–64.

Pescador SVB, Bortoluzzi F, Santos E, Anzoategui M [2013]. Responsabilidade social corporativa: um estudo sobre práticas em micro/pequenas empresas com aplicação de indicadores 

Ethos-Sebrae. Ciências Sociais Aplicadas Revista 13(25):223–258.

Pinheiro SMD [2012]. Responsabilidade Social Empresarial: uma abordagem atual. Portugal: 

Universidade de Porto.

Pinto MCS, Leitão SP [2006]. Economia de Comunhão, empresas para um capitalismo transformado. Rio de Janeiro: FGV.

Ventura ECF [2003]. Responsabilidade Social das empresas sob a ótica do novo espírito capitalista. In: Encontro Anual Da Anpad. Atibaia-SP. Rio de Janeiro-RJ: Anais.
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Understanding Small Enterprises: Proceedings from the 2017 Conference 45

Vocational Colleges: Unique Opportunities to 

Enhance Safety and Health in Small Businesses—

Findings from the Technical Education Curricula for 

Health and Safety (TECHS) Study

Anca Bejan, MS, CIH, COHC; David L. Parker, MD, MPH; Maryellen Skan, 

MPH; Min Xi, PhD

HealthPartners Institute, Bloomington, MN

Background

Collision repair and machine and metal manufacturing are industries with a large 

percentage of small businesses [U.S. Census Bureau 2017], whose owners face unique 

challenges in implementing health and safety regulatory requirements. Workers in 

these trades experience injuries and illnesses at rates above average for many types of 

incidents [U.S. Department of Labor 2017] and are unlikely to receive safety and health 

training on the job [Brosseau et al. 2014]. Numerous studies have examined the effectiveness of health and safety interventions with business owners [Bejan et al. 2015], 

and researchers in those studies have recommended finding ways to involve workers in 

making safety and health decisions in the workplace. Previous research has found that 

72% of collision repair shop technicians and 47% of machinists working in manufacturing companies attended some classes or graduated from vocational college programs in 

their trade [Parker at al. 2014, 2017]. 

In 2013, more than 1.5 million sub-baccalaureate occupational educational credentials 

were awarded in the United States. Of these, nearly 200,000 were in manufacturing, 

construction, repair, and transportation [IES-NCES n.d.]. As early as 1995, the National Institute for Occupational Safety and Health (NIOSH) engaged in activities to increase knowledge in occupational safety and health among vocational college students 

and instructors and supported efforts to develop health and safety curricula for young 

workers. However, a decade later, Schulte et al. [2005] concluded that “little quantitative information exists on (1) the extent of OSH training provided within these programs and (2) the effectiveness of the program for reducing occupational injuries and 

illnesses.” We propose that graduates of vocational college programs who have a good 

understanding of safety and health hazards in their trade and are knowledgeable about 

the available solutions may be able to assist business owners with improving workplace 

safety and health.

The Technical Education Curricula for Health and Safety (TECHS) study is a 

NIOSH-funded educational intervention being conducted in partnership with two vocational colleges in Minnesota. The goal of this study is to evaluate the impact of comprehensive trade-specific safety and health curricula delivered systematically throughout a 
46 Understanding Small Enterprises: Proceedings from the 2017 Conference 

2-year program on students’ health and safety knowledge, skills, attitudes, and work practices at graduation and one year afterward. An extensive baseline evaluation and student 

assessments were conducted prior to designing and implementing the new curricula.

This report presents (1) a summary of the educational practices and materials used 

to teach safety and health to auto body collision technology (ABCT) and machine tool 

technology (MTT) students and (2) the results of a student safety and health survey 

administered in May 2015.

Methods and Materials

Instructors teaching in the ABCT and MTT programs were invited to participate in discussion groups and one-on-one interviews and to complete surveys on the materials and 

methods used to teach and assess their students’ health and safety knowledge. 

Students enrolled in ABCT and MTT programs were asked to complete an anonymous 

survey 1 to 2 weeks prior to the end of the 2014–2015 academic year. The surveys contained questions on important safety and health issues jointly identified by the participating instructors and study staff with expertise in industrial hygiene and occupational 

medicine. ABCT students answered 21 questions on isocyanates, respirators, solvents 

and acids, fire and electrical safety, and eye and hearing protection. MTT students answered 20 questions on machine guarding, lockout/tagout, materials handling, and eye 

and hearing protection. No student-specific identifiers were collected.

All study materials and methods were approved by the institutional review board of 

Park Nicollet Institute.

Results

Instructors 

Six ABCT and seven MTT instructors participated in all baseline activities. The ABCT 

instructors have been working in the industry for an average of 32 years (standard 

deviation [SD] = 9 years; range = 21–42 years), have been teaching for an average of 

21 years (SD = 12 years; range = 2–35 years), and have been in their jobs at the college 

for an average of 18 years (SD = 13 years; range = 2–35 years). The MTT instructors 

have been working in the industry for an average of 27 years (SD = 10 years; range = 

10–35 years), have been teaching for an average of 14 years (SD = 10 years; range = 

2–26 years), and have been in their jobs at the college for an average of 11 years (SD = 

9 years; range = 2–22 years).

Key findings

• Fifty percent of the ABCT instructors and 17% of the MTT instructors reported 

not having adequate time to cover information on health and safety in class.

• Instructors lack trade-specific health and safety training and have few opportunities to receive it from knowledgeable sources.

• Students receive most of their health and safety information as assigned reading 

from books, handouts, and trade group–designed education materials (CDs).
Understanding Small Enterprises: Proceedings from the 2017 Conference 47

• All video clips reviewed were outdated and not trade-relevant.

• Some handouts contained incomplete and (at times) misleading information. 

• Instructors placed a lot of emphasis on rules related to personal protective equipment, especially the use of safety glasses in the shop. 

• “Teaching moments” often occur when instructors notice unsafe acts in the shop. 

Students that are not present miss these training opportunities.

• Instructors report teaching safety primarily during the first year of each program.

• Instructors described many of the safety issues as “plain common sense.”

• No comprehensive health and safety assessment instruments were identified.

Our work indicates that the means and methods of teaching and assessing health and 

safety knowledge, skills, attitudes, and work practices in the ABCT and MTT programs 

studied are inadequate.

Students

Fifty-one ABCT students from College A and 25 from College B completed surveys. Students completing 2 years of instruction (Y2) in College A had survey scores that ranged 

from 57% to 91% (mean = 76%; SD = 10%). Students in College B had scores ranging 

from 57% to 91% (mean = 72%; SD = 10%). Survey scores of students that completed 1 

year of instruction (Y1) were 29% to 90% (mean = 66%; SD = 13%) in College A and 67% 

to 91% (mean = 81%; SD = 7%) in college B. 

The number of years of instruction made a significant difference in the survey scores 

within each college (p = 0.02). However, the difference was not always in the expected 

direction. At the end of the first year of instruction, students attending College B correctly answered significantly more questions than students attending College A (p < 

0.0001) (Table 1).

Table 1. ABCT student survey scores

College A, Y2

(n = 12)

College A, Y1

(n = 39)

College B, Y2

(n = 11)

College B, Y1

(n = 14)

Survey section

Mean

(%)

SD

(%)

Mean

(%)

SD

(%)

Mean

(%)

SD

(%)

Mean

(%)

SD

(%)

Overall 76a 10 66a,c 13 72b 10 81b,c 7

Isocyanates 72 26 71 21 71 21 81 21

Respirators 63 23 66 24 56 17 75 26

Fire and Electrical 

Safety

81d 10 69 19 88d 6 86 7

Eye and Hearing 

Protection

81e 22 65 26 58e 22 67 23

Solvents and Acids 82 25 79 25 75 27 88 22

a-e Significantly different; p < 0.05. 
48 Understanding Small Enterprises: Proceedings from the 2017 Conference 

The following are examples of knowledge gaps among graduating ABCT students:

• 78% do not know that a tight-fitting respirator fits well only if the user shaved the 

same day;

• 57% were unaware that bonding clamps are not effective if placed on painted metal surfaces;

• 48% do not know that safety glasses are marked with Z87 on the lens or temple;

• 48% do not know that removing tape and sanding recently applied clear coat can 

expose them to uncured isocyanates;

• 30% do not know that isocyanates induce asthma and that the main routes of exposure are inhalation and skin contact.

Seventy-eight MTT students from College A and 51 from College B completed surveys. 

There were no significant differences between the scores of students attending college 

for 1 year versus 2 years. The graduating class (Y2) of College B had significantly higher 

survey scores (mean = 81%; SD = 10%) than the graduating class of College A (mean = 

67%; SD = 14%; p = 0.0001) (Table 2).

Table 2. MTT student survey scores

College A, Y2

(n = 24)

College A, Y1

(n = 54)

College B, Y2

(n = 29)

College B, Y1

(n = 23)

Survey section

Mean

(%)

SD

(%)

Mean

(%)

SD

(%)

Mean

(%)

SD

(%)

Mean

(%)

SD

(%)

Overall 67a 14 74 14 81a 10 75 15

Machine Guarding 51b 19 61 20 69b 17 65 21

Eye and Hearing 

Protection 

66c 21 68 22 84c 18 68 22

Lockout/Tagout 84 19 82 17 83 20 75 21

Materials Handling 74d 21 86 14 90d 13 89 13

a-d Significantly different; p < 0.05. 

The following are examples of knowledge gaps among graduating MTT students:

• 68% do not know that a pressure mat is not an acceptable way to guard the point 

of operation;

• 40% do not know that safety glasses are marked with Z87 on the lens or temple;

• 38% do not know that noise-induced hearing loss does not depend on whether the 

exposure occurs at work or at home;

• 30% do not understand the purpose of outage protection;

• 30% do not know that coolants can cause skin rashes and lung problems.

Graduating class survey scores were not significantly influenced by previous employment in the trade or by employment in the trade during the academic year 2014–2015 

(data not shown).
Understanding Small Enterprises: Proceedings from the 2017 Conference 49

Conclusions and Next Steps

TECHS study baseline activities show that the current materials and methods used to 

teach and assess student health and safety knowledge in the collision repair and machine tool technology trades are inadequate. As a result, students are graduating with 

incomplete knowledge of important safety and health issues that are likely to influence 

their work-related adverse health outcomes. 

The TECHS study staff, in collaboration with lead instructors from the two participating 

ABCT and MTT programs, has designed comprehensive safety and health curricula. Implementation of the new curricula at the participating colleges began with the 2015–2016 

academic year. The ABCT curriculum contains modules on isocyanates, solvents, acids 

and bases, dust and fumes, hearing protection, eye protection, respirators, fire safety, and 

electrical safety. The MTT curriculum contains modules on machine guarding, lockout/

tagout awareness, hearing protection, eye protection, and materials handling. 

All the materials and activities follow the principles of student-centered active-learning 

instruction. Each training module is composed of classroom instruction, lab activities, 

homework, and a quiz. Student success is measured by an end-of-the-year survey that 

assesses safety and health-related knowledge, skills, attitudes, and work practices. To 

date, instructor feedback has been positive. Faculty recommendations will be used to 

update the TECHS curricula prior to dissemination.

The TECHS study is an example of how creating formal collaboration opportunities 

between educational systems and the health and safety professional community can 

benefit students, instructors, and the local business community. 

References 

U.S. Census Bureau [2015]. Statistics of US businesses, https://www.census.gov/data/tables/2015/

econ/susb/2015-susb-annual.html. 

U.S. Department of Labor [ND]. Bureau of Labor Statistics: injuries, illnesses and fatalities, 

https://www.bls.gov/iif/oshsum.htm. Accessed October 11, 2017.

Brosseau LM, Bejan A, Parker DL, Xi M, Skan M [2014]. Workplace safety programs, practices 

and conditions in auto collision repair businesses. J Occup Environ Hyg 11:354–365.

Bejan A, Parker DL, Brosseau LM, Xi M, Skan M [2015]. Two-year follow-up of the Collision Auto 

Repair Safety Study (CARSS). Ann Occup Hyg 59(5):534–546.

Parker DL, Yamin S, Xi M, Gordon R, Most I, Stanley R [2017]. Findings from the National Machine Guarding Program: safety climate, hazard assessment, and safety leadership in small 

metal fabrication businesses. J Occup Environ Med, doi: 10.1097/JOM.0000000000001166. 

Epub ahead of print.

Parker DL, Brosseau LM, Bejan A, Xi M [2014]. Understanding safety climate in small automobile collision repair shops. Am J Ind Med 57(1):78–86.

IES-NCES [ND]. Institute of Education Sciences–National Center for Education Statistics, 

https://nces.ed.gov/surveys/ctes/tables/S128.asp. Accessed October 11, 2017.

Schulte PA, Stephenson CM, Okun AH, Palassis J, Biddle E [2005]. Integrating occupational 

safety and health information into vocational and technical education and other workforce 

preparation programs. Am J Public Health 95:404–411. 
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Understanding Small Enterprises: Proceedings from the 2017 Conference 51

Assessment of Psychosocial Policies in Small and 

Medium-Sized Enterprises

Filip Pelgrims; Hilde De Raeve; Sofie Vandenbroeck 

IDEWE, Heverlee, Belgium

Introduction

A well elaborated occupational safety and health (OSH) policy is crucial, yet small and 

medium-scaled enterprises (SMEs) often fail to implement a good prevention program. 

Online risk-assessment tools such as BRIE (Better Risk Inventarisation and Evaluation) 

have been developed to guide occupational health nurses during company visits. BRIE 

provides a list of important sector-specific OSH issues (such as psychosocial issues); 

advice regarding good practices; legal information and preventive actions; and an evaluation of sector-specific occupational risks.

Methods

BRIE risk assessments were performed in a convenience sample of SMEs during the 

period 2013–2014. A selection of psychosocial factors (N = 7) was assessed and scored 

with yes or no. For example,

1. Has a psychosocial risk analysis been performed? 

2. Has the company formalized a resolution regarding unacceptable behavior in the 

workplace? 

3. Is there a policy addressing undesirable behavior? 

Only the SMEs for which all psychosocial factors were assessed and scored were included for analysis. Frequencies were calculated. 

Results

Data were available from 8,100 SMEs (response = 35%). About 93% of the companies had 

not yet performed a psychosocial risk analysis. A resolution and policy regarding unacceptable behavior were available in 41.5% and 32% of the SMEs. In 39.5% of the SMEs, 

employees know who the confidential counsellor is. In 18.5% of the SMEs there was no 

register for unacceptable behavior, and in 49% there was no policy on alcohol and drugs.

Discussion 

BRIE risk assessments reveal that in a significant number of SMEs, there are no assessments or policies regarding psychological risks or unacceptable behavior. SMEs therefore need additional support and information. A well-instructed prevention expert, such 

as an OSH nurse, can use a BRIE assessment as a first step to assess company policies.
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Understanding Small Enterprises: Proceedings from the 2017 Conference 53

Use of IDEWE’s General Prevention System (iGPS) to 

Implement and Manage Occupational Safety, Health, 

and Well-Being in Small Enterprises

I. Sommen; E. Van de Plas

IDEWE, Leuven, Belgium

Introduction

Serious accidents are most prevalent in small and medium-sized enterprises (SMEs), 

most likely because of their poor performance in using risk assessment and risk management systems. Despite of all their efforts, SMEs often do not possess the knowledge 

required to secure occupational safety, health, and well-being (OSH). How can we guide 

SMEs in risk management and subsequent development of preventive measures? 

Methods

As the largest Belgian external service for prevention and protection at work, IDEWE 

(originally the Interdisciplinaire Dienst voor het Welzijn, or Interdisciplinary Service 

for Well-being) provides services to 35,000 enterprises and their 600,000 employees. To 

lead SMEs toward OSH, IDEWE developed a document management tool, named GPS: 

IDEWE’s General Prevention System. 

The GPS strategy translates into a cohesive modular structure (seven modules) that 

allows organization and execution of the OSH tasks and assignments in an SME. Wellbeing at work is applied and integrated into the GPS system, supplemented with other 

aspects of OSH (Environment, Energy Efficiency, Construction Safety, Food Safety, 

Playground Safety, etc.).

The features of GPS are threefold: 

1. GPS is a strategy to implement risk reduction within the framework of occupational risk and health in a medium enterprise. It steers the company’s dynamic 

risk management system. 

2. GPS is a structure that includes the different fields involved in safety and health 

(safety at work, occupational medicine, ergonomics, occupational hygiene, psychosocial aspects of work) and handles them interdisciplinarily. 

3. GPS facilitates a pragmatic and coherent system to optimize the internal safety 

tasks and culture.
54 Understanding Small Enterprises: Proceedings from the 2017 Conference 

Figure 1. General Prevention System—Management of OSH (Illustration created by the 

authors, Sommen and Van de Plas, 2017)

Enterprise

People

Equipment

Product

Environment

People Equipment

Product Environment

Enterprise

Risk Management

Conformity

Entry and Change

Enterprise

OSH-level

Check

Plan

Adjust Do

Time

Daily Management

Damage Investigation

Risk Assessment
Understanding Small Enterprises: Proceedings from the 2017 Conference 55

Training and One-on-One Support

For the purpose of this small article, we focused on the use of GPS in SMEs during the 

period 2011–2016. 

IDEWE trained 1,903 new users in a 6-day practical course to implement GPS in their 

SMEs; 1,031 of these users followed up on an annual basis (via a reunion day) to keep 

track of new developments and changing legislation. Since 2014, 53 new users received 

GPS training in a 2-day course for very small enterprises (fewer than 20 employees).

Furthermore, 1,052 prevention experts in SMEs receive one-on-one support from IDEWE to implement GPS and carry out customized preventive measures. The support is 

given via a contractual consultancy base (a team of 120 prevention specialists), in visits 

to the enterprise ranging from 6 to 144 half-day visits a year. During a visit, the enterprise’s prevention expert works with the IDEWE prevention specialist to implement risk 

reduction within the interdisciplinary framework of occupational risk and health.

Results

Feedback from these users supplemented GPS as a pragmatic, coherent risk management 

tool in which all relevant documents can easily be found. The GPS strategy translates into 

a cohesive modular structure that allows organization and execution of OSH tasks and 

assignments. Model documents are provided, along with a section for managing enterprise-specific reports. By using GPS, enterprises can comply with Belgian OSH law. 

Conclusion

On the basis of these results, IDEWE decided to digitalize the document management 

tool and make it an online platform: iGPS. Extra benefits for users will be automatic 

backup, securing the latest versions of all their documents, and easy access from any 

workstation, including tablets and phones. The system can notify the user when new 

(model) documents are posted. 

Since 2016, more than 3,000 users have logged onto the platform (my.idewe.be), implementing the document management system and using the template documents. Hence, 

iGPS has grown to be a practical tool for use by prevention workers to guide SMEs in 

their OSH policy. 
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Understanding Small Enterprises: Proceedings from the 2017 Conference 57

Working Successfully with Small Business Owners: 

Results and Lessons from the Collision Auto Repair 

Safety Study (CARSS)

Anca Bejan1; David L. Parker1; Lisa Brosseau2; Maryellen Skan1; Min Xi1

1 HealthPartners Institute, Bloomington, MN

2 University of Illinois, Chicago, IL

Introduction

In the United States approximately 220,000 people work in 33,648 collision repair 

establishments, of which only 3,421 have more than 20 employees. The majority of establishments (18,471 shops) have fewer than 4 employees [U.S. Census Bureau 2015]. 

Collision repair business owners face unique challenges in implementing health and 

safety regulatory requirements. They often are unaware of safety laws and seek information from easily accessible sources such as equipment or materials suppliers. However, these sources often lack training and have financial interests that may play a role 

in the type and amount of information provided to business owners. In addition, owners 

may be reluctant to develop and enforce safety rules or to regard the identification and 

control of risks as a priority, and they may have limited resources to hire professional 

safety consultants [Parker et al. 2012]. 

In collision repair shops, the technicians encounter a wide variety of physical and 

chemical hazards during vehicle repair, assembly, and painting. Exposure to several of 

these hazards (such as isocyanates and noise) can have serious and permanent consequences. Whittaker and Reeb-Whitaker [2009] showed that work-related compensable 

asthma claims in Washington state were nine times higher for collision painting technicians compared with workers in other industries, and Bejan et al. [2011] documented 

noise exposure levels above 50% dose (85 dBA 8-hr time-weighted average).

The Collision Auto Repair Safety Study (CARSS), conducted between 2007 and 2014, 

was designed to assist business owners located within 50 miles of the Minneapolis–St. 

Paul metropolitan area with understanding and improving safety and health conditions 

in their shops. Brosseau et al. [2014] describes in detail the intervention mapping process followed to identify intervention targets, change objectives, strategies for motivating workplace improvements, and outcome measures, as well as the shop assessment 

form used in this study.

The study had two phases: an active phase and a passive phase. During the active 

phase of CARSS, a health and safety assessment was conducted at baseline, and business owners were assisted with creating and implementing a Shop Improvement Plan. 

In consultation with study staff, owners assigned a deadline to each item listed in the 

Shop Improvement Plan. Technical assistance provided included quarterly reminders 
58 Understanding Small Enterprises: Proceedings from the 2017 Conference 

and newsletters, safety training, respirator fit testing, and medical evaluation for respirator users. A study website was created and hosted health and safety information, 

including checklists, training, and sample safety programs. One year post-enrollment, 

all shops participated in another health and safety assessment, referred to as the Year 1 

assessment. The outcomes of this phase of the study were described in detail by Parker 

et al. [2015]. The passive phase of CARSS is the focus here. 

Methods

For one year after the completion of the active phase of the study, business owners 

received up to three reminder postcards on the following topics: 

1. Safety checklists available on the study website: electrical safety, jacks, and jack 

stands; ladders; slings, ropes, and chains; and welding safety

2. Content of study website and available assistance

3. Due dates of annually required training. 

Business owners were not contacted directly by the study staff. However, all their assistance requests were answered. After one year of participation in the passive phase of 

CARSS, all owners were contacted via telephone and invited to participate in a health 

and safety assessment—referred to here as the Year 2 assessment. The assessment used 

the same 92-item survey used for baseline and Year 1 assessments. The results were 

communicated to owners in a written report. 

Data analysis included computation of means and standard deviations of business assessment scores and percentage of businesses in which each assessment 

item was present. Year 1 and Year 2 assessment scores were compared with the 

sign and Cochran-Mantel-Haenszel tests, and all data analyses controlled for the 

“shop” variable.

Results

Forty-nine shops received baseline assessments, and 33 were visited for both the 

Year 1 and Year 2 assessments. There were no differences in demographics, scores 

at baseline, or Year 1 scores between the 33 participating shops and the 12 shops 

that did not participate in the Year 2 assessment. At baseline, these 33 shops had 

40% to 81% of assessment items present (mean = 55%; SD = 10%). At Year 1, the 

shops had 60% to 81% of assessment items present (mean = 73%; SD = 11%). At Year 

2, the shops had 63% to 89% of assessment items present (mean = 73%; SD = 9.5%). 

All improvements from baseline to Year 1 and from baseline to Year 2 were statistically significant (p < 0.05). 

Fifty-three items were assigned to one of the following safety topics: facility and equipment safety (33 items), written safety documentation and records (13 items), and 

personal protective equipment (7 items). These items were examined in detail, and the 

only significant change between Year 1 and Year 2 was in the area of personal protective 

equipment (Table 1). 
Understanding Small Enterprises: Proceedings from the 2017 Conference 59

Table 1. Business safety score at baseline, Year 1, and Year 2, by safety topic

Baseline Year 1 Year 2

Mean SD Mean SD Mean SD

% Items Present

Overall 55 10 73a 11 73b 10

Facility and equipment safety 72 10 78a 10 79b 9

Written safety documentation and records 14 20 60a 28 56b 24

Personal protective equipment 72 20 83a 14 89b,c 12

a

Significantly different from baseline (p < 0.05) b

Significantly different from baseline (p < 0.05) c

Significantly different from year 1 (p < 0.05)

Facility and equipment safety

No statistically significant change in the percentage of items present was observed 

between Year 1 and Year 2 (78% vs. 79%). An item-by-item examination indicated that 

some improvements continued to occur in the second year of the study (16 items). 

However, there was a decline in the number of businesses that had explosion-proof 

lights in the paint booth, easily accessible emergency exits, a suitable eye wash station, 

correctly grounded flammable liquids containers, and properly stored oxygen cylinders. 

Written safety documentation and records

Overall, the business safety score declined slightly from Year 1 to Year 2 (60% vs. 56%; p 

= 0.26) At Year 2 significantly fewer shops had up-to-date Right-to-Know and respirator 

training than in Year 1. Similarly, 30% fewer shops had conducted annual respirator fit 

testing (73% vs. 42%; p = 0.02). There was a non-significant decrease in the percentage 

of shops in which respirator users had medical certification (76% vs. 73%). 

Personal protective equipment

Overall, business safety improved significantly between Year 1 and Year 2 (83% vs. 89%; 

p = 0.006). There was no change in the percentage of shops (82%) that provided body 

technicians with appropriate gloves (other than disposable, medical-grade latex gloves). 

The percentage of shops that required employees to use hearing protection when operating compressed-air tools increased from 64% to 88% (p = 0.01). A non-significant increase (52% to 61%) occurred in the percentage of shops that required the use of safety 

glasses during operations such as grinding, working under cars, or cleaning items with 

compressed air. 

Analysis by number of reminder postcards

Of the 33 businesses, 2 did not receive any reminder postcards, 3 received one, 9 received two, and the remaining 19 received three. At Year 2, there were no statistically 

significant differences in overall business safety scores between the shops that received 

two or fewer postcards and shops that received three postcards. There was no difference in the likelihood of requesting assistance, based on the number of reminders sent, 

and there was no association between the date of the service request and the date of 

receiving a reminder postcard.
60 Understanding Small Enterprises: Proceedings from the 2017 Conference 

For a detailed analysis of the Year 2 assessment results, including the role of the Shop Improvement Plan after in-person follow-up activities ceased, please refer to Bejan et al. [2015].

Discussion 

Results indicate that most business owners were able to implement and maintain health 

and safety improvements during both phases of the CARSS. However, once the study 

staff–initiated activities ceased, improvements were more likely to continue if the deficiencies to be corrected had been included in a formal Shop Improvement Plan. The 

reminder cards did not appear to provide sufficient incentives for owners to continue 

implementation of the recommended health and safety improvements. 

Conclusion

Keys to the success of this intervention were establishing a partnership with the local 

business association; conducting preliminary activities to gain insight into shop owners’ 

and workers’ knowledge and attitudes towards safety; building relationships with owners, employees, and regulatory authorities; and being creative in designing and offering 

incentives throughout the study. It was important to owners that the researcher was affiliated with a non-regulatory organization (a research institute) and had strong support 

of the local business association. Positive owner attitudes towards CARSS participation 

were fostered by researchers’ ability to inspire trust; their good understanding of the 

technical aspects of the industry; their ability and willingness to assist with issues not 

related to the study (such as air permits, neighbors’ complaints, and OSHA inspection 

findings); and their ability to maintain confidentiality. 

The collision repair industry has seasonal variations in workload, and during the study 

some businesses changed locations. Therefore, it was essential that we adopted flexible 

timelines to accommodate the demands facing business owners. We also created incentives and opportunities for celebrating owners’ and workers’ achievement of milestones, 

such as the implementation of 50% or 100% of the recommendations selected. Last but 

not least, it was important to remain connected to the business community, share the 

results of the study, and make all members aware of the study opportunities for free health 

and safety assistance. Bejan and Skan [2013] offer an example of such outreach efforts. 

We recommend that, in addition to working closely with business owners and creating 

tools that are straightforward and easy to use, researchers should incorporate activities 

in future interventions that increase workers’ awareness of safety and health hazards in 

their workplace and offer opportunities for their direct involvement in creating change.

References

Bejan A, Brosseau LM, Parker DL [2011]. Supplemental personal noise exposure. Letter to the 

editor. J Occup Environ Hyg 8:D73─D74, https://doi.org/10.1080/15459624.2011.585097.

BejanA, Parker DL, Brosseau LM, Xi M, Skan M [2015]. Two-year follow-up of the Collision Auto 

Repair Safety Study (CARSS). Ann Occup Hyg 59(5):534–546.

Bejan A, Skan M [2013]. Old CARSS, new CARSS: how a federally funded study created an affordable way to improve safety in YOUR business. AASP News June.
Understanding Small Enterprises: Proceedings from the 2017 Conference 61

Brosseau LM, Bejan A, Parker DL, Xi M, Skan M [2014]. Workplace safety programs, practices 

and conditions in auto collision repair businesses. J Occup Environ Hyg 11:354–365.

Parker DL, Bejan A, Brosseau LM [2012]. A qualitative evaluation of owner and worker health 

and safety beliefs in small auto collision repair shops. Am J Ind Med 55(5):474–82.

Parker DL, Bejan A, Brosseau LM, Skan M, Xi M [2015]. The Collision Auto Repair Safety Study 

(CARSS): a health and safety intervention. Am J Ind Med 58(1):88–100.

U.S. Census Bureau [2015]. Statistics of US businesses, https://www.census.gov/data/tables/2015/

econ/susb/2015-susb-annual.html.

Whittaker SG, Reeb-Whitaker C [2009]. Characterizing the health and safety needs of the collision repair industry. J Occup Environ Hyg 6:273–282.
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Understanding Small Enterprises: Proceedings from the 2017 Conference 63

Occupational Health Nurse as an Alternative 

Resource in a Small-Scale Enterprise in Japan

Jiro Moriguchi; Rie Murata; Yuko Nyuhara; Ryoko Hashimoto; 

Keiko Kajioka; Masayuki Ikeda

Kyoto Industrial Health Association, Kyoto, Japan

Introduction

The Economic Census for Business Frame by the Ministry of Economy, Trade, and 

Industry in Japan showed that in 2014, 59.8% of all employees work for small-scale 

enterprises (SSEs) with fewer than 50 employees. The Industrial Safety and Health 

Law in Japan stipulates that enterprises with 50 or more employees must establish a 

health committee, appoint an occupational physician (OP), and select health officers 

from among their employees. Moreover, large-scale enterprises with 1,000 or more employees must appoint a full-time OP. However, SSEs do not need to appoint an OP, and 

occupational health (OH) activities such as health guidance and workplace inspections 

are usually not enforced in SSEs.

To improve this situation, the Ministry of Health, Labour, and Welfare in Japan established Regional Occupational Health Centers (ROHCs). ROHCs are the national OH 

providers for enterprises with fewer than 50 employees. There are about 350 ROHCs 

in Japan. Their services, which are free, include health guidance for employees based 

on the results of their health examinations and advice for work environment improvements through worksite visits. However, because of budget shortages at the ROHCs and 

time shortages among registered OPs, the utilization rate by enterprises has been quite 

low for many years. Therefore, employees’ OH is generally poorer in SSEs than in middle-scale and large-scale enterprises in Japan.

Kyoto Industrial Health Association is an OH service provider in Kyoto, Japan. It provides general health examinations as well services such as these: examinations at mobile units for employees with specific concerns of exposure to hazardous materials such 

as chemicals; examination of work environments for hazardous materials at enterprises; 

health guidance for employees; occupational health instructions by OPs in enterprises; 

mental health services for employees; and outpatient clinics for patients with work-related diseases. OH service providers like Kyoto Industrial Health Association have been 

trying to offer various services for SSEs in Japan, such as periodic health examinations, 

work-environment evaluations, guidance for healthy lifestyles, and clinical services. 

However, these trials have not achieved satisfactory outcomes yet. 

For example, Japan’s Ministry of Health, Labour, and Welfare reported that OH activities related to general health examination—such as consulting with physicians regarding the examination results of each employee and health guidance based on the examination results obtained from OH nurses—were lower in SSEs than in large-scale and 

medium-scale enterprises in 2010 (Table 1).
64 Understanding Small Enterprises: Proceedings from the 2017 Conference 

Hiring an OH nurse is not considered to be a duty of employers in Japan. However, 

employers in large-scale and middle-scale enterprises often hire OH nurses. These employers have expectations from OH nurses in the areas of management of work-related 

diseases, health guidance after health examination, and health promotion. Experienced 

OH nurses are not only skillful in their basic domain but also are able to manage work 

and work environments like OPs, and the salary of OH nurses is generally lower than 

that of OPs. 

To improve OH services in SSEs, an OH service organization in Japan recently started 

placing OH nurses in these enterprises.

Methods

In 2012, the employer of Enterprise A, with 36 employees, requested basic OH support 

from Kyoto Industrial Health Association. Then one OH nurse began providing basic 

OH service monthly for this enterprise. The OH nurse provided health guidance to employees and conducted workplace inspections. She also made recommendations to the 

employer regarding improvements in the work environment, based on the results of a 

health questionnaire survey and observations through workplace inspection. 

In our multidisciplinary OH team for an SSE, one OH nurse takes initiative for this 

team. As mentioned above, experienced OH nurses are not only skillful in their basic domain but also are able to manage work environments, mental health problems, 

and other matters. If a difficult problem emerges which the OH nurse cannot solve by 

herself, then the professional in each OH domain such as the OPs, work environment 

evaluation experts, and clinical psychologists will support her to solve the problem.

Results

At this enterprise, the OH nurse elucidated from the health questionnaire results that 

the rating was low for the questionnaire item “full recovery after sleep.” When providing health guidance to the employees, she also acquired the information that most 

employees usually stay late at work, until 8 or 9 p.m. Therefore, the OH nurse provided 

health guidance on proper sleep habits for all employees and informed the employer 
Understanding Small Enterprises: Proceedings from the 2017 Conference 65

that this sleep problem was related to overtime work. Through the information obtained 

from the OH nurse, the employer realized that the overtime working conditions for 

some employees was problematic. He decided to hire several part-time workers.

After the OH nurse provided health guidance on sleep habits for all employees and informed the employer about their health condition, responses to the questionnaire item 

“full recovery after sleep” improved significantly, along with the reduction in overtime 

work, from 2012 to 2014 (Figure 1). These results suggest that activities by OH nurses 

can improve employees’ health conditions in SSEs.

In this enterprise, upon deliberation with the OH nurse, the employer decided to recruit 

additional workers to reduce overtime work. Then the sleep habits of the employees 

improved. Hasle and Limborg have reported that the employer in SSEs is the key person 

in OH activities [Hasle and Limborg 2006]. OH professionals in SSEs may have better 

opportunities to inform and educate the employer through direct conversations with him 

or her than those in middle-scale or large-scale enterprises [Moriguchi et al. 2010]. 

When a photo was taken to show the effect of the workplace inspection by the OH 

nurse at the OH committee in the enterprise after the improvement, the employer of 

this enterprise accepted the request of our OH nurse and volunteered to demonstrate 

poor conditions in working with computers (straight arm, no arm rest, and working 

without a sun shade) in the photo. This episode could be a symbol of the good communication between the employer and the OH nurse in this enterprise.

For clarity, several OH nurse activities in other SSEs were introduced. In one enterprise, OH improved with monthly visits by the OH nurse. For example, voluntary health 
66 Understanding Small Enterprises: Proceedings from the 2017 Conference 

consultations requested by the employees increased from 0 in 2016 to 4 in 2017. Moreover, physicians were consulted sooner than previously regarding the health examination results of each employee. In 2016, the health officer in this enterprise performed 

this legal task with our OH nurse just before the next year’s health examination. However, in 2017, he performed this task within 4 months after the health examination. The 

OH nurse explained to the health officer that asking for an OP’s opinion on employees’ 

work restrictions, based on their health examination results, is always a legal obligation 

of enterprises. Therefore, his attitude changed. 

In another enterprise, based on the advice of the OH nurse, the employer arranged an 

OP consultation with an employee after sick leave due to a mental health condition. 

Because the return-to-work recommendation for an employee in Japan can be provided 

only by an OP, as per the Industrial Safety and Health Law in Japan, the employer had 

to arrange an OP consultation in this case.

Our reported findings have several limitations. OH nurse activities were implemented 

only in a few SSEs. Most OH nurse activities were implemented in subsidiary enterprises of large-scale enterprises. Effects of OH nurse activities in a wide range of OH levels 

in SSEs are unclear. Further investigations of OH nurse activities in many SSEs should 

be considered. 

Discussion 

These results suggest that the activities of OH nurses can improve employees’ health 

conditions in SSEs. The communication between employers and OH professionals is 

important for the development of successful OH activities. 

References

Hasle P, Limborg HJ [2006]. A review of the literature on preventive occupational health and 

safety activities in small enterprises. Rev Ind Health 44(1):6–12.

Moriguchi J, Ikeda M, Sakuragi S, Takeda K, Muto T, Higashi T, Weel ANH, van Dijk FJ [2010]. 

Activities of occupational physicians for occupational health services in small-scale enterprises in Japan and in The Netherlands: comparative study. Int Arch Occup Environ Health 

83(4):389–398.
Understanding Small Enterprises: Proceedings from the 2017 Conference 67

Applying Fundamentals of Total Worker Health®

Approaches: Essential Elements for Advancing 

Worker Safety, Health, and Well-being

Sarah Mitchell; Reid Richards; Heidi Hudson; A. Romina Stormo; 

Michelle Lee

National Institute for Occupational Safety and Health

Introduction

In 2016, the National Institute for Occupational Safety and Health (NIOSH) published 

Fundamentals of Total Worker Health® Approaches: Essential Elements for Advancing Worker Safety, Health, and Well-being. This workbook serves as a practical starting 

point for employers, workers, labor representatives, and other professionals interested 

in implementing workplace safety and health programs that align with the Total Worker 

Health (TWH) approach. TWH strategies explore opportunities to both protect workers and advance their health and well-being by improving the conditions of their work, 

primarily through workplace policies, programs, and practices. 

Because TWH approaches are adaptable to a wide range of workplaces, organizations, 

and industries, these strategies are of particular interest to small- and medium-sized 

businesses, many of which frequently face challenges related to staffing, resources, and 

time. Workers’ contributions and skills are often considered the centerpiece or greatest 

asset of many small firms. Therefore, integrated concepts that call for worker participation in all aspects of program design and encourage customization of interventions 

for greatest health impact are well suited to smaller firms. With TWH’s uniquely organizational and integrated approach, rather than one that is only individually focused, 

TWH strategies provide small enterprises with an expanded opportunity to protect and 

promote the health of their workers. 

The goals of this paper are to (1) familiarize employers with the fundamentals workbook content and layout; (2) provide examples of policies, programs, and practices that 

incorporate the five defining elements of TWH; and (3) provide guidance on how to 

utilize featured tools and resources to assist with planning and implementation efforts. 

Methods

What is the Fundamentals Workbook? 

Fundamentals of Total Worker Health® Approaches, developed with peer and stakeholder input from small and medium-sized businesses, focuses on five defining elements 

of TWH. Offering a user-friendly entry point, this workbook can provide a baseline 

“snapshot” of where your organization is on the path to TWH; identify initial steps 
68 Understanding Small Enterprises: Proceedings from the 2017 Conference 

to improve your workforce safety, health, and well-being in alignment with the TWH 

approach; and help you measure progress as you implement interventions relevant to 

your organization.

Five Defining Elements of TWH

The five defining elements of TWH are guiding principles that provide practical direction for organizations seeking to develop policies, programs, and practices that contribute to worker safety, health, and well-being. Infused within each defining element are 

tips for success, examples to illustrate TWH in action, and relevant resources. Below we 

briefly highlight each defining element. 

Defining Element 1: Demonstrate leadership commitment to worker safety and 

health at all levels of the organization. Commitment to worker safety and health 

throughout all levels of an organization, as reflected in words and actions, is critical 

[Sorensen et al. 2012]. Organizational leaders should acknowledge and communicate 

widely the value of workforce safety and health as a core function and prioritize worker 

safety and health on the same level as quality of services and products. 

Defining Element 2: Design work to eliminate or reduce safety and health hazards 

and promote worker well-being. A TWH-aligned health approach prioritizes a hazard-free work environment for all workers. Its prevention approach is consistent with 

traditional occupational safety and health prevention principles of the NIOSH Hierarchy of Controls, as applied to TWH (Figure 1).

Defining Element 3: Promote and support worker engagement throughout program 

design and implementation. Ensure that workers involved in daily operations as well 

as supervisory staff are engaged in identifying safety and health issues, contributing 

to program design, and participating in all aspects of program implementation and 

evaluation.

Defining Element 4: Ensure confidentiality and privacy of workers. Note that workplace policies that discriminate against or penalize workers for their individual health 

conditions or create disincentives for improving health are inconsistent with the TWH 

approach.

Defining Element 5: Integrate relevant systems to advance worker well-being. TWH 

emphasizes the role of organizations in shaping worker safety and health outcomes. 

Organization must recognize that a multilevel perspective on policy, environmental, organizational, and social concerns may be best for tackling complex challenges to worker 

safety, health, and well-being [Best 2011].

As organizations use the defining elements to plan TWH interventions and programmatic content, it may be useful to explore a conceptual model based on a familiar tool from 

traditional occupational safety and health, the Hierarchy of Controls. 

The Hierarchy of Controls Applied to Total Worker Health

Developed specifically to help increase understanding of TWH policies, programs, and practices, the Hierarchy of Controls Applied to NIOSH TWH illustrates the prioritization of efforts to advance worker safety, health, and well-being. Like the traditional Hierarchy of Controls, strategies are presented in 
Understanding Small Enterprises: Proceedings from the 2017 Conference 69

descending order of anticipated effectiveness, as suggested by the cascading arrows. The Hierarchy of Controls Applied to NIOSH TWH expands the traditional 

hierarchy from occupational safety and health to include controls and strategies 

that more broadly advance worker well-being. To apply this model, those implementing a TWH approach begin by eliminating workplace conditions that 

cause or contribute to worker illness and injury or otherwise negatively impact 

well-being. These include factors related to supervision throughout the management chain. The second is replacing unsafe, unhealthy working conditions 

or practices with safer, health-enhancing policies, programs, and management 

practices that improve the culture of safety and health in the workplace. The 

third step, redesigning the work environment for safety, health, and well-being, 

includes removing impediments to well-being, enhancing employer-sponsored 

benefits, and providing flexible work schedules. Providing safety and health 

education and resources to enhance knowledge for all workers is the final step 

before encouraging personal change for improvements to health, safety, and 

well-being. This encouragement includes assisting workers with individual risks 

and challenges and providing support for making healthier choices. 

Figure 1: Hierarchy of Controls Applied to NIOSH Total Worker Health®
70 Understanding Small Enterprises: Proceedings from the 2017 Conference 

Self-Assessment and Action Plan

Worksheet 1: Self-Assessment

Worksheet 2: Action Plan

The workbook includes two worksheets to frame and evaluate work design through the 

lens of Total Worker Health. The first (Worksheet 1) is a self-assessment that allows 

readers to consider how existing programs, policies, and practices could be adjusted or 

expanded to more effectively address TWH in an organization. The second (Worksheet 

2), an action plan, provides guidance, through pointed questions and the defining elements, for next steps toward implementing a TWH approach. 

Application of TWH Approaches

Implementing a TWH approach is an ongoing effort in which workers’ safety, health, and 

well-being are top priorities. In many settings, TWH is a constellation of interventions, 
Understanding Small Enterprises: Proceedings from the 2017 Conference 71

policy changes, and practices that create a robust culture of safety, worker protection, 

and greater health opportunity. TWH programs are voluntary and participatory, giving 

workers a voice in the conditions of their work and a say in workplace offerings. Putting 

TWH into action often starts with an organizational focus, looking at the challenges to 

keeping workers safe and healthy. Changes to policy, the built environment, and programs follow. Enduring, system-wide levers for better health take priority over programs 

promoting individual behavior change.

The application of TWH practices, policies, and programs emphasizes organizational 

approaches, including paid family and sick leave, paid medical benefits, equitable wages, 

safe staffing levels, and voluntary overtime; attention to work-life integration; recognition 

of work factors as potential causes of chronic conditions; and prevention of discrimination, harassment, and violence. Additional examples of TWH application are interpersonal-level interventions (such as health-enhancing work organization and healthier supervisory practices, respect, fair performance appraisals, and advancement opportunities) 

and individual-level interventions (such as programs to help workers manage their health 

challenges, worker participation in workplace problem solving, and voluntary participation in confidential occupational health services). 

On our Promising Practices webpage, the NIOSH Office for TWH highlights real-life 

examples of organizations that are moving toward such an approach. In addition, scientists both within the Institute and at the NIOSH-funded Centers of Excellence for TWH 

are leading a number of research-to-practice initiatives. The following example demonstrates strategies targeting small and medium-sized employers.

Healthy Environments in Workplaces and Communities

The Nebraska Safety Council (NeSC) is a TWH Affiliate and not-for-profit 501(c)(3) 

organization, with over 600 member organizations in various industries, including manufacturing, state and local governments, and construction. NeSC offers trainings, educational materials, and interactive consultations for its members in addition to integrated 

resources through the WorkWell division organizations to help employees achieve optimal 

well-being. In 2014, The University of Iowa Healthier Workforce Center for Excellence, a 

NIOSH TWH-funded Center, awarded NeSC a community pilot grant. NeSC then offered 

hands-on resources to participating small businesses in the community via the pilot grant 

program. It focused on implementation of TWH interventions at three small Nebraska 

businesses in the cities of Lincoln and Beatrice, based on previous interactions with 

leadership and their interest in TWH solutions. NeSC created customized solutions such 

as providing interactive training and consultations, assisting with policy development 

and communication, offering training modules, and providing practical support. Each of 

the businesses was already meeting state and federal guidelines for workplace safety but 

sought assistance from NeSC to expand safety beyond regulatory requirements with a 

TWH approach. 

The Nebraska Safety Council/WorkWell experiences emphasize the importance of interaction between leadership and workers in establishing TWH programs, policies, and 

practices in small businesses. NeSC focuses on what each business is already doing to 

keep its workers safe, healthy, and well. This allows critical next steps to build upon the 

foundation present at the business. By meeting the businesses “where they were” with 

safety, health, and well-being, NeSC developed infrastructure and allowed workers to 

lead changes, enabling the businesses to create sustainable impact [NIOSH 2015]. 
72 Understanding Small Enterprises: Proceedings from the 2017 Conference 

NIOSH Centers of Excellence for Total Worker Health

NIOSH funds six Centers of Excellence (Centers) to conduct research on the concepts 

of TWH. These Centers are partnering with those in their regions to better champion worker safety and health. The scientists at the Centers, along with their partners 

in government, business, labor, and the community, are essential in moving research 

into practice. The Centers use multidisciplinary research projects, including intervention-focused research, outreach and education, and evaluation activities, to improve 

our understanding of which solutions work. The scientists at the Centers, along with 

their partners in government, business, labor, and community, are conduits for the 

research-to-practice effort that holds promise for having a positive impact on the health 

and productivity of American workers. 

Conclusion

With the 2016 publication of the workbook Fundamentals of Total Worker 

Health® Approaches: Essential Elements for Advancing Worker Safety, Health, and 

Well-being, NIOSH prioritized a hazard-free work environment for all workers. The 

workbook applies a modern prevention approach—consistent with traditional occupational safety and health prevention principles—that recognizes that job-related factors 

can have an important impact on the well-being of workers, their families, and their 

communities. Although it is still a developing field and more research is needed, the 

TWH approach holds promise for small and medium-sized enterprises. Its flexibility, 

adaptability, and participatory approach make it ideally suited for any organization 

looking to begin or continue developing a worker safety and health program. 

References

Best A [2011]. Systems thinking and health promotion. Am J Health Promo 25(4):eix–ex.

NIOSH [2017]. NIOSH Centers of Excellence for Total Worker Health®, https://www.cdc.gov/

niosh/twh/centers.html.

NIOSH [2016]. Fundamentals of Total Worker Health approaches: essential elements for advancing worker safety, health, and well-being. By Lee MP, Hudson H, Richards R, Chang CC, 

Chosewood LC, Schill AL, on behalf of the NIOSH Office for Total Worker Health. Cincinnati, 

OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. DHHS (NIOSH) Publication No. 

2017-112.

NIOSH [2015]. Promising practices for Total Worker Health. Small businesses, big impact: the 

Nebraska Safety Council/WorkWell. Total Worker Health in Action! eNewsletter 4(3), https://

www.cdc.gov/niosh/TWH/newsletter/TWHnewsv4n3.html.

Sorensen G, Barbeau E [2012]. Steps to a healthier U.S. workforce: integrating occupational 

health and safety and worksite health promotion: state of the science. In: NIOSH. Research 

compendium. The NIOSH Total Worker Health program: seminal research papers. Presented 

at the Steps to a Healthier U.S. Workforce symposium, https://www.cdc.gov/niosh/docs/2012-

146/pdfs/2012-146.pdf.

TOTAL WORKER HEALTH® is a registered trademark of the US Department of Health 

and Human Services.
Understanding Small Enterprises: Proceedings from the 2017 Conference 73

Total Worker Health in Childcare Centers: 

Preliminary Results from a Community-based Model

Brenda Jacklitsch, PhD, MS; Thomas Cunningham, PhD

National Institute for Occupational Safety and Health

Background

Small businesses deliver fewer workplace health promotion and occupational safety and 

health activities than larger businesses [Linnan et al. 2008; Sims 2008]. In addition, small 

businesses tend to need more external assistance with integrated safety and employee 

health programs such as Total Worker Health [Newman et al, 2015], and they endure a 

higher burden of occupational injuries and illnesses [Mendeloff et al. 2006]. Business size 

has also been shown to be one of the best predictors of a small business’s involvement 

with workplace health promotion and safety activities [Linnan et al. 2008; Sinclair and 

Cunningham 2014]. Many factors, such as these, affect small businesses’ lack of motivation to engage in prevention: lack of resources, isolation, low probability of inspection, 

and inaccurate perceptions of illness and injury rates [De Kok 2005; Hasle and Limborg 

2006; Lentz and Wenzl 2006; Parker et al. 2007; Sinclair and Cunningham 2014].

For this study, the Total Worker Health concept and suggested programming were 

introduced to small businesses. Total Worker Health (TWH®) is defined as “policies, 

programs, and practices that integrate protection from work-related safety and health 

hazards with promotion of injury and illness prevention efforts to advance worker 

well-being” [NIOSH 2017]. Considerations in designing the study included the need 

for multiple levels of intervention to support employee health and wellness promotion 

efforts, including support from the community [Faghri et al. 2010; Baker et al. 1996; 

DeJoy and Southern 1993]. Working with a local business network in a small geographic area was also suggested as a successful approach [O’Donnell 2012]. Identifying local 

businesses already familiar to our partners was ideal. Developing a strong business case 

for TWH that included financial costs and benefits, personal effort required, time commitment, compatibility with existing systems, and expected outcomes would also be 

essential for participants to remain open to the concept and potentially gain insight into 

successful future adoption [Rogers 2003; Maddux 1999].

The Intermediary–Small Business Diffusion Model was used as the basis for structuring and 

designing this study (Figure 1). The model was previously published by the NIOSH Small 

Business Assistance Program, and its utility has since been demonstrated in other studies 

[Cunningham and Sinclair, 2015; Bruening et al. 2015; Sinclair et al. 2013]. The model 

consists of two stages, an initiator–intermediary stage and an intermediary–small business 

stage, which provide a framework for identifying who small businesses use for information, 

how to reach out to those intermediaries, and how to work with those intermediaries 

to then reach out to and engage small businesses. This model is ideal for learning about 

both small businesses and intermediaries, as stages may overlap at multiple points.
74 Understanding Small Enterprises: Proceedings from the 2017 Conference 

Figure 1. The intermediary–small business diffusion model

Initiator-Intermediary Phase

Intermediary

Organizations

Step 1

Analyze 

characteristics 

of small 

businesses 

and potential 

intermediary 

organizations

Analyze ways 

that small 

businesses 

perceive 

occupational 

health and 

safety

Develop 

messages 

and select 

channels for 

reaching small 

businesses

Small 

businesses 

engage in 

workplace 

prevention 

activities

Engage small 

businesses 

using selected 

strategies

Develop 

messages 

and select 

channels for 

reaching 

intermediary 

organizations

Engage 

intermediary 

organizations 

using selected 

strategies

Analyze 

ways that 

intermediary 

organizations 

perceive 

provision of OSH 

information and 

services to small 

businesses

Step 2 Step 3 Step 4

Step 5 Step 6 Step 7 Step 8

Initiator

Organizations

Monitor

Intermediary-Small Business Phase

The overarching, larger study targeted two communities (Northern Kentucky and 

Greater Cincinnati). Each set of community partners, or intermediaries, selected 

slightly different approaches for identifying small businesses as participants. Cincinnati-based partners wanted a geographic approach, whereas Northern Kentucky–based 

partners preferred a sector-based approach (such as childcare centers). Intermediary 

community partners included health departments, business health services, and safety consultants. Health departments were ideal partners because of their interest in 

new channels to deliver health objectives, experience in data collection, and interest 

in health outcome changes. Business health services were ideal partners because they 

already offered employee health services to businesses, were interested in market 

research, and understood the importance of both prevention and return-to-work activities. Safety consultants were ideal partners because of their knowledge related to 

workplace safety and regulations and their ability to discuss options to decrease risk of 

injury and illness.

The goals of this study were (1) to understand perceptions of the cost and benefits of 

TWH approaches among small business owners/operators and employees; (2) to understand perceptions of TWH among community organizations that serve small businesses; 

and (3) to explore methods for encouraging use of TWH approaches by small businesses, particularly childcare centers. 
Understanding Small Enterprises: Proceedings from the 2017 Conference 75

Methods

Participating childcare centers were eligible if they had fewer than 50 employees or 

more than five employees. Initial outreach efforts via phone calls and interview data 

collection were conducted by the health department. 

Study steps included (1) baseline interviews with the owner or manager, (2) individual 

business consultations and provided services, and (3) exit interviews with the owner 

or manager. Baseline interviews gathered initial perceptions about the TWH concept 

and determined what the childcare center may be doing or may be interested in doing 

for employee health and occupational safety and health. During the business consultations, consultants met with childcare centers and provided resources as requested. For 

childcare centers, the services included a TWH Training Day delivered on a Saturday 

by the partnered intermediaries (for example, an ergonomist presented on lifting, stress 

management techniques, and vaccinations). Exit interview questions were similar to 

those in the baseline interviews but also sought to elicit descriptions of changes in perceptions.

All interviews were recorded and transcribed. The transcribed interviews were analyzed 

by an inductive approach with thematic coding and a subsequent iterative process for 

further clarification of themes [Braun 2006; Gale et al. 2013]. During familiarization, or 

phase 1, the research team independently reviewed the transcripts and then together 

reached consensus on important themes and ideas. The team developed a codebook 

to guide data analysis. In phase 2 (generating initial codes), the research team systematically coded interesting features, direct quotations, and patterns across the entire 

data set, reviewing differences in coding until consensus was reached. During phase 3 

(searching for themes), the data were reviewed, gathered into relevant groups, and collated into potential themes. During phase 4 (reviewing themes), the team used the constant comparison method to examine and refine the themes by comparing and contrasting information within each interview and across all the interviews and focus groups 

[Boeije 2002; Corbin and Strauss 2014]. In phase 5 (defining and naming themes), 

the team conducted ongoing analysis to refine each theme and further condense the 

themes into a cohesive narrative. 

Results

Eight participants completed baseline interviews and participated in business consultations, but only five completed exit interviews. Participants were characterized as being 

the owners of the childcare center and reported good overall health. Childcare centers were characterized as having good work climates, good staff, and positive working 

relationships. The age of employees ranged from young adult college students to senior 

citizens. Most childcare centers did not provide health insurance, and paid holidays 

and sick leave varied by facility. Some of the biggest challenges these childcare centers 

faced—in general and in relationship to the study—for implementing a TWH program 

were money and time. There was concern about the cost of employee health initiatives, 

as some facilities were consistently on the brink of closing because of finances. There 

was also a lot of concern about finding or making time for additional employee-focused 

programming.
76 Understanding Small Enterprises: Proceedings from the 2017 Conference 

Overall, exit interview responses demonstrated that childcare center providers reflected 

increased attention and recognition of safety issues through more conversations and 

awareness that what’s good for the children is good for the employees and the center 

as a whole. Participants described one-time trainings/activities related to safety, such 

as lifting children or safety in the classroom (Table 1). No respondents described new 

programming or formal, structured activities related specifically to safety. 

Table 1. Changes made and lessons learned about safety

Themes Example Quotes

Increased attention and 

recognition of safety issues, 

especially personal safety

“All of our safety rules and things like that are there for the 

children, but I think this brought to their attention that 

they’re there to protect themselves as well.”

“Definitely opened eyes and put some more focus on certain 

things that were brought to our attention that we kind of 

knew in the back of our head.”

“We had a lot of conversations—individual conversations 

with people.”

Recognized that what’s good for kids is good for all of us and 

the whole center.

One-time safety-related 

training/activity 

“We did have training on how to lift children.”

“The fire department is going to be coming in and walking 

through to assess some of the safety things here at the center.”

“We’ve talked about safety in the classroom at our teacher 

meetings.”

In addition, childcare center providers showed an increased awareness of and attention 

to factors that influence employee health. They described small, informal changes they 

had made to promote employee health and wellness (such as healthy foods at meetings) 

or one-time trainings and activities that were designed to promote employee health. 

Some respondents described changes being made by individual employees to improve 

their health that were not related to the workplace, such as starting gardens (Table 2). 

No respondents described new programming or formal, structured activities related to 

total worker health.
Understanding Small Enterprises: Proceedings from the 2017 Conference 77

Table 2. Changes made and lessons learned about employee health

Themes Example Quotes

Small, informal activities to 

support employee health

“We started eating healthy at our staff meetings and I started 

bringing in healthy foods instead of getting, you know, cheese 

coneys and chips and stuff.”

“We did have a garden this year.”

“We usually try to do like a potluck every once in a while. 

We started trying to do, like, the healthier—bring in your 

healthiest dish.”

Small, informal activities to 

boost morale/reduce stress

“As kind of like a team-building activity, we took the staff out 

to dinner (to a restaurant) just to kind of reward them...you 

know, kind of build relationships.”

“I kind of had like a teacher meeting where we all came in and 

it was quiet and I had the lights off and had relaxing music 

and we had healthy foods that we partaked [sic] in, and I had 

everybody put their biggest problem on a piece of paper and 

then we crumpled it up, put it in a bowl, and then put it outside 

and said ‘Let’s just not think about those. Do you want to just 

talk about, you know...think of how we can relax.’”

Increased attention to and 

recognition of health and 

wellness issues

“We do a lot of water, stay away from a lot of pop and stuff 

like that.”

“I feel more that people are calling and saying ‘I need help,’ ‘I 

can’t,’ you know, where normally I think they were afraid to 

call. You know, because they felt like they couldn’t do their job, 

but I think now they’re—my phone rings a little bit more now.”

One-time training/activity “Ergonomics training”

“They came in to check BMI.”

“Chiropractor came in.”

“(Company) did a training for us on stress management.”

Reports of individual staff 

changes

“There’s a couple of them that have—are working on quitting 

smoking.”

“There’s a couple of them that are working on losing weight.”

“She exercises, she also uses the steps for stuff like that and her 

eating habits have changed.”

“I’m cooking more, using more fresh fruits and vegetables.”
78 Understanding Small Enterprises: Proceedings from the 2017 Conference 

Childcare center providers were split on the opinion of TWH (that is, integrated safety 

and wellness activities) being a good idea. Many of the providers felt that safety should 

continue to be separated so that, as one participant said, “important things don’t get 

jumbled up.” However, participants did express that the following activities would be 

desirable: cost-effective employee health programs (such as exercise programs, gym 

memberships, walking clubs, and pedometer challenges), health programs for both employees and clients (that is, parents), lifting safety, and free and useful safety training.

Conclusion

The study findings presented on childcare centers are a piece of a larger study examining two communities and a larger variety of small businesses. Although the childcare 

centers presented here were somewhat open to the idea of a TWH program for their 

employees, there were restrictions to potential future adoption, such as cost and time 

availability. Despite these restrictions, these childcare centers did find certain potential 

future activities related to TWH to be desirable. As each childcare center was somewhat 

unique, it is likely important to not design a one-size-fits-all TWH program. Instead, a 

successful TWH program should be flexible and tailored to the needs and desires of the 

owners and employees. In addition, it is important for the TWH program to give the 

childcare center a sense of ownership and for a couple program champions to be identified in order to increase the likelihood of success.

References

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their prevention. J Occup Environ Hyg 3(2):D8–14, doi:10.1080/15459620500496715.
Understanding Small Enterprises: Proceedings from the 2017 Conference 79

Linnan L, Bowling M, Childress J, Lindsay G, Blakey C, Pronk S, Wieker S, Royall P [2008]. Results of the 2004 National Worksite Health Promotion Survey. Am J Public Health 98(8):1503–

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Understanding Small Enterprises: Proceedings from the 2017 Conference 81

Correlation between Weekly Exercise Duration & 

Light Duty and Lost Time: A Cross-Sectional Analysis 

of an Occupational Working Population

Skyler D. Walker; Holden L. Brown; Matthew S. Thiese; Ulrike Ott;

 Kurt T. Hegmann

Rocky Mountain Center for Occupational and Environmental Health

Introduction

The United States Office of Disease Prevention and Health Promotion guidelines suggest 150 minutes per week of moderate activity [American College of Sports Medicine 

2013]. Physical inactivity doubles the risk of developing cardiovascular disease, type 

2 diabetes, and obesity [Wen et al. 2011]. These diseases can cost hundreds of billions of dollars in loss of productivity nationally [Stewart et al. 2003]. We performed 

a cross-sectional analysis to determine the association of different durations of leisure-time physical activity (PA) and the prevalence of light work and lost time in an 

industrial working population.

Methods

This was a cross-sectional study analyzing baseline data from a large prospective cohort 

study. Workers were enrolled from 27 different employers having 30 different production facility types located in Texas, Wisconsin, Utah, and Illinois. At baseline enrollments, workers completed a laptop-administered questionnaire. Data quantified included demographics, PA (such as baseball, walking, skiing, tennis, and yoga), and light 

duty/lost time (LD/LT) prevalence. 

Moderate activity was defined as any activity between 3 and 5.9 Metabolic Equivalent of 

Tasks (METs), and vigorous activity as an energy expenditure greater than or equal to 

an MET value of 6. Workers were split into groups according to minutes per week of PA: 

1–60, 61–150, 151–315, and 316+. We performed multivariate logistic regression analyses to assess correlations between exercise duration and LD/LT. 

Results

We included 827 workers in our analysis. The majority of workers were male (63.8%) 

with a mean age of 38.8 (±12.1) years. The median amount of PA performed was 82.5 

minutes per week, with 25.9% (n = 214) indicating they did not participate in any PA. 

Workers who exercised 1–60 and 61–150 minutes per week were 1.3 (p = 0.20) and 

1.1 (p = 0.97) times more likely to be prescribed LD/LT, respectively. Workers who 

exercised 151–315 and 316+ minutes per week had a 0.7 (p = 0.42) and 0.4 (p < 0.05) 
82 Understanding Small Enterprises: Proceedings from the 2017 Conference 

chance of being prescribed LD/LT, respectively (figure 1). A test for trend showed a significant negative correlation between LD/LT and increased level of exercise (p < 0.05).

Discussion 

This cross-sectional analysis shows a positive correlation between worker productivity 

and weekly PA durations (Figure 1). These results may be used to implement a worker exercise program in order to increase the productivity and well-being of workers. A 

longitudinal study on exercise intervention in the workplace could be useful to confirm 

this relationship.

Figure 1. Correlation between weekly exercise and light duty/lost time.

References

American College of Sports Medicine [2013]. ACSM’s guidelines for exercise testing and prescription. Baltimore: Lippincott Williams & Wilkins.

Stewart WF, Ricci JA, Chee E, Morganstein D, Lipton R [2003]. Lost productive time and cost 

due to common pain conditions in the US workforce. JAMA 290(18):2443–2454.

Wen CP, Wai JPM, Tsai MK, Yang YC, Cheng TYD, Lee MC, Hui TC, Tsao CK, Tsai SP, Wu X 

[2011]. Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study. Lancet 378(9798):1244–1253.
Understanding Small Enterprises: Proceedings from the 2017 Conference 83

Assessment of the Relevance and Impact of 

Promoting Marketable Skills for the Informal Sector 

in Addis Ababa, Ethiopia

Yesuneh Gizaw1; Samuel Urkato2; Dereje Getu3; Tewdros T. Woldeyes2

1Wolaita Sodo University

2RCRD Consultancy Firm

3DAB Development Research and Training Consultancy Firm

Abstract 

Concern World Wide Ethiopia (CWWE) received a grant from the European Union (EU) 

to implement a Promoting Marketable Skills training program for the informal sector in 

selected woredas (city administrative districts) of Addis Ababa. Six woredas from three 

sub-cities were selected to assess the performance of the project, using the evaluation 

criteria of relevance and impact. Surveys, key informant interviews, and focus group 

discussions were conducted to gather primary data, and reports of the project were 

utilized for desk review. The study indicated that the project was relevant in addressing 

the identified needs of the target group. Over 60% of the participants responded that 

the project was relevant to their interests, previous experiences, and the demands of 

the labor market, and 86% indicated that the skills acquired through the training were 

relevant to the job market. The results of the study revealed that the impact of the 

training was very positive: over 91% of participants indicated that their competence had 

improved, over 61% indicated that their life had been changed, 55% indicated that they 

were employed or managed their own business, and 76% indicated a significant difference in income (which ranged from 500 to 2,000 birr per month).

Key Words: informal sector, marketable skills, relevance, impact, CWWE, EU, survey, 

key informant interviews, focus group discussions 

Introduction

Employment problems recently have become a central global concern, and nearly all 

governments and development partners are fully engaged in finding lasting solutions. In 

the past, development planning efforts were concentrated on the growth of a modern 

industrial sector that would serve the domestic market, facilitate absorption of redundant or surplus workers in the urban economy, and create rapid economic growth and 

development. However, the anticipated ability of the modern industrial sector to absorb 

migrants was never achieved. 

Although various conceptualizations of the informal sector have been debated since 

the early 1970s [Bangasser 2009; Hart 197], today it encompasses about 500 million 

workers around the world [ILO 2013, 2014]. The informal sector’s capacity for 
84 Understanding Small Enterprises: Proceedings from the 2017 Conference 

employment generation in the economy has been recognized by scholars, policymakers, and lately governments in developing countries. The informal sector therefore 

represents an important part of the economy and certainly of the labor market in most 

developing countries. It plays a major role in employment creation, productivity, and 

income generation. It is widely believed that employment generation in the informal 

sector is necessary for the survival of countries that lack social safety nets and for 

absorption of growing numbers of unemployed members of the labor force. Empirical 

enquiries have confirmed the vastness, resilience, and dynamism of the informal sector 

[Akande and Akerele 2008]. 

Ethiopia is one of the emerging economies, similar to other countries in developing 

regions such as sub-Saharan Africa. Though the country has had double-digit economic 

growth over the last decade, Ethiopia is still one of the poorest countries in sub-Saharan 

African, with a total estimated population of 87,952, 000 [CSA 2014]. According to the 

Central Statistical Agency [CSA 2014], urban unemployment has decreased to 17.5%, 

from 26% in 2008. However, unemployment (especially among youths) in Ethiopia has 

become a major development issue. A significant portion of the urban workforce works 

without pay for a family business; more than 40% are self-employed in the informal 

economy, most of which live on the edge of poverty. In addition, 75% of the workforce is 

concentrated in low-skill employment sectors such as commerce, services, and elementary occupations. As an intervention to those issues, the Ethiopian government has 

crafted an integrated plan and has been implementing it with two growth and transformation plans and previous integrated development plans. 

In line with this, the 2008 Technical and Vocational Education and Training (TVET) 

strategy aimed to provide more opportunities to a wider range of different target groups 

in Ethiopia. The TVET system addresses not only school dropouts but also people without formal education, including illiterate or least educated people; farmers and their 

families; unemployed people who need initial education and training or retraining to 

support their reintegration into the labor market; people with disabilities; and people 

from marginalized ethnic groups and other groups. 

The prevalence of poverty in Ethiopia, as reflected in population data, is determined on 

the basis of a poverty line that stratifies by the per capita income or consumption below 

which an individual is considered to be poor. The proportion of people in Ethiopia categorized as absolutely poor (those whose total consumption expenditure was less than 

US $124.28 per year) was 44% during 1999–2000 [MOFED 2002]. Moreover, an estimated 37% in urban areas and 45% in rural areas were categorized as poor [MOFED 2002]. 

The most vulnerable segments of the Ethiopian population are (1) the rural land-less, 

(2) small holders, (3) victims of drought due to shortage of rainfall, (4) female-headed 

households, (5) the urban unemployed (in particular) and urban poor (in general), and 

(6) street children [Asmamawu 2004]. 

In recognition of these facts, Concern World Wide Ethiopia has initiated and implemented a program known as Promoting Marketable Skills in the Informal Sector in Addis Ababa. Thus, it is legitimate to question how the project has changed the livelihoods 

of its beneficiaries. The objective of this assessment study was to evaluate the relevance 

and impact of the program in the intervention area.
Understanding Small Enterprises: Proceedings from the 2017 Conference 85

Methods

The evaluation, conducted from February to June 2016 in all targeted woredas of Addis 

Ababa, involved the following methods.

• Beneficiary survey. The beneficiaries for the study were selected by simple random sampling from within the sampling frame. To generate quantitative data, a 

structured survey questionnaire was developed and administered to 281 beneficiaries by trained enumerators. 

• Key informant interviews. Potential key informants who had sufficient information about the project were conveniently selected and interviewed. 

• Focus group discussions. Focus group discussions were also conducted in the 

targeted woredas. 

• Desk review and on-site observations. Desk reviews and field visit observations 

were also part of the data collection. 

• Data analysis. The quantitative data were analyzed via SPSS version 20. Text 

data, secondary data, and findings of focus group discussions/key informant interviews were managed and analyzed via content analysis for key themes. 

Evaluation Criteria and Evaluation Questions

Criteria for final evaluation of the project were adopted from the standard evaluation 

criteria developed by the Development Assistance Committee [DAC 1991]: relevance, effectiveness, efficiency, impact, and sustainability. The current study focused on relevance 

and impact, with special attention given to questions related to those two criteria.

Relevance

Relevance was considered to be the extent to which the objectives stated in the project 

application actually corresponded with identified problems or real needs. Evaluators 

asked these questions:

• To what extent are the objectives of the program still valid and relevant in relation 

to the priority and focus of the targeted area? 

• Are the activities and outputs of the program consistent with the overall goal and 

the attainment of its objectives? 

• Are the activities and outputs of the program consistent with the intended impacts and effects?

Impact

Impact was considered to be changes in human development and well-being brought 

about by development initiatives, either directly or indirectly and intended or unintended. Evaluators asked these questions:

• What has happened to the life of those targeted as a result of the program or project? 

• What real difference has the activity made to the beneficiaries? 

• How many people have been affected?
86 Understanding Small Enterprises: Proceedings from the 2017 Conference 

Results

Demographic Characteristics of Respondents

The survey study had 281 participants (99 male and 182 female). With regard to educational level, over 66% had completed grade 9 to 12 (40%, grade 10 to 12). Approximately 

36% of the study participants were married, 57% were single, and the rest were divorced 

or widowed. Table 1 depicts the demographic characteristics of the study participants.

Table 1. Demographic characteristics of the 281 study participants

Category

Number of 

Participants Percentage

Sex Male

Female

99

182

35.23%

64.77%

Marital status Married

Single

Divorced or widowed

90

160

21

36%

57%

7%

Level of education Cannot read and write

Can read and write

Grade 5 to 8 

Grade 9 to 12

12

5

77

187

4.28

1.78

27.40

66.55

Relevance of the Project 

The relevance of the Promoting Marketable Skills in the Informal Sector project has 

received critical attention in many parts of the world [NCEUS 2009]. In this study, evidence for understanding the relevance of the project was collected from various sources: desk reviews, key informant interviews, focus group discussions, on-site observation 

of project areas, and beneficiary surveys. 

Relevance and Complementariness to the Country’s Sector Policy and Strategy 

The project objective was to contribute toward the first Millennium Development Goals 

(MDG1) by increasing employability, productivity, and income. As indicated by the 

2008 TVET strategy documents, integrated development plans, the two growth and 

transformation plans, and key government officials and experts who participated in the 

key informant interviews, the Promoting Marketable Skills project aligns with and complements the policies, strategic focuses, and priorities of Ethiopia. 

Relevance in Addressing the Identified Needs of the Target Groups 

Focus group discussion participants pointed out that the identified skills strongly 

aligned with their interests and previous experiences. Because the trainings were relevant to the needs of the targeted groups, some focus group discussion participants indicated that they have started their own businesses, and others reported being employed 

in organizations. The survey data supported the focus group findings. The majority of 

participants (57%) reported that they chose skill areas on the basis of their experience 

(12.5%) or market demand for the skills (46.80%). These data agree with the findings of 

a similar study conducted in Ethiopia [Elias 2015].
Understanding Small Enterprises: Proceedings from the 2017 Conference 87

Relevance of the Acquired Skills to the Labor Market

Targeted beneficiaries who participated in the focus group discussions in the three 

sub-cities also noted that the identified potential marketable skills were relevant to 

labor market demands. However, in some cases such as auto painting and leather work, 

they said, it was not easy to either own a business or be employed because workers 

need greater skills and experience than informal TVET trainees like them generally 

have. Participants in the key informant interviews also believed that the six selected 

marketable skills were in high demand in the labor market. Of the more than 30 marketable skills proposed, the six were selected on the basis of a market survey in the 

study areas. 

Among beneficiaries interviewed about how they chose a training program (Figure 1), 

nearly 47% mentioned the high demand for such skills in the market. Indeed, market 

demand was the driving factor for the selection of skill areas. The highest enrollment 

of study participants was for training in the construction sector, at 66% (gypsum work, 

25%; plumbing, 17%; shoemaking, 14%; and mental work, 10%); the remaining enrollments were in service sectors such as Barberry (19%) and auto painting (16%). These 

findings of the survey align well with those of the 2013 National Labor Force Survey of 

the CSA. According to that survey, in major cities of the country, the Minor Industrial 

Division of construction work (including plumbing and other construction installation 

activities, as well as metal and finishing work) accounted for the majority of the labor 

force, especially the informal sector workers. Therefore, it appears that the training 

program scheme was duly responsive to the job market demands in Ethiopia. 

Figure 1. Beneficiaries’ training enrollment rates, as proxy indicators of labor demand area

Impact 

Table 2 indicates the monthly income of the beneficiaries, ranging from 500 to 2,000 

birr or more. Nearly 76% of the participants pointed out that their monthly income tremendously increased after the training. The average income per month is around 1,250 

birr (equivalent to US $56.82, on the basis of US $1 = 22 birr). The daily income is 

around US $1.89, which surpasses the poverty line of US $1.25 a day. Thus, this project 

helped reduce abject urban poverty. In addition, study participants indicated that as a 

result of the training, their competence improved (over 91% of participants), their life 

has changed (over 61%), or they are employed or manage their own business (55%).
88 Understanding Small Enterprises: Proceedings from the 2017 Conference 

Table 2. Employability of the surveyed beneficiaries 

Monthly income category, 

in Ethiopian birr

Number of employed beneficiaries 

(N = 213) Remark

Up to 500

500–1000

1000–1500

1500–2000

Above 2000

36

49

52

46

30

The amount of 

monthly income from 

employment after 

receiving the skilldevelopment training

Discussion 

The project was found to be very relevant to the National (Ethiopian) TVET Strategy of 

2008. The project was relevant in addressing the identified needs of the target group. Its 

implementation in the three sub-cities of Addis Ababa helped to achieve the first MDG by 

improving productivity as well as boosting household income of the target beneficiaries. It 

also aligned with the first growth and transformation plan of the country and the MDG 

by empowering women in their economic status, where 70% of target beneficiaries were 

female. Through this project, the beneficiaries’ monthly income increased (range, 500 

to 2000 birr), as indicated in focus group discussions, key informant interviews, and surveys. The project has helped reduce urban poverty by improving productivity and the employability of the target groups. For key stakeholders, it was relevant in successfully equipping beneficiaries with the six most appropriate skills for engagement in the labor market. 

Conclusions

According to GTP II (Ethiopia’s growth and transformation plan draft document), the 

major strategic directions for the social welfare and labor sectors are (1) expanding 

social security services to ensure that they are beneficial to women, youths, people 

with disabilities, and the elderly and (2) expanding employment and labor market 

information services to ensure citizens are benefitted. Despite progress, employment 

generation and poverty eradication still remain at the top of the development agenda. 

Ethiopia therefore remains committed to sustaining an inclusive, pro-poor development 

strategy over the coming years to meet these challenges. Micro and small enterprises 

will be expanded as part of a plan to focus on manufacturing industries to increase their 

productivity and competitiveness. Therefore, scaling up of the project in Addis Ababa 

as well as in other regions of Ethiopia is critical, especially in alignment with the GTP 

II and the United Nations Sustainable Development Goals to empower women, people 

with special needs, and youths.

Acknowledgments

The authors appreciate the Concern World Wide Ethiopia (CWWE) office’s commissioning of this project and the active engagement of all the stakeholders in shaping and 

informing the evaluation study. 
Understanding Small Enterprises: Proceedings from the 2017 Conference 89

References

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economy. Ibidan, Nigeria: Nigerian Institute of Social and Economic Research (NISER).

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Asmamawu E [2004]. Understanding poverty: the Ethiopian context. Presented at The Gambia 

AAPAM Roundtable Conference, April 19–23, 2004, Banjul, The Gambia.

Bangasser PE [2000]. The ILO and the informal sector: an institutional history. Geneva: International Labour Office.

CSA [2014]. The Ethiopian observatory. Addis Ababa, Ethiopia: Central Statistical Agency.

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Hailemariam EZ [2015]. Challenges and prospects of informal sector in alleviating urban poverty in Yeka subcity of Addis Ababa city administration, Ethiopia. Addis Ababa, Ethiopia: Addis 

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ILO [2013]. The formal and informal sectors in Colombia. Geneva: International Labour Office.

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Ministry of Finance and Economic Development (MoFED) [2002]. Sustainable Development and 

Poverty Reduction Program (SDPRP). Addis Ababa, Ethiopia: Ministry of Finance and Economic Development.

NCEUS [2009]. Skill formation and employment assurance in the unorganized sector. New Delhi, India: National Commission for Enterprises in the Unorganised Sector, www.nceus.gov.in.

Sengupta AK, Srivastava RS, Kannan KP, Malhotra VK, Yugandhar BN, Papola TS [2009]. The 

challenge of employment in India: an informal economy perspective. Report of the National 

Commission for Enterprises in the Unorganised Sector, Government of India. Vol. 1. New Delhi, India: National Commission for Enterprises in the Unorganised Sector.
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Understanding Small Enterprises: Proceedings from the 2017 Conference 91

Overlapping Vulnerabilities and Immigrant Safety 

Training in Small Construction Firms

Brenna Keller, MPH; Thomas Cunningham, PhD; Rebecca Guerin, MA; 

 Michael Flynn, MA

National Institute for Occupational Safety and Health

Introduction

In 2015, the American Society of Safety Engineers (ASSE) and the National Institute for 

Occupational Safety and Health (NIOSH) published the report Overlapping Vulnerabilities: 

The Occupational Health and Safety of Young Immigrant Workers in Small Construction 

Firms [NIOSH, ASSE 2015]. This report focused on three populations that research 

indicates are at increased risk for adverse work-related health outcomes—Hispanic immigrants (individuals born in Latin America who currently live in the United States), employees of small businesses (firms with fewer than 20 employees), and young workers 

(<25 years old)—with a specific focus on implications for the construction industry. 

The report began with an examination of demographic trends and occupational risk 

factors for each vulnerable group. Vulnerability does not exist in a vacuum; vulnerable 

workers are often members of two or more at-risk groups. These overlapping vulnerabilities create a unique risk environment for workers. Using the example of young Hispanic immigrants working in small businesses, we presented a conceptual model for understanding how the vulnerabilities interact for workers who are members of all three 

groups. These vulnerable groups were chosen because they often overlap; about 40% of 

the 1.5 million Hispanic immigrants working in construction are with firms that have 

fewer than 10 employees, and about 50% of all young Hispanic immigrants working in 

construction are with very small businesses [U.S. Census Bureau 2014].

The report by NIOSH and ASSE concluded with a call to business leaders, researchers, 

and policy makers to consider the efforts needed to address and reduce the occupational health disparities experienced by vulnerable workers. Following the report, ASSE 

conducted a survey with construction business representatives and shared the results 

with NIOSH researchers. NIOSH researchers analyzed the data to further explore the 

training experiences of foreign-born workers in the construction industry and to identify needs for further research and interventions to protect workers experiencing overlapping vulnerabilities. The full results of the survey have been published in the journal 

Safety Science [Cunningham et al. 2018].

Methods

The survey explored how workplace safety and health training differs between 

smaller construction businesses (fewer than 50 employees) and larger ones (50 or 
92 Understanding Small Enterprises: Proceedings from the 2017 Conference 

more employees) that employ foreign-born workers, as well as between companies in 

which less than 25% versus 25% or more of the workforce is foreign-born. The survey 

consisted of 34 items and was based on a comprehensive review of the professional and 

academic literature. It was cognitively tested with potential respondents to ensure the 

items were understandable. Revisions were made to the instrument on the basis of the 

results of this testing. To establish content validity, the survey was reviewed by eight occupational safety and health experts. Their suggested revisions were incorporated into 

the final survey instrument.

The survey was administered online by ASSE, who recruited respondents via email using a snowball-sampling method. Following the initial recruitment email, the survey was 

available for a period of 4 weeks. To increase the number of small residential construction business respondents, another recruitment email was sent to 19 residential construction business representatives following an initial review of the survey responses. 

Statistical analyses of the survey data used the IBM SPSS, version 23.0. Descriptive 

statistics were analyzed for all response categories. Pearson’s chi-square tests of association were computed for categorical variables (α = 0.05) to analyze response differences 

on survey items between small and large businesses and companies with fewer or more 

foreign-born workers. The survey contained several questions for which respondents 

could provide more than one answer. To allow significance analyses for these items, 

each response option was made into a separate variable. Participants were coded as 

either answering (selecting that option) or not answering. To reduce type I and type 

II errors, multiple comparisons were corrected by means of the Benjamini-Hochberg 

method (Q = 0.10) [Benjamini and Hochberg 1995; McDonald 2014].

Results

The results of the data analysis examining differences between small and large businesses are published elsewhere [Cunningham et al. 2018], and selected results are presented here. There were 50 responses representing small businesses and 215 responses 

representing large businesses. The results show that, among businesses represented in 

the sample, there are deficits in the amount, frequency, and format of workplace safety 

and health training provided to foreign-born workers in smaller construction firms versus larger firms. Smaller companies provided significantly less initial safety training (p

= 0.012) and ongoing safety training (p = 0.042). Smaller companies were less likely to 

employ a supervisor who speaks the same language as foreign-born workers (p < 0.001) 

and significantly less likely to have training in a different language for foreign-born 

workers (p = 0.002). The lower overall access to training for foreign-born workers in 

smaller firms is consistent with findings in other studies (for example, [Dodge Data & 

Analytics 2016]) and may be due to multiple factors such as a lack of resources and 

lack of capacity for occupational safety and health implementation in smaller firms. 

Table 1 highlights some of the results of the two sets of analyses presented here. 

Among the companies responding, in 158 less than 25% of the workforce was foreign-born (“fewer foreign-born workers”) and in 83, 25% or more of the workforce was 

foreign-born (“more foreign-born workers”). The foreign-born worker groups varied 

little in the amount of training received, with no significant differences in the amount of 

either initial or ongoing safety training. However, there were some language-related 
advantages for foreign-born workers in companies with more foreign-born workers. 

These companies were more likely to employ a supervisor who speaks the same language as foreign-born workers (p < 0.001), to present training in the workers’ primary 

language (p = 0.003), and to deliver safety communications in the workers’ primary language (p = 0.013). These advantages may be due to the fact that companies in this sample with more foreign-born workers also tended to be larger companies, which would 

likely have more resources to devote to training foreign-born workers. Foreign-born 

workers at smaller companies experience both the language and cultural barriers of 

being foreign-born as well as the training barriers common in small businesses, such as 

a lack of time, resources, and personnel.

Table 1. Characteristics of safety training among construction firms

Business Size Foreign-Born Workers

Characteristics

Small 

(%)

Large 

(%) p value

Fewer 

(%)

More 

(%) p value

Employ supervisor/foreman/lead person who speaks the same language as 

foreign-born workers

Yes 37.5 68.9 <.001* 54.9 78.0 <.001*

Type of safety training foreign-born workers receive†

Pre-work safety 

orientation

50.0 84.2 <.001*§ 71.5 89.2 .002*§

Job-specific training 52.0 83.7 <.001*§ 69.9 92.8 <.001*§

Ongoing training 52.0 86.0 <.001*§ 72.8 90.4 .002*§

OSHA 10-hour training 26.0 51.2 .001*§ 42.4 50.6 .224

Required training due to 

federal/state requirements

40.0 73.0 <.001*§ 60.1 74.7 .024*§

Training required by a 

collective bargaining 

agreement

6.0 29.8 <.001*§ 20.9 30.1 .111

Hours per month that foreign-born workers receive ongoing safety training

0–2 61.8 42.9 .042* 50.0 40.3 .114

3+ 38.2 57.1 50.0 59.7

Method of delivering training to foreign-born workers†

Text-based print material 40.0 66.0 .001*§ 55.7 69.9 .032*§

Hands-on training 56.0 80.5 <.001*§ 69.0 88.0 .001*§

Classroom lectures and 

demonstrations

52.0 81.9 <.001*§ 71.5 84.3 .027*§

(Continued)

Understanding Small Enterprises: Proceedings from the 2017 Conference 93
Table 1 (Continued). Characteristics of safety training among construction firms

Business Size Foreign-Born Workers

Characteristics

Small 

(%)

Large 

(%) p value

Fewer More

(%) (%) p value

Online training modules 

including webinars

22.0 32.6 .144 32.3 25.3 .261

Picture-based print 

material

32.0 47.4 .019*§ 40.5 55.4 .027*§

Recorded video 30.0 48.4 .019*§ 43.7 48.2 .503

Recorded audio 18.0 16.3 .768 17.1 14.5 .598

Informal talks 42.0 65.6 .002*§ 57.0 71.1 .032*§

How the training offered to foreign-born workers differs from that of native workers†

Language 26.0 49.8 .002*§ 34.2 66.3 <.001*§

Literacy level 10.0 16.3 .264 12.7 21.7 .068

Frequency 4.0 5.1 1.000‡ 4.4 6.0 .756‡

Delivery method 18.0 24.7 .317 20.3 32.5 .035*

Content 0.0 6.0 .137‡ 3.8 7.2 .349‡

No difference 38.0 44.7 .393 45.6 37.3 .220

Frequency of communications with foreign-born workers about safety-related issues

Daily 51.3 69.3 .029* 61.6 76.8 .020*

Not daily 48.7 30.7 38.4 23.2

*Statistically significant at α = 0.05. †

Multiple response questions; only the percentage of those who responded is reported.

‡

Fisher’s exact test (not significant).

§

Significant by the Benjamini-Hochberg procedure; Q = 0.10.

Conclusion

The survey results suggest that a targeted training approach is needed for foreign-born 

workers, particularly those working for small construction businesses. Foreign-born 

workers in smaller businesses experience significant communication barriers that can 

impact the effectiveness of training. These data suggest foreign-born workers, regardless 

of how many there are or the size of the company, are not receiving adequate levels

of safety training. These results provide evidence to support the claims made in the 

Overlapping Vulnerabilities report, demonstrating that foreign-born workers in small 

construction businesses experience increased occupational safety training barriers.

94 Understanding Small Enterprises: Proceedings from the 2017 Conference
Understanding Small Enterprises: Proceedings from the 2017 Conference 95

The partnership between NIOSH and ASSE is continuing with efforts to create a pilot 

training program that focuses on foreign-born construction workers and their employers. The training program will address the overlap of business size, nativity, age, and 

work arrangement. This program has two goals: (1) to increase the likelihood that safe 

practices will be used to prevent falls on sites operated by small construction businesses 

and (2) to increase workers’ self-efficacy related to occupational safety and health. Initial phases of the program are in development and include interviewing small construction business owners to understand the barriers they experience providing training to 

foreign-born workers and to get their feedback on existing training materials that may 

be included in a training package.

The training program will deliver both technical and soft skills. The technical skills will 

focus on two common areas of work for small construction firms (roofing and residential construction), with an emphasis on fall protection. Soft skills give workers the 

ability to address safety concerns with one another and with their supervisor when they 

encounter potentially dangerous situations at work. Vulnerable workers often face additional barriers to speaking up if there is a problem. For example, foreign-born workers 

may not know their rights in the United States, and they may have a difficult language 

barrier with their supervisor. Soft skills training would help workers develop strategies 

on how to address such issues. It also could help employers understand the barriers 

their workers face and how to develop open communication with their workers.

Although the exact format of the training is under development, the training program 

is expected to be participatory and include more visual elements to overcome language 

and literacy barriers. Although Spanish training materials are available, they are often 

direct translations from English that do not consider workers’ comprehension of the 

material. Because many foreign-born workers have limited formal education, which results in low literacy and a lack of learning skills [Arcury et al. 2010], translations can be 

worthless. Training materials are also rarely simultaneously tailored to multiple vulnerable groups. Therefore, it is obvious that specific interventions are needed to address 

the deficits in occupational safety and health training received by foreign-born workers 

in small construction firms, and these interventions must acknowledge their unique 

barriers to workplace safety and health.

References

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and health training of agricultural workers. J Agromed 15(3):236–248. 

Benjamini Y, Hochberg Y [1995]. Controlling the false discovery rate: a practical and powerful 

approach to multiple testing. J R Statist Soc B 57(1):289–300.

Cunningham TR, Guerin RJ, Keller B, Flynn MA, Salgado C, Hudson D [2018]. Differences in 

safety training among smaller and larger construction firms with non-native workers: evidence 

of overlapping vulnerabilities. Safety Sci 103:62–29.

Dodge & Data Analytics [2016]. Building a safety culture: improving safety and health in the 

construction industry, http://www.cpwr.com/sites/default/files/research/Building%20a%20

Safety%20Culture%20SmartMarket%20Report%202016%20ff.pdf.

McDonald JH [2014]. Multiple comparisons. In: Handbook of biological statistics. 3rd Ed. pp. 

254–260. Baltimore, MD: Sparky House Publishing. 

NIOSH, ASSE [2015]. Overlapping vulnerabilities: the occupational safety and health of young 

workers in small construction firms. By Flynn MA, Cunningham TR, Guerin RJ, Keller B, 

Chapman LJ, Hudson D, Salgado C. Cincinnati, OH: U.S. Department of Health and Human 
96 Understanding Small Enterprises: Proceedings from the 2017 Conference 

Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2015-178.

U.S. Census Bureau [2014]. 2010–2014 March supplement to the Current Population Survey: 

calculations by CPWR Data Center. Silver Spring, MD: CPWR—The Center for Construction 

Research and Training.
Understanding Small Enterprises: Proceedings from the 2017 Conference 97

Improved Safety Tools for Small Enterprises through 

Lean Start-up and Design Thinking

Garrett Burnett, MS, MBA; Gino Fazio, BA; Amanda Terminello, MPH

National Institute for Occupational Safety and Health

Background

Work in the construction industry is consistently among the most hazardous in the 

United States in terms of injuries, illnesses, and fatalities [BLS 2016]. Although the 

definition of “small” is fluid, in 2007 roughly 80% of construction payroll establishments had fewer than 10 employees [CPWR 2013]. These smaller enterprises “suffer a 

disproportionate share of fatal work injuries” within the construction industry [CPWR 

2013]. Several traits of small businesses that have been identified as contributors to this 

disparity should influence the design of any product or service meant to improve health 

and safety outcomes for small construction businesses. These include 

1. isolation from broader industry networks [Champoux and Brun 2003; Hasle and 

Limborg 2006];

2. lack of dedicated safety resources [Champoux and Brun 2003; Hasleet al. 2012];

3. lack of a safety culture [Cunningham and Sinclair 2015];

4. owners playing an outsized role in the survival of the company [Hasle and Limborg 

2006; Hasle et al. 2012]; and

5. lack of awareness of the level of risk [Hasle et al. 2010]. 

Here we describe the efforts of the Research to Practice Team at the National Institute 

for Occupational Safety and Health (NIOSH) to supply small construction businesses 

with information to improve worker health and safety outcomes. Because the goal was 

to create a tool that would provide some measure of assistance that might otherwise be 

shared via a safety consultant, we entitled the project as the Virtual Safety Consultant. 

Initial project plan

The original conception for the Virtual Safety Consultant involved recasting existing 

NIOSH publications in a simpler, shorter format to make the documents more usable 

by small business owners. The project scope was narrowed to include only publications 

that were relevant to the construction industry, specifically residential construction. 

The project was organized into five major phases: 

1. inventory all existing NIOSH publications for construction content; 

2. organize the content by profession and task; 

3. summarize the content, rewrite it in plain language, and provide illustrations 

when valuable;
98 Understanding Small Enterprises: Proceedings from the 2017 Conference 

4. design these newly produced modules for the web; and 

5. use the web-based modules to feed a mobile app. 

This plan did not include any analysis of customer demand. As the project began, it was 

uncertain which elements of NIOSH construction content should be synthesized. What 

information would there be demand for? This marked a pivot from the initial project plan 

toward incorporating principles from lean start-up, design thinking, and agile methods.

Lean start-up, design thinking, and agile methods 

Although the details and histories of lean start-up, design thinking, and agile methods 

differ, these business concepts have several traits in common. Each forces the user to 

understand customer or audience needs and motivations. Each requires users to articulate and then challenge assumptions in an iterative manner. Each functions by testing 

scaled versions of a product. And each of the approaches encourages users to test the 

riskiest assumptions first and to fail quickly. Whereas they are useful for different stages 

in a product’s lifecycle, these practices all create value for the end customer.

Lean Start-up

Lean start-up was born out of the highly successful Toyota manufacturing process, and 

the term was first coined in 2008 by entrepreneur Eric Ries. Lean start-up values rapid 

development and the creation of what is termed a “minimum viable product” (MVP)—

in essence, the simplest version of a product, based on a minimum set of features 

necessary for customers to take the product seriously. The MVP is built around the designer’s perceptions of what the end customers will value. These assumptions are tested 

by early users, and their responses are measured. Evidence-based decisions can then 

be incorporated into the next iteration of the product. More features are added to the 

MVP as test data prove that the product accurately addresses user demand. If the core 

assumptions are wrong, a project pivot is necessary. The pivot is a structured course 

correction designed to test “a new fundamental hypothesis about the product, strategy, 

and engine of growth” [Ries 2011].

Design Thinking

Whereas lean start-up emphasizes getting an MVP to market as quickly as possible, 

design thinking takes a step back, placing more emphasis on learning about customer 

needs before any product development occurs. An audience is identified and assumptions about that audience are articulated. “Customer discovery” interviews test the validity of the assumptions. Each time an assumption is proven true, it is refined to probe 

a deeper level of customer need. When assumptions are disproven, they enable a pivot 

toward a new line of customer discovery. The information accrued through the customer discovery process informs the development of the MVP, which is then iteratively 

tested with customers [Osterwalder and Pigneur 2010; Martin 2009].

Agile Method

The agile method is used mainly in software development. It is thought to bring more 

adaption to a changing environment, allowing a quick response to change through 

iteration. Being unable to forecast everything, an agile process starts with a vision of 

the project’s endpoint but accepts that the path to that endpoint will be in constant flux 
Understanding Small Enterprises: Proceedings from the 2017 Conference 99

[Sims and Johnson 2012]. This approach is guided by the “Agile Manifesto,” which emphasizes people over processes and tools, prototypes over documentation, responding to change 

over following a plan, and customer collaboration over rigid contracts [Pressman 2014].

Applying These Methods to the Virtual Safety Consultant 

After deciding to incorporate facets of design thinking, lean start-up, and agile methods 

in the Virtual Safety Consultant, we took the first step, which was to articulate project 

assumptions: 

1. Small construction businesses care about safety.

2. The universe of NIOSH research covers enough to be valuable.

3. A hazard-recommendation approach works.

4. Small construction businesses want a tool.

5. Digital is the right medium.

Iterative design

The first three assumptions were tested by presenting reviewers with different types of content on the same topic in an effort to build a minimum viable product. Unlike a full, accurate, approved tool, an MVP is something that can be tested and takes little effort to 

create. To keep the MVP minimal, we focused it on only five common residential construction topics: painting, framing, insulation, excavation, and electrical work. Within each topic, 

several modules presented content in four different ways: how-to instructions; hazard identification plus recommendations; regulations; and incident reports. In the building of these 

modules, the limitations of the second assumption became quickly evident. Therefore, the 

modules included regulations from the U.S. Occupational Safety and Health Administration 

(OSHA), incident reports from NIOSH’s fatality investigation program, hazard identification from NIOSH publications, and how-to instructions from across the internet.

For example, the painting section contained modules on OSHA regulations for removing 

lead paint; a story of a painter who was electrocuted; information about the hazards of 

sandblasting and how to avoid them; and instructions on how to paint high walls and 

ceilings, courtesy of Home Depot. Each of the five topics included about 30 modules, 

resulting in 150 short modules in total. 

Three participants who represented the target audience (a carpenter who worked in a 

small shop, a full-service maintenance operator for an apartment complex, and a proprietor of a handyman company) reviewed the MVP via individual, permissions-protected websites using Blogger, a free-web management tool from Google. For 6 consecutive 

weeks, the reviewers were assigned a series of modules to review and participated in 

weekly qualitative phone interviews. Web analytics and interview notes were collected 

and analyzed, and reviewer feedback was incorporated into the following weeks’ modules, informing the iterative development of the MVP.

Lessons learned

All three of the professional reviewers were drawn in by the incident reports. Each 

report described the timeline and setting of a real workplace fatality and recommendations on how to protect against a future incident of a similar nature. The reviewers 
100 Understanding Small Enterprises: Proceedings from the 2017 Conference 

strongly identified with the subjects in each of the scenarios, some even sharing personal stories of similar situations they had encountered. During one iterative development 

cycle, the recommendations were removed and the web page was modified to prompt 

reviewers to answer what should have been done to avoid the fatality. Reviewers were 

deeply engaged even with this minor level of interactivity. 

None of the reviewers had any interest in reading regulations, even in a simplified form. 

They also responded positively to how-to videos that demonstrated a process or best 

practice. Long video length or low production quality didn’t dissuade viewership, as 

long as the person in the video seemed competent. The reviewers also liked seeing lists 

of tools and supplies that could be used for job planning and checklists that could help 

keep a job on track. 

The weekly feedback and iterations made to the MVP demonstrated that the customers were not looking specifically for a safety and health tool. They desired content that 

would help them do their jobs better, more quickly, and less expensively, and if it improved their safety and health, then that was a nice bonus. 

Customer discovery

This experiment with the Virtual Safety Consultant MVP left the project team with new 

questions and a new hypothesis to test more broadly: Small business owners and managers will use our tool to do their jobs better, but also more safely. 

This hypothesis was founded on several assumptions, which needed to be tested. The 

first three assumptions were

1. Small construction businesses seek out information on how to do their work better and more efficiently.

2. Safety is not a top priority for small construction businesses. 

3. Small construction business owners are not safety experts. 

To test these assumptions, we conducted customer discovery interviews in person and 

over the phone. Specifically, interviews were targeted to residential construction business owners and managers with 20 or fewer employees and other stakeholders in this 

ecosystem. In total, 24 interviews were conducted: 13 with small business owners or 

managers, 5 with contractors or laborers, and 6 with industry intermediaries (researchers, chambers of commerce, or small business administration). 

Lessons learned 

Through these interviews, it became apparent that the target audience members do 

indeed seek out information about their work, and almost universally they start by 

searching the internet. In their peer networks, they value input from suppliers, manufacturers, and colleagues with whom they have worked.

It was expected that cash flow would be the top business priority for the audience. This 

assumption was wrong; most interviewees mentioned meeting customer needs as their 

top business priority. Several also described workforce maintenance (“finding warm and 

sober bodies”) as being a primary stressor. Universally, they cared about safety. However, as it was assumed, safety was not the top priority. 
Understanding Small Enterprises: Proceedings from the 2017 Conference 101

The last assumption (lack of safety expertise) was only partially true. Interviewees took 

pride in their experience and considered safety knowledge to be a part of what made 

them a pro. Many knew the greatest hazards they faced in a given task. However, the 

interviews did not probe about in-depth safety expertise or knowledge outside of their 

area of expertise. Some interviewees spoke about barriers they face to engaging in 

safety practices. 

Conclusion 

This project started as an attempt to build a tool—a Virtual Safety Consultant—to supply small construction businesses with information to improve their health and safety 

outcomes. As this project began, however, customer demands and preferences were not 

fully understood. This lead to a pivot to incorporate lean start-up, design thinking, and 

agile methods. Participant reviews and customer discovery interviews were conducted 

with the target audience. This feedback challenged project assumptions and enabled 

us to iteratively build upon the minimal viable product. Involving small construction 

business owners while designing the Virtual Safety Consultant makes it more likely to 

be usable for them. 

This project is not complete. The project team will continue to apply these methods and 

insights to revamp and retest the minimal viable product, in an effort to move closer to 

designing a tool that small construction businesses will actually want to use. 

References

BLS [2016]. National census of fatal occupational injuries in 2015. Washington, DC: U.S. Department of Labor, Bureau of Labor Statistics, https://www.bls.gov/news.release/pdf/cfoi.pdf.

Champoux D, Brun J-P [2003]. Occupational health and safety management in small size enterprises: an overview of the situation and avenues for intervention and research. Safety Sci 

41:301–318.

CPWR [2013]. The construction chart book: the U.S. construction industry and its workers. 5th 

ed. Silver Spring, MD: The Center for Construction Research and Training.

Cunningham TR, Sinclair R [2015]. Application of a model for delivering occupational safety and 

health to smaller businesses: case studies from the U.S. Safety Sci 71:213–225.

Hasle P, Limborg HJ [2006]. A review of the literature on preventive occupational health and 

safety activities in small enterprises. Indust Health 44:6–12.

Hasle P, Bager B, Granerud L [2010]. Small enterprises: accountants as occupational health and 

safety intermediaries. Safety Sci 48:404–409.

Hasle P, Kvorning LV, Rasmussen CD, Smith LH, Flyvholm MA [2012]. A model for design of 

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Pressman RS [2014]. Software engineering: a practitioner’s approach. 8th ed. New York: McGraw-Hill Education.

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Understanding Small Enterprises: Proceedings from the 2017 Conference 103

Aging Workforce Issues in Small Businesses: 

Preliminary Findings

Bermang Ortiz; Juliann C. Scholl

National Institute for Occupational Safety and Health

Background

Among construction workers, workplace musculoskeletal disorders (WMSDs) are a 

significant portion of non-fatal injuries and a major cause of functional impairments 

[LeMasters et al. 2006], disability [Brenner and Ahern 2000], and lost productivity 

[Meerding et al. 2005]. Construction workers tend to experience higher rates of WMSDs 

(such as pain, aches, and joint stiffness) than do workers in other industries [Dong et 

al. 2016]. These rates also increase among older workers (see Figure 1). Between 1985 

and 2015, the average age of construction workers in the United States increased by 

6.5 years, with the average age being 42.5 in 2015. That is higher than the increase in 

average age of workers in all other industries, which was 4.9 years (42.2 average age in 

2015) [Dong et al. 2016].

Figure 1. Rates of Musculoskeletal Injury Across Age Groups in Construction and All 

Industries 

Small businesses make up about 80% of all construction enterprises but often do 

not have adequate access to resources on worker safety [CPWR 2013]. For example, 

small contractors (1–9 employees) lag behind large contractors (500+ employees) in 
104 Understanding Small Enterprises: Proceedings from the 2017 Conference 

indicators of safety culture [CPWR 2016]. Whereas 90% of large firms have safety 

goals and objectives included in their overall mission, only 37% of small enterprises 

do. Also, 74% of large construction contractors include safety and health agenda 

items in their regular meetings, compared to 25% of small companies. Whereas 80% 

of large contractors require 10-hour OSHA training, only 53% of small businesses 

have this requirement.

Addressing the aging workforce requires an evidence-based theoretical framework. One 

is work ability, which is workers’ capacities to continue working in their jobs given reasonable working conditions and adequate resources [Ilmarinen 1999; Silverstein 2008]. 

There are four ways employers can meet the needs of their aging workers. First, they 

can make changes or improvements to the work environment, which includes physical 

or environmental conditions that can improve or impede worker safety and health [Silverstein 2008]. Second, employers can adapt and make improvements to the Organization of work, which refers to such things as work schedules, job designs, relationships 

with supervisors and co-workers, and decisions related to work organization [Silverstein 

2008]. Third, Organizations might also offer programs that benefit individual worker 

health, such as information about healthy diet or training to improve skills. According 

to Ilmarinen [1999] and Silverstein [2008], companies can take individual measures 

to protect workers as well as promote their health and improve their skill sets. Finally, 

social support refers to making community-based support services available or protecting workers from age-based discrimination [Silverstein 2008].

Creating resources and guidance that are inclusive of the needs of small businesses 

requires an understanding of the issues of work ability and the needs of aging workers 

that resonate with small business owners. The findings in this report address issues 

identified by small business owners that suggest ways to generate and disseminate 

resources for small businesses. The findings have implications for ways to benefit aging 

construction workers, as well as workers in other sectors.

Methods

Respondents

The researchers conducted a focus group of nine small-business owners, who employ 

fewer than 20 workers in physically demanding and not physically demanding jobs. 

Two of the nine participants own construction firms. Other industries and occupational groups represented were warehousing, firefighters, clerical settings, and light 

retail companies. 

Data Collection

The purpose of the focus group interview was to collect verbatim responses from 

the small business owners for qualitative analysis (described below). A facilitator, 

who was a member of a research firm external to NIOSH, conducted the focus group 

session. She posed series of questions (generated by the researchers) to the respondents to gather their experiences, perspectives, and knowledge about the aging workforce. The session was conducted at the office of the research firm and lasted about 

90 minutes. The session was audio-recorded and the recorded responses were later 

transcribed into a script format.
Understanding Small Enterprises: Proceedings from the 2017 Conference 105

The NIOSH researchers developed the focus group questions with the facilitator’s input in 

advance of the session. The questions touched on the perceived health and safety needs of 

aging workers; generational differences and/or tensions that might affect safety and health 

outcomes; currently used and needed guidance that address safety and health issues at 

work; current safety and health practices they implement at work; and barriers and challenges that prevent them from addressing the safety and health needs of aging workers.

Data Analysis

The researchers obtained a verbatim transcript of the focus group session and coded 

the responses inductively, using the NVivo 11 software package. Thematic analysis 

was used to code responses into one or more of four primary themes representing the 

components of the work ability model: (a) work environment, (b) work organization 

and psychosocial factors, (c) individual employee needs, and (d) social support. The 

authors implemented intercoder agreement (ICA) by independently coding one-fourth 

of the original transcript. The ICA revealed an average of 60% agreement across the four 

primary themes. Once the researchers resolved the coding discrepancies, they coded 

the remaining responses by separating statements that reflected distinct thoughts about 

one of the four primary themes. Multiple thoughts that repeated a more specific aspect 

of that primary theme were coded into emergent sub-themes. Coding continued until 

the analysis reached saturation [Fusch and Ness 2015].

Results

Each of the four primary themes represents an approach to meeting the work ability 

needs of aging workers. Each primary theme contains sub-themes that reflect more specific aspects. Figure 2 illustrates the final coding of the themes and sub-themes according to the work ability framework.

Figure 2. Approaches to Meeting the Work Ability Needs of Aging Workers
106 Understanding Small Enterprises: Proceedings from the 2017 Conference 

Work Environment

The sub-themes emerging within Work Environment were ergonomic risk factors 

(proper movement during tasks; interaction between equipment and the people who 

use them), slips/trips/falls (caused by poor surfaces or other physical hazards), physical 

environment (physical aspects that help or hinder safety; building issues), eye/vision 

(threats to eye health or efforts to safeguard the eyes), and hearing/noise (hearing loss 

or damage, not because of age-related decline). When talking about older workers, one 

small business owner commented that a physical threat was “. . . slips and falls. Yeah, 

going down physically; going down.” The physical environment was viewed as especially 

impactful on older workers. Another participant commented:

From our perspective—small businesses operating in the older 

building, right?—there’s a lot of risk with this. There’s, you know, 

from lead potential from even the build-up of dust to, you know, 

some animals and all that good stuff, and this is in downtown.

These and other comments suggest that small business owners view adjustments to the 

work environment important, especially to accommodate age-related changes, such as 

strength and endurance, balance, and vision or hearing declines.

Work Organization and Psychosocial Factors

Within Work Organization and Psychosocial Factors, the sub-themes were age stereotypes (views of traits or characteristics attributed to an age group; perceived or actual 

differences among age groups), adaptability (ability to adjust to changing conditions or 

demands), stress (response to an excessive demand or threat at work), and work flexibility (work schedules or arrangements that help workers maintain a work/life balance 

and improve productivity and efficiency). Some participants seemed to perceive that 

older workers are hesitant to learn new ways of doing things:

Some work that we do . . . with municipalities, etc., with older or 

more-seasoned workers is that when a particular safety measure 

or policy is put in place, as simple as putting on a hardhat, that the 

folks who have been in that space for 25/30/40 years, they don’t see 

any reason for that at all.

When discussing how workers’ needs changed, one owner described what might encourage older workers to be more adaptable:

I would say they look for more of a, a more well defined job description with some parameters. You know, where there’s a lot of physical 

activity, you better make sure that you’ve got the up-to-date and 

necessary equipment to assist them to help them do their job.

Another comment linked adaptability with stress: “Our greatest risk is accumulated 

stress because we’re not moving around a lot and we’re dealing with tight schedules and 

having to be creative instantly and pull a rabbit out of your hat all the time.” In general, 

older workers were perceived as less adaptable, and this limited adaptability could be 

seen as a source of stress for older workers.
Understanding Small Enterprises: Proceedings from the 2017 Conference 107

Individual Employee Needs

The theme of Individual Employee Needs included chronic disease (persistent 

health conditions that become more severe with age), training (enabling employees 

to improve their skills and organizational knowledge), disability (physical, cognitive, sensory, or other impairment that is not attributed to the job), and age-related 

declines (physical or cognitive losses due to age, not working conditions). Many 

small business owners appeared to express concern about their employees’ chronic conditions. One comment suggested a personal interest in how employees were 

handling their conditions:

We have a number of folks who have terminal illnesses and you 

know they have to take medication and things of that nature, and 

I guess I don’t ask them if they are okay because I see them and I 

know they are medicating for their own safety.

Another concern was the need for training but its perceived lack of effectiveness with 

older workers:

We’ve done training and that’s around awareness, but the individuals have to actually practice what they learn to change the behavior 

toward more safe and safety behavior. And that’s a challenge where 

we think, you know, you can teach [an] old dog new tricks but some 

of the old dogs say, you know, in the last 60/65/70 years, I’m good.

In general, the owners appeared to recognize that employees have various individual 

needs that could be addressed through company-wide efforts, such as healthcare and 

wellness programs, appropriate design of training, and age-specific approaches to training. However, there appeared to be challenges to bringing the training or programs to 

the workers.

Social Support

Social support implies that many aspects of daily living outside of work (related to 

family or employment laws, for instance) can affect the way a company can manage 

an aging workforce and meet employees’ work ability needs. Many of the comments 

emerging in the social support discussion touched on economics, or how limited 

resources were a major barrier to providing for workers’ economic needs. One owner 

said this:

I often find in the retail sector you often get minimum wage workers who work in that industry for a long period of time . . . And so, 

having a solid 401(k), sick leave, vacation time, and the like, and so 

extending those opportunities to part-time workers to the extent that 

it makes sense, and often small businesses can’t afford to do that.

Such economic issues were coded under social support because owners’ comments suggested that there were economic forces external to their company that forced them to 

cut certain benefits. To combat the lack of resources, many owners talked about looking 

to their industry peers for information or just for a source of comparison:
108 Understanding Small Enterprises: Proceedings from the 2017 Conference 

In a strategic sense meaning, what I try and do is compare our 

claim’s data on property and casualty and our workers compensation 

to peers in the industry. Are we higher, lower, average? And if I know 

I’m higher or I know I’m average, I have some room for improvement. 

Things that are working if I’m below benchmark are probably pretty 

good, but the data is not easy to obtain.

Discussion and Conclusion

The factors affecting work ability (work environment, work organization, individual employee needs, and social support) suggest useful avenues for the development of effective tools and integrated approaches that may lead to safe and healthy workplaces not 

only for older workers but for workers of all ages. The initial results of the needs assessment point to the necessity of guidance that focuses on work demands (such as modification of work tasks), work organization (such as flexible schedules), workers’ health 

and function (such as wellness programs), and workers’ and managers’ professional 

skills (such as training on new technologies and training on age stereotypes). Success in 

developing useful and relevant guidance in these areas requires further understanding 

of the needs of specific sub-sectors (such as construction) and their workers. 

References

Brenner H, Ahern W [2000]. Sickness absence and early retirement on health grounds in the 

construction industry in Ireland. J Occup Environ Med 57(9):615–620.

The Center for Construction Research and Training (CPWR) [2013]. The construction chart 

book: the U.S. construction industry and its workers, 5th ed., https://www.cpwr.com/sites/default/files/publications/5th%20Edition%20Chart%20Book%20Final.pdf.

Dong XS [2016]. Challenges & opportunities of an aging workforce [PowerPoint], https://

niosh-connect.adobeconnect.com/p59p3ni9caf/?launcher=false&fcsContent=true&pbMode=normal.

Fusch PI, Ness LR [2015]. Are we there yet? Data saturation in qualitative research. The Qualitative Report 20(9):1408–1416, http://www.nova.edu/ssss/QR/QR20/9/fusch1.pdf.

Ilmarinen J [1999]. Ageing workers in the European Union: status and promotion of work ability, 

employability and employment. Helsinki: Finnish Institute of Occupational Health and Ministry of Social Affairs and Health, 274 pages.

LeMasters G, Bhattacharya A, Borton E, Mayfield L [2006]. Functional impairment and quality 

of life in retired workers of the construction trades. Exper Aging Res 32(2):227–242.

Meerding WJ, Ijzelenberg W, Koopmanschap MA, Severens JL, Burdorf A [2005]. Health problems lead to considerable productivity loss at work among workers with high physical load 

jobs. J Clin Epidemiol 58(5):517–523.

Silverstein M [2008]. Meeting the challenges of an aging workforce. Am J Ind Med 51:269–280.
Understanding Small Enterprises: Proceedings from the 2017 Conference 109

Conference Participants

Adele Abrams

Law Office of Adele L. Abrams PC

Ahmed Al-Bayati

Western Carolina University

Vern Anderson

CDC/NIOSH

Ing-Marie Andersson

Dalarna University

Ann-Beth Antonsson

IVL Swedish Environmental Research 

Institute

Avery Artman

Center for Health, Work & Environment, 

Colorado School of Public Health

Willie Avelar

Serck Services

Cristina Banks

Interdisciplinary Center for Healthy 

Workplaces, UC Berkeley

Becky Baugh

RA Nelson LLC

Greg Baxter

U.S. Department of Labor OSHA

Anca Bejan

HealthPartners Institute

Eileen Betit

CPWR-The Center for Construction 

Research and Training

John Boudreau

University of Southern California

Yvonne Boudreau

CDC/NIOSH

Willian Brazile

Colorado State University

Colleen Brents

Colorado State University

Lisa Brosseau

University of Illinois at Chicago

Carol Brown

Center for Health, Work & Environment, 

Colorado School of Public Health

Kelsey Brown

Colorado School of Public Health

Kultida Bunjongsiri

Sukhothai Thammathirat Open University

Garrett Burnett

CDC/NIOSH

Jaime Butler-Dawson

Center for Health, Work & Environment, 

Colorado School of Public Health

Sandrine Caroly

Pacte Laboratory University of GrenobleFrance

Daniele Champoux

IRSST

Crystal Chaparro

Center for Health, Work & Environment, 

Colorado School of Public Health

Raena Chatwin

MINES and Associates

Yesuneh Gizaw Chernot

Wolaita Sodo University

Laurie Cluff

RTI International

Tom Coohill

Coohills Restaurant

Mizraim Cordero

Denver Metro Chamber of Commerce

Tori Crain

Colorado State University

Thomas Cunningham

CDC/NIOSH
110 Understanding Small Enterprises: Proceedings from the 2017 Conference 

Kelsie Daigle

Colorado State University

Ann Marie Dale

Washington University School of Medicine

Hilde De Raeve

IDEWE

Gaudin Deborah

Pacte Laboratory – Universite Grenoble 

Alpes

Caitlin DeClercq

University of California, Berkeley

Brandon Dickinson

Oliver Manufacturing

Wenyi Fan

Center for Health, Work & Environment, 

Colorado School of Public Health

Gino Fazio

CDC/NIOSH

Gwenith Fisher

Colorado State University

Josefina Flores Morales

University of California, Los Angeles – 

Sociology Department

Michael Flynn

CDC/NIOSH

Brian Foxhoven

Ergonomic Innovations

Sabrina Freewynn

SAIF

Cody Goodson

City and County of Denver – Public Works

Michelle Haan

Center for Health, Work & Environment, 

Colorado School of Public Health

Katie Haas

Eagle County Public Health and 

Environment

Giselle Habeych

Center for Health, Work & Environment, 

Colorado School of Public Health

Jamie Hackbarth

Colorado Office of Economic Development

Peter Hasle

Sustainable Production, Aalborg University

Brian Hennigan

Willman Design

Deborah Hoefler

Community College of Aurora

Kelly Holmes

Native Max

John Howard

CDC/NIOSH

Heidi Hudson

CDC/NIOSH

Enda Ilyas Lubis

BPJS Ketenagakerjaan

Brenda Jacklitsch

CDC/NIOSH

Patty Jeffries

Colorado State University

Kimberly Jinnett

Center for Workforce Health and 

Performance

Shamusideen Kadiri

Zub Chord Tech Ventures

Brenna Keller

CDC/NIOSH

Kazutaka Kogi

Ohara Memorial Institute for Science of 

Labour

Rachel Kramer

UC San Diego Center for Community 

Health

Melanie Kramer

Colorado State University

Josh Kreul

Horizon Glass

Lyndsay Krisher

Center for Health, Work & Environment, 

Colorado School of Public Health

Amanda Kujawa

Center for Health, Work & Environment, 

Colorado School of Public Health
Understanding Small Enterprises: Proceedings from the 2017 Conference 111

Anthony LaMontagne

Deakin University

Hans Jorgen Limborg

Team Working Life and Roskilde University

Kyle Littman

Avid4Adventure

Marc Malenfer

INRS

Luz Marin

Indiana University of Pennsylvania

Meridith Marshall

OEDIT

Todd Maul

John Elway Dealers

Alicia McGough

C&L Water Solutions Inc.

Norvil Antonio Mera Chu

Universidad de Piura

Ethan Merk

Flood & Peterson

Shayna Micucci

Colorado Department of Public Health

and Environment

Cheri Miller

The Christ Hospital Health Network

Keith Minor

Metro Mix, LLC

Sarah Mitchell

CDC/NIOSH

Jiro Moriguchi

Kyoto Industrial Health Association

Cameron Mustard

Institute for Work and Health

Amran Nasution

BPJS Ketenagakerjaan

Lee Newman

Center for Health, Work & Environment, 

Colorado School of Public Health

George Nix

John Elway Chevrolet

Bermang Ortiz

CDC/NIOSH

Ulrike Ott

Rocky Mountain Center for Occupational 

and Environmental Health

Krista Pahkin

Finnish Institute of Occupational Health

Helena Palmgren

Finnish Institute of Occupational Health

David Parker

HealthPartners Institute

Filip Pelgrims

IDEWE

Paulo Pereira

UNIFEA – Centro Universitario das 

Faculdades Associadas de Ensino

Dana Peterson

Garfield County

Emily Prisco

Aurora Organic Farms

Cheri Prochazka

Fitzsimons Credit Union

Kristina Rajala

The Finnish Institute of Occupational 

Health

Loli Respini

Town of Frisco

Knut Ringen

CPWR – The Center for Construction 

Research and Training

Kaylee Rivera

Center for Health, Work & Environment, 

Colorado School of Public Health

Diane Rohlman

University of Iowa

John Rosecrance

Colorado State University

Alexis Rydell

Dalarna University

Alicia Salvatore

University of Oklahoma College of 

Public Health
112 Understanding Small Enterprises: Proceedings from the 2017 Conference 

Yumi Sano

The Ohara Memorial Insstitute for Science 

of Labour

Jason Santistevan

ATI

Stephanie Sayler

University of Michigan School of Public 

Health

Mitzi Schindler

Aurora Chamber of Commerce

Juliann Scholl

CDC/NIOSH

Paul Schulte

CDC/NIOSH

Natalie Schwatka

Center for Health, Work & Environment, 

Colorado School of Public Health

Joshua Scott

Center for Health, Work & Environment, 

Colorado School of Public Health

Noah Seixas

University of Washington

Vicki Shabo

National Partnership for Women and 

Families

David Shapiro

Executives Partnering to Invest in 

Children (EPIC)

Adelyn Shimizu

Colorado State University

Erin Shore

Center for Health, Work & Environment, 

Colorado School of Public Health

Patrik Silvola

National Coalition Against Domestic 

Violence

Ilonka Sommen

IDEWE

Glorian Sorensen

Harvard Chan School of Public Health/

Dana-Farber Cancer Institute

Shalyn Stevens

Colorado State University

John Stuligross

Center for Health, Work and Environment

Kevin Suber

S & K Cleaning solutions

Lorna Szczukowski

Jennifer Tellis

Tri-County Health Department

Tommaso Tempesti

University of Massachusetts Lowell

Liliana Tenney

Center for Health, Work and Environment, 

Colorado School of Public Health

Isabelle Thibau

Interdisciplinary Center for Healthy 

Workplaces, UC Berkeley

Brenda Thompson

Center for Health, Work & Environment, 

Colorado School of Public Health

Janalee Thompson

Colorado State University

Albert Tien

Workplace Health Without Borders

Molly Tran

Center for Health, Work & Environment, 

Colorado School of Public Health

Candace Tsai

Colorado State University

Eric Tyrell

Metro Mix, LLC

Sheryl Ulin

University of Michigan

Joshua Vigil

U.S. Small Business Administration

Tammy Wagner

Lung-Friendly Institute

Skyler Walker

Rocky Mountain Center for Occupational 

and Environmental Health
Understanding Small Enterprises: Proceedings from the 2017 Conference 113

Kevin Walters

Colorado State University

Kimberly Watkinson

Avery Brewing Co.

David Weil

Brandeis University

Annie Weist

Rebecca Weitzel

Good Life Wellness Solutions

Ashton Williams

Colorado School of Public Health

Kuck Hyeun Woo

Soonchunhyang University Hospital, Gumi
114 Understanding Small Enterprises: Proceedings from the 2017 Conference 

Conference Agenda

Tuesday, October 24, 2017

6:00–8:00 pm Welcome Reception

Wednesday, October 25, 2017

Time Session Presenter

8:00–8:30am Registration and Coffee

8:30–10:00am Worker Well-Being and Sustainable 

Business Health Plenary

Welcome Address Paul Schulte

Mizralm Cordero

Thomas Cunningham

Lee Newman

Keynotes Gloria Sorensen

Peter Hasle

10:00–11:15am Poster Session

11:15am–12:00pm Lunch

12:00–1:45pm Research to Practice Plenary

Keynote John Boudreau

Panel Discussion Anca Bejan

Garrett Burnett

Heidi Hudson

Tony LaMontagne

David Parker

1:45–2:00pm Break

2:00–400pm Concurrent Workshops

Improving Safety in Small Enterprises David Parker

Daniele Champoux

Paul Schulte

Kazutaka Kogi

The Informal Economy Jaime Butler-Dawson

Lyndsay Krisher

Yesuneh Gizaw

Shamusideen Kadiri

Josefina Flores Morales
Understanding Small Enterprises: Proceedings from the 2017 Conference 115

Time Session Presenter

Tools, Resources, and Systems

for Small Enterprises

Ilonka Sommen

Marc Malenfer

Filip Pelgrims

Natalie Schwatka

Total Worker Health® in 

Small Enterprises

Ann-Beth Antonsson

Diane Rohlman

Liliana Tenney

Brenda Jacklitsch

Vulnerable workers Stephanie Sayler

Noah Seixas

Michael Flynn

Kevin Walters

Workers and Their Families Vicki Shabo

Kelsie Daigle

Shalyn Stevens

Michelle Haan

4:00-4:15pm Break

4:15–5:45pm Concurrent Workshops

Ergonomics in Small Enterprises Sheryl Ulin

Caitlin DeClercq

Colleen Brents

Impact of Business Size Ann Marie Dale

Tommaso Tempesti

Cameron Mustard

Meaningful Work Adelyn Shimizu

Ethan Merk

Joshua Scott

Support Networks Albert Tien

Helena Palmgren

Marc Malenfer

The Role of Public Health in 

Small Enterprises

Deborah Hoefler

Cheri Prochazka

Mitzi Schindler

Jennifer Tellis

Katie Haas

Cheri Miller
116 Understanding Small Enterprises: Proceedings from the 2017 Conference 

Time Session Presenter

USE Conference in Review: What 

Have We Learned and Achieved Since 

Then

Ann-Beth Antonsson

Lisa Brosseau

Thomas Cunningham

Peter Hasle

Hans Jorgen Limborg

David Parker

Diane Rohlman

Paul Schulte

Noah Seixas

Thursday, October 26, 2017

Time Session Presenter

8:00–8:30am Registration and Coffee

8:30–10:00am Small Business Perspective 

Plenary I

Keynote Knut Ringen

Panel Discussion Bill Brazile

Tom Coohill

Thomas Cunningham

Joshua Vigil

10:00–10:15am Break

10:15am–12:15pm Concurrent Workshops

Health and Safety Management 

Systems

Willie Avelar

Brandon Dickinson

Todd Mall

Keith Minor

Georg Nix

Bill Brazile

Patty Jeffries

Jason Santistevan

Kevin Suber

Eric Tyrell
Understanding Small Enterprises: Proceedings from the 2017 Conference 117

Time Session Presenter

Health Services for Small Enterprises Kuck Hyeun Woo

Jiro Moriguchi

Kristina Rajala

Anca Bejan

Prevention in High Risk Industries Hans Jorgen Limborg

Sandrine Caroly

Deborah Gaudin

Yumi Sano

Paulo Pereira

Occupational Safety & Health in 

Small Industrial Settings

Kultilda Bunjongsiri

Norvil Antonio Mera Chu

Alexis Rydell

David Parker

Wellness Programs in Small 

Enterprises

Cristina Banks

Isabelle Thibau

Laurie Cluff

Natalie Schwatka

Claire Brockbank

Kim Jinnett

Lee Newman

Rachel Kramer

Workplace Health and Safety in 

Construction

Garrett Burnett

Gino Fazio

Thomas Cuningham

Bermang Ortiz

Juliann Scholl

Eileen Betit

12:30–1:30pm Lunch

1:30–3:45pm Small Business Perspective Plenary II

Keynote David Weil

Panel Discussion Josh Kreul

Kyle Littman

Emily Prisco

Diane Rohlman

3:45–4:30pm Awards Presentation
118 Understanding Small Enterprises: Proceedings from the 2017 Conference 

Friday, October 27, 2017

Time Session Presenter

7:30–8:00am Registration and Breakfast

8:00–10:00am The Future: Where Do We Go from 

Here Plenary

Keynote Luz Stella Marin

Panel Discussion Kelly Holmes

Meridith Marshall

Liliana Tenney

Kimberly Watkinson

10:00–10:15am Break

10:15–11:15am Integrated Approaches Plenary

Keynotes Lisa Brosseau

Tony LaMontagne

11:15am–12:00pm Closing Remarks Greg Baxter

John Howard

Lee Newman
Understanding Small Enterprises: Proceedings from the 2017 Conference 119

Poster Presentations

October 25, 10:00 – 11:15am

1. A Mixed-Methods Analysis of Logging Injuries in Montana and Idaho

John Rosecrance (presenting on behalf of Elise Lagerstrom)

Colorado State University

2. Applying Fundamentals of Total Worker Health Approaches: Essential Elements for 

Advancing Worker Safety, Health, and Well-Being

Sarah Mitchell

Office for Total Worker Health, National Institute for Occupational Safety

and Health (NIOSH)

3. Correlation between Weekly Exercise Duration and Light Duty and Lost Time: A 

Cross-Sectional Analysis of an Occupational Working Population

Skyler Walker

Rocky Mountain Center for Occupational and Environmental Health, University of 

Utah School of Medicine

4. Health-Related Predictors of Workers’ Compensation Claims

Erin Shore

Center for Health, Work & Environment, Colorado School of Public Health

5. Occupational Physical Activity in Active and Sedentary Work

Janalee Thompson

Center for Health, Work & Environment, Colorado School of Public Health

6. Opioid Use: Case-Control Analyses of Workers’ Compensation Data

Ulrike Ott

Rocky Mountain Center for Occupational and Environmental Health, University of 

Utah School of Medicine

7. Overlapping Vulnerabilities of Immigrant Safety Training in Small 

Construction Firms

Brenna Keller

National Institute for Occupational Safety and Health (NIOSH)

8. Safety Visits to Small Private Day Care for Babies and Toddlers

Hilde De Raeve

Group IDEWE, External Service for Prevention and Protection at Work

9. Sleep Habits and Frequency of Excessive Daytime Sleepiness in Shift-Work Security 

Agents from an Agency in Piura-Peru

Norvil Antonio Mera Chu

Universidad de Piura

10. Social Media Influence: Messaging and Marketing Total Worker Health to Engage 

Small Businesses and their Millennials

Kaylee Rivera

Center for Health, Work & Environment, Colorado School of Public Health
120 Understanding Small Enterprises: Proceedings from the 2017 Conference 

11. The Role of Leadership as a Success Factor in the Establishment of Preventive 

Culture in SMEs in the Food Industry

Constanze Nordbrock

Berufsgenossenschaft Nahrungsmittel und Gastgewebe

12. Total Worker Health: Overcoming the Barrier of Perceived Cost for a Small 

Business’ Small Budget

Tonia Smith

City of Cincinnati Health Department

13. Vocational Colleges – Unique Opportunities to Enhance Safety and Health in Small 

Businesses. The Technical Education Curricula for Health and Safety (TECHS) Study

Anca Bejan

HealthPartners Institute
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