Barriers and facilitative factors in the implementation of workplace health promotion activities in small and medium-sized enterprises: a qualitative study.

Background: There is an immense difference between large companies and small and medium-sized enterprises (SMEs) in implementation of evidence-based interventions (EBIs). Previous literature reveals various barriers that SMEs face during implementation, such as a lack of time, accessibility, and resources. However, few studies have comprehensively examined those influential factors at multi-levels. This study aims to identify the factors influencing the implementation of non-communicable disease prevention activities (tobacco, alcohol, diet, physical activity, and health check-up) in SMEs using Consolidated Framework for Implementation Research (CFIR).

Methods: We conducted 15 semi-structured interviews with health managers and/or employers in 15 enterprises with less than 300 employees, and four focus groups among public health nurses/nutritionists of health insurers who support SMEs in four prefectures across Japan. A qualitative content analysis by a deductive directed approach was performed. After coding the interview transcript text into the CFIR framework constructs by two independent researchers, the coding results were compared and revised in each enterprise until an agreement was reached.

Results: Of the 39 CFIR constructs, 25 were facilitative and 7 were inhibitory for workplace health promotion implementation in SMEs, which were across individual, internal, and external levels. In particular, the leadership engagement of employers in implementing the workplace health promotion activities was identified as a fundamental factor which may influence other facilitators, including "access to knowledge and information," "relative priority," "learning climate," at organizational level, and "self-efficacy" at the health manager level. The main barrier was the beliefs held by the employer/manager that "health management is one's own responsibility."

Conclusions: Multi-level factors influencing the implementation of non-communicable diseases prevention activities in SMEs were identified. In resource-poor settings, strong endorsement and support, and positive feedback from employers would be important for health managers and employees to be highly motivated and promote or participate in health promotion. Future studies are needed to develop context-specific strategies based on identified barriers and facilitative factors, and empirically evaluate them, which would contribute to narrowing the differences in worksite health promotion implementation by company size.