Assessment of a Worksite Health Promotion Readiness Checklist

Abstract

Objective:

To assess the utility of a Worksite Health Promotion Readiness Checklist (WRCL) designed to evaluate the worksite’s readiness for implementing health promotion and health protection programs.

Methods:

The WRCL was pilot tested in worksites with (WHPy) and without (WHPn) health promotion programs. The two parts of WRCL scores (observational and administrative) for WHPy and WHPn sites were compared within and between the worksites to establish WRCL utility and sensitivity.

Results:

Observational WRCL (completed by two observers per site) demonstrated high interrater reliability (P < 0.05) for most items. Administrative WRCL (completed by three administrators per site) showed some discrepant responses between administrators. Overall, both sections of WRCL produced higher scores for WHPy sites.

Conclusions:

WRCL could be a valid and reliable instrument to measure readiness of a worksite toward health promotion and health protection programs.

With the significant increases in health care costs, worksite health promotion (WHP) programs have been identified as a potentially effective approach to reduce the risk factors for chronic diseases. Chronic diseases are major contributors to death and disability and to the associated increases in health care costs.^1,2 The majority of health care expenditures are associated with end of life costs, especially with hospitalization expenses and the technology used to increase the quantity rather than the quality of a person’s life.^3,4 Wellness programs at work have shown some reductions in employee absenteeism and presenteeism and thus cost savings for the participating worksites.^5-7 However, worksite health promotion programs often disproportionately reach higher income employees and those who are healthier.

In addressing employee health at the workplace, attention is typically centered separately on the areas of health promotion, occupational safety/health, and employee assistance programs. To improve employees’ health, an integrative or systems approach is essential to address not only workplace safety but also employee health risks and behaviors related to job performance, worksite ergonomics, and safety. It has been argued that the effectiveness of WHP programs could be improved when combined with worksite health protection programs addressing occupational health, ergonomics, and safety.^8-10 According to Baker et al, both worksite health promotion and occupational health and safety practitioners should collaborate on comprehensive programs because the influences of individual behavior, psychosocial, organizational, and contextual factors are interrelated.⁵

Furthermore, integrating health protection with health promotion programs may create more cost effective interventions because of the use of shared resources.^8-10 According to Healthy People 2010, the five key elements for successful WHP programs are 1) health education, 2) supportive social and physical work environment, 3) integration with the organization’s structures, 4) linkage with other related programs such as employee assistance, and 5) worksite screening and education.^11,12 Additionally, health and wellness programs must be tailored to the worksite’s organization, policies, culture, size, and geographical area. Experts suggest that a “one size fits all” approach to improve employees’ health through worksite health promotion programs may be less successful than more contoured programs.

The WorkLife Initiative developed by the National Institute for Occupational Safety and Health (NIOSH) envisions workplaces that are both free of recognized exposure hazards and also have established health promoting and sustaining policies, programs, and practices. NIOSH also envisions employees with ready access to effective programs and services that protect their health, safety, and well-being.^13,14

To have an effective worksite health promotion program, it is also essential to have both a favorable physical environment and a managerial and organizational culture that is supportive of a health-promoting work environment.¹¹ Bringing about organizational and cultural change requires a combination of education, behavior change intervention, customized facilities, services, and strategies. It is important that employers demonstrate a commitment to health and wellness that is fully integrated with their mission, values, and long-term vision, paving the way for sustainable lifestyle changes.¹⁵

A framework for assessing overall progress toward implementing health promotion and health protection programs seems an appropriate prerequisite for successful implementation. To measure the impact and outcomes of wellness programs, evaluation systems are vital for WHP program success. Assessment tools such as the Occupational Safety and Health Administration (OSHA) checklist have been developed to address workplace safety and environmental hazards, but they have no recognized utility for assessing health behaviors. Instruments developed to evaluate WHP programs are mostly specific to a limited number of program areas. In developing evaluation tools, a system approach is necessary to address organizational culture, physical environment, and health and safety risks. The first step for developing a successful integrated health promotion and health protection program is to assess level of readiness, including management support, policies, and the physical work environment.

We have developed an assessment tool entitled the Worksite Health Promotion Readiness Checklist (WRCL) for measuring the needs and level of readiness for worksite health promotion and health protection programs. The purpose of this research was to assess the response coherence, reliability, and convergent validity of this instrument. The study hypothesis was that worksites having health promotion and health protection activities would score higher in the corresponding parts of the WRCL, compared to worksites without those activities.

METHODS

Background for WRCL Development

The WRCL was developed by academic investigators and experts in the field of health promotion, occupational safety, ergonomics, and work organization. The WRCL relied on relevant literature and existing tools and was guided by an ecological model.¹⁶ A brief review of contributory instruments and the basis for their inclusion follows.

The Checklist of Health Promotion Environments at Worksites (CHEW), a 112-item instrument, was developed by Oldenburg et al for direct observation to assess characteristics of worksite environments known to influence health-related behaviors including physical activity, healthy eating, alcohol consumption, and smoking. The three environmental dimensions assessed by the CHEW were physical characteristics of the worksite, features of the information environment, and characteristics of the immediate neighborhood around the workplace.¹⁷ It has acceptable face validity and generates objective, interpretable indicators that are useful for informing the development, implementation, and evaluation of health behavior programs in the workplace. The WRCL incorporated some CHEW items on the physical environmental factors that are important for WHP programs.¹⁷

Similarly, the HeartCheck instrument is an organizational assessment tool, constructed to measure the structures of an organization that support employee heart health: smoking, nutrition, fitness, stress, screening, and administrative support.¹⁸ A related instrument, “WorkCheck,” was framed similarly, having the same content areas as HeartCheck, but emphasizing components addressed by a managed care provider.¹⁹ It included items such as mental health, violence prevention, safety, maternal health, substance abuse, and disability management.^18,19 Both HeartCheck¹⁸ and WorkCheck instruments were consulted for inclusion of WRCL elements on organizational factors influencing worksite health promotion.

The Health Employment Research Organization (HERO) developed the “Health Management Best Practice Scorecard” to measure organizational support. Scorecard items are based on best practices in Employee Health Management and are divided into six sections: strategic planning, leadership engagement, program level management, programs, engagement methods, and measurement and evaluation.^20,21 The HERO was consulted as a content check for the WRCL. However, although the HERO assesses management attitude toward employee health, it does not describe in detail the availability of resources like the physical environment, health, and safety.

The WRCL items on workplace health and safety were developed in a parallel fashion by consulting existing tools toward safety climate at worksites. For example, one useful source was Basen-Engquist et al,²² who tested the validity and internal consistency of a new measure of organizational health and safety climate that was used in a large randomized trial of a worksite cancer prevention program (Working Well Trial).

In developing the WRCL, we also reviewed studies recommending development of practical tools, including other checklists.^23,24 Plotnikoff et al²³ developed and tested a comprehensive multilevel workplace physical activity assessment tool (WPAAT) to evaluate workplace physical activity. The three-phase project was based on an ecological framework¹⁶ with an occupational health and safety program to operationalize the ecological model.

Similar tools to the WRCL have been developed recently. The “Community–Wide Cardiovascular Risk Reduction Assessment instrument” was developed by Goetzel et al²⁵ to encourage and guide businesses with less than 500 employees to implement new ways or improve existing worksite health promotion programs. This tool provides feedback on worksite characteristics, worksite policies, practices and environment, and organizational support.

A recently developed health promotion evaluation tool by Dunet et al²⁶ is the Swift Worksite Assessment and Translation. This evaluation method is used to identify promising practices in existing WHP programs and guide recommendations. The set of criteria used in the interpretative assessments for the Swift Worksite Assessment and Translation include categories such as health promotion program goals, present WHP practices, policy supports, and environmental supports.²⁶ These criteria represent integral parts of a successful WHP program and are also included in our WRCL instrument.

WRCL Instrument

The WRCL was developed in two parts, reflecting the reality that some environmental characteristics can be assessed by observation but others, especially administrative and organizational features, are difficult to observe directly, especially by someone who does not work within the organization. Thus, the first part is an interview format questionnaire with the worksite administrator (WRCL-ADS) consisting of 45 items, whereas the second part is an observational survey (WRCL-OBS) consisting of 63 items.

WRCL-ADS pursues detailed knowledge about present workplace health promotion and health protection activities, policies, and support. Each scored item has response options of “Yes, No and Don’t Know.” For the purpose of data analysis, all scored items in the data sheet are given a nominal score of “Yes = 2,” “No = 0,” and “Don’t Know” marked as “D/K” without any numerical value.

WRCL-OBS was designed to be completed by a trained observer during a tour of the worksite. It consists of 63 questions that are used to assess the physical characteristics of a worksite which influence health promotion and health protection activities. Each item has response options of “Yes, No, and Not Applicable.” For the purpose of data analysis, the item responses are given nominal values of “Yes = 2” and “No = 0,” and “Not applicable” marked as “N/A” without a numerical value.

Study Sites

Six New England nursing home worksites, all belonging to the same national company were selected from a larger project for WRCL pilot testing. These sites were classified on the basis of prior knowledge as having on-site health promotion activities (WHPy) or not having on-site health promotion activities (WHPn), with three in each group. All six nursing homes had health protection programs (safe resident handling, tripping hazards, standard precautions etc.) managed by the same corporate office. Institutional similarity and geographical proximity were the main selection criteria.

Procedure

Approval to collect WRCL data was obtained from the regional health and safety representative of the company. The checklist and the pilot testing procedure were approved by the University of Connecticut’s Institutional Review Board. A memorandum was sent to all six nursing homes by the company administrator regarding the WRCL survey.

A packet was mailed to each center administrator with a cover letter explaining the project purpose and three copies of the WRCL-ADS survey. In each nursing home, the survey was completed by the Administrator, the Director of Nursing, and either a Wellness Coordinator or another person in a similar position such as the Administrator of Social Services.

Two researchers were trained to complete the WRCL-OBS. During a scheduled visit and tour of the facility, each observer completed the survey independently for each nursing home. The research team also collected the surveys and ensured their completeness.

Data Analysis

The WRCL-ADS was divided into three sections: Health Promotion (HP), Organizational Culture and Management (OR), and Health and Safety (HS) (Table 1).

TABLE 1.

WRCL-ADS Sections

WRCL-ADS Sections	Topics Covered	Number of Items
HP	Goals and mission related to health Current health promotion Activities wellness committee On-site wellness programs On-site health screenings Health fairs Educational sessions Nutrition standards Discounted meals and gym memberships Drug testing Smoking and alcohol abuse programs	21
OR	Flexible work time Number of scheduled meetings over lunch Leave policies Vacation time allowances Break schedules at work	12
HS	Medical emergency protocols Assault prevention Sexual harassment prevention OSH inspections Educational materials on OHS Communication on safety topics Safety training Injury reduction	12

OHS indicates Occupational Health and Safety.

The item responses in each section were scored nominally. Data from the three administrative respondents from each site were reduced to a single item score per site by combining the responses as shown in Table 2. The questions with discordant answers among the respondents received an intermediate value. Items that had “Don’t Know” responses from all three administrative respondents were also treated as disagreeing with each other. The questions identified as having discordant responses among the three administrators in each site were identified for item analysis.

TABLE 2.

Criteria for Data Reduction

2	0	2	2	2	0	D/K	0	2	0
2	0	0	D/K	2	0	D/K	D/K	2	0
D/K	D/K	D/K	D/K	2	0	D/K	D/K	0	2
= 2	= 0	= 1	= 2	= 2	= 0	= 1	= 0	= 2	= 0

Yes = 2; No = 0; Don’t Know = D/K.

A maximum possible score was calculated for each section for each site by adding up the responses to all the questions from that section, based on the scoring criteria described before. The maximum possible scores were different for each site dependent on the worksite characteristics. The percentage of maximum possible scores for each section for each site were calculated and used as a normalized score for further analysis. The mean score for WHPy and WHPn sites were then calculated for each section. The scores were compared between the WHPn and WHPy sites to validate the pilot test results. The composite scores for all questions in the WRCL-ADS sections of HP, OR, and HS generated a new smaller data set consisting of the six independent sites.

The WRCL-OBS was divided into three sections: Physical Environment (PE), Work Setting (WS), and Safety Environment (SE) (Table 3). Each item was analyzed for agreement between the two observers for each section of the WRCL-OBS. The items that had disagreement were identified for further discussion. The questions from each section were added to calculate a maximum possible score for each section. The nominal values given for “Yes and No” were added up. Items that had “Not Applicable” responses for some sites were excluded while calculating total scores for that section. The mean of obtained scores from the two observers were calculated. This mean score was used to get the percentage for each site in comparison to the maximum score.

TABLE 3.

WRCL-OBS Sections

WRCL-OBS Sections	Topics Covered	Number of Items
PE	General physical structure Nutritional facilities Exercise facilities Signs & posters Workplace surroundings	40
WS	Structured exercise programs Relaxation facilities Health and childcare Employee team sports Work pacing Team work	12
SE	Noise level Temperature Ergonomic specialist, Office safety specialist ergonomic equipment Equipment organization Housekeeping	11

The same as the WRCL-ADS, the total score may differ based on the site characteristics. For example, if the site did not have stairs, the questions on PE related to staircases’ lighting, having rails etc., were not scored in the total scored for that site. The data were entered into SPSS 14 to generate descriptive statistics and to analyze interrater reliability with the Kappa coefficient. Statistical significance was judged as a P-value of 0.05.

RESULTS

All the six centers were medium-sized workplaces with more than 100 employees, working in three shifts. In each center, a majority of employees were women and fewer than 25% worked at desk jobs doing administrative and/or clerical work. The remaining 75% of the employees were nurses or nursing aides providing direct care to residents.

Each facility typically had one Administrator, one Director of Nursing, and an Assistant Administrator. Some of the facilities also had a Wellness Coordinator. The administrator of social services, recreation director, or other similar positions acted as the Wellness Coordinator in these worksites. The WRCL-ADS was completed by a total of 18 individuals (three administrative staff per site).

WRCL-ADS Results

There were some differences in the mean scores for each section of the administrative survey between the WHPn and the WHPy sites (Fig. 1). The highest values were observed for the HS section for both sites.

FIGURE 1.

WRCL-ADS scores.

Response Coherence of the WRCL-ADS

For the HP section, the WHPn sites had a lower mean score (49.9) compared with the WHPy sites (59.3). Noticeably, one WHPn site (site 3) had a high score equivalent to those in the WHPy group. One WHPy center (site 5) had an extremely low score of 20.8.

In the OR section, the WHPn sites also had a lower mean score (69) than the WHPy sites (71.4). For this section again site 3 from WHPn had a high score comparable to the WHPy sites, whereas site 4, from WHPy had lower scores comparable to the WHPn sites.

In the HS section, the WHPn sites had a lower mean score (81.1) than the WHPy sites (89.7). One WHPy site (site 5) had a lower score than those of the other centers.

The sites’ discrepancies will be discussed further in the discussion section of the article. The questions with disagreement in responses among administrators in each center are identified in Table 4. Noticeably, none of the sites have any items with responses as “Don’t Know” from all three administrators.

TABLE 4.

Disagreement for WRCL-ADS

HP section Site 4	Does the workplace have a planning document or other written measurable goals and objectives for employee wellness?
HP section Site 4	Does the workplace have a designated Wellness champion
HP section	Are opportunities for health promotion activities available to all employees: please answer all that apply?
Sites 1 & 2	All shifts
Site 2	Part-time workers
Sites 2 & 3	Others
HP section Sites 1 & 2	Does the workplace have explicit policies or procedures that promote and support health promotion activities for employee health?
OR section Sites 4 & 5	Does the workplace provide job flexibility for employees to participate in wellness activities?
OR section Sites 4	Does the workplace have maternity leave after pregnancy/delivery or adoption (paid extended leave after short-term disability payment ends)?
OR section Sites 2, 4, & 5	Does the workplace provide leave policies that cover family emergencies/responsibilities beyond the family leave act (e.g., total or partial paid leave greater than 12 wk)?
OR section Sites 1 & 4	Does the workplace allow job rotations for employees?
HS section Site 5	Does the workplace have an injury reduction program?

WRCL-OBS Results

The interrater reliability of the WRCL-OBS items showed 100% agreement between the two observers, except for two questions in the SE section and three questions in the WS section. Table 5 depicts the disagreement between observers in the WRCL-OBS.

TABLE 5.

Disagreement Between Observers

SE section	56c. Is soiled laundry in the hallways?
	56d. Is there an odor of urine or excrement?
	57. The overall housekeeping in this facility is Very good, Good, Bad, or Very bad.
WS section	58. Are there a number of nurses working in proximity to each other that could work together in teams?
	59. Do the nurses who work in proximity to each other interact with each other?
	62. Does the nursing staff appear to have time to take breaks and relax during their working hours?

The observer’s disagreements for these questions on safety environment and work setting are more situational or perceptional. The reason for the disagreement may be attributed to the different timing of the site observation by the two observers completing the survey.

In the PE section, the WHPn sites had a lower mean score (67.2) than the WHPy sites (73.3). In the WS sections, the WHPy sites had a lower mean score (46.6) than WHPn sites (49.9). The SE section provided the mean scores for WHPn and WHPy sites that were similar (90.3 and 89.9 respectively). Within each section, there were few differences within or between the WHPn and WHPy groups (Fig. 2).

FIGURE 2.

WRCL-OBS scores.

DISCUSSION

Evaluation of health promotion programs in the past decade have focused on developing checklists to measure individual indicators affecting health promotion at worksites such as physical environment, organizational environment, and management support. Some of the checklists are developed to measure effectiveness of programs toward a specific topic such as obesity or cardiovascular disease prevention.^17,18,24

To our knowledge, none of the checklists evaluated the workplace readiness by integrating health promotion and health protection strategies for developing worksite health promotion and health protection programs. In this study, we evaluated the utility of the WRCL and sensitivity of its use between two types of worksites. We divided the sample of six nursing homes; based on offering some types of health promotion programming. The health promotion programs offered were not the same at each center, and it was based on the company’s reported activities. Our hypothesis was that the sites that offer some types of health promotion programming should score higher than the sites that do not offer any programs, indicating higher readiness. The responses to the WRCL-ADS showed that for each section, the centers with health promotion programs had higher scores than sites without health promotion programs. We could postulate that the WRCL is sensitive enough to distinguish the differences between worksites based on health program offerings. Oldenburg et al advocated scoring as a way of comparing worksites in each domain and giving an indication on the salience of health promotion at worksites. Similarly, the EAT checklist, HeartCheck, and other instruments have been used to compare control and intervention sites. Checklists that can be scored also may identify improvements overtime.^17,18,24 In these studies, summary scores have been most useful where responses (yes, no) are dichotomous. Summary scores were used to establish the utility of the WRCL by comparing the sites with and without health promotion.

For the WRCL-ADS, among the WHPn sites, site 3 had higher scores for all three sections, which were on par with the WHPy sites. This may be explained by the delayed response from this site’s administrators completing the WRCL-ADS. During this delay period, some health promotion interventions were started at this site. The reason for the delay reported by the site administrator was the administrative staffs were busy with inspections and internal review procedures. However, the higher scoring on this site even though it was originally one of our control sites (WHPn), could indicate the sensitivity of the WRCL in picking up the differences.

Among the WHPy sites, site 5 consistently had the lowest scores. This low score can be attributed to disagreement between the three administrators. The Executive Director was more likely to report that health promotion events were taking place, whereas the Director of Nursing and the Assistant Director of Nursing disagreed. Employee involvement is crucial in the success of health promotion programs. Most programs are not initiated, or maintained because of a traditional top-down approach and lack of communication from top management to middle management and employees. Although top management support is necessary it does not guarantee acknowledgment of the program by middle and lower management as indicated in this site.²⁷ This is an important finding and with the WRCL, we were able to render this issue.

Overall, for the HS section, both the WHPn and WHPy sites scored similarly. The lack of a significant difference in scores between the WHPn and WHPy sites for health and safety was not unexpected, because health and safety typically does not involve health promotion programming/activities. OSHA rules and federal health and safety laws and policies are followed by all sites in a similar way, and these corporate wide mandates may account for the similar scores across the worksites. In an independent survey of the sites, all these sites indicated that worksite health and safety issues are important. This correlates well with the high scores on the HS section. Plotnikoff et al²³ found similar results in their pilot test of the WPAAT. All workplaces scored high on their safety and risk management component. From the WPAAT study, they concluded that the reason for high scores was recognition of the government’s safety standards legislation. This evidence supports the sensitivity of the WRCL instrument.

In general, even though the WHPy sites claimed to have some kind of wellness activities in place, our observational checklist and the administrator surveys showed low readiness scores. The 2004 National Worksite Health Promotion Survey also showed that worksites with self-reported health promotion programs had low survey scores.¹¹ Workplaces with lower scores lacked intensive health promotion programs, measured by the five key evaluation criteria discussed earlier.

It is imperative to note that the overall section scores are meaningful when evaluated in the context of the maximum possible scores for the specific site or even comparing different sites. They can be used to identify and improve areas in health promotion and health protection programs and for planning future WHP programming. Initial scores for a site can also be used as a benchmark for subsequent evaluations to identify improvements over time.

Literature on WHP shows that multilevel approaches to individual, organizational, and community factors create a need for multilevel intervention evaluation methods.^8,9 Assessment tools like the CHEW evaluate the physical environment specifically; the WPAAT assesses physical activity in the context of the multiple environments that coexist in the workplace. Our instrument, the WRCL, proposes an integrative approach in evaluating a variety of health promotion and health and safety aspects of a workplace.

The disagreement among the administrators and very low scores on the WRCL-ADS sections suggests differences in perspective or communication problems within the managerial staff. Clearly, the selection of the individual(s) who provide responses could have an important influence on the results. Linnan et al¹¹ reported that lack of management support was one of the barriers for successful health promotion programs. Others have noted the importance of a consensus between administrative personnel, as a key component of a successful workplace program, as was observed in this study. As a caveat, the one instance where the administrator was overly optimistic about programs, could reflect a lack of awareness of the true level of need and the resource requirements for a successful program.²⁷

The administrative staff at a worksite has to be aware of health promotion and health protection policies and programs. The importance of the workplace mission, goals, and policies needs to be stressed among the administrators.

The observational part of the WRCL instrument shows positive results supporting the hypothesis. There was good interrater reliability for most items in the survey with 100% agreement between observers with P < 0.05 for almost all questions. The WHPn and WHPy sites had almost similar scores; however, the WHPn sites scored relatively less compared with the WHPy sites. The scores support the hypothesis stating that WHPy sites will score higher compared with WHPn sites. As observed, the working conditions were similar in most sites and scored similar in all sites except for one of the WHPn sites scoring high. Site 2 scored high because of the relaxation facilities that were provided for the staff and the flexibility offered to them during work to use these facilities. This facility in particular had a relaxation room for employees with all amenities that could be used during work hours or break time.

The questions under safety environment and working conditions had disagreements on questions that were more situational or perceptional with a Likert response scale. The reason for the disagreement is attributed to the different time of observation of the two observers completing the checklist. These questions need to be modified to improve the instrument. During the early development of the Heart Check instrument,¹⁸ four sites were used for reliability testing. Because of the small sample size that prevented them in the more traditional way of interrater reliability like kappa statistics, the study used a predetermined standard of 80% rater agreement as minimum measure of consistency. By using the same criteria as a standard for rater agreement, we had 100% agreement in most questions between the two observers.

The SE section had no significant differences between the intervention and control sites. All sites had a score of 80% or higher of their total score. The reason for these high and nonvariant scores is because of the government legislations for safety standards that are followed by all worksites.

CONCLUSION

The content validity of the instrument was established by thorough evaluation of items in specific areas. Face validity of the WRCL was established by the research group and also the administrative staff in six nursing homes.

The WRCL appears to be a valid tool (content validity and face validity) for the assessment of worksite readiness for implementation of worksite health promotion and health protection programs. The WRCL measures the level of readiness for successful health promotion programming by evaluating the management/organizational and physical environment of the workplace. The results from this pilot study may lead to the development of a more generalized format, with application to other types of organizations and industries.

Nonparametric analysis, quality of the instrument, and hypothesis testing support the use of the WRCL as a valid and reliable instrument to measure worksite readiness toward an integrated health promotion and health protection program. The results are consistent with those from other instruments like the CHEW and Heart Check, which support the concept of health promoting environments and organizational support.^17,18

Employers have considerable control over the work environment and can make small but conscious decisions to change their employees’ habits and behaviors with relative ease. Many employers, especially from small worksites (<500 employees), fail to understand the availability of existing resources and perceive that wellness programs are necessarily expensive.²⁸ The WRCL may be used as a valuable tool in identifying available resources for worksite health promotion and health protection programs.

Worksite Health Promotion and Occupational Safety practitioners may also use tools such as the WRCL to assess the readiness for WHP and implement programs in consultation with administrators and employees in a participatory approach integrating an ecological model. Further research is needed to establish the more general validity of this type of integrated instrument for assessing readiness. Some of the directions for future study with this instrument include the following:

Modification to the existing WRCL instrument can be made to improve its quality and possibly reduce the number of discrepancies in responses.

Development of a more generalized format that can be used to survey different types and sizes of workplaces.

An action plan can be developed that guides the worksite toward appropriate planning of WHP depending on the responses to the WRCL and phasing in program implementation based on the global scores.

An on-line version can be developed for ease of use of the instrument.

Further research is required to test this instrument in more sites to establish its usefulness and stronger validity in any worksite.

Limitations

One of the major limitations for this study was the number of sites used for the pilot test. Increasing the sample size may further increase the validation of this assessment tool.