The enterprises included in this study conducted several WHP activities to prevent NCDs, except risky alcohol use prevention. Tables 1 and 2 show the characteristics of enterprise and participants. Of the 15 enterprises, the data from one enterprise were treated as complementary data which was the same as the focus groups, because during the interview, it was found that they were a cooperative union, and supported the health promotion activities at its member establishments, instead of conducting WHP activities for their own employees.
Of the 39 CFIR constructs assessed, 25 were facilitative and 8 were inhibitory for WHP program implementation among SMEs (Table 3). Non-evidence-based activities were not included in the analysis (e.g., setting aside one day a month to not eat sweets). Quotes were labeled by the enterprise (alphabetically anonymized), the respondent (health manager or employer), and activity topics. Due to the word limit, selected results are shown in the manuscript. The full results with quotes, the constructs identified from the focus groups, and a table of factors and barriers by CFIR constructs according to each topic of the WHP activities are shown in the supplementary files 2-4.
Intervention characteristic domain
Relative Advantage
When deciding on a topic for the WHP activity, when the health manager recognized its relative advantages over other topics within NCD prevention, it was more likely to be selected and be proactively implemented. At one enterprise, the health manager selected exercise since it is relevant for all ages and allows everyone to participate in and benefit from it, as compared to other interventions such as those related to smoking or blood pressure.
Outer setting domain
Cosmopolitanism
One health manager mentioned the advantage of networking with other companies on program implementation. In the case of company located within an industrial park sharing the health checkup bus, the implementation of health checkup was perceived to be highly advantageous in terms of leading to a collaboration with other organizations in the industrial park.
"Now, all of the employees in this industrial park gather (to receive health checkups). Until four or five years ago, only our company had done them." (D, health manager, health checkups)
The health manager of the cooperative union (the enterprise recruited as an interview target, and later treated as complementary data same as interviews of public health nurses) reported that it was effective to make an opportunity for health managers from various companies to meet each other and share their concerns and ideas, as most of them were conducting WHP activities by themselves.
Inner setting domain
Networks and Communication
Within the enterprises, formal networks such as health committees had a role to play in the two-way communication; they were responsible for bringing the employees’ voices to the forefront as well as for communicating health-related information to the employees. Such internal communication facilitated implementation.
Relative Priority
Many health managers mentioned that the enterprise’s prioritization of WHP activities was relative to other things as a facilitative factor. Specifically, if health management was a part of the company’s overall management vision, it was easy to obtain the leader's approval and implement health promotion measures immediately.
"It's going to cost, and we talked to the employer and (health and safety) committee. (Omit) The most important thing was that it would help employees manage their health. So, we got the go-ahead right away." (F, health manager, tobacco control)
However, one employer mentioned that WHP implementation was a lower priority compared to customer-focused activities or productivity. Such a relatively low priority can be a barrier to implementation, and is likely to be highly dependent on the business conditions of SMEs at any given time.
Learning Climate
When health managers feel that the employer perceived them as an indispensable and knowledgeable person in the WHP implementation, they proactively examine, plan, and implement the WHP activities. In one enterprise, the health manager, who previously had no knowledge of health management, but was trusted by the employer and assigned this task, proactively implemented the program through trial and error. When the implementation went well, the manager felt affirmed, raising their “self-efficacy”, and the motivation to continue the program, and the implementation of other activities further increased, thereby, creating a virtuous cycle.
"The representative just told me he wanted to do health management for the employees. It was a great learning experience for me to work on our own." "(When deciding on the WHP activities to adopt) The employer basically gave me permission to select whichever I wanted. (Omit) I didn't ask (my superiors) which one they preferred. We kind of just said, ‘This is the one we'll go with" (A, health manager, physical activity)
Leadership Engagement
There were two ways in which employers engaged in WHP activities—communicating the company's philosophy linked to the WHP to all the employees, and supporting those who are engaging the implementation—both of which were strong drivers of implementation. Direct and repeated communication from the employer at general meetings and other occasions led others within the company to relatively prioritize WHP activities more and, hence, implementation progressed.
"The current representative of the company believes that the happiness of employees and those close to them will lead to contributions to customers and the local community. (Omit) I think the most important thing is the representative’s way of thinking." (A, health manager, physical activity)
Similarly, extending support to those in charge of the program, such as allowing them to participate in external trainings related to WHP program implementation during working hours, facilitated implementation.
"I was told that I can participate in such things (such as seminars on WHPs outside the company) as much as I want because they see it as part of my work." (A, health manager, physical activity)
Multiple public health nurses/nutritionists in the focus groups supported these findings, as they also mentioned that “The employer’s voice is essential,” and “The influence of employers and health care managers is significant in ensuring the sustainability of WHP implementation.”
On the other hand, health managers who were not given enough time or support to implement WHP-related tasks inevitably gave lower priority for WHP implementation. In this enterprise, one year after declaring that they would perform blood pressure control activities, they still had not purchased a blood pressure monitor.
"I'd like to help where I can (for implementing WHP activities), but I'm so busy with my other duties and I tend to forget." (C, health manager, blood pressure)
Access to Knowledge and Information
As many SMEs did not have existing resources to initiate WHP activities, many health managers reported that access to external knowledge and information, such as participation in study sessions during working hours and support from JHIA health nurses, was necessary to proceed the implementation. This accessibility to information was enhanced by support from the employer and the positive attitudes of health managers.
In contrast, when access to such external knowledge and information was difficult, even if the sense of urgency in the health manager increased, it did not lead to the actual implementation. In one enterprise implementing blood pressure management, nothing was implemented after installing blood pressure monitors despite having a sense of urgency to do something more, because they did not know what to do and had poor access to knowledge and information.
Characteristics of individuals
Knowledge and Beliefs About the Intervention
Some employers and health managers reported that they were clearly aware of having to conduct WHP activities as part of their regular task, rather than as an additional task, as they believed that the health promotion of employees is one of the issues the enterprise should engage in.
“Employees are the most important. In order to keep employees to work with high motivation for a long time, (spending resources) for their well-being is an investment, not a cost.” (K, employer, tobacco control and health checkups)
However, some employers or health managers were convinced that health behavior is no good unless each employee's awareness is changed, and it led to the belief that the WHP activities would have a limited effect, as a result of which the actual implementation was limited.
"It's not good if the person themselves is not aware of what’s going on. (Omit) I try to do things for myself. (omit) I'm diabetic, so I'm trying hard to lower my blood pressure, but until each of us is aware of it, it won't affect us (no matter what those around us say)." (B, health manager, blood pressure)
Self-Efficacy
Some employers reported, or health manager reported as an employer’s perception, that they (employers) entrusted health managers with the task of health promotion and they were able to accomplish it with the help of adequate time and manpower. Then, the managers’ sense of self-efficacy increased, thereby leading to a virtuous cycle and continued implementation in the subsequent years (see “learning climate” and “peer pressure” as well).
Individual Identification with Organization
Some health managers described that the employer’s sincere concern for the employees lead the employees' desire to respond to the employer's concern for them, and such relationships of mutual trust between the employer and the employees facilitated implementation.
Process domain
Change Agent
Most of employers and health managers perceived the public health nurses or nutritionists at JHIA as key members when implementing WHP activities, as they provided useful advice or information about WHP. In addition, they perceived that health lectures by public health nurses are more effective as employees were more receptive to the information coming from them.
The relationships between CFIR constructs
The diagram depicting the relationships between CFIR constructs showed that the “leadership engagement” of employers to implement the WHP activities influenced other facilitators. The identified employer’s “leadership engagement” in this study included 1) appointing health promotion as part of the duties of the health manager, 2) preparing resources (cost, time, and human resources) for WHP implementation, 3) putting WHP on the agenda in existing meetings, while sharing the aim of WHP, and 4) sincere desire for their employees’ happiness and health, and trust in the health managers.
Appointing health promotion as part of the duties of the health manager increased the “relative priority” of WHP implementation, and preparing resources (mainly time to learn and implement WHP), including allowing employees to attend a training session for WHP programs during working hours improved “access to knowledge and information” of the health managers regarding how to implement the WHP activities and awareness of the importance of WHP. Employers’ sincere desires for employee happiness and health, trust in the health manager, and acknowledging the hard work of the health manager led their trust in the employers, and in turn, the willingness to acknowledge and repay their employers’ concern for them, which also facilitated the implementation.
Further, employers’ engagement, including all the above-mentioned factors, fostered “relative priority” to implement the WHP in the enterprise and “learning climate” that allows health managers to try new WHP activities and the freedom to make mistakes and learn from them. Moreover, such increased “knowledge and information” as well as improved “implementation climate” cause greater motivation and skills among health managers, “self-efficacy” regarding the implementation of WHP activities and trying to obtain further knowledge and skills, thereby leading to a virtuous cycle of implementation.