Country HSE Manager, ABB UK and HSE Manager for ABB Motion

October 26, 2018

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The development of a health culture assessment tool (HCAT)

David Day, Head of SHE at nuclear specialist Nuvia UK, discusses his research into the aspects of health culture.

A while ago, I was contemplating how I can get people to buy into health as much as they do for safety. I thought there must be tools out there to help me. I decided to look – and what I found was revealing.

I was struck by the lack of HCATs available to organisations. Furthermore, the HCATs that are available are not user-friendly and are designed to be completed by specialists, thus ignoring the views of frontline employees.

This was my Eureka moment – if I can’t find a tool, I will develop one! This is how I did it.

What do I mean by ‘health’?

Even at its most general level, ‘health’ is a difficult construct to define. Disagreements are common because health can have medical, social, economic and spiritual components (Reference 1; Reference 2). I needed a definition to work with; but in my research I found many definitions were too complex and difficult to apply. However, I found a workable definition in the world of NEBOSH (reference 3) who define ‘health’ as:

The protection of the bodies and minds of people from illness resulting from the materials, processes or procedures used in the workplace.

What is ‘health culture’?

Next, I needed to be clear on what I understand by the term ‘health culture’. Whilst the concept of health culture does exist in literature (reference 4; reference 5), I couldn’t find a suitable definition. Dejoy and Della (2014) (reference 6) theorise that ‘health culture’ is a subdomain of organisational culture that influences health policy practices, which in turn creates a health climate. I couldn’t find this in any definition, therefore it needed further investigation. A clear conceptualisation was found in the safety culture literature. I transferred the work of Reason (1998) (reference 7) into the context of health and arrived at the following definition:

Something that an organisation is (intangible), in terms of beliefs, attitudes, and values of its employees regarding the pursuit of health; and something an organisation has (tangible), in terms of the structures, systems, practices, controls, and policies regarding the management of health risks.

Finding a suitable culture model

I then had to find a suitable foundation for the HCAT. In my career, I have worked extensively with the Hudson Ladder (reference 8) (see figure 1) so I thought I would give this a go. The research shows that it has been used in the context of health culture (reference 9) and is reported to be user-friendly (reference 10). All in all, a good basis on which to develop a new health culture assessment tool.

Figure 1 – The Hudson Ladder 

Hudson Ladder

Health culture aspects

Having set my definitions, I needed to understand what the key aspects of health culture that the HCAT would assess. To find this out, I searched extensively for health culture aspects in journals, research papers and culture assessment tools. My findings are shown in table 1.

Table 1 – Key aspects of health culture


Developing the HCAT culture grid

The next step was to identify a suitable research methodology, so, once again, I turned to the work of Hudson. Using a similar approach used by Hudson and colleagues (reference 11), in-depth interviews were carried out with 9 employees ranging from senior management to frontline personnel. The interviews lasted between 60 and 90 minutes and were recorded with the permission of the interviewee.

Interviewees were asked to read definitions of health and an explanation of the Hudson Ladder; then I held a discussion about the cultural levels of the Ladder to ensure the interviewee understood the concept. Next, using the health culture aspects mentioned previously, interviewees were asked to describe how an organisation would manage a health culture aspect at each level of the Hudson Ladder. Each interview recording was then transcribed and the answers were analysed by using recognised methods (references 12-14). Statements were then presented on a cultural grid (see Figure 2).

Figure 2 – An excerpt from the HCAT

An excerpt from the HCAT

Where are we now?

More than thirty employees – including frontline operatives, Safety, Health and Environmental Managers, Project Engineers and Trade Union Safety Representatives – have been consulted on the quality, suitableness and usability of the HCAT. All agreed that the HCAT is user-friendly and simple to use. We are now planning on rolling the tool out across the organisation and will assess its effectiveness in the coming months. Then it will be over to industry; the more people use it the better it becomes.


Reference 1 – Larson, J.S. (1999). The conceptualization of health. Medical Care Research and Review, Vol. 56 (2), 123-136.
Reference 2 – Hassan, E., Austin, C., Celia, C., Disley, E., Hunt, P., Marjanovic, S., Shehabi, A., Villalba-Van-Dijk, L. & Van Stolk, C. (2009). Health and Wellbeing at Work in the United Kingdom. Department of Health, London.
Reference 3 – Hughes, P., & Ferrett, E. (2011). Introduction to health and safety at work: the handbook for the NEBOSH National General Certificate. Butterworth-Heinemann.
Reference 4 – European Agency for Safety and Health at Work (2011). Occupational health and safety culture assessment: a review of main approaches and selected tools.
Reference 5 – Aldana, S.G., Anderson, D.R., Adams, T.B., Whitmer, R.W., Merrill, R.M., Victoria George, V. & Noyce, J. (2012).  A review of the knowledge base on healthy worksite culture. Journal of Occupational and Environmental Medicine, 54 (4).
Reference 6 – Dejoy, D.M. & Della, L.J. (2014). Culture, Communication, and Making Workplaces Healthier. In Arla Day, E., Kelloway, K. & Hurrell, Jr., J.J. (Eds). Workplace well-being: how to build psychological healthy workplaces. Chichester, Wiley Blackwell.
Reference 7 – Reason, J.T. (1998). Achieving a safe culture: theory and practice. Work Stress, 12:3, 293-306.
Reference 8 – Hudson, P.T.W. (2007). Implementing a safety culture in a major multi-national. Safety Science, 45, 697–722.
Reference 9 – Tappin, D.C., T.A. Bentley, T.A. & L.E. Ashby, L.E. (2015). An implementation evaluation of a qualitative culture assessment tool. Applied Ergonomics, 47, 84-92.
Reference 10 – Ashcroft, D.M., Morecroft, C., Parker, D. & Noyce, P.R. (2005). Safety culture assessment in community pharmacy: development, face validity, and feasibility of the Manchester Patient Safety Assessment Ladder. Quality and Safety in Health Care, 14, 417-421.
Reference 11 – Parker, D., Lawrie, M. & Hudson, P. (2006). A framework for understanding the development of organisational safety culture. Safety Science, 44, 555-562.
Reference 12 – Auquier, P., Pernoud, N., Bruder, N., Simeoni, M.C., Auffray, J.P., Colavolpe, C., François, G., Gouin, F., Manelli, J.C., Martin, C., Sapin, C. & Blache, J.L. (2005). Development and validation of a perioperative satisfaction questionnaire. Anesthesiology, 102 (6), 1116-1123.
Reference 13 – Carlton, J., Elliott, J., Rowen, D., Stevens, K., Basarir, H., Meadows, K. & Brazier, J. (2017). Developing a questionnaire to determine the impact of self-management in diabetes: giving people with diabetes a voice. Health and Quality of Life Outcomes, 15.
Reference 14 – Holt, D.T., Achilles, A.A., Hubert, S. & Harris, S.G. (2007). Readiness for organizational change: the systematic development of a scale. The Journal of Applied Behavioral Science, 43, 233-255.

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Nigel Evelyn-Dupree
Nigel Evelyn-Dupree
3 years ago

That’s alright then, the Global Pandemic of RSI’s in DSE operators are only predictable in 58% of operators but, of course, dismissed as only “temporary” so can be ignored although, costing 20%, 30 days presenteeism, rather than lost productivity or disability as that would be a hazard and risk….

Ann McCracken
Ann McCracken
3 years ago

“health culture’ is a sub domain of organisational culture” – interesting that years ago the HSE removed ‘culture’ from the Management Standards – yet I believe it is a vital part of the whole health of any organisation. In our Organisation Risk Assessment for Stress/Wellbeing we have a unique way to measure culture and ‘feelings’ – but not everyone want to know!