Abstract
Purpose:
Organizational health refers to work environments that promote both employee health and work productivity. As there is no consistent definition of this concept, this mixed-methods study contributes to the characterization and operationalization of organizational health in the public sector.
Methods:
To characterize organizational health, data from two focus group interviews, with six municipal work environment specialists and ten key stakeholders, were analyzed using inductive content analysis. Quantitative data, consisting of two survey items, on self-assessed production loss due to health and work environment problems (estimated on a 10-point Likert scale ranging from no to complete production loss) and sickness absence statistics were collected from a Swedish municipality.
Results:
Results showed that organizational health is indicated at the organizational level by the presence of sufficient preconditions for fulfilling objectives, at the workplace level by team capability and stability, and at the individual level by employees with low sickness absence, multiple development opportunities, and job satisfaction. Workplaces with organizational health were operationalized as workplaces where at least 80% of employees estimated their productivity loss due to health problems as ≤ 5, and productivity loss due to work environment problems as ≤ 3 on 10-point Likert scales, yielding a proxy indicator of organizational health. Of 330 workplaces in the municipality, 70 had organizational health, having less sickness absence than did the remaining workplaces [adjusted odds ratio 0.78 (95% CI 0.75–0.81)].
Conclusion:
Organizational health is a multifaceted concept. The operationalization captures some aspect of the qualitative findings on organizational health. The operationalized definition, that is, the absence of productivity loss due to adverse individual health and work environment conditions, has implications for future research and practice.
Introduction
Healthy public-sector workplaces are necessary to sustain public access to education, healthcare, social care, and other society services. Nevertheless, worker recruitment and retention in public-sector services are major challenges in many European countries due to demographic factors and adverse working conditions, including excessive workload, stress, and limited opportunities for professional development (Lidwall et al., 2018; WHO, 2022). Shifting attention from conducting solely risk-based occupational health and safety management (to prevent employee ill-health) to helping organizations promote employee health has been suggested as one way to improve the public-sector situation (Teoh et al., 2023). Several approaches have been used to create health-promoting organizations, guided by varied theoretical frameworks and terminology (Boot et al., 2024; Schulte et al., 2024), resulting in conceptual confusion with no consistent definition of what constitutes organizational health. Three common and partly overlapping concepts for addressing or understanding organizational health have been used in the past: health promotion, organizational health or healthy organizations, and organizational virtuousness.
Of these, health promotion emphasizes increasing resources that support a positive health process. This construct springs from a salutogenic perspective on health, emphasizing factors and resources that contribute to positive health development, such as buffering against risks (Bauer, 2006). In the workplace setting, the health promotion approach applies principles and strategies from public health to improve employee health and wellbeing, often on an individual level, although organizational-level interventions have been recommended (Aust et al., 2023; Dahlqvist et al., 2023; Larsson et al., 2016; Teoh et al., 2023).
As the workplace already has established structures and potential to reach many individuals, it is considered a favorable context for promoting health in individuals, especially in situations where universal access to healthcare is present. Such efforts may benefit both employees and the organization, fostering a positive process of improving health and productivity (Shain and Kramer, 2004).
Another concept, commonly called organizational health or healthy organizations (Grawitch et al., 2006; Raya and Panneerselvam, 2013), is rooted in organizational psychology and management research and has been conceptualized through system theory, a framework for understanding organizational dynamics and how the components of an organization interact with one another and with the external environment (Macintosh et al., 2007). In this perspective, signs of health in the organization are understood in terms of capability, resilience, and performance (Xenidis and Theocharous, 2014). Employee health is manifested in terms of competence, development, and engagement and is related to business success, although it is not explicitly included in objectives, strategic achievements, or human resources (HR) practices (Jaafari et al., 2023; Raya and Panneerselvam, 2013). Relationships between individual health outcomes and organizational success have been studied using different healthy workplace practice frameworks (i.e., employee involvement and development, health and safety, and work–life balance), but these have not integrated the outcomes of organizational success and individual health as mutually beneficial (Grawitch et al., 2006).
A further concept that has gained attention is organizational virtuousness, emerging from the field of positive organizational scholarship (POS) (Cameron and Spreitzer, 2011). This theoretical framework represents a shift from a risk and problem perspective toward a focus on how to strengthen factors helping both the employees and the organization to thrive and flourish, being beneficial in terms of wellbeing and improved work performance (Donaldson and Villalobos, 2024). Organizational practices, routines, and behaviors can foster virtuousness, which is assumed to encourage a positive spiral of social interaction, communication flow, and efficient resource uses (Meyer, 2018).
Organizational virtuousness also encompasses moral dimensions of shared values that facilitate social interaction and collaboration. These shared values are seen as crucial for resilience, effectively buffering against challenges (Cameron et al., 2011). There is limited knowledge of the effect of this virtuousness on organizational performance, although findings have shown that positive practices are associated with individual wellbeing as well as organizational indicators of productivity (Areskoug Josefsson et al., 2018; Cameron et al., 2011).
These three theoretical perspectives on how to define healthy and health-promoting organizations have different strengths and limitations. Currently, there is a lack of agreement on which construct best describes organizational health in the Swedish public sector. Public sector organizations are characterized by complex and sometimes conflicting goals, and outcomes are typically assessed using a combination of economic, client satisfaction, and work environment indicators (Albinsson and Arnesson, 2018). Across international contexts, public sector are politically governed and centrally managed, with strong expectations of efficiency, accountability, and high-quality service provision (Gebczyńska and Brajer-Marczak, 2020; McLean, 2019).
Here, the term “organizational health” is adopted as it highlights organizational factors with the potential to shape workplace functioning. While organizational perspectives are emphasized here, we argue that a robust concept of organizational health should also encompass individual health and the work environment, as these dimensions influence productivity and organizational outcomes (Katz et al., 2019). The organizational health construct may then be used to design interventions and take action to create healthy workplaces in the public sector, a prerequisite for retaining personnel and providing the public with education, healthcare, social care, and other social services.
In this study we explore a broad construct of organizational health encompassing employee health, the work environment, and organizational performance. The aims are accordingly:
(1) to characterize organizational health within the public sector;
(2) to operationalize organizational health using quantitative measures of self-assessed productivity loss due to health and work environment problems at the workplace; and
(3) to identify workplaces with organizational health and test the operationalization of organizational health.
Methods
Study design
In this study, a co-creative research approach was used to capture the complex human experience of knowledge in the area of interest (Greenhalgh et al., 2016). To disentangle this multidimensional construct, an exploratory sequential mixed-methods study design was used (Fetters et al., 2013). Qualitative data from two focus groups were used, in combination with quantitative measures derived from data collected by the participating organizations as part of their work environment management, consisting of employee surveys and statistics on sickness absence.
Study setting and participating organizations
The public sector in Sweden consists of 290 municipalities, which are responsible for preschools, schools, social care, and other social services, and 21 regions, which are geographical and administrative areas responsible for providing both primary and specialist healthcare. Three municipalities (two medium-sized and one small) and two regions representing geographical areas in northern and southern Sweden gave informed consent to participate in a larger project. The participants were recruited via the snowball method from previous collaborations among the authors.
Representatives of the five participating organizations, mainly from HR, formed a group of key stakeholders (n = 10). Representatives of the participating organizations were expected to share valuable experiences of organizational health and of solutions for assessing it, as well as certain practices connected to the concept. This purposive sampling was intended to achieve high information power and generate diverse qualitative material. The interviews gave a rich account of the challenges, details, and in-depth reflections. This study used qualitative data from all five participating organizations to characterize and operationalize organizational health, along with quantitative data from one medium-sized municipality.
Data collection
Qualitative data collection
The qualitative data were collected from two focus group interviews (aims 1 and 2) and one expert review (aim 3) in the spring of 2025.
The first focus group interview was conducted with the group of key stakeholders (n = 10) from all five participating organizations. This group comprised managers and personnel from HR and other strategic positions experienced in managing and developing the work environment and occupational health issues. The second interview was conducted with a group of work environment specialists (n = 6) from one municipality. The participants had extensive knowledge of systematically applying the measures, including sickness absence data and survey items, to identify risk factors and follow-up interventions. In their practice, they provide workplace support concerning how work is organized and managed. The latter group was also used in the expert review when testing the operationalization of organizational health data derived from their municipality.
Both focus group interviews were performed in two separate parts. In the first part, data for exploring what characterizes organizational health were collected using a semi-structured interview guide (see Supplementary Appendix 1). In the second part, data to operationalize organizational health were collected via cognitive interviewing (Willis, 2004) based on two items from the employee survey measuring production loss due to health problems and work environment problems. The key stakeholder group and the work environment specialist group were invited to discuss and elaborate on the items and to determine a cutoff for employee health. A criterion-based approach (HadŽibajramović et al., 2019) was used to classify levels of health and work environment problems on a 10-point Likert scale. The expert group's knowledge was applied to capture the distinct condition for the items' cut-off.
The classification process was conducted in phases: ratings were first completed in smaller groups, then compared and discussed as a whole group. Different cut-offs were tested and compared to expert estimates of the number of workplaces with organizational health. Scoring below the cutoff suggests that the employee has minor problems, but that their health falls within the range of acceptable variation and can be considered acceptable. The same scoring estimation was performed based on employees' experiences of work environment problems. Both focus groups also estimated the percentage of employees at a workplace who had to reach the health cutoff and the work environment cutoff, to consider the workplace as having organizational health. This was set as an operational definition of a workplace with organizational health.
The focus group interview with key stakeholders lasted 120 min and was conducted by one author (MA). The interview was conducted in a hybrid setting in which two focus group members participated digitally. Field notes were taken by two other authors (EF, JW). The participants' notes grading the level of health and work environment problems were collected. After the workshop, the authors summarized the information gathered. The focus group interview with the work environment specialists lasted 90 min and was conducted by one author (MA); the interview was audio recorded.
In the expert review, when testing the operationalization of organizational health, the work environment specialists in the municipality were presented with a list of workplaces suggested as having organizational health according to the derived operationalization mentioned above, for qualitative reflection based on their knowledge. The expert review was audio recorded.
The recorded interviews were transcribed verbatim using the tool Lingsoft (Lingsoft Language Services OY, Helsinki, Finland) and then checked and corrected by one of the authors (EF).
Quantitative data collection
The quantitative data were retrieved from one municipality and included employee surveys conducted by the employer in 2021 and 2023, and monthly data on sickness absence covering the period from 1 January 2020 to 1 June 2024.
The employee survey comprised questions about how the employees perceived their work conditions, and its results were to be integrated into the management of the work environment. The survey was distributed to all employees in the municipality and had a total response rate of approximately 80%. Workplaces with fewer than seven respondents were excluded for confidentiality reasons. The focus of the research project was to study workplaces with functions specific to the public sector; workplaces consisting of management and politicians were excluded. In total, 440 workplaces (n = 7,288 employees) in 2021 and 448 workplaces (n = 7,295) in 2023 were available for the project. The workplace size ranged from 7 to 68 employees (mean 16.6) in 2021 and from 7 to 81 (mean 17.4) in 2023. The data were analyzed at the workplace level, and 345 workplaces with data from both measurement points were identified (Figure 1).
Figure 1
Two items, tested as valid to measure production loss due to health problems (Lohela Karlsson et al., 2015b) or work environment problems (Lohela Karlsson et al., 2015a), were used in this study:
Over the past 7 days, have you experienced any health-related problems (any physical or emotional problems or symptoms) while at work? If yes, during the past seven days, how much did your health problems affect your performance while you were working? (graded scale ranging from 1 = health problems had no impact on my work to 10 = health problems completely prevented me from performing my work).
Over the past 7 days, have you experienced work environmental problems (any physical, psychological, or social problems that might arise in the work environment)? If yes, how much did work environment problems affect your performance while you were working? (graded scale ranging from 1 = work environment problems had no impact on my work to 10 = work environment problems completely prevented me from performing my work).
Monthly data on sickness absence, calculated at the workplace level as the percentage of absence relative to expected working hours for the group, were retrieved from the municipality's personnel system in the form of short-term (1–14 days), long-term (>60 days), and total (i.e., short-term plus long-term) sickness absence. In total, 330 of the 345 workplaces (95%) could be matched with statistics on sickness absence, resulting in the final study sample (Figure 1).
Data analysis
Characterizing organizational health (Aim 1)
The data from the focus group interviews were analyzed via inductive content analysis (Elo and Kyngäs, 2008), given the exploratory study design required for Aim 1. The data, which were based on semantic expressions, were coded separately by two authors (EF, MA). The codes were then extracted into meaningful code chunks and discussed with the other authors until agreement was reached (see example in Table 1). The approach was to search for patterns, moving from abstract to a general level (Graneheim et al., 2017). An overarching theme along with subthemes were identified, divided into categories and subcategories according to prevalence, and that they captured central issues pertaining to the research question (Braun and Clarke, 2006).
Table 1
| Overarching theme | Subtheme | Category | Code | Quotation |
|---|---|---|---|---|
| Organizational health is complex and contextual | Indication of organizational health at the workplace | Capability and resources in the workplace group | Productivity | “Somewhere, there's a signal when a unit delivers on its mission, that they have some kind of ability to collaborate… can take on complex tasks.” |
Semantic expressions were coded into code chunks and then categorized.
Categories were identified into themes.
The COREQ checklist (Tong et al., 2007) was used to support adherence to qualitative research criteria.
Operationalizing organizational health (Aim 2)
To operationalize organizational health, the data from both focus group interviews were coded via deductive content analysis (Graneheim et al., 2017) and categorized into different levels to set cutoffs for the health and work environment items. The cutoffs were used to identify workplaces with organizational health.
Testing the operationalization of organizational health (Aim 3)
The testing was performed in two steps. First, the workplaces identified as having organizational health were reviewed by the expert group of work environment specialists to check whether any of them had work environment problems despite their assigned organizational health status. Using a deductive content approach, statements were coded into categories to confirm or reject the findings.
Second, differences in sickness absence between workplaces with and without organizational health were investigated. This was done by analyzing the monthly proportion of sick leave days using a generalized additive model (GAM) with a binomial distribution. GAM extends standard regression models by allowing non-linear relationships between predictors and the outcome, which is particularly useful for capturing gradual time trends and seasonal variation in longitudinal data.
The outcome was defined as the proportion of sick days relative to total staff days per workplace and month. The total number of personnel at each workplace was included as weights to account for differences in workplace size. Odds ratios (ORs) were estimated to compare workplaces with and without organizational health (binary indicator).
Three variants of sick leave were examined as outcomes: short-term absence (< 2 weeks), long-term absence (>60 days), and total absence. Crude odds ratios were first calculated. In the adjusted regression model, time trends and seasonal patterns in relation to organizational health were adjusted for using the date (month and year) in a smooth spline function, and municipal departments (e.g., the Preschool, Social Care, and Technical Services departments, n = 15) were included as random factors to account for possible clustering within departments. As a sensitivity analysis of the classification of a workplace, additional regression models were performed using different cut-offs to identify organizational health.
Analyses were performed with R (version 4.2.2) and the mgcv package.
Results
To characterize organizational health
The analysis of the focus group interviews identified one overarching theme: organizational health is complex and contextual. The appearance of what seems healthy can vary from different perspectives. Organizational health is manifested at several levels in the organization, and conflicting outcomes may appear; for example, high productivity, a sign of organizational health, may not always be healthy for the individual. In the coding, three subthemes emerged that are meaningful for a contextual understanding of organizational health: the indication of organizational health at the organizational level, the indication of organizational health at the workplace, and the indication of organizational health in the individual. Each subtheme consisted of categories and subcategories (Table 2).
Table 2
| Main theme | Subtheme | Category | Subcategory |
|---|---|---|---|
| Organizational health is complex and contextual | Indication of organizational health at the organizational level | To strive to fulfill the objectives of the assignment | To reach objectives |
| To minimize disruptions that can affect objectives | |||
| Conditions provided by the organization | Sufficient conditions | ||
| Supportive leadership | |||
| Indication of organizational health at the workplace | Capability and resources in the workplace group | Cooperation and a functioning team | |
| Continuity and stability in the workgroup | |||
| Indication of organizational health in the individual | Supportive, encouraging, health-promoting work environment | Wellbeing, inclusion, and meaning | |
| Development opportunities and job satisfaction | |||
| Absence of ill-health | Low sickness absence |
An overarching theme and subthemes were identified.
Divided into categories and subcategories according to prevalence and inclusion of the central issue of the research question.
Indication of organizational health at the organizational level
In the analysis of the interviews, the subtheme organizational health indicated at the organizational level was defined in two categories: to strive to fulfill the objectives of the assignment and conditions provided by the organization. Adequate working conditions must be in place to enable employees to fulfill the objectives of their assignments. This involves clearly defining objectives and ensuring that they are well-understood. It also requires possessing the knowledge and ability to provide necessary support, as well as the management capacity to identify obstacles or underlying factors that may hinder goal achievement. If such obstacles are present, the work conditions need to be adjusted so that employees can perform their work accurately and reach objectives:
This is where the anchoring process becomes essential, and we have made an effort to understand one another. We sometimes refer to it as “defining the assignment,” to put it simply. And in that sense, it provides an excellent starting point [for dialogue on how to fulfill objectives] (Work environment specialist in focus group interview 2).
How are they [i.e., problems] visible, and what are the consequences? Therefore, when the school had intervened in root causes [i.e., the schedule], there was a clear improvement (Work environment specialist in focus group interview 2).
The organization has the responsibility to ensure that the structural conditions of work are sufficient for employees to perform their work duties and stay healthy over time. Conditions were specified as adequate support, clearly assigned work tasks, opportunities for recovery, and the assignment of temporary staff when employees are on sick leave. Overall, the identified themes indicated the importance of trust and confidence in the management and organization, which should be supportive and acknowledge challenging work conditions or job strain:
If you are given the right conditions, then you can stay healthy over time… and that includes… when the burden is heavy… the manager needs to see that and—“I can see that you are under a lot of pressure now and I think we should…”—then you get support and can stay healthy in the long run (Work environment specialist in focus group interview 2).
Indication of organizational health at the workplace level
In the subtheme indication of organizational health at the workplace level, one category was identified in the analysis of the interviews, that is, capability and resources of the team, indicating that when the group performs their assignments and cooperates, this is characteristic of a workplace with organizational health:
Somewhere, there is a signal when a unit delivers on its mission, that they have some kind of ability to collaborate. Can take on complex tasks… (Work environment specialist in focus group interview 2).
If you consider that you are dependent on one another in a work group, there can't be so many who don't have the ability to work (Work environment specialist in focus group interview 2).
Continuity and stability in the team were recognized in terms of present employees. The employees support one another and can cover for absent colleagues for shorter periods, without that negatively affecting the work environment.
Indication of organizational health at the individual level
Organizational health at the individual level was categorized as supportive, encouraging, health-promoting work environment and absence of ill-health. The interviews indicated that employees were part of a work environment where they could thrive and be appreciated. Low sickness absence was regarded as a sign of health and as contributing to robust teams. Another aspect mentioned was that performance should be sustainable over time. Sometimes, some individuals strained themselves to compensate for a high workload or dysfunctional teams:
We have these workplaces with low sickness absence… but do they have full access to their resources? No (Work environment specialist in focus group interview 2).
The complexity of experiencing meaningful work in relation to whether it strengthens individual resources was also expressed. Nevertheless, the organization needs to take responsibility for maintaining a balance between demands and resources:
The meaning of having a job: I can contribute. There was a lot that came out that I interpret as [health] promoting being in that context. They also took care of one another. They took care of new people in a very nice way. In the tough environment that homecare is anyway, with lots of technical things and demands to do the job in a short time and so on, I can still see that work contributed [to meaningfulness] … but that is a difficult question (Work environment specialist in focus group interview 2).
Operationalize organizational health
The group of key stakeholders and the group of work environment specialists noted the complexity of operationalizing organizational health via only two items. They stressed the importance of considering the context and factors outside the work environment.
Compared with productivity loss due to work environment problems, higher ratings for productivity loss due to employees' health problems were found to be more acceptable since health problems may be temporary, due to personal reasons such as symptoms related to an infection or a diagnosis. In addition, work environmental problems could affect all employees, whereas health problems among individual employees typically affect fewer employees in the workplace.
Experiencing health problems affecting productivity
Employee estimates of ≤ 5 on a 10-point Likert scale for productivity loss due to health problems were considered acceptable according to both focus groups. Exceeding this cutoff calls for further assessment of the need for support, according to the focus group of work environment specialists. However, productivity loss due to health problems could not be used on its own, and other information had to be considered (i.e., mainly sickness absence).
Experiencing work environment problems affecting productivity
Both focus groups concluded that employee estimates of ≤ 3 on a 10-point Likert scale for productivity losses due to work environment problems were acceptable. At higher levels, the risk of negative effects was regarded as substantial. They also added that qualitative information on what the numbers represented was essential.
A workplace with organizational health
After discussion based on knowledge and experience, both focus groups gave their opinions on how many individuals at the workplace must reach both cutoffs to consider a workplace as having organizational health. In this assessment, they agreed on 75%−80%. They explained that if some employees could not perform, this would lead to work environment problems, productivity challenges, and difficulty fulfilling the organizational objectives. The importance of sustained organizational health over time was also highlighted.
A workplace with organizational health was operationalized using the following conditions: at least 80% of employees estimated their productivity loss due to health problems to be ≤ 5 on a 10-point Likert scale, and productivity loss due to work environment problems to be ≤ 3 on a similar scale. To be included, workplaces should reach the cutoff for both measures in 2021 and 2023.
Testing the definition of organizational health
In total, 70 of 330 workplaces (22%) in the municipality were identified as having organizational health according to the above operationalization. In the qualitative expert review, several workplaces were recognized as well-functioning in terms of low sickness absence and positive leadership practices; however, the participants had limited knowledge of all workplaces.
There were a few workplaces from schools and education with organizational health, confirmed by the focus group:
Schooling doesn't come up much [on the list], given their challenges, group sizes and the enormous difficulties of actually fulfilling their assignment and goals (Work environment specialist in focus group interview 2).
Some workplaces stood out:
This home care service unit, included on the list [amongst many who have severe problems], also works okay (Work environment specialist in focus group interview 2).
In one department, no workplace reached the cut-off organizational health. The focus group confirmed severe problems in workplaces within the department, and several participants had provided support for these. Regression models revealed that workplaces with organizational health were consistently associated with lower odds of sick leave. For total sickness absence, the adjusted odds ratio was 0.78 (95% CI 0.75–0.81) for workplaces with organizational health vs. those without (Table 3, Figure 2). The strongest effect was observed for long-term sickness absence (>60 days), with an adjusted OR of 0.68 (95% CI 0.65–0.71).
Table 3
| Sickness absence | Crude | Adjusted |
|---|---|---|
| Total number of days | ||
| No organizational health (n = 275) | 1 | 1 |
| Organizational health (n = 70) | 0.75 (0.73–0.78) | 0.78 (0.75–0.81) |
| Short-term (<14 days) | ||
| No organizational health (n = 275) | 1 | 1 |
| Organizational health (n = 70) | 0.85 (0.81–0.89) | 0.90 (0.85–0.94) |
| Long-term (>60 days) | ||
| No organizational health (n = 275) | 1 | 1 |
| Organizational health (n = 70) | 0.67 (0.64–0.70) | 0.68 (0.65–0.71) |
Odds ratios (ORs) with 95% confidence intervals (CIs) for the association between organizational health and sick leave.
Results are shown for crude models and models adjusted for time trends and departments.
Figure 2
For sensitivity analysis, additional regression models with alternative cut-offs of 75% and 85% of employees meeting the criteria were applied, compared with the primary definition of 80% (see Supplementary Appendix 2).
Discussion
Our aim was to explore how organizational health is characterized in the public sector, operationalize, and test the organizational health construct. Results show that the concept of organizational health is complex and contextual, and indications of organizational health can be observed at the organizational, workplace, and individual levels. Organizational health encompasses functioning and stable teams that fulfill the objectives of their assignments at the workplace level; however, that relies on the presence of sufficient organizational-level conditions in terms of clearly defined objectives, sufficient knowledge and managerial support, and adequate working conditions. At the individual level, organizational health comprises a work situation that can create meaning and opportunities for fulfillment for the individual employee, as well as the absence of ill health. Furthermore, results indicate that the definition of organizational health could be operationalized using quantitative survey items with which employees rated their production loss due to health and work environment problems. When testing this operationalization, sickness absence over time was lower in workplaces with organizational health than in those without.
Defining and operationalizing organizational health in the public sector
Organizational health, in terms of healthy organizations and healthy workplaces, has been defined using various theories in the past (Bauer, 2006; Cameron and Spreitzer, 2011; Macintosh et al., 2007). These theoretical definitions share similarities, although they differ in their emphasis and expected outcomes, especially in their balance between productivity and successful business goals, on the one hand, and employee health promotion or a focus on facilitating employee thriving and flourishing, on the other. When investigating how organizational health could best be characterized for practical use in the public sector, we found a more balanced definition highlighting the complexity and importance of the context to a greater degree than other definitions. Similarly, a recent review in the healthcare setting identified two themes indicating a need to integrate the preventive and promotional perspectives both in actions to fulfill organizational goals and in considering how these actions affect the ability of employees to perform their jobs at a reasonable quality level (Akerstrom et al., 2025). In a study of Swedish municipalities with low sickness absence, the authors concluded that organizational strategies and planning are important for healthy workplaces (Stöllman et al., 2025).
Our findings of what characterizes organizational health share the same key components with the theories of health promotion, organizational health, and organizational virtuousness (Bauer, 2006; Cameron and Spreitzer, 2011; Macintosh et al., 2007), but greater emphasis is put on the complexity and importance of the context and the need to balance individual productivity against employee health and the work environment.
This differs from the organizational health perspective of Jaafari et al. (2023), in which health is reflected by how productive or effective the organization is. However, this emphasis on performance has been criticized, since such a narrow focus may fail to capture the complexity of health in an organization (Grawitch et al., 2006). Instead, and in line with our findings, the need to target individual health and the work environment to a greater degree, as organizational and productivity assets, has been suggested (Raya and Panneerselvam, 2013). Consistent with this, the health promotion concept, which emphasizes individual health to a great degree when defining organizational health, has been criticized for not considering the outcome of interventions in terms of organizational achievements (Eriksson et al., 2017). Instead, the effectiveness of health-promoting interventions is often evaluated in terms of health-related outcomes such as their effect on mental or musculoskeletal health, depending on the intervention target (Proper and van Oostrom, 2019), while the effect on productivity or on how well work is performed is not directly considered, but merely assumed to exist.
Realization of the need for a more balanced definition of organizational health is not new, and the concept of organizational virtuousness takes account of how aspects such as ethical norms and values, in combination with psychological wellbeing or health, contribute to positive organizational outcomes (Goyal et al., 2024). The concept of organizational virtuousness also includes systematically addressing the presence of contextual and workplace resources that buffer against negative challenges and can foster a self-reinforcing positive process (Areskoug Josefsson et al., 2018; Aubouin-Bonnaventure et al., 2023). This systemic approach was not explicitly expressed in the focus group. However, its outcome, believed to enhance employee wellbeing, which in turn fosters work engagement, was in some sense expressed in the focus group interviews in terms of inclusion and meaning. While this positive process engendered by virtuousness is hypothesized to increase productivity, the causal link remains unclear (Cameron et al., 2011). Thus, our findings on what characterizes organizational health share the overall idea of balancing productivity and employee health with the concept of organizational virtuousness, but provide a broader definition that also embraces greater complexity (von Thiele Schwarz et al., 2024).
Operationalizing the organizational health construct enabled us to further explore organizational health. First, we investigated whether self-assessments of individual productivity loss due to work environment and health problems, which had previously been used in work environment economics (Lohela Karlsson et al., 2015a, 2013), could capture the complexity and the balance between productivity loss, on one hand, and employee health and working conditions, on the other. Our results indicate that these two survey items could indeed identify workplaces with organizational health with high validity, despite their focus on productivity loss rather than factors promoting productivity. These findings are promising, but more studies are needed to investigate the reliability of this operationalization and what specific working conditions foster organizational health.
Second, aggregating these self-assessments from the individual to the organizational levels facilitated a deeper understanding of the findings. In terms of the balance between individual health and organizational-level working conditions, the productivity loss due to individuals' own health was assessed to affect the organizational health of a workplace less than the productivity loss due to work environment problems. Work environment problems have also been shown to affect production loss more than the reduction in productivity related to employees' individual health impairment (Lohela Karlsson et al., 2013). This might indicate that our findings on what characterizes organizational health definition are slightly closer to the definition of (Jaafari et al. 2023) than to the health promotion concept Bauer, (2006). In addition, the stability of the working group was assessed as adequate if four of five employees in the group had low productivity loss due to individual health and working problems. The acceptance of some productivity loss indicates that a total absence of ill-health and work environment problems may not be applicable or even achievable. Conversely, functional presenteeism, that is, when an employee attends work while affected by health problems and not at full capacity, can be adaptive for overall health if demands are adjusted and sufficient resources and support are provided in the workplace (Karanika-Murray and Biron, 2020). This was described in the focus group as the positive aspect for the individual of inclusion and meaningfulness in belonging to a workgroup, further highlighting the complexity of assessing organizational health. Adjusting working conditions and providing support become more feasible in less-strained work structures that allow for temporary lower performance. However, the public sector context is characterized by mission-driven work shaped by multiple stakeholders and managerial constraints. While public service motivation, to deliver service and do good for others, may facilitate goal attainment, it may also entail an increased risk of presenteeism (Knies et al., 2024). The risk of irreplaceability may contribute to personnel working while ill, as expressed in the focus group as a characteristic of a lack of organizational health, when the employee does not take responsibility for sustaining resources.
Strengths and limitations
The mixed-method applied made it possible to deepen our understanding of organizational health connected to practice, and to clarify the meaning of the outcome of measures captured by the survey items (Fetters et al., 2013; Åkerblad et al., 2021). A strength of this study was that the surveys had a high response rate and were completed at two time points. There are limitations in the testing of operationalized organizational health. The expert review had several weaknesses. First, the number of workplaces on the list was so many that the participants could not have in-depth knowledge of their status at measurement points. Secondly, false negatives were not considered. Thirdly, the risk of participants agreeing to a list presented to them is high. To enhance the robustness of the operationalized concept, exploring it with other measures or another more structured qualitative testing would have been beneficial. However, this was not applicable in this study. For validation of the measure, these steps would be necessary.
Sickness absence may serve and is often regarded as an indicator of health, the work environment, and productivity, but it represents a rather incomplete perspective. One potential limitation of this study was its use of sickness absence in testing organizational health, since it can be considered a less-than-reliable measure of health status (Aronsson et al., 2011; Skagen and Collins, 2016). Employees may work even when ill due to a demanding workload and limited supportive organizational structures in terms of assigning temporary staff. An employee continuing to work while affected by health issues, resulting in lower performance capacity, that is, presenteeism, may mask organizational ill-health in the short term; however, the practice may not be sustainable over time and increases the risk of health problems and long-term sickness absence, potentially affecting the organization's productivity and costs (Hansen and Andersen, 2009; Skagen and Collins, 2016; Lui et al., 2018). In contrast, data on sickness absence have clear advantages, as they are derived from records and are not self-reported. Here, we obtained data directly linked to each workplace. A limitation of the study is the use of survey items from a single municipality, which limits the generalizability of the findings to other organizations. To enhance the robustness of the present operationalization, it would have been beneficial, as expressed by the focus group, to explore it using other measures; however, owing to a lack of valid measures, this approach was not applicable.
Implications
The results of the present study have implications for both research and practice. The proposed conceptualization of organizational health may be used in future studies to improve our knowledge of what distinguishes workplaces characterized by organizational health. As current knowledge of how organizational factors (i.e., how work is organized and managed) contribute to organizational health is limited, further research is needed to explore how, and by what pathways, organizational health can be achieved (Akerstrom et al., 2025). The operationalization can be used by HR and managers to identify and distinguish workplaces with or without organizational health. In combination with other measures, organizational health broadens the assessment of the health and work environment, and can be applied within occupational health and safety management (OHSM) to systematically evaluate and intervene in, and follow up on the work environment, and assessing how work is organized, designed, and managed (Nielsen and Abildgaard, 2013; Swedish Work Environment Authorithy (SWEA), 2023). As shown, organizational health is complex and context-dependent, and this context must be considered in OHSM work. We suggest acknowledging the specific contextual needs of the organization and the workplace, adjusting to different settings, considering the specific characteristics of the job demands, and being flexible in providing support. In addition, we address the multiple levels at which organizational health is manifested.
Conclusion
Organizational health is a multifaceted and context-sensitive concept that manifests at different levels within an organization. Indications of organizational health can be observed at the organizational, workplace, and individual levels. Organizational health encompasses functioning and stable teams that fulfill the objectives of their assignments at the workplace level, but also relies on the presence of sufficient organizational-level conditions in terms of clearly defined objectives, sufficient knowledge, and managerial support. At the individual level, organizational health comprises a work situation that can create meaning and opportunities for fulfillment for the individual employee as well as the absence of ill health. Additional factors related to central regulations, budgetary conditions, and structural constraints are institutional mechanisms that may also provide insight into the characteristics of organizational health (Gile et al., 2022). Associations between employees' prerequisites for goal attainment and employer health outcomes (Akerstrom et al., 2025) further highlight the concept's complexity and interdependency between health and productivity.
Statements
Data availability statement
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
Ethics statement
Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.
Author contributions
EF: Writing – review & editing, Writing – original draft, Formal analysis. MA: Writing – review & editing, Conceptualization, Formal analysis. ST: Writing – review & editing, Formal analysis. AT: Writing – review & editing, Formal analysis, Visualization. JW: Writing – review & editing, Conceptualization, Formal analysis, Funding acquisition.
Funding
The author(s) declared that financial support was received for this work and/or its publication. This research was funded by AFA Insurance, a non-profit company owned by Swedish labor market parties (project number 20240060). The funding body had no role in designing the study, in collecting, analyzing, and interpreting the data, or in writing the manuscript. Financial support was also provided through a regional agreement between Umeå University and Region Västerbotten (ALF).
Acknowledgments
The authors thank Helén Nordenstam for support in collecting data and establishing contact with representatives from the organizations. The authors also want to thank participating organizations and AFA Insurance for funding this research.
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The author(s) declared that Generative AI was not used in the creation of this manuscript.
Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/forgp.2026.1817625/full#supplementary-material
References
1
ÅkerbladL.Seppänen-JärveläR.HaapakoskiK. (2021). Integrative strategies in mixed methods research. J. Mix. Methods Res.15, 152–170. doi: 10.1177/1558689820957125
2
AkerstromM.WahlströmJ.LindegårdA.ArvidssonI.Fagerlind StåhlA.-C. (2025). Organisational-level risk and health-promoting factors within the healthcare sector—a systematic search and review. Front. Med.11:1509023. doi: 10.3389/fmed.2024.1509023
3
AlbinssonG.ArnessonK. (2018). The managerial position in a Swedish municipal organization: possibilities and limitations. Econ. Ind. Democr.39, 500–535. doi: 10.1177/0143831X16639656
4
Areskoug JosefssonK.AvbyG.Andersson BäckM.KjellströmS. (2018). Workers' experiences of healthy work environment indicators at well-functioning primary care units in Sweden: a qualitative study. Scand. J. Prim. Health Care36, 406–414. doi: 10.1080/02813432.2018.1523987
5
AronssonG.GustafssonK.MellnerC. (2011). Sickness presence, sickness absence, and self-reported health and symptoms. Int. J. Workplace Health Manag.4, 228–243. doi: 10.1108/17538351111172590
6
Aubouin-BonnaventureJ.FouquereauE.CoillotH.LahianiF.-J.ChevalierS. (2023). A new gain spiral at work: relationships between virtuous organizational practices, psychological capital, and well-being of workers. Int. J. Environ. Res. Public Health20:1823. doi: 10.3390/ijerph20031823
7
AustB.MøllerJ. L.NordentoftM.FrydendallK. B.BengtsenE.JensenA. B.et al. (2023). How effective are organizational-level interventions in improving the psychosocial work environment, health, and retention of workers? A systematic overview of systematic reviews. Scand. J. Work Environ. Health49, 315–329. doi: 10.5271/sjweh.4097
8
BauerG. (2006). The EUHPID Health Development Model for the classification of public health indicators. Health Promot. Int.21, 153–159. doi: 10.1093/heapro/dak002
9
BootC. R. L.LaMontagneA. D.MadsenI. E. H. (2024). Fifty years of research on psychosocial working conditions and health: from promise to practice. Scand. J. Work Environ. Health50, 395–405. doi: 10.5271/sjweh.4180
10
BraunV.ClarkeV. (2006). Using thematic analysis in psychology. Qual. Res. Psychol.3, 77–101. doi: 10.1191/1478088706qp063oa
11
CameronK.MoraC.LeutscherT.CalarcoM. (2011). Effects of positive practices on organizational effectiveness. J. Appl. Behav. Sci.47, 266–308. doi: 10.1177/0021886310395514
12
CameronK. S.SpreitzerG. M. (2011). The Oxford Handbook of Positive Organizational Scholarship. Oxford: Oxford University Press.
13
DahlqvistI.StåhlC.SeverinJ.AkerstromM. (2023). Shifting from an individual to an organizational perspective in work environment management – a process evaluation of a six-year intervention program within the Swedish public sector. BMC Public Health23:1108. doi: 10.1186/s12889-023-16059-y
14
DonaldsonS. I.VillalobosJ. (2024). Positive mindset: PsyCap's roles in PERMA+4 and positive organizational psychology, behavior, and scholarship 20. Organ. Dyn.53, 1–7. doi: 10.1016/j.orgdyn.2024.101084
15
EloS.KyngäsH. (2008). The qualitative content analysis process. J. Adv. Nurs.62, 107–115. doi: 10.1111/j.1365-2648.2007.04569.x
16
ErikssonA.OrvikA.StrandmarkM.NordsteienA.TorpS. (2017). Management and leadership approaches to health promotion and sustainable workplaces: a scoping review. Societies7:14. doi: 10.3390/soc7020014
17
FettersM. D.CurryL. A.CreswellJ. W. (2013). Achieving integration in mixed methods designs—principles and practices. Health Serv. Res.48, 2134–2156. doi: 10.1111/1475-6773.12117
18
GebczyńskaA.Brajer-MarczakR. (2020). Review of selected performance measurement models used in public administration. Adm. Sci.10:99. doi: 10.3390/admsci10040099
19
GileP. P.Van De KlundertJ.Buljac-SamardzicM. (2022). Human resource management in Ethiopian public hospitals. BMC Health Serv. Res.22:763. doi: 10.1186/s12913-022-08046-7
20
GoyalR.SharmaH.SharmaA. (2024). A thorough examination of organizations from an ethical viewpoint: a bibliometric and content analysis of organizational virtuousness studies. Bus. Ethics Environ. Responsib.33, 129–144. doi: 10.1111/beer.12597
21
GraneheimU. H.LindgrenB.-M.LundmanB. (2017). Methodological challenges in qualitative content analysis: a discussion paper. Nurse Educ. Today56, 29–34. doi: 10.1016/j.nedt.2017.06.002
22
GrawitchM. J.GottschalkM.MunzD. C. (2006). The path to a healthy workplace: a critical review linking healthy workplace practices, employee well-being, and organizational improvements. Consult. Psychol. J. Pract. Res.58, 129–147. doi: 10.1037/1065-9293.58.3.129
23
GreenhalghT.JacksonC.ShawS.JanamianT. (2016). Achieving research impact through co-creation in community-based health services: literature review and case study. Milbank Q.94, 392–429. doi: 10.1111/1468-0009.12197
24
HadŽibajramovićE.AhlborgG.Grimby-EkmanA. (2019). Concurrent and lagged effects of psychosocial job stressors on symptoms of burnout. Int. Arch. Occup. Environ. Health92, 1013–1021. doi: 10.1007/s00420-019-01437-0
25
HansenC. D.AndersenJ. H. (2009). Sick at work—a risk factor for long-term sickness absence at a later date?J. Epidemiol. Community Health63, 397–402. doi: 10.1136/jech.2008.078238
26
JaafariM.AlzumanA.AliZ.TantryA.AliR. (2023). Organizational Health Behavior Index (OHBI): a tool for measuring organizational health. Sustainability15:13650. doi: 10.3390/su151813650
27
Karanika-MurrayM.BironC. (2020). The health-performance framework of presenteeism: towards understanding an adaptive behaviour. Hum. Relat.73, 242–261. doi: 10.1177/0018726719827081
28
KatzA. S.PronkN. P.McLellanD.DennerleinJ.KatzJ. N. (2019). Perceived workplace health and safety climates: associations with worker outcomes and productivity. Am. J. Prev. Med.57, 487–494. doi: 10.1016/j.amepre.2019.05.013
29
KniesE.BoselieP.Gould-WilliamsJ.VandenabeeleW. (2024). Strategic human resource management and public sector performance: context matters. Int. J. Hum. Resour. Manag.35, 2432–2444. doi: 10.1080/09585192.2017.1407088
30
LarssonR.ÅkerlindI.SandmarkH. (2016). Managing workplace health promotion in municipal organizations: the perspective of senior managers. Work53, 485–498. doi: 10.3233/WOR-152177
31
LidwallU.BillS.PalmerE.Olsson BohlinC. (2018). Mental disorder sick leave in Sweden: a population study. Work59, 259–272. doi: 10.3233/WOR-172672
32
Lohela KarlssonM.BergströmG.BjörklundC.HagbergJ.JensenI. (2013). Measuring production loss due to health and work environment problems: construct validity and implications. J. Occup. Environ. Med.55, 1475–1483. doi: 10.1097/JOM.0000000000000005
33
Lohela KarlssonM.BuschH.AboagyeE.JensenI. (2015b). Validation of a measure of health-related production loss: construct validity and responsiveness - a cohort study. BMC Public Health15:1148. doi: 10.1186/s12889-015-2449-z
34
Lohela KarlssonM.HagbergJ.BergströmG. (2015a). Production loss among employees perceiving work environment problems. Int. Arch. Occup. Environ. Health88, 769–777. doi: 10.1007/s00420-014-1003-0
35
LuiJ. N. M.AndresE. B.JohnstonJ. M. (2018). Presenteeism exposures and outcomes amongst hospital doctors and nurses: a systematic review. BMC Health Serv. Res.18:985. doi: 10.1186/s12913-018-3789-z
36
MacintoshR.MacleanD.BurnsH. (2007). Health in organization: towards a process-based view*. J. Manag. Stud.44, 206–221. doi: 10.1111/j.1467-6486.2007.00685.x
37
McLeanW. C. (2019). Investigating healthy organizations: development and testing of a public organization wellness quotient (WQ). Boca Raton, FL: Florida Atlantic University.
38
MeyerM. (2018). The evolution and challenges of the concept of organizational virtuousness in positive organizational scholarship. J. Bus. Ethics153, 245–264. doi: 10.1007/s10551-016-3388-z
39
NielsenK.AbildgaardJ. S. (2013). Organizational interventions: a research-based framework for the evaluation of both process and effects. Work Stress27, 278–297. doi: 10.1080/02678373.2013.812358
40
ProperK. I.van OostromS. H. (2019). The effectiveness of workplace health promotion interventions on physical and mental health outcomes – a systematic review of reviews. Scand. J. Work Environ. Health45, 546–559. doi: 10.5271/sjweh.3833
41
RayaR. P.PanneerselvamS. (2013). The healthy organization construct: a review and research agenda. Indian J. Occup. Environ. Med.17, 89–93. doi: 10.4103/0019-5278.130835
42
SchulteP. A.SauterS. L.PandalaiS. P.TiesmanH. M.ChosewoodL. C.SchulteCunninghamT. R.et al. (2024). An urgent call to address work-related psychosocial hazards and improve worker well-being. Am. J. Ind. Med.67, 499–514. doi: 10.1002/ajim.23583
43
ShainM.KramerD. M. (2004). Health promotion in the workplace: framing the concept; reviewing the evidence. Occup. Environ. Med.61, 643–648. doi: 10.1136/oem.2004.013193
44
SkagenK.CollinsA. M. (2016). The consequences of sickness presenteeism on health and wellbeing over time: A systematic review. Soc. Sci. Med.161, 169–177. doi: 10.1016/j.socscimed.2016.06.005
45
StöllmanÅ.StoetzerU.SvartengrenM.MolinF. (2025). Organizational factors behind low sickness absence in Swedish municipalities—An explorative qualitative study. Front. Public Health13:1519981. doi: 10.3389/fpubh.2025.1519981
46
Swedish Work Environment Authorithy (SWEA) (2023) AFS 2023:2. Planning and Organization of Work Environment Management. Stockholm.
47
TeohK.Dhensa-KahlonR.ChristenseM.FrostF.HattonE.NielsenK. (2023). Organisational Wellbeing Interventions: Case Studies from the NHS.Technical Report. Birkbeck: University of London.
48
TongA.SainsburyP.CraigJ. (2007). Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int. J. Qual. Health Care19, 349–357. doi: 10.1093/intqhc/mzm042
49
von Thiele SchwarzU.SørensenO. H.TafvelinS.RoczniewskaM. (2024). Complexity embraced: a new perspective on the evaluation of organisational interventions. Work Stress, 38:373–379. doi: 10.1080/02678373.2024.2349000
50
WHO (2022). Health and Care Work Force in Europe: Time to Act.Bucharest: World Health Organisation.
51
WillisG. B. (2004). Cognitive Interviewing: A Tool for Improving Questionnaire Design.
52
XenidisY.TheocharousK. (2014). Organizational health: definition and assessment. Proc. Eng.85, 562–570. doi: 10.1016/j.proeng.2014.10.584
Summary
Keywords
health promotion, organizational health, productivity loss, public sector, work environment
Citation
Forsell E, Akerstrom M, Tafvelin S, Tornevi A and Wahlström J (2026) Organizational health in public-sector workplaces: a mixed-method study. Front. Organ. Psychol. 4:1817625. doi: 10.3389/forgp.2026.1817625
Received
25 February 2026
Revised
28 May 2026
Accepted
10 June 2026
Published
30 June 2026
Volume
4 - 2026
Edited by
Gabriele Giorgi, European University of Rome, Italy
Reviewed by
Philipos Petros Gile, Erasmus University Rotterdam, Netherlands
Faezah Othman, Universiti Teknologi MARA—Kampus Bandaraya Melaka, Malaysia
Sally Gutierez, University of Science Malaysia (USM), Malaysia
Updates
Copyright
© 2026 Forsell, Akerstrom, Tafvelin, Tornevi and Wahlström.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Elin Forsell, elin.forsell@umu.se
ORCID: Elin Forsell orcid.org/0009-0005-6395-5036; Magnus Akerstrom orcid.org/0000-0002-8469-6193; Susanne Tafvelin orcid.org/0000-0003-4263-8080; Andreas Tornevi orcid.org/0000-0001-8608-0168; Jens Wahlström orcid.org/0000-0003-0696-7506
Disclaimer
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.