Employers’ views of the “Healthy Hub Roadshow”: a workplace HIV testing intervention in England*

ABSTRACT We explored employer uptake and perceptions of workplace human immunodeficiency virus (HIV) testing delivered to employees as part of Healthy Hub Roadshow, a multi-component general health check. Intervention included health checks with tailored advice delivered to 776 employees at 20 events hosted by 11 different workplaces (29 approached, 38% employer uptake). Delivery partners were third sector organisations with significant expertise in HIV testing and support. Health checks included optional HIV test (using 4th generation Insti finger prick rapid tests), Body Mass Index (BMI), blood glucose, blood pressure, and cholesterol. Mixed-methods evaluation included post-event online survey and qualitative interviews with participating employers. Declining employers were invited to complete an online feedback survey. Workplace HIV testing was positively received by all participating organisations, although 78% (14/18) of declining organisations did not provide their reasons for non-participation. Factors of importance to employers included the perceived trustworthiness of delivery partners, being able to provide engaging opportunities for employee health, offering HIV testing as part of a wider health check, and having visible top-level managerial support. Concerns about hosting the events were rare and related to having limited budgets for future events, and the potential loss of productivity related to attendance during work time. Employers indicated that they would not actively seek out workplace HIV testing as part of health promotion efforts, but they were highly receptive to its inclusion in workplace health and wellbeing provision by credible external delivery partners. In conclusion, workplaces are an untapped arena for HIV awareness raising and testing in the UK. Employers should be encouraged and supported to offer opt-in HIV testing as part of a wider workplace health and wellbeing provision for employees.


Introduction
Human immunodeficiency virus (HIV) testing rates are low in the UK (Gourlay et al., 2017) and an estimated 17% of people living with HIV are unaware of their diagnosis (Skingsley et al., 2015 ). We evaluated the delivery of the Healthy Hub Roadshow, a multi-component general health check designed to increase access to HIV testing in line with UK guidance (NICE, 2016;Nash, Furegato, Gill, Connor, and Contributors, 2017 ) and delivered to 776 employees at 20 events hosted by 11 different organisations. Delivery partners were third sector organisations with significant expertise in HIV testing and support. Optional checks included HIV tests (using 4th generation Insti finger prick rapid tests), offered alongside Body Mass Index (BMI), blood glucose, blood pressure and cholesterol tests together with tailored health advice and optional post-event text messaging for HIV and general health promotion. Employee engagement and perceptions are reported elsewhere (Evans, Hussain, & Blake, 2017). In this paper, we report: [1] the level of employer engagement with workplace HIV testing through opt-in general health check events at the Healthy Hub Roadshow; [2] the reasons why employers chose to host an event or declined to participate; [3] perceptions of employers towards workplace health checks more generally, and specifically HIV testing in the workplace.

Methods
Ethical approval was obtained from the local institutional review board (Ref: LT12042016). We conducted online surveys (with participating and non-participating organisations) and post-event interviews (with participating employers). Twenty-nine organisations, employing high numbers of agency, mobile and migrant workers, were invited to host a health check event between June-September 2016. Fourteen companies did not respond, four agreed to take part then withdrew. Eleven participating organisations (38%; 4 medium, 4 large) hosted 20 events and represented the following sectors: leisure (n = 1), manufacturing (n = 2), distribution/retail (n = 4), hospital (n = 1), local authority (n = 1), food production (n = 1), and food industry (n = 1). Organisations were classified by size according to their number of employees: micro (0-9 employees); small (10-49 employees); medium (50-249 employees); large (>249 employees). Data were collected from one key representative of each workplace including those that declined as well as those agreeing to participate. Representatives were senior managers involved in decision-making for employee welfare. All declining organisations (n = 18) were sent an e-mail containing a link to a brief, five-item online survey. Items included: company size; whether they had wellbeing as part of their organisational policy; whether they had wellbeing as part of their employee provision; which health and wellbeing services they currently offered, if any; and reasons for declining Healthy Hub Roadshow. Reminder emails were sent to non-responders up to three times at approximately two-week intervals. For participating organisations, key representatives were contacted via email containing a link to a 14-item online questionnaire developed by the study team (Appendix 1) and were invited to participate in a post-event interview (Appendix 2) either faceto-face on the day of the event, or by telephone as soon as possible afterwards.
Online surveys were hosted on Bristol Online Survey (BOS; https://www.onlinesurveys.ac.uk). Questionnaire data were analysed using SPSS PASW Version 22.0. Interviews were audio recorded with consent, transcribed verbatim and analysed thematically (Braun & Clarke, 2006) using NVIVO.

Declining organisations
Of 18 declining organisations, five (1 large, 2 small, 2 medium) provided reasons including: lack of space to host the event (n = 1); already offering a wellbeing programme (n = 1, large); not the right time of the year (n = 1), or management opinion that HIV testing was an inappropriate service to offer their employees (n = 2). None of the responding organisations offered HIV education or HIV testing to employees.

Online evaluation
Of 11 organisations that participated in the Healthy Hub Roadshow (38% of those approached), 10 completed the online evaluation questionnaire (2 medium, 8 large organisations). None of these organisations currently offered opt-in HIV testing. Two public sector organisations offered HIV education to employees (1 Public Hospital, 1 Local Government). All 10 responders deemed it appropriate to include opt-in HIV testing within a general health check. Of responders, 100% reported that they found the events useful, informative and appropriate in terms of content, activities and focus. Nine companies planned to offer more health and wellbeing services to their employees in the future; none of these plans included HIV education and/or HIV testing for employees.

Interview evaluation
Of 11 organisations that participated in the Healthy Hub Roadshow, six company representatives (CRs) agreed to a post-event interview; conducted by telephone (n = 4) and face-to-face (n = 2). Two key themes were generated.
[I] organisational perceptions of workplace health checks All interviewees perceived the concept of opt-in workplace HIV testing favourably. However, they commonly raised concerns relating to lack of knowledge around HIV testing, and employer responsibilities if workers declared themselves HIV positive.
The "trustworthiness" and "credibility" of the organisations delivering health checks influenced decisions to take part. Top-level support from senior management and "workplace health champions" was viewed as crucial for the successful engagement of employees, and to enhance the perception of "permission" and "acceptability" (CR2, Retail) for attendance among the wider workforce. Budgets for employee health and wellbeing were reported to be limited; free services were more attractive to employers and allowed them to provide "more comprehensive health checks" (CR2, Retail) than might otherwise have been available.
The events were perceived as a mechanism for the organisation to increase opportunities for their employees to access health services: "bringing the doctor to them rather than they going to the doctor" (CR3, Food Industry). One organisation expressed a minor concern regarding the "loss of production time" for employees attending health checks during the working day (CR1, Manufacturing). Others described opportunities for employees to undertake tests at work (over and above their usual break allowances) as less disruptive to organisations than employees individually taking time away from work to source similar tests.
[II] organisational perceptions of workplace HIV testing There was a general consensus that employers would not normally seek out HIV testing for inclusion in a health check: "It wouldn't be high enough on our agenda" (CR1, Manufacturing), but that they would be receptive to an offer from an external organisation: " … if somebody came to us … then yes we would be interested" (CR1, Manufacturing).
Decisions to host an event were positively influenced by the offer of a wider package of tests, rather than HIV testing in isolation: "we obviously sold to them as an event on health check and then the option of sexual awareness and HIV testing available to people who wish to do it" (CR3, Food Industry). This was perceived as a mechanism to reduce anxiety around HIV testing, and "normalise" HIV testing as per national guidance (Wise, 2008) by offering it alongside other optional health tests more routinely offered at work "I would say people saw it as an opportunity to get it [HIV test] done at the time" (CR6, Food Production).
The notion of offering HIV testing as a stand-alone health test was perceived less positively: "If they just thought it was HIV testing event, I don't know whether we would have same amount of people that come" (CR3, Food Industry).

Discussion
To our knowledge, this is the first study to report the perceptions of UK employers towards workplace HIV testing embedded within an opt-in general health check.
None of the employers provided opt-in HIV testing to their employees at the outset, and HIV awareness was rarely included in workplace health promotion activities. Perceptions of employers towards opt-in HIV testing within a general health check were overwhelmingly positive. Factors of importance to employers included the perceived trustworthiness of delivery partners, being able to provide engaging opportunities for employee health, offering HIV testing as part of a wider health check (rather than as an isolated testing or within sexual health support), and having visible top-level managerial support. Employers indicated that they would not actively seek out workplace HIV testing as part of health promotion efforts, but they were highly receptive to its inclusion in workplace health and wellbeing provision by credible external delivery partners.
Concerns about hosting the events were rare and related to having limited budgets for future events, with only one employer concerned about loss of employee productivity related to attendance for testing during work time. Employers identified a need for more support and guidance around HIV testing at work. This concurs with the findings of a recent survey of 98 employers (Blake, Banerjee, & Evans, 2018).

Challenges and limitations
Initial identification of the key individuals responsible for health and wellbeing provision within an organisation was challenging. The inclusion of HIV testing may have been a deterrent for some employers which would not be unexpected given the high levels of stigma surrounding HIV (Howarth et al., 2017;Walker, 2017) and HIV testing (Earnshaw, Smith, Chaudoir, Lee, & Copenhaver, 2012).

Conclusion
Workplaces are an untapped arena for HIV awareness raising and testing in the UK. Employers should be encouraged to promote health and wellbeing to their workforce, and to offer HIV testing as part of an opt-in general health check. Evidence-based guidance for employers on workplace HIV testing could help to raise awareness about HIV, and support employees in making decisions about workplace health provisions. 12. Please provide any further comments on the usefulness, acceptability and appropriateness of these events: 13. Please give us your suggestions on how the events could be improved: 14. Please provide any further comments on how your company may address HIV in the workplace in future: