Closing the Loop: Integrating Workplace Health into Primary Prevention of NCDs in India – Lessons from Tamil Nadu

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Sowmiya, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7804717/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Non-communicable diseases (NCDs) continue to represent a growing epidemic, accounting for nearly two-thirds of death and adding a significant economic burden through lost productivity. Tamil Nadu, one of India’s most industrialized states, bears a particularly substantial burden, with 63% of its disease burden attributed to NCDs. Workplaces, where millions of adults spend the majority of their daytime, present a high-risk environment while offering strategic opportunities for prevention. This study aimed to explore how organized sectors can function as platforms for NCD screening and care. Methods Utilizing qualitative methodologies, we conducted 201 in-depth interviews with health officials, industry managers, workplace health providers, and employee representatives across a variety of factories and institutions. Each interview was accompanied by structured observation, daily debriefings, iterative transcription checks, and independent coding by two researchers to ensure methodological rigor. The team developed themes through consensus, triangulating perspectives from both industry and health systems. Results The findings revealed a contradictory trend with systemic enablers like effective coordination of the district health department and Employees’ State Insurance, resource availability and proactive social responsibility engagement enhanced reliability and reinforced continuity of care. Conversely, barriers included Human Resource shortages, logistical delays, rigid shift schedules, and stigma surrounding NCDs which hindered participation. Industries promoting employee wellness through their leadership, functional occupational health units, and flexible scheduling achieved majority of worker participation, whereas others faced challenges. Conclusions The study reiterates that successful workplace NCD screening is possible because of the program but with deeper trust, leadership, and employee-centered design it will achieve the intended outcomes. Integrating these elements into Tamil Nadu’s industrial landscape can transform workplaces into sustainable nodes of preventive health. NCD Screening Organized Sector Health systems Figures Figure 1 Figure 2 Figure 3 Background Non-Communicable Diseases (NCDs) in the post-pandemic scenario require an effort that includes of tracking of people to prevent and/or postpone NCDs [ 1 ]. Toward that effort, it is imperative that health systems are inclusive in outreach, to ensure comprehensive coverage and to leave no resident behind. Present scenarios reveal that NCDs are responsible for 66% of total mortality in India [ 2 ]. It is a concern that almost 1 out of 4 men and close to 1 out of 5 women over 15 years old report having hypertension, while fewer men and women report diabetes (13.1% and 11.3%, respectively). The World Economic Forum report that NCDs will cost India $ 3.55 trillion in lost output by 2030 [ 3 ]. Measured in Disability-Adjusted Life Years (DALYs) NCDs in Tamil nadu is reported to be 63%, with close to 1 out of 4 men and women over 15 years old reporting hypertension and diabetes (NFHS-5, Tamil Nadu) [ 4 ]. With the goal to stem the rise, the Government of Tamil Nadu (GoTN) has operationalized over 8,000 Health and Wellness Centres which provides more than 95% of the population with access to screening within a 5 km radius [ 5 ]. Furthermore, the GoTN has consistently innovated to provide initiatives such as Mobile NCD Camps and digital tracking via Makkalai Thedi Maruthuvam. Innovation also includes convergence within the health system, including the Employees’ State Insurance (ESI) and the Directorate of Industrial Safety and Health (DISH), to help bridge gaps in screening access for the workforce. Tamil Nadu is one India’s foremost industrialized state providing significant contribution to the nation’s manufacturing and services sectors. It is within the first three ranks in terms of number of factories and industrial workers, with close to 40,000 registered factories employing more than 2.3 million workers in the organized manufacturing sector alone as per the Annual Survey of Industries [ 6 ]. Furthermore, Tamil Nadu is also crucial hub for Information Technology and Business Process Management sectors with over 600,000 professionals across major cities of Tamil Nadu [ 7 ]. Together both these sectors account for a substantial proportion of working-age adult population – many of whom are increasingly at risk for NCDs due to their lifestyles both at work and at home. The time is now to integrate NCD prevention into organized employment sectors particularly in low-and middle-income countries (LMICs) where the burden of both infectious and rising chronic conditions compromises the health systems. Data reveals that over 77% of all NCD deaths occur in LMICs [ 8 ]. Workplace and occupational settings are strategic opportunities as they bring together large populations of working- age adults exposed to common risk factors like sedentary work, irregular shifts, occupational stress and dietary changes [ 9 , 10 ]. Studies from different countries have demonstrated positive outcomes such as enhanced productivity, decreased absenteeism while lowering out-of-pocket health expenses for workers as a result of early detection of hypertension and diabetes [ 11 – 13 ]. In India, non-communicable diseases are responsible for two-thirds of all fatalities, and the economic impact of reduced productivity is expected to surpass $ 3.5 trillion by 2030 [ 3 ]. Therefore, involving the organized sector is essential for both health and economic reasons. In order to increase the effectiveness of any work place health promotion initiatives, organizations and people must endeavor to eliminate obstacles and enhance facilitators [ 14 ]. This implementation research by examining “abling” ecosystems—both enabling and disabling screening ecosystem related to hypertension and diabetes furthered the organized sector as a strategic setting for outreach, with significant potential to bridge gaps in NCD prevention and control. Methods With the intent of understanding organized sector landscape to validate the organized sector as a setting for NCD screening, both enabling and disabling environments of the stakeholders were undertaken. The stakeholders in our study included - Health ecosystem and the Industries / Factories. The tools for the study included Checklist for in-depth interviews for healthcare providers and industry stakeholders. Figure 1 shows the districts that are part of the sample frame and Table 1 provides the industries that were sampled. Table 1 Industries that were sampled Company Name Ashwini Fisheries Ltd. GHCL Limited Perambalur Sugar Mills Bimetal GHCL Mills Rockman Industries Carborundum Universal Industry Hatsun Sakthi Auto Components Color Jersey Indian Oil Schwing Stetter India Pvt Ltd D.C.W. Limited Indian Petroleum Sivaraj Spinning Mills Pvt Ltd. Dalmia Cements (Bharath) Ltd Kone Elevator India Pvt Ltd. Sri Shanmugavel Mills Pvt Ltd, Unit II Dhanalakshmi Sreenivasan Sugars (P) Ltd KPR Garments & Apparels Ltd Vedha Spinning Mills Pvt Ltd, Unit-1 Fenner India Limited KPR Mill Limited Lotus Footwear Enterprises Ltd. First Step Baby Wear Kusauto India Pvt Ltd Madura Coats Pvt Limited Manna Foods Pvt Ltd MRF Tyres Nippon Paint India Pvt Ltd Qualitative Methodology A qualitative design was employed to explore the enablers and barriers in workplace-based NCD screening in Tamil Nadu. In-depth interviews were conducted with multiple stakeholders across the health system and industry sectors. A total of 201 interviews were completed. Each interview team comprised one interviewer and one observer to ensure both conversational flow and systematic documentation. The methodological framework was given in Fig. 2. Data Management and Transcription Interviews were audio-recorded, and field notes were documented simultaneously. At the conclusion of each day, the interview team and project staff (n = 3) debriefed to discuss emerging insights and contextual nuances. The audio recordings were transcribed verbatim. Each transcript underwent two reviews by the project lead and data manager to ensure accuracy and completeness prior to inclusion in the analysis dataset. Coding and Analysis Thematic analysis was conducted as per Braun and Clarke’s six-step framework [ 15 ]. Two researchers independently performed the coding process. Discrepancies in code assignment were iteratively discussed until consensus was achieved. The finalized codes were subsequently organized into categories and developed into themes through team discussions. The project leads actively engaged in the theme development process to ensure alignment with programmatic contexts. Atlas.ti software was employed to manage data, codes, and analytic memos. These themes were generated for both enabling and disabling behaviors. The number of people interviewed is listed in table 2 Table 2 Number of People interviewed Category Stakeholder Role Number Interviewed Industry Stakeholders Human Resource Manager 61 Industry Stakeholders Employee Welfare Officer 11 Industry Stakeholders Workplace Safety Officer 13 Industry Stakeholders Healthcare Providers from the Industry 35 Industry Stakeholders Representative of Employee Union (if present) 1 Government Health Providers Joint Director – NCD – DPH (State level) 1 Government Health Providers District NCD Program Coordinator 4 Government Health Providers District Industry Safety Officer 22 Government Health Providers Block Medical Officer 11 Government Health Providers PHC Medical Officer 22 Government Health Providers PHC Staff Nurse (NCD) 20 Ethical Clearance – Ethical clearance was obtained from the Institutional Ethics committee, SRM Institute of Science and Technology (Reference Number: 0059/IEC/2024). Study was approved by DPH SAC committee (DPHPM/DPHSAC/2024/075) and permission was obtained from the Directorate of Public Health and Preventive Medicine, Tamil Nadu. Written informed consent was obtained from all participants before data collection. Confidentiality and anonymity of participant data were strictly maintained throughout the study, adhering to ethical research principles. Results Results of the qualitative analysis revealed broader themes and the Fig. 3 shows the final thematic map of enablers and barriers. Theme 1: Systemic Enablers Workplace screenings were more successful when supported by well-defined institutional mechanisms such as coordination between Deputy Director of Health Services – District level (DDHS-D) and ESI, timely resource provision, and proactive CSR engagement. Inter-Agency Coordination At the district level, the Deputy Directors of Health Services (DDHS) played a crucial role in coordinating the health teams with industries while ensuring that ESI facilities were prepared to handle referrals. At the state level, authorizations and oversight from the Directorate of Public Health (DPH), National Health Mission (NHM), and Directorate of Industrial Safety and Health (DISH) provided the foundations for the industries to engage. Effective collaboration between the Deputy Director of Health Services – District level (DDHS-D) and the ESI network ensured seamless referral pathways helped reduce the duplication of efforts and enabled standardized follow-up care. Clear roles and responsibilities across agencies brought accountability and minimized administrative delays. One of our interviewee’s words about coordination, “Here, the PHC and ESI are working in coordination. The PHC is responsible for diagnosis, while the ESI takes care of follow-up.” Block Medical Officer (BMO) Thadikombu, Dindugal Timely Resource Provision Availability of vital equipment (e.g., hemoglobin analyzers, glucose testing kits), skilled personnel, and logistical support was crucial. This prevented disruptions in screening schedules, which in turn-built credibility and trust among workers, a crucial component to ensure continuity of care. From the Health systems, “ On the government side, we face no barriers; everything is clarified promptly. Even when staff members are on leave, additional personnel are provided at the PHC, so manpower is not an issue. Financially, funds are never a problem, and we never lack medicines or reagents for blood tests, even for a day.” BMO Thoothukudi Corporate Social Responsibility (CSR) Engagement Proactive CSR initiatives provided financial and logistical backing, filling critical resource gaps that public systems could not immediately address. CSR-supported wellness activities (e.g., awareness sessions, nutrition supplementation, follow-up camps) amplified the reach and sustainability of screening programs. BMO of Samyanallur noted, “Overall, the industry is engaged with us through their CSR initiatives, providing comprehensive support such as supplying fogging machines and renovating the PHC. This strong collaboration has facilitated our access to the site, making it considerably easier to carry out our activities.” Theme 2: Industry Engagement & Infrastructure Industries branded by proactive management support and the presence of functional Occupational Health Units (OHUs), robust infrastructure and flexibility in scheduling reported more efficient screening processes. Leadership & Management Support Management commitment was a decisive factor in successful implementation. Industries where senior leadership endorsed screenings, allocated time, and motivated workers created an environment where participation was higher. Supportive management also enabled smoother coordination with external health teams (DDHS-D, ESI, NGOs), reducing friction during planning and execution. In the experience of the Samyanallur, BMO, “ "Inside (the Industry), the hospitality was very good, and the ambience was pleasant. The administrative people present there were very welcoming and had a very good rapport with us." Occupational Health Units (OHUs) Industries with functional OHUs provided immediate follow-up, continuity of care, and better data management of workers’ health records. OHUs also acted as focal points for liaising with district health officials and CSR partners, ensuring institutional memory and sustainability of screening activities. Provision of Infrastructure & Space Availability of dedicated, hygienic spaces for screening (such as training halls, dispensaries, or canteens temporarily repurposed) was a major facilitator. Adequate infrastructure created a sense of acceptability and order, enhancing worker trust and reducing resistance. At the Hatsun factory, the nurse attributed the success of the program to the provision of infrastructure, “The main reason is proactive planning, supported by facilitation in administrative management, employee cooperation, excellent infrastructure, and funding.” Scheduling Flexibility Industries that flexed work shifts or staggered screening schedules avoided disruptions to production while ensuring that maximum workers participated. Flexibility in timing also supported female workers and shift-based employees, reducing absenteeism from health screenings. The manager of the MRF in his interview reported. “We are able to ensure that all of the workers get screened as we follow a stringent rotation of staff and it is mandatory for the workers to get screened.” Theme 3: Barriers in Logistics and Human Resources Recurrent issues included lack of manpower, inadequate supply of testing kits, and challenges in mobilizing contractual or migrant workers. Human Resource Constraints An insistent challenge encountered was the inadequacy of manpower. Health workers frequently had to manage large groups with minimal staff support, resulting in expedited processes or incomplete coverage. Contractual staff were not consistently available, and frequent rotations led to a lack of continuity in follow-up care. The mobilization of migrant or contractual workers was particularly challenging due to language barriers, irregular shifts, and concerns about wage loss. Supply-Side Gaps Screenings were frequently hampered by unavailability of essential materials such as glucometers, strips, and hemoglobin testing kits. Limited stock not only slowed down the process but also undermined worker trust which is crucial for consistent engagement. As one health worker noted, “Medicines and testing supplies are not always available in sufficient quantities during screening camps, leading to interruptions in services.” Operational Challenges Lack of transport facilities and delays in moving screening teams across multiple worksites created scheduling conflicts. Absence of backup equipment (e.g., spare batteries, additional test kits) further prolonged screening times. In industries with large worker populations, logistical bottlenecks led to re-visiting to ensure completion of screening. The NCD coordinator from Ariyalur remarked, “ sites closer to the town is easier for us to provide services, when the sites are far away, we have to depend on other division for transport. This delays and dilutes our efforts .” Theme 4: Scheduling and Shift Conflicts Screening after or before shifts often led to poor turnout. Workers on night shifts were especially underrepresented. One employer admitted, “We couldn’t interrupt production hours.” Pre- and Post-Shift Fatigue Employees required to undergo health screenings prior to the commencement of their shifts frequently prioritized timeliness at work over these health assessments due to time constraints. Conversely, post-shift screenings often coincided with fatigue and a pressing desire to return home, a situation particularly prevalent among women with domestic responsibilities. Perambalur BMO shared his challenges, in his words, “Coordinating logistics between industries and health teams is difficult. Factories prioritize work schedules, making smooth execution of screenings harder” Night-Shift Worker Exclusion Individuals working night shifts are frequently excluded from consideration. Their disrupted sleep patterns, coupled with schedules that cater exclusively to daytime activities, diminish their likelihood of inclusion. Consequently, this results in the systematic underrepresentation of a vulnerable demographic that may face unique health risks due to disrupted circadian rhythms and extended working hours. The size of the factory is a crucial indicator as recounted by the BMO Manapparai who reported “In some industries, they work in three shifts. Because of that, there are some difficulties. For example, if someone has worked the night shift, we can’t call them again in the morning for screening. So, for such people, it will take us around 2–3 days to complete the screening.” Employer Reluctance to Interrupt Production Employers often prioritized uninterrupted production over health screenings, especially in export-driven industries with strict timelines. As one employer admitted: “We couldn’t interrupt production hours.” This sentiment highlighted the structural conflict between health promotion and economic output. The BMO from an industry in Krishnagiri in his words, “Even if we get permission and set up a camp inside, people don’t always come. It feels like we are just sitting idle. From the industry’s side, there isn’t much cooperation—if we ask them, they say that production is their top priority, so they don’t pay much attention to us.” Gendered Implications For female workers, inflexible scheduling exacerbated the difficulties of reconciling factory employment with domestic responsibilities. The lack of flexibility frequently resulted in reduced participation in screenings. Theme 5: Administrative Gaps Communication delays between DISH, employers, and health departments led to last-minute approvals and confusion as this is a pilot effort further compounded by the absence of well-defined protocols. Communication Breakdowns Insufficient coordination in communication among the Directorate of Industrial Safety and Health (DISH), employers, and health departments frequently resulted in minimal delays in the execution of responsibilities. The dissemination of information was fragmented; industries were occasionally informed at short notice about the screening schedule, while health teams received incomplete worker data or insufficient logistical details. A health Inspector reported challenges with regards to communication, “Frequent communication issues arise between the health department and industries. Misunderstandings or lack of updates delay smooth organization of camps.” Last-Minute Approvals Permissions from DISH or local authorities were often granted at the latest possible moment due to bureaucratic processes, thereby affording industries minimal time to establish the necessary infrastructure or adjust production schedules. This reactive approach disrupted the mobilization of workers and diminished participation, particularly in larger units that require advance notification. The BMO of Krishnagiri shared the challenges in seeking approvals since much is done at the last minute, "First of all, getting permission in these industries itself is very difficult. If we ask, we don’t always get an immediate response. Only after talking to several people, we are able to finally get permission." Absence of Standard Protocols In the absence of explicit operational guidelines as this effort is a pilot effort, each district and industry developed its own methodologies, resulting in considerable variability in the quality and scope of screenings. While some industries offered substantial internal support, others provided minimal assistance due to ambiguous expectations. Many of the stakeholders felt that there is a need for a standard protocol, in one of the stakeholders words, “There is no uniform protocol for conducting screenings. Each camp is organized differently, depending on management's willingness, reducing consistency and efficiency.” Accountability Gaps When screenings did not achieve the expected coverage, it was often unclear whether the responsibility lay with industries, DISH, or health departments. This lack of accountability diluted ownership once resolved through established protocol will help in sustaining the momentum. One of the BMO’s who commented, “Responsibility for coordinating and ensuring worker participation is often unclear. Industries and health staff shift accountability, weakening follow-up and effectiveness.” Theme 6: Behavioral and Awareness Challenges Stigma around diabetes or hypertension, poor understanding of follow-up needs, and language barriers impeded health-seeking behavior among workers. Stigma and Fear Numerous employees perceive conditions such as diabetes and hypertension as indicative of weakness or diminished employability. The fear of being labelled as "unfit" deters some individuals from participating in health screenings. This stigma is particularly pronounced among younger employees who are worried about their job security. In his in-depth interview, the BMO of Trichy added, “There is still a social stigma lingering in rural areas, as I have observed. People think that if someone has diabetes or high blood pressure, it shouldn’t be known to the neighbors.” Limited Awareness of Follow-Up Needs While initial health screenings were generally accepted, there was a limited understanding of the necessity for subsequent tests, lifestyle modifications, or consistent medication use. Some workers perceived a single screening as an adequate assessment of their health status. Misconceptions, such as the belief that continuous medication use leads to dependency, further diminished adherence to recommended health practices. About the lack of awareness, the BMO Manapparai added, "What I feel is, when a patient is told by a WHV (Women Health Volunteer) that their blood pressure is high or their sugar level is high, they don’t take it seriously. Hardly around 30% of them actually turn up for follow-up, and even when asked to go to the hospital, they don’t treat it as something serious enough to go back." Language and Communication Barriers Migrant and contractual workers from diverse linguistic backgrounds, encounter challenges in comprehending health-related advice. The materials are seldom translated, and health discussions are occasionally presented using technical terminology, leading to confusion. Consequently, informed consent and understanding of risk factors are diminished within these populations. An unnamed health worker added, about poor communication, “In some factories, communication between health staff and workers is limited due to language differences or lack of clarity, reducing understanding and participation”. Low Health-Seeking Behavior Workers prioritized daily wages and production commitments over health appointments. Preventive health was often perceived as secondary, especially when illness was not immediately disabling. This cultural orientation towards “curative care only when sick” reduced the uptake of long-term preventive strategies. In general, there is apathy that is revealed by a BMO, "Barriers are there in everything. My first issue is, when we do a blood test and tell them they have diabetes, they don’t believe it. If we say they have high blood pressure, they get very anxious but still don’t believe it. Even if we take an ECG and show them changes in the heart, they don’t accept it when we say this is the reason. Because of this, they neither take tablets nor come for treatment, so doing follow-up becomes very difficult." Discussion The findings of this study highlight the complex interplay of systemic enablers, industry engagement, and human factors in shaping the effectiveness of workplace NCD screening programs. While the overall initiative demonstrated strong potential, the results suggest that success depended less on the mere presence of a program and more on the quality of coordination, management commitment, and responsiveness to worker realities. Systemic Enablers: Coordination and Resources: At the systemic level, inter-agency coordination emerged as a critical enabler. The Deputy Directors of Health Services (DDHS) played a pivotal role in facilitating seamless linkages between district health teams, industries, and the ESI network. This finding is substantiated by research from Indonesia where strong relationships between local health authorities and communities strengthened continuity of care and built trust in preventive programs [ 16 ]. Establishing clearly defined roles and responsibilities with established referral pathways minimized duplication of efforts while promoting accountability. Timely provision of equipment and trained personnel helped in seamless process and built worker confidence. Corporate Social Responsibility (CSR) initiatives also addressed critical gaps, supporting Somani’s (2022) observation that private sector contributions to infrastructure and wellness activities enhance the reach and sustainability of health programs [ 17 , 18 ]. As one health officer noted, “When CSR was aligned with health goals, things moved faster,” highlighting the catalytic effect of organizational goodwill. Building trust among stakeholders is key to success of programs such as this, which is reliant on seamless coordination, and availability of resources both human and others such as consumables. The intent of the Government of Tamil Nadu is timely and required to address the current surge in NCDs and has the potential to lay the foundation for a workplace-based wellness that can close the loop in provision of healthcare services in Tamil Nadu. Industry Engagement and Infrastructure The role of industry leadership was equally significant. Management support was not merely representational; it directly facilitated worker participation, improved coordination, and facilitated seamless process with external health teams. These findings align with global evidence indicating that leadership endorsement is a crucial enabler of workplace health interventions [ 19 , 20 ]. In instances where the management allocated time, encouraged employees, and extended necessary infrastructure, participation rates were nearly universal. For example, in a large textile unit, management's decision to adjust shifts for women workers enabled near-complete coverage, illustrating how flexibility is the key to bridge the gap between production demands and employee wellness. Occupational Health Units (OHUs) served as institutional anchors by ensuring continuity of care, maintaining data systems, and liaising with district officials and CSR partners while fostering the importance of health in respective industries. On the contrary, industries lacking OHUs or exhibiting weak management engagement faced challenges in mobilization, reflecting patterns observed in small and medium enterprises globally, where the absence of dedicated units undermines program sustainability [ 21 ]. Barriers in Logistics and Human Resources This initiative of the GoTN has few areas that needs fine-tuning. Despite the existence of supportive environments, few areas of systemic gaps are visible. The implementation was repeatedly impeded by shortages of healthcare personnel, limited availability of test kits, and logistical challenges. Health workers reported instances of screening "200 people with only one glucometer," highlighting that motivated healthcare workers alone cannot compensate for insufficient resources. These limitations decreased coverage, eroded trust, and aggravated inequities in access. This observation supports the broader literature on the under investment in workplace health [ 22 – 25 ] and emphasizes the necessity for adequate investment in human resources for health (HRH) to ensure reasonable program scaling. Scheduling and Shift Conflicts: Worker Realities Scheduling has appeared to be a pivotal factor influencing worker participation. This is due to the fact that there is conflict between promoting productivity over health promotion among the upper management. Furthermore, night-shift workers were consistently under-represented highlighting a systemic exclusion of the subgroup. System level contradictions between economics and employee health are rarely reported and documented. This is particularly true of gendered aspect of the timing that disproportionately affect women, who are caught between intensified workplace limitations and work at home leading to poor workplace screening participation. Considering that 40% of the women workforce in India is from Tamil Nadu, there needs to be exclusive protocols to ensure inclusivity of women through other modes. These findings reinforce arguments in the literature advocating for flexible scheduling as an essential element of equity in occupational health programs [ 18 ]. Administrative Gaps and Governance Weaknesses Administrative challenges further diluted the implementation process. Poor communication among the stakeholders resulted in last-minute scheduling changes and poor coordination. Not having standardized protocols forced improvisation leading to variety in quality and coverage. These gaps in governance reduced efficiency and also compromised accountability weakening the momentum. This situation aligns with global discussions on the critical importance of institutional clarity and accountability in industry-public health partnerships [ 26 ]. Behavioral and Awareness Challenges Behavioral and cultural barriers significantly inhibited the program's impact. Stigma among the communities about conditions such as diabetes and hypertension compounded by apprehension of being perceived as “unfit” driven by inadequate awareness about need for follow-up care limited worker engagement beyond the initial screening. Furthermore, most employees prioritized wage-earning over preventive care and among migrant workers language barriers and misconceptions prevailed leading to exclusion of these subgroups. As one worker expressed, "Taking medicines continuously makes you dependent." These attitudes reflect a broader cultural inclination aligning with national survey findings and underscore the necessity for tailored health education and culturally sensitive communication [27, 28]. Toward Enabling Industry Engagement Taken together, these findings point to a dual lesson. On the one hand, industries with strong management support, OHUs, infrastructure provision, and scheduling flexibility demonstrate that workplace health programs can be highly effective, equitable, and sustainable. On the other, gaps in resources, governance, and awareness highlight that without systemic commitment, well-intentioned programs falter. Building enabling environments for industry engagement therefore requires not only inter-agency coordination and CSR alignment but also a conscious effort to humanize program design — recognizing worker realities, gendered burdens, and cultural perceptions of health. Furthermore, the findings from this study can be viewed from the Consolidated Framework for Implementation Research (CFIR) which posits how intervention success depends on the interplay between the Outer, Inner settings, Individual characteristics and the implementation process itself. Systemic enablers like the inter-agency coordination and CSR engagement reflect the outer setting where external policies, resources and incentives shape program feasibility. Industry leadership and OHUs and infrastructure provision are the inner setting directing the organizational culture and management priorities influencing worker participation. Individual Characteristics include worker level barriers such as stigma, fear of being labelled unfit and poor awareness of follow-up needs, underscoring the need for culturally sensitive health communication. Finally, gaps in protocols, last-minute approvals, and fragmented communication highlight weaknesses in implementation processes, reducing program fidelity and sustainability. By framing workplace NCD screening within CFIR, this study demonstrates that success requires orientation across multiple domains—policy, organizational culture, workforce realities, and operational processes—although the existence of a program such as this is the start of improved and integrated service. Moving forward, developing a standardized protocol that delineates roles and responsibilities across the health system, coupled with enforcement by DISH and supported by sustained awareness campaigns, will be essential to institutionalizing workplace NCD screening. This study provides the health system a crucial link towards integrating NCD screening as part of Primary Prevention among the organized sector, a cohort that is difficult to reach regularly. Furthermore, findings from this study reinforce the effectiveness of workplace screening when the system works seamlessly with proactive employers. Being a pilot initiative, this effort is instrumental in accessing the organized force, which in the next 10 years is expected to grow rapidly. This outreach by the health systems will not only ensure healthy employees but also will enhance economic outcomes. With NCDs responsible for close to 2/3rds of the disease burden in Tamil Nadu. An effort such as this to routinize preventive screening at workplaces is a triple win, for health systems, employers and the employees. The outcomes of this research indicate that enablers to an effective screening program with the organized sector is possible only when there is similar level of engagement by all the stakeholders ensuring that resources are provided timely both human and consumables building trust among all stakeholders. Furthermore, industries that proactively prioritize employee wellness exhibit support at their highest level which translates into availability of infrastructure, human resources as well as employee participation [ 27 ]. Conclusions The findings indicate a twofold lesson: workplace health should be integrated into institutional frameworks and leadership priorities rather than being treated as a secondary concern to production. For Tamil Nadu, a highly industrialized state in India, this alignment could not only help reduce the increasing prevalence of hypertension and diabetes but also protect productivity and economic growth. Creating supportive environments that blend systemic coordination with industry leadership and worker-focused strategies can turn workplaces into key centres for preventing non-communicable diseases, ensuring equity, continuous care, and long-term sustainability. Tamil Nadu stands as a beacon similar to how Brazil leveraged industry-based wellness programs or how South Africa integrated workplace HIV prevention, Tamil Nadu’s model offers a transferable framework for chronic disease prevention in LMICs. Abbreviations NCD Non–Communicable Disease LMICs Low middle income countries DALYs Disability–Adjusted Life Years GoTN Government of Tamil Nadu DISH Directorate of Industrial Safety and Health ESI Employee’s State Insurance DDHS D–Deputy Director of Health Services–District level DPH Directorate of Public Health NHM National Health Mission PHC Primary Health Centre BMO Block Medical Officer CSR Corporate Social Responsibility OHU Occupational Health Units Statements and Declarations Ethics approval and consent to participate Ethical approval for the study was obtained from the SRM-IST (IEC) Institutional Ethics Committee (Reference Number: 0059/IEC/2024) and Tamil Nadu DPH Scientific Advisory Committee. Written informed consent was obtained from all participants before data collection. Confidentiality and anonymity of participant data were strictly maintained throughout the study, adhering to ethical research principles. Consent for publication Not Applicable Availability of data and materials Data are available from the corresponding author on reasonable request. Competing Interests The authors have no relevant financial or non-financial interests to disclose. Funding Operational Research Program—Tamil Nadu Health System Reform Program (TNHSRP) Coordinated by Indian Institute of Technology Madras (IITM), Chennai. Author contributions Conceptualization and methods: GV, PM and DK. Data collection and analysis: SK, BM, PM and KC Supervision: GV, PM and DK. Writing Draft: SK, BM and KC Review and editing draft manuscript: GV All 6 authors read and approved the final manuscript. Acknowledgements The authors thank S Uma, I.A.S., Former Project Director, Thiru. M Govinda Rao, I.A.S., Project Director, Operational Research Program, Tamil Nadu Health System Reform Program (TNHSRP), Ministry of Health and Family Welfare, Government of Tamil Nadu for funding this study; Shobha, Expert Advisor, RCH, TNHSRP, and V R Muraleedharan, Department of Humanities and Social Sciences, Indian Institute of Technology Madras, Chennai, for organizing regular project review meetings, providing input, and administrative support. The authors gratefully acknowledge the financial support by SRM School of Public Health, Faculty of Medicine and Health Sciences, SRMIST, Kattankulathur for bearing the defrayed costs of publishing this article References Shu J, Jin W. Prioritizing non-communicable diseases in the post-pandemic era based on a comprehensive analysis of the GBD 2019 from 1990 to 2019. Sci Rep. 2023;13:1–17. https://doi.org/10.1038/S41598-023-40595-7;SUBJMETA. Kulothungan V, Ramamoorthy T, Mohan R, Mathur P. 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Scand J Work Environ Health. 2018;44:568. https://doi.org/10.5271/SJWEH.3763. dos Reis FL, Bertoloto JCF, da Costa Rodrigues T, de Castro Cardoso Toniasso S, Baldin CP, Rodrigues JB, et al. The efficacy of interventions in the workplace promoting exercise and a healthy diet among shift workers: A systematic review. PLoS One. 2025;20:e0325071. https://doi.org/10.1371/JOURNAL.PONE.0325071. Toscano CM, Zhuo X, Imai K, Duncan BB, Polanczyk CA, Zhang P, et al. Cost-effectiveness of a national population-based screening program for type 2 diabetes: The Brazil experience. Diabetol Metab Syndr. 2015;7:1–11. https://doi.org/10.1186/S13098-015-0090-8/TABLES/5. Tarro L, Llauradó E, Ulldemolins G, Hermoso P, Solà R. Effectiveness of Workplace Interventions for Improving Absenteeism, Productivity, and Work Ability of Employees: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. 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A Global Journal of Interdisciplinary Studies. 2024;7. Somani NA. Assessing the Role of the Private Sector in Non-Communicable Disease Prevention, Management, and Control: A Systematic review. University of Waterloo; 2022. Liu L, Zhang C, Fang CC. Effects of health-promoting leadership, employee health on employee engagement: employability as moderating variable. Int J Workplace Health Manag. 2022;15:1–18. https://doi.org/10.1108/IJWHM-07-2020-0122. Tryon K, Bolnick H, Pomeranz JL, Pronk N, Yach D. Making the workplace a more effective site for prevention of noncommunicable diseases in adults. J Occup Environ Med. 2014;56:1137–44. https://doi.org/10.1097/JOM.0000000000000300. Saito J, Odawara M, Takahashi H, Fujimori M, Yaguchi-Saito A, Inoue M, et al. Barriers and facilitative factors in the implementation of workplace health promotion activities in small and medium-sized enterprises: a qualitative study. Implement Sci Commun. 2022;3:1–13. https://doi.org/10.1186/S43058-022-00268-4/TABLES/3. Rantala E, Vanhatalo S, Perez-Cueto FJA, Pihlajamäki J, Poutanen K, Karhunen L, et al. Acceptability of workplace choice architecture modification for healthy behaviours. BMC Public Health. 2023;23:2451. https://doi.org/10.1186/s12889-023-17331-x. Chau JY, Engelen L, Kolbe-Alexander T, Young S, Olsen H, Gilson N, et al. “In Initiative Overload”: Australian Perspectives on Promoting Physical Activity in the Workplace from Diverse Industries. Int J Environ Res Public Health. 2019;16:516. https://doi.org/10.3390/ijerph16030516. Weber MB, Rhodes EC, Ranjani H, Jeemon P, Ali MK, Hennink MM, et al. Adapting and scaling a proven diabetes prevention program across 11 worksites in India: the INDIA-WORKS trial. Res Sq. 2023;:rs.3.rs-3143470. https://doi.org/10.21203/RS.3.RS-3143470/V1. Sedani A, Stover D, Coyle B, Wani RJ. Assessing Workplace Health and Safety Strategies, Trends, and Barriers through a Statewide Worksite Survey. Int J Environ Res Public Health. 2019;16:2475. https://doi.org/10.3390/ijerph16142475. Collins BX, Wilkins CH. Overcoming Barriers to Health Equity in Precision Medicine Research. The American Journal of Bioethics. 2024;24:86–8. https://doi.org/10.1080/15265161.2024.2303146. Verburgh M, Verdonk P, Appelman Y, Brood-van Zanten M, Hulshof C, Nieuwenhuijsen K. Workplace Health Promotion Among Ethnically Diverse Women in Midlife With a Low Socioeconomic Position. Health Education & Behavior. 2022;49:1042–55. https://doi.org/10.1177/10901981211071030. Pham CT, Lee CB, Nguyen TLH, Lin JD, Ali S, Chu C. Integrative settings approach to workplace health promotion to address contemporary challenges for worker health in the Asia-Pacific. Glob Health Promot. 2020;27:82–90. https://doi.org/10.1177/1757975918816691. Karmegam D, Veliah G, Murugesan B, Chakkaraiappan K, Kothandaraman S, Muthuperumal P. Implementing Workplace NCD Screening as a Health Systems Initiative: Participation, Satisfaction and Short-Term Detection in Tamil Nadu [preprint]. Research Square; 2025. doi:10.21203/rs.3.rs-7642521/v1 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7804717","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":527101305,"identity":"803878dd-6749-435d-943e-8c14e107ca6f","order_by":0,"name":"Geetha Veliah","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYJACZiCWAzEOMEDJAwR0MDYDCWOI4gQStCQ2gNkJDITVy7s3H39cUHM4ff7s04kHf/5gkOO7kcB4uACPFsMzxxKbZxw7nLvhXO6GwzwJDMaSNxIYDs/Ap2VGjmEzD1ta7gYe3g2HgQ5L3ADSwoNPy/z3H5t5/qWly/fwbjj4I4GhnqAWeQkexmbeNpsEhjO8Gw4AHZZgQEiLAU+a4WzePhvDDUAth3nSJAxnnnnYgN+W9sMPPvN8k5AHOmzzxx82NvJ8x5MPf8ZrywFUvgQQMzbg0QC0Bb/0KBgFo2AUjAIgAADKclM+rtqwAwAAAABJRU5ErkJggg==","orcid":"","institution":"SRM Institute of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Geetha","middleName":"","lastName":"Veliah","suffix":""},{"id":527101306,"identity":"1d0b875a-a55d-4fde-8ec8-67fa758105ae","order_by":1,"name":"Prakash Muthuperumal","email":"","orcid":"","institution":"SRM Institute of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Prakash","middleName":"","lastName":"Muthuperumal","suffix":""},{"id":527101307,"identity":"ffdcc3e8-38ac-4c8f-bcf6-fc260ee061d3","order_by":2,"name":"Dhivya Karmegam","email":"","orcid":"","institution":"SRM Institute of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Dhivya","middleName":"","lastName":"Karmegam","suffix":""},{"id":527101308,"identity":"8b0d62de-8c42-41ff-9d8b-39e626d74ea0","order_by":3,"name":"K. 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18:58:23","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":104846,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7804717/v1/7cea7cffb06fd060a686c30a.html"},{"id":93263189,"identity":"49432e15-5d11-456b-982f-810b9047bd8a","added_by":"auto","created_at":"2025-10-10 18:58:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":94303,"visible":true,"origin":"","legend":"\u003cp\u003eDistricts included in the study sample frame\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7804717/v1/558f47670da5aea00705310a.png"},{"id":93263683,"identity":"586ac0fd-0005-4152-a501-9e67884c7289","added_by":"auto","created_at":"2025-10-10 19:06:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":39638,"visible":true,"origin":"","legend":"\u003cp\u003eMethodological Framework\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7804717/v1/1ead3cc38df08ec18f452c88.png"},{"id":93263194,"identity":"d8f877c0-0854-4394-bf86-7efdbe58252b","added_by":"auto","created_at":"2025-10-10 18:58:23","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":139667,"visible":true,"origin":"","legend":"\u003cp\u003eThematic Map\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7804717/v1/f76289a5fca9268426db9132.png"},{"id":104427327,"identity":"6ede1d11-8444-4236-a102-c2a927c32b73","added_by":"auto","created_at":"2026-03-11 14:57:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1380410,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7804717/v1/18e09a8c-2357-49be-99fc-385e12f8bfc7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Closing the Loop: Integrating Workplace Health into Primary Prevention of NCDs in India – Lessons from Tamil Nadu","fulltext":[{"header":"Background","content":"\u003cp\u003eNon-Communicable Diseases (NCDs) in the post-pandemic scenario require an effort that includes of tracking of people to prevent and/or postpone NCDs [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Toward that effort, it is imperative that health systems are inclusive in outreach, to ensure comprehensive coverage and to leave no resident behind. Present scenarios reveal that NCDs are responsible for 66% of total mortality in India [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It is a concern that almost 1 out of 4 men and close to 1 out of 5 women over 15 years old report having hypertension, while fewer men and women report diabetes (13.1% and 11.3%, respectively). The World Economic Forum report that NCDs will cost India \u003cspan\u003e$\u003c/span\u003e3.55 trillion in lost output by 2030 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMeasured in Disability-Adjusted Life Years (DALYs) NCDs in Tamil nadu is reported to be 63%, with close to 1 out of 4 men and women over 15 years old reporting hypertension and diabetes (NFHS-5, Tamil Nadu) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. With the goal to stem the rise, the Government of Tamil Nadu (GoTN) has operationalized over 8,000 Health and Wellness Centres which provides more than 95% of the population with access to screening within a 5 km radius [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Furthermore, the GoTN has consistently innovated to provide initiatives such as Mobile NCD Camps and digital tracking via Makkalai Thedi Maruthuvam. Innovation also includes convergence within the health system, including the Employees\u0026rsquo; State Insurance (ESI) and the Directorate of Industrial Safety and Health (DISH), to help bridge gaps in screening access for the workforce.\u003c/p\u003e\u003cp\u003eTamil Nadu is one India\u0026rsquo;s foremost industrialized state providing significant contribution to the nation\u0026rsquo;s manufacturing and services sectors. It is within the first three ranks in terms of number of factories and industrial workers, with close to 40,000 registered factories employing more than 2.3\u0026nbsp;million workers in the organized manufacturing sector alone as per the Annual Survey of Industries [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Furthermore, Tamil Nadu is also crucial hub for Information Technology and Business Process Management sectors with over 600,000 professionals across major cities of Tamil Nadu [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Together both these sectors account for a substantial proportion of working-age adult population \u0026ndash; many of whom are increasingly at risk for NCDs due to their lifestyles both at work and at home.\u003c/p\u003e\u003cp\u003eThe time is now to integrate NCD prevention into organized employment sectors particularly in low-and middle-income countries (LMICs) where the burden of both infectious and rising chronic conditions compromises the health systems. Data reveals that over 77% of all NCD deaths occur in LMICs [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Workplace and occupational settings are strategic opportunities as they bring together large populations of working- age adults exposed to common risk factors like sedentary work, irregular shifts, occupational stress and dietary changes [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Studies from different countries have demonstrated positive outcomes such as enhanced productivity, decreased absenteeism while lowering out-of-pocket health expenses for workers as a result of early detection of hypertension and diabetes [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In India, non-communicable diseases are responsible for two-thirds of all fatalities, and the economic impact of reduced productivity is expected to surpass \u003cspan\u003e$\u003c/span\u003e3.5 trillion by 2030 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Therefore, involving the organized sector is essential for both health and economic reasons.\u003c/p\u003e\u003cp\u003eIn order to increase the effectiveness of any work place health promotion initiatives, organizations and people must endeavor to eliminate obstacles and enhance facilitators [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This implementation research by examining \u0026ldquo;abling\u0026rdquo; ecosystems\u0026mdash;both enabling and disabling screening ecosystem related to hypertension and diabetes furthered the organized sector as a strategic setting for outreach, with significant potential to bridge gaps in NCD prevention and control.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWith the intent of understanding organized sector landscape to validate the organized sector as a setting for NCD screening, both enabling and disabling environments of the stakeholders were undertaken. The stakeholders in our study included - Health ecosystem and the Industries / Factories. The tools for the study included Checklist for in-depth interviews for healthcare providers and industry stakeholders. Figure\u0026nbsp;1 shows the districts that are part of the sample frame and Table\u0026nbsp;1 provides the industries that were sampled.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eIndustries that were sampled\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eCompany Name\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAshwini Fisheries Ltd.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGHCL Limited\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePerambalur Sugar Mills\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBimetal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGHCL Mills\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRockman Industries\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCarborundum Universal Industry\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHatsun\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSakthi Auto Components\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eColor Jersey\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndian Oil\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSchwing Stetter India Pvt Ltd\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eD.C.W. Limited\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndian Petroleum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSivaraj Spinning Mills Pvt Ltd.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDalmia Cements (Bharath) Ltd\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKone Elevator India Pvt Ltd.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSri Shanmugavel Mills Pvt Ltd, Unit II\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDhanalakshmi Sreenivasan Sugars (P) Ltd\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKPR Garments \u0026amp; Apparels Ltd\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eVedha Spinning Mills Pvt Ltd, Unit-1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFenner India Limited\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKPR Mill Limited\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLotus Footwear Enterprises Ltd.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFirst Step Baby Wear\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKusauto India Pvt Ltd\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMadura Coats Pvt Limited\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eManna Foods Pvt Ltd\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMRF Tyres\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNippon Paint India Pvt Ltd\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eQualitative Methodology\u003c/h2\u003e\u003cp\u003eA qualitative design was employed to explore the enablers and barriers in workplace-based NCD screening in Tamil Nadu. In-depth interviews were conducted with multiple stakeholders across the health system and industry sectors. A total of 201 interviews were completed. Each interview team comprised one interviewer and one observer to ensure both conversational flow and systematic documentation. The methodological framework was given in Fig.\u0026nbsp;2.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData Management and Transcription\u003c/h3\u003e\n\u003cp\u003eInterviews were audio-recorded, and field notes were documented simultaneously. At the conclusion of each day, the interview team and project staff (n\u0026thinsp;=\u0026thinsp;3) debriefed to discuss emerging insights and contextual nuances. The audio recordings were transcribed verbatim. Each transcript underwent two reviews by the project lead and data manager to ensure accuracy and completeness prior to inclusion in the analysis dataset.\u003c/p\u003e\n\u003ch3\u003eCoding and Analysis\u003c/h3\u003e\n\u003cp\u003eThematic analysis was conducted as per Braun and Clarke\u0026rsquo;s six-step framework [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Two researchers independently performed the coding process. Discrepancies in code assignment were iteratively discussed until consensus was achieved. The finalized codes were subsequently organized into categories and developed into themes through team discussions. The project leads actively engaged in the theme development process to ensure alignment with programmatic contexts. Atlas.ti software was employed to manage data, codes, and analytic memos. These themes were generated for both enabling and disabling behaviors. The number of people interviewed is listed in table 2\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eNumber of People interviewed\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStakeholder Role\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNumber Interviewed\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndustry Stakeholders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHuman Resource Manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndustry Stakeholders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmployee Welfare Officer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndustry Stakeholders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWorkplace Safety Officer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndustry Stakeholders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealthcare Providers from the Industry\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndustry Stakeholders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRepresentative of Employee Union (if present)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGovernment Health Providers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eJoint Director \u0026ndash; NCD \u0026ndash; DPH (State level)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGovernment Health Providers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDistrict NCD Program Coordinator\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGovernment Health Providers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDistrict Industry Safety Officer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGovernment Health Providers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBlock Medical Officer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGovernment Health Providers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePHC Medical Officer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGovernment Health Providers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePHC Staff Nurse (NCD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eEthical Clearance \u0026ndash; Ethical clearance was obtained from the Institutional Ethics committee, SRM Institute of Science and Technology (Reference Number: 0059/IEC/2024). Study was approved by DPH SAC committee (DPHPM/DPHSAC/2024/075) and permission was obtained from the Directorate of Public Health and Preventive Medicine, Tamil Nadu. Written informed consent was obtained from all participants before data collection. Confidentiality and anonymity of participant data were strictly maintained throughout the study, adhering to ethical research principles.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eResults of the qualitative analysis revealed broader themes and the Fig.\u0026nbsp;3 shows the final thematic map of enablers and barriers.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eTheme 1: Systemic Enablers\u003c/h3\u003e\n\u003cp\u003eWorkplace screenings were more successful when supported by well-defined institutional mechanisms such as coordination between Deputy Director of Health Services \u0026ndash; District level (DDHS-D) and ESI, timely resource provision, and proactive CSR engagement.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eInter-Agency Coordination\u003c/h2\u003e\u003cp\u003eAt the district level, the Deputy Directors of Health Services (DDHS) played a crucial role in coordinating the health teams with industries while ensuring that ESI facilities were prepared to handle referrals. At the state level, authorizations and oversight from the Directorate of Public Health (DPH), National Health Mission (NHM), and Directorate of Industrial Safety and Health (DISH) provided the foundations for the industries to engage. Effective collaboration between the Deputy Director of Health Services \u0026ndash; District level (DDHS-D) and the ESI network ensured seamless referral pathways helped reduce the duplication of efforts and enabled standardized follow-up care. Clear roles and responsibilities across agencies brought accountability and minimized administrative delays. One of our interviewee\u0026rsquo;s words about coordination, \u003cem\u003e\u0026ldquo;Here, the PHC and ESI are working in coordination. The PHC is responsible for diagnosis, while the ESI takes care of follow-up.\u0026rdquo;\u003c/em\u003e Block Medical Officer (BMO) Thadikombu, Dindugal\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eTimely Resource Provision\u003c/h3\u003e\n\u003cp\u003eAvailability of vital equipment (e.g., hemoglobin analyzers, glucose testing kits), skilled personnel, and logistical support was crucial. This prevented disruptions in screening schedules, which in turn-built credibility and trust among workers, a crucial component to ensure continuity of care. From the Health systems, \u0026ldquo;\u003cem\u003eOn the government side, we face no barriers; everything is clarified promptly. Even when staff members are on leave, additional personnel are provided at the PHC, so manpower is not an issue. Financially, funds are never a problem, and we never lack medicines or reagents for blood tests, even for a day.\u0026rdquo;\u003c/em\u003e BMO Thoothukudi\u003c/p\u003e\n\u003ch3\u003eCorporate Social Responsibility (CSR) Engagement\u003c/h3\u003e\n\u003cp\u003eProactive CSR initiatives provided financial and logistical backing, filling critical resource gaps that public systems could not immediately address. CSR-supported wellness activities (e.g., awareness sessions, nutrition supplementation, follow-up camps) amplified the reach and sustainability of screening programs.\u003c/p\u003e\u003cp\u003eBMO of Samyanallur noted, \u003cem\u003e\u0026ldquo;Overall, the industry is engaged with us through their CSR initiatives, providing comprehensive support such as supplying fogging machines and renovating the PHC. This strong collaboration has facilitated our access to the site, making it considerably easier to carry out our activities.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eTheme 2: Industry Engagement \u0026amp; Infrastructure\u003c/h2\u003e\u003cp\u003eIndustries branded by proactive management support and the presence of functional Occupational Health Units (OHUs), robust infrastructure and flexibility in scheduling reported more efficient screening processes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eLeadership \u0026amp; Management Support\u003c/h2\u003e\u003cp\u003eManagement commitment was a decisive factor in successful implementation. Industries where senior leadership endorsed screenings, allocated time, and motivated workers created an environment where participation was higher. Supportive management also enabled smoother coordination with external health teams (DDHS-D, ESI, NGOs), reducing friction during planning and execution. In the experience of the Samyanallur, BMO, \u0026ldquo;\u003cem\u003e\"Inside (the Industry), the hospitality was very good, and the ambience was pleasant. The administrative people present there were very welcoming and had a very good rapport with us.\"\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eOccupational Health Units (OHUs)\u003c/h2\u003e\u003cp\u003eIndustries with functional OHUs provided immediate follow-up, continuity of care, and better data management of workers\u0026rsquo; health records. OHUs also acted as focal points for liaising with district health officials and CSR partners, ensuring institutional memory and sustainability of screening activities.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eProvision of Infrastructure \u0026amp; Space\u003c/h2\u003e\u003cp\u003eAvailability of dedicated, hygienic spaces for screening (such as training halls, dispensaries, or canteens temporarily repurposed) was a major facilitator. Adequate infrastructure created a sense of acceptability and order, enhancing worker trust and reducing resistance. At the Hatsun factory, the nurse attributed the success of the program to the provision of infrastructure, \u003cem\u003e\u0026ldquo;The main reason is proactive planning, supported by facilitation in administrative management, employee cooperation, excellent infrastructure, and funding.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eScheduling Flexibility\u003c/h2\u003e\u003cp\u003eIndustries that flexed work shifts or staggered screening schedules avoided disruptions to production while ensuring that maximum workers participated. Flexibility in timing also supported female workers and shift-based employees, reducing absenteeism from health screenings. The manager of the MRF in his interview reported. \u003cem\u003e\u0026ldquo;We are able to ensure that all of the workers get screened as we follow a stringent rotation of staff and it is mandatory for the workers to get screened.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eTheme 3: Barriers in Logistics and Human Resources\u003c/h2\u003e\u003cp\u003eRecurrent issues included lack of manpower, inadequate supply of testing kits, and challenges in mobilizing contractual or migrant workers.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eHuman Resource Constraints\u003c/h2\u003e\u003cp\u003eAn insistent challenge encountered was the inadequacy of manpower. Health workers frequently had to manage large groups with minimal staff support, resulting in expedited processes or incomplete coverage. Contractual staff were not consistently available, and frequent rotations led to a lack of continuity in follow-up care. The mobilization of migrant or contractual workers was particularly challenging due to language barriers, irregular shifts, and concerns about wage loss.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eSupply-Side Gaps\u003c/h2\u003e\u003cp\u003eScreenings were frequently hampered by unavailability of essential materials such as glucometers, strips, and hemoglobin testing kits. Limited stock not only slowed down the process but also undermined worker trust which is crucial for consistent engagement. As one health worker noted, \u003cem\u003e\u0026ldquo;Medicines and testing supplies are not always available in sufficient quantities during screening camps, leading to interruptions in services.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eOperational Challenges\u003c/h2\u003e\u003cp\u003eLack of transport facilities and delays in moving screening teams across multiple worksites created scheduling conflicts. Absence of backup equipment (e.g., spare batteries, additional test kits) further prolonged screening times. In industries with large worker populations, logistical bottlenecks led to re-visiting to ensure completion of screening. The NCD coordinator from Ariyalur remarked, \u0026ldquo;\u003cem\u003esites closer to the town is easier for us to provide services, when the sites are far away, we have to depend on other division for transport. This delays and dilutes our efforts\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eTheme 4: Scheduling and Shift Conflicts\u003c/h2\u003e\u003cp\u003eScreening after or before shifts often led to poor turnout. Workers on night shifts were especially underrepresented. One employer admitted, \u003cem\u003e\u0026ldquo;We couldn\u0026rsquo;t interrupt production hours.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003ePre- and Post-Shift Fatigue\u003c/h2\u003e\u003cp\u003eEmployees required to undergo health screenings prior to the commencement of their shifts frequently prioritized timeliness at work over these health assessments due to time constraints. Conversely, post-shift screenings often coincided with fatigue and a pressing desire to return home, a situation particularly prevalent among women with domestic responsibilities. Perambalur BMO shared his challenges, in his words, \u003cem\u003e\u0026ldquo;Coordinating logistics between industries and health teams is difficult. Factories prioritize work schedules, making smooth execution of screenings harder\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eNight-Shift Worker Exclusion\u003c/h2\u003e\u003cp\u003eIndividuals working night shifts are frequently excluded from consideration. Their disrupted sleep patterns, coupled with schedules that cater exclusively to daytime activities, diminish their likelihood of inclusion. Consequently, this results in the systematic underrepresentation of a vulnerable demographic that may face unique health risks due to disrupted circadian rhythms and extended working hours. The size of the factory is a crucial indicator as recounted by the BMO Manapparai who reported \u003cem\u003e\u0026ldquo;In some industries, they work in three shifts. Because of that, there are some difficulties. For example, if someone has worked the night shift, we can\u0026rsquo;t call them again in the morning for screening. So, for such people, it will take us around 2\u0026ndash;3 days to complete the screening.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eEmployer Reluctance to Interrupt Production\u003c/h2\u003e\u003cp\u003eEmployers often prioritized uninterrupted production over health screenings, especially in export-driven industries with strict timelines. As one employer admitted: \u003cem\u003e\u0026ldquo;We couldn\u0026rsquo;t interrupt production hours.\u0026rdquo;\u003c/em\u003e This sentiment highlighted the structural conflict between health promotion and economic output. The BMO from an industry in Krishnagiri in his words, \u003cem\u003e\u0026ldquo;Even if we get permission and set up a camp inside, people don\u0026rsquo;t always come. It feels like we are just sitting idle. From the industry\u0026rsquo;s side, there isn\u0026rsquo;t much cooperation\u0026mdash;if we ask them, they say that production is their top priority, so they don\u0026rsquo;t pay much attention to us.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eGendered Implications\u003c/h2\u003e\u003cp\u003eFor female workers, inflexible scheduling exacerbated the difficulties of reconciling factory employment with domestic responsibilities. The lack of flexibility frequently resulted in reduced participation in screenings.\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eTheme 5: Administrative Gaps\u003c/h2\u003e\u003cp\u003eCommunication delays between DISH, employers, and health departments led to last-minute approvals and confusion as this is a pilot effort further compounded by the absence of well-defined protocols.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eCommunication Breakdowns\u003c/h2\u003e\u003cp\u003eInsufficient coordination in communication among the Directorate of Industrial Safety and Health (DISH), employers, and health departments frequently resulted in minimal delays in the execution of responsibilities. The dissemination of information was fragmented; industries were occasionally informed at short notice about the screening schedule, while health teams received incomplete worker data or insufficient logistical details. A health Inspector reported challenges with regards to communication, \u003cem\u003e\u0026ldquo;Frequent communication issues arise between the health department and industries. Misunderstandings or lack of updates delay smooth organization of camps.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\u003ch2\u003eLast-Minute Approvals\u003c/h2\u003e\u003cp\u003ePermissions from DISH or local authorities were often granted at the latest possible moment due to bureaucratic processes, thereby affording industries minimal time to establish the necessary infrastructure or adjust production schedules. This reactive approach disrupted the mobilization of workers and diminished participation, particularly in larger units that require advance notification. The BMO of Krishnagiri shared the challenges in seeking approvals since much is done at the last minute, \u003cem\u003e\"First of all, getting permission in these industries itself is very difficult. If we ask, we don\u0026rsquo;t always get an immediate response. Only after talking to several people, we are able to finally get permission.\"\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\u003ch2\u003eAbsence of Standard Protocols\u003c/h2\u003e\u003cp\u003eIn the absence of explicit operational guidelines as this effort is a pilot effort, each district and industry developed its own methodologies, resulting in considerable variability in the quality and scope of screenings. While some industries offered substantial internal support, others provided minimal assistance due to ambiguous expectations. Many of the stakeholders felt that there is a need for a standard protocol, in one of the stakeholders words, \u003cem\u003e\u0026ldquo;There is no uniform protocol for conducting screenings. Each camp is organized differently, depending on management's willingness, reducing consistency and efficiency.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\u003ch2\u003eAccountability Gaps\u003c/h2\u003e\u003cp\u003eWhen screenings did not achieve the expected coverage, it was often unclear whether the responsibility lay with industries, DISH, or health departments. This lack of accountability diluted ownership once resolved through established protocol will help in sustaining the momentum. One of the BMO\u0026rsquo;s who commented, \u003cem\u003e\u0026ldquo;Responsibility for coordinating and ensuring worker participation is often unclear. Industries and health staff shift accountability, weakening follow-up and effectiveness.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eTheme 6: Behavioral and Awareness Challenges\u003c/h3\u003e\n\u003cp\u003eStigma around diabetes or hypertension, poor understanding of follow-up needs, and language barriers impeded health-seeking behavior among workers.\u003c/p\u003e\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e\u003ch2\u003eStigma and Fear\u003c/h2\u003e\u003cp\u003eNumerous employees perceive conditions such as diabetes and hypertension as indicative of weakness or diminished employability. The fear of being labelled as \"unfit\" deters some individuals from participating in health screenings. This stigma is particularly pronounced among younger employees who are worried about their job security. In his in-depth interview, the BMO of Trichy added, \u003cem\u003e\u0026ldquo;There is still a social stigma lingering in rural areas, as I have observed. People think that if someone has diabetes or high blood pressure, it shouldn\u0026rsquo;t be known to the neighbors.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec32\" class=\"Section2\"\u003e\u003ch2\u003eLimited Awareness of Follow-Up Needs\u003c/h2\u003e\u003cp\u003eWhile initial health screenings were generally accepted, there was a limited understanding of the necessity for subsequent tests, lifestyle modifications, or consistent medication use. Some workers perceived a single screening as an adequate assessment of their health status. Misconceptions, such as the belief that continuous medication use leads to dependency, further diminished adherence to recommended health practices. About the lack of awareness, the BMO Manapparai added, \u003cem\u003e\"What I feel is, when a patient is told by a WHV (Women Health Volunteer) that their blood pressure is high or their sugar level is high, they don\u0026rsquo;t take it seriously. Hardly around 30% of them actually turn up for follow-up, and even when asked to go to the hospital, they don\u0026rsquo;t treat it as something serious enough to go back.\"\u003c/em\u003e\u003c/p\u003e\u003cdiv id=\"Sec33\" class=\"Section3\"\u003e\u003ch2\u003eLanguage and Communication Barriers\u003c/h2\u003e\u003cp\u003eMigrant and contractual workers from diverse linguistic backgrounds, encounter challenges in comprehending health-related advice. The materials are seldom translated, and health discussions are occasionally presented using technical terminology, leading to confusion. Consequently, informed consent and understanding of risk factors are diminished within these populations. An unnamed health worker added, about poor communication, \u003cem\u003e\u0026ldquo;In some factories, communication between health staff and workers is limited due to language differences or lack of clarity, reducing understanding and participation\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec34\" class=\"Section3\"\u003e\u003ch2\u003eLow Health-Seeking Behavior\u003c/h2\u003e\u003cp\u003eWorkers prioritized daily wages and production commitments over health appointments. Preventive health was often perceived as secondary, especially when illness was not immediately disabling. This cultural orientation towards \u0026ldquo;curative care only when sick\u0026rdquo; reduced the uptake of long-term preventive strategies. In general, there is apathy that is revealed by a BMO, \u003cem\u003e\"Barriers are there in everything. My first issue is, when we do a blood test and tell them they have diabetes, they don\u0026rsquo;t believe it. If we say they have high blood pressure, they get very anxious but still don\u0026rsquo;t believe it. Even if we take an ECG and show them changes in the heart, they don\u0026rsquo;t accept it when we say this is the reason. Because of this, they neither take tablets nor come for treatment, so doing follow-up becomes very difficult.\"\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this study highlight the complex interplay of systemic enablers, industry engagement, and human factors in shaping the effectiveness of workplace NCD screening programs. While the overall initiative demonstrated strong potential, the results suggest that success depended less on the mere presence of a program and more on the quality of coordination, management commitment, and responsiveness to worker realities.\u003c/p\u003e\n\u003ch3\u003eSystemic Enablers: Coordination and Resources:\u003c/h3\u003e\n\u003cp\u003eAt the systemic level, inter-agency coordination emerged as a critical enabler. The Deputy Directors of Health Services (DDHS) played a pivotal role in facilitating seamless linkages between district health teams, industries, and the ESI network. This finding is substantiated by research from Indonesia where strong relationships between local health authorities and communities strengthened continuity of care and built trust in preventive programs [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Establishing clearly defined roles and responsibilities with established referral pathways minimized duplication of efforts while promoting accountability. Timely provision of equipment and trained personnel helped in seamless process and built worker confidence.\u003c/p\u003e\u003cp\u003eCorporate Social Responsibility (CSR) initiatives also addressed critical gaps, supporting Somani\u0026rsquo;s (2022) observation that private sector contributions to infrastructure and wellness activities enhance the reach and sustainability of health programs [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. As one health officer noted, \u0026ldquo;When CSR was aligned with health goals, things moved faster,\u0026rdquo; highlighting the catalytic effect of organizational goodwill. Building trust among stakeholders is key to success of programs such as this, which is reliant on seamless coordination, and availability of resources both human and others such as consumables. The intent of the Government of Tamil Nadu is timely and required to address the current surge in NCDs and has the potential to lay the foundation for a workplace-based wellness that can close the loop in provision of healthcare services in Tamil Nadu.\u003c/p\u003e\u003cdiv id=\"Sec37\" class=\"Section2\"\u003e\u003ch2\u003eIndustry Engagement and Infrastructure\u003c/h2\u003e\u003cp\u003eThe role of industry leadership was equally significant. Management support was not merely representational; it directly facilitated worker participation, improved coordination, and facilitated seamless process with external health teams. These findings align with global evidence indicating that leadership endorsement is a crucial enabler of workplace health interventions [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In instances where the management allocated time, encouraged employees, and extended necessary infrastructure, participation rates were nearly universal. For example, in a large textile unit, management's decision to adjust shifts for women workers enabled near-complete coverage, illustrating how flexibility is the key to bridge the gap between production demands and employee wellness. Occupational Health Units (OHUs) served as institutional anchors by ensuring continuity of care, maintaining data systems, and liaising with district officials and CSR partners while fostering the importance of health in respective industries. On the contrary, industries lacking OHUs or exhibiting weak management engagement faced challenges in mobilization, reflecting patterns observed in small and medium enterprises globally, where the absence of dedicated units undermines program sustainability [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec38\" class=\"Section3\"\u003e\u003ch2\u003eBarriers in Logistics and Human Resources\u003c/h2\u003e\u003cp\u003eThis initiative of the GoTN has few areas that needs fine-tuning. Despite the existence of supportive environments, few areas of systemic gaps are visible. The implementation was repeatedly impeded by shortages of healthcare personnel, limited availability of test kits, and logistical challenges. Health workers reported instances of screening \"200 people with only one glucometer,\" highlighting that motivated healthcare workers alone cannot compensate for insufficient resources. These limitations decreased coverage, eroded trust, and aggravated inequities in access. This observation supports the broader literature on the under investment in workplace health [\u003cspan additionalcitationids=\"CR23 CR24\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and emphasizes the necessity for adequate investment in human resources for health (HRH) to ensure reasonable program scaling.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec39\" class=\"Section2\"\u003e\u003ch2\u003eScheduling and Shift Conflicts: Worker Realities\u003c/h2\u003e\u003cp\u003eScheduling has appeared to be a pivotal factor influencing worker participation. This is due to the fact that there is conflict between promoting productivity over health promotion among the upper management. Furthermore, night-shift workers were consistently under-represented highlighting a systemic exclusion of the subgroup. System level contradictions between economics and employee health are rarely reported and documented. This is particularly true of gendered aspect of the timing that disproportionately affect women, who are caught between intensified workplace limitations and work at home leading to poor workplace screening participation. Considering that 40% of the women workforce in India is from Tamil Nadu, there needs to be exclusive protocols to ensure inclusivity of women through other modes. These findings reinforce arguments in the literature advocating for flexible scheduling as an essential element of equity in occupational health programs [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec40\" class=\"Section3\"\u003e\u003ch2\u003eAdministrative Gaps and Governance Weaknesses\u003c/h2\u003e\u003cp\u003eAdministrative challenges further diluted the implementation process. Poor communication among the stakeholders resulted in last-minute scheduling changes and poor coordination. Not having standardized protocols forced improvisation leading to variety in quality and coverage. These gaps in governance reduced efficiency and also compromised accountability weakening the momentum. This situation aligns with global discussions on the critical importance of institutional clarity and accountability in industry-public health partnerships [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eBehavioral and Awareness Challenges\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBehavioral and cultural barriers significantly inhibited the program's impact. Stigma among the communities about conditions such as diabetes and hypertension compounded by apprehension of being perceived as \u0026ldquo;unfit\u0026rdquo; driven by inadequate awareness about need for follow-up care limited worker engagement beyond the initial screening. Furthermore, most employees prioritized wage-earning over preventive care and among migrant workers language barriers and misconceptions prevailed leading to exclusion of these subgroups. As one worker expressed, \"Taking medicines continuously makes you dependent.\" These attitudes reflect a broader cultural inclination aligning with national survey findings and underscore the necessity for tailored health education and culturally sensitive communication [27, 28].\u003c/p\u003e\u003cp\u003e\u003cb\u003eToward Enabling Industry Engagement\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTaken together, these findings point to a dual lesson. On the one hand, industries with strong management support, OHUs, infrastructure provision, and scheduling flexibility demonstrate that workplace health programs can be highly effective, equitable, and sustainable. On the other, gaps in resources, governance, and awareness highlight that without systemic commitment, well-intentioned programs falter. Building enabling environments for industry engagement therefore requires not only inter-agency coordination and CSR alignment but also a conscious effort to humanize program design \u0026mdash; recognizing worker realities, gendered burdens, and cultural perceptions of health.\u003c/p\u003e\u003cp\u003eFurthermore, the findings from this study can be viewed from the Consolidated Framework for Implementation Research (CFIR) which posits how intervention success depends on the interplay between the Outer, Inner settings, Individual characteristics and the implementation process itself. Systemic enablers like the inter-agency coordination and CSR engagement reflect the outer setting where external policies, resources and incentives shape program feasibility. Industry leadership and OHUs and infrastructure provision are the inner setting directing the organizational culture and management priorities influencing worker participation. Individual Characteristics include worker level barriers such as stigma, fear of being labelled unfit and poor awareness of follow-up needs, underscoring the need for culturally sensitive health communication. Finally, gaps in protocols, last-minute approvals, and fragmented communication highlight weaknesses in implementation processes, reducing program fidelity and sustainability. By framing workplace NCD screening within CFIR, this study demonstrates that success requires orientation across multiple domains\u0026mdash;policy, organizational culture, workforce realities, and operational processes\u0026mdash;although the existence of a program such as this is the start of improved and integrated service.\u003c/p\u003e\u003cp\u003eMoving forward, developing a standardized protocol that delineates roles and responsibilities across the health system, coupled with enforcement by DISH and supported by sustained awareness campaigns, will be essential to institutionalizing workplace NCD screening.\u003c/p\u003e\u003cp\u003eThis study provides the health system a crucial link towards integrating NCD screening as part of Primary Prevention among the organized sector, a cohort that is difficult to reach regularly. Furthermore, findings from this study reinforce the effectiveness of workplace screening when the system works seamlessly with proactive employers. Being a pilot initiative, this effort is instrumental in accessing the organized force, which in the next 10 years is expected to grow rapidly. This outreach by the health systems will not only ensure healthy employees but also will enhance economic outcomes. With NCDs responsible for close to 2/3rds of the disease burden in Tamil Nadu. An effort such as this to routinize preventive screening at workplaces is a triple win, for health systems, employers and the employees.\u003c/p\u003e\u003cp\u003eThe outcomes of this research indicate that enablers to an effective screening program with the organized sector is possible only when there is similar level of engagement by all the stakeholders ensuring that resources are provided timely both human and consumables building trust among all stakeholders. Furthermore, industries that proactively prioritize employee wellness exhibit support at their highest level which translates into availability of infrastructure, human resources as well as employee participation [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe findings indicate a twofold lesson: workplace health should be integrated into institutional frameworks and leadership priorities rather than being treated as a secondary concern to production. For Tamil Nadu, a highly industrialized state in India, this alignment could not only help reduce the increasing prevalence of hypertension and diabetes but also protect productivity and economic growth. Creating supportive environments that blend systemic coordination with industry leadership and worker-focused strategies can turn workplaces into key centres for preventing non-communicable diseases, ensuring equity, continuous care, and long-term sustainability. Tamil Nadu stands as a beacon similar to how Brazil leveraged industry-based wellness programs or how South Africa integrated workplace HIV prevention, Tamil Nadu\u0026rsquo;s model offers a transferable framework for chronic disease prevention in LMICs.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNCD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNon\u0026ndash;Communicable Disease\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLMICs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLow middle income countries\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDALYs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDisability\u0026ndash;Adjusted Life Years\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGoTN\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGovernment of Tamil Nadu\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDISH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDirectorate of Industrial Safety and Health\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eESI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEmployee\u0026rsquo;s State Insurance\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDDHS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eD\u0026ndash;Deputy Director of Health Services\u0026ndash;District level\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDPH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDirectorate of Public Health\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNHM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNational Health Mission\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePHC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePrimary Health Centre\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBMO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBlock Medical Officer\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCSR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCorporate Social Responsibility\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eOHU\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eOccupational Health Units\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Statements and Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthical approval for the study was obtained from the SRM-IST (IEC) Institutional Ethics Committee (Reference Number: 0059/IEC/2024) and Tamil Nadu DPH Scientific Advisory Committee. Written informed consent was obtained from all participants before data collection. Confidentiality and anonymity of participant data were strictly maintained throughout the study, adhering to ethical research principles.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOperational Research Program—Tamil Nadu Health System Reform Program (TNHSRP) Coordinated by Indian Institute of Technology Madras (IITM), Chennai.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization and methods: GV, PM and DK.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData collection and analysis: SK, BM, PM and KC\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSupervision: GV, PM and DK.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWriting Draft: SK, BM and KC\u003c/p\u003e\n\u003cp\u003eReview and editing draft manuscript: GV\u003c/p\u003e\n\u003cp\u003eAll 6 authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank S Uma, I.A.S., Former Project Director, Thiru. M Govinda Rao, I.A.S., Project Director, Operational Research Program, Tamil Nadu Health System Reform Program (TNHSRP), Ministry of Health and Family Welfare, Government of Tamil Nadu for funding this study; Shobha, Expert Advisor, RCH, TNHSRP, and V R Muraleedharan, Department of Humanities and Social Sciences, Indian Institute of Technology Madras, Chennai, for organizing regular project review meetings, providing input, and administrative support.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors gratefully acknowledge the financial support by SRM School of Public Health, Faculty of Medicine and Health Sciences, SRMIST, Kattankulathur for bearing the defrayed costs of publishing this article\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eShu J, Jin W. Prioritizing non-communicable diseases in the post-pandemic era based on a comprehensive analysis of the GBD 2019 from 1990 to 2019. Sci Rep. 2023;13:1\u0026ndash;17. https://doi.org/10.1038/S41598-023-40595-7;SUBJMETA.\u003c/li\u003e\n\u003cli\u003eKulothungan V, Ramamoorthy T, Mohan R, Mathur P. Assessing progress of India in reduction of premature mortality due to four noncommunicable diseases towards achieving the WHO 25\u0026times;25 goal and the sustainable development goals. Sustainable Development. 2024;32:2020\u0026ndash;30. https://doi.org/10.1002/SD.2761.\u003c/li\u003e\n\u003cli\u003eBloom DE, Cafiero-Fonseca ET, Candeias V, Adashi E, Bloom L, Gurfein L, et al. Economics of Non-Communicable Diseases in India. 2014.\u003c/li\u003e\n\u003cli\u003eGovernment of India Ministry of Health and Family Welfare. NFHS-5, COMPENDIUM OF FACT SHEETS INDIA AND 14 STATES/UTs (Phase-11). 2021.\u003c/li\u003e\n\u003cli\u003eGovernment of Tamil Nadu. Health and family welfare Department Policy Note. 2025.\u003c/li\u003e\n\u003cli\u003eGovernment of India. Annual Survey of Industries (Factory Sector). 2024.\u003c/li\u003e\n\u003cli\u003eWHO. Noncommunicable diseases | Knowledge Action Portal on NCDs. 2023. https://knowledge-action-portal.com/en/content/noncommunicable-diseases. Accessed 1 Oct 2025.\u003c/li\u003e\n\u003cli\u003eDemou E, Maclean A, Cheripelli LJ, Hunt K, Gray CM. Group-based healthy lifestyle workplace interventions for shift workers: a systematic review. Scand J Work Environ Health. 2018;44:568. https://doi.org/10.5271/SJWEH.3763.\u003c/li\u003e\n\u003cli\u003edos Reis FL, Bertoloto JCF, da Costa Rodrigues T, de Castro Cardoso Toniasso S, Baldin CP, Rodrigues JB, et al. The efficacy of interventions in the workplace promoting exercise and a healthy diet among shift workers: A systematic review. PLoS One. 2025;20:e0325071. https://doi.org/10.1371/JOURNAL.PONE.0325071.\u003c/li\u003e\n\u003cli\u003eToscano CM, Zhuo X, Imai K, Duncan BB, Polanczyk CA, Zhang P, et al. Cost-effectiveness of a national population-based screening program for type 2 diabetes: The Brazil experience. Diabetol Metab Syndr. 2015;7:1\u0026ndash;11. https://doi.org/10.1186/S13098-015-0090-8/TABLES/5.\u003c/li\u003e\n\u003cli\u003eTarro L, Llaurad\u0026oacute; E, Ulldemolins G, Hermoso P, Sol\u0026agrave; R. Effectiveness of Workplace Interventions for Improving Absenteeism, Productivity, and Work Ability of Employees: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. International Journal of Environmental Research and Public Health 2020, Vol 17, Page 1901. 2020;17:1901. https://doi.org/10.3390/IJERPH17061901.\u003c/li\u003e\n\u003cli\u003eSharma M, John R, Afrin S, Zhang X, Wang T, Tian M, et al. Cost-Effectiveness of Population Screening Programs for Cardiovascular Diseases and Diabetes in Low- and Middle-Income Countries: A Systematic Review. Front Public Health. 2022;10:820750. https://doi.org/10.3389/FPUBH.2022.820750/BIBTEX.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77\u0026ndash;101. https://doi.org/10.1191/1478088706QP063OA.\u003c/li\u003e\n\u003cli\u003eMuthuperumal P, Chakkaraiappan K, Sowmiya, K, Balaji M, Veliah G, Karmegam D. Barriers and facilitators for implementing NCD-related health promotion activities in the workplace: A scoping review. Discov Soc Sci Health. 2025; \u003cstrong\u003e5\u003c/strong\u003e, 130. https://doi.org/10.1007/s44155-025-00291-5 \u003c/li\u003e\n\u003cli\u003eAkanksha Somani C, Deuskar V. CORPORATE SOCIAL RESPONSIBILITY IN BANKING: AN EMPLOYEE PERSPECTIVE. A Global Journal of Interdisciplinary Studies. 2024;7.\u003c/li\u003e\n\u003cli\u003eSomani NA. Assessing the Role of the Private Sector in Non-Communicable Disease Prevention, Management, and Control: A Systematic review. University of Waterloo; 2022.\u003c/li\u003e\n\u003cli\u003eLiu L, Zhang C, Fang CC. Effects of health-promoting leadership, employee health on employee engagement: employability as moderating variable. Int J Workplace Health Manag. 2022;15:1\u0026ndash;18. https://doi.org/10.1108/IJWHM-07-2020-0122.\u003c/li\u003e\n\u003cli\u003eTryon K, Bolnick H, Pomeranz JL, Pronk N, Yach D. Making the workplace a more effective site for prevention of noncommunicable diseases in adults. J Occup Environ Med. 2014;56:1137\u0026ndash;44. https://doi.org/10.1097/JOM.0000000000000300.\u003c/li\u003e\n\u003cli\u003eSaito J, Odawara M, Takahashi H, Fujimori M, Yaguchi-Saito A, Inoue M, et al. Barriers and facilitative factors in the implementation of workplace health promotion activities in small and medium-sized enterprises: a qualitative study. Implement Sci Commun. 2022;3:1\u0026ndash;13. https://doi.org/10.1186/S43058-022-00268-4/TABLES/3.\u003c/li\u003e\n\u003cli\u003eRantala E, Vanhatalo S, Perez-Cueto FJA, Pihlajam\u0026auml;ki J, Poutanen K, Karhunen L, et al. Acceptability of workplace choice architecture modification for healthy behaviours. BMC Public Health. 2023;23:2451. https://doi.org/10.1186/s12889-023-17331-x.\u003c/li\u003e\n\u003cli\u003eChau JY, Engelen L, Kolbe-Alexander T, Young S, Olsen H, Gilson N, et al. \u0026ldquo;In Initiative Overload\u0026rdquo;: Australian Perspectives on Promoting Physical Activity in the Workplace from Diverse Industries. Int J Environ Res Public Health. 2019;16:516. https://doi.org/10.3390/ijerph16030516.\u003c/li\u003e\n\u003cli\u003eWeber MB, Rhodes EC, Ranjani H, Jeemon P, Ali MK, Hennink MM, et al. Adapting and scaling a proven diabetes prevention program across 11 worksites in India: the INDIA-WORKS trial. Res Sq. 2023;:rs.3.rs-3143470. https://doi.org/10.21203/RS.3.RS-3143470/V1.\u003c/li\u003e\n\u003cli\u003eSedani A, Stover D, Coyle B, Wani RJ. Assessing Workplace Health and Safety Strategies, Trends, and Barriers through a Statewide Worksite Survey. Int J Environ Res Public Health. 2019;16:2475. https://doi.org/10.3390/ijerph16142475.\u003c/li\u003e\n\u003cli\u003eCollins BX, Wilkins CH. Overcoming Barriers to Health Equity in Precision Medicine Research. The American Journal of Bioethics. 2024;24:86\u0026ndash;8. https://doi.org/10.1080/15265161.2024.2303146.\u003c/li\u003e\n\u003cli\u003eVerburgh M, Verdonk P, Appelman Y, Brood-van Zanten M, Hulshof C, Nieuwenhuijsen K. Workplace Health Promotion Among Ethnically Diverse Women in Midlife With a Low Socioeconomic Position. Health Education \u0026amp; Behavior. 2022;49:1042\u0026ndash;55. https://doi.org/10.1177/10901981211071030.\u003c/li\u003e\n\u003cli\u003ePham CT, Lee CB, Nguyen TLH, Lin JD, Ali S, Chu C. Integrative settings approach to workplace health promotion to address contemporary challenges for worker health in the Asia-Pacific. Glob Health Promot. 2020;27:82\u0026ndash;90. https://doi.org/10.1177/1757975918816691.\u003c/li\u003e\n\u003cli\u003eKarmegam D, Veliah G, Murugesan B, Chakkaraiappan K, Kothandaraman S, Muthuperumal P. Implementing Workplace NCD Screening as a Health Systems Initiative: Participation, Satisfaction and Short-Term Detection in Tamil Nadu [preprint]. Research Square; 2025. doi:10.21203/rs.3.rs-7642521/v1 \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"NCD Screening, Organized Sector, Health systems","lastPublishedDoi":"10.21203/rs.3.rs-7804717/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7804717/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eNon-communicable diseases (NCDs) continue to represent a growing epidemic, accounting for nearly two-thirds of death and adding a significant economic burden through lost productivity. Tamil Nadu, one of India\u0026rsquo;s most industrialized states, bears a particularly substantial burden, with 63% of its disease burden attributed to NCDs. Workplaces, where millions of adults spend the majority of their daytime, present a high-risk environment while offering strategic opportunities for prevention. This study aimed to explore how organized sectors can function as platforms for NCD screening and care.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eUtilizing qualitative methodologies, we conducted 201 in-depth interviews with health officials, industry managers, workplace health providers, and employee representatives across a variety of factories and institutions. Each interview was accompanied by structured observation, daily debriefings, iterative transcription checks, and independent coding by two researchers to ensure methodological rigor. The team developed themes through consensus, triangulating perspectives from both industry and health systems.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe findings revealed a contradictory trend with systemic enablers like effective coordination of the district health department and Employees\u0026rsquo; State Insurance, resource availability and proactive social responsibility engagement enhanced reliability and reinforced continuity of care. Conversely, barriers included Human Resource shortages, logistical delays, rigid shift schedules, and stigma surrounding NCDs which hindered participation. Industries promoting employee wellness through their leadership, functional occupational health units, and flexible scheduling achieved majority of worker participation, whereas others faced challenges.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe study reiterates that successful workplace NCD screening is possible because of the program but with deeper trust, leadership, and employee-centered design it will achieve the intended outcomes. Integrating these elements into Tamil Nadu\u0026rsquo;s industrial landscape can transform workplaces into sustainable nodes of preventive health.\u003c/p\u003e","manuscriptTitle":"Closing the Loop: Integrating Workplace Health into Primary Prevention of NCDs in India – Lessons from Tamil Nadu","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-10 18:58:18","doi":"10.21203/rs.3.rs-7804717/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"31ecaac3-9b40-4e47-b3d2-5b477e7d1fd6","owner":[],"postedDate":"October 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-11T14:57:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-10 18:58:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7804717","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7804717","identity":"rs-7804717","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}