Physical activity for small- and medium-sized enterprises: what features work in real life? A Delphi study

Regular physical activity is essential for preventing noncommunicable diseases and benefits both employees and organizations. Although small- and medium-sized enterprises (SMEs) employ most of the European workforce, they are often underrepresented in research on workplace health promotion. Most existing evidence from initiatives to promote health-enhancing physical activity (HEPA) focuses on large organizations and lacks insights into feasibility within SMEs. This study aimed to identify real-life HEPA initiatives perceived as most feasible for SMEs and to explore expert consensus on transferable features. We conducted a three-stage hybrid e-Delphi study including a grey literature review, an expert survey, and expert panel discussions, integrating both quantitative scoring and qualitative discussion. Experts independently rated the feasibility of workplace HEPA initiatives and participated in moderated sessions to interpret the findings and identify transferable elements. A total of 714 real-life HEPA initiatives were identified and categorized according to behaviour and intensity. Of these, 390 were evaluated by 17 international experts using predefined criteria, including feasibility by company size. No initiative-level consensus was reached across the WHO European Region. Panellists identified transferable features (most frequently in active-living and exercise/fitness domains) and emphasized adaptability, low-threshold approaches and enterprise size as an indicator. This study contributes a structured analysis of feasible workplace HEPA initiatives for SMEs, using a Delphi-based consensus process. The findings provide guidance for developing practical tools tailored to the needs and capacities of SMEs in the European context.