Integrated Interventions for Improving Total Worker Health: A Panel Report From the National Institutes of Health Pathways to Prevention Workshop: Total Worker HealthWhat's Work Got to Do With It?
Nearly 50 years ago (December 1970) the Occupational Safety and Health Act was signed into law to ensure safe and healthful working conditions for men and women in the United States. The subsequent years brought many changes, including distribution of the workforce across various sectors, an aging and increasingly diverse workforce, and progressively porous boundaries between work and home. A growing segment of the population works part time; many persons hold several jobs, and workers are employed as contractors. According to 2014 data from the Bureau of Labor Statistics, 4679 workers were killed on the job (1) Private industry reported nearly 3 million work related, nonfatal injuries and illnesses (2) underscoring the need for vigilant workplace safety and protection from exposure to chemical, physical, and biological hazards. That the relationship between work and health is not unidirectionalthat is, that work affects health, and health affects workis increasingly being recognized. Observational studies show that the average cost of workers' compensation increases substantially for employees with comorbid conditions. Other analyses show an association between workers with chronic health conditions and an increased likelihood of a safety incident or injury occurring on the job. Safety, health, and well being may benefit from a broad view of the potential role of the workplacenot only in reducing work related deaths, injuries, and illnesses, but also in preventing and managing comorbid conditions that reduce workplace productivity and life expectancy. The Total Worker Health (TWH) concept, defined by the National Institute for Occupational Safety and Health (NIOSH) as policies, programs, and practices that integrate protection from work related safety and health hazards with promotion of injury and illness prevention efforts to advance worker well being, encompasses this perspective (3) This concept integrates siloed (isolated) research and programmatic efforts in occupational safety and health and worksite health promotion, including studies on developing and evaluating worksite initiatives that unite the 2 approaches. In addition, the TWH concept expands the focus of occupational health research to this broader agenda and applies a public health perspective that evaluates contextual (for example, organizational and environmental) and individual determinants of health risk, with the objective of developing a robust, evidence based approach to improving workplace health and well being. From 9 to 10 December 2015, the National Institutes of Health (NIH) convened the Pathways to Prevention workshop Total Worker HealthWhat's Work Got to Do With It? The workshop's goals were to ascertain the scientific evidence related to integrating worksite health promotion with occupational safety and health protection, including factors that influence the effectiveness of an integrated approach (what works and for whom) and develop research recommendations to better understand the effectiveness of integrated interventions. An independent panel considered a commissioned systematic evidence review of the literature in integrated interventions, prepared by the RTIUniversity of North Carolina Evidence based Practice Center (4) along with opinions presented by a group of experts and workshop participants. The evidence synthesis and public workshop agenda focused on answering the following key questions: What studies assess integrated interventions? What are the known benefits and harms of integrated interventions? What are the characteristics of effective integrated interventions and programs? What factors influence the effectiveness of integrated interventions? This report summarizes the main findings, conclusions, and recommendations for future intervention research about the TWH model. The Appendix lists the participants, panelists, and speakers from the workshop. State of the Science in Integrated Interventions What Studies Assess Integrated Interventions? The literature on integrated interventions is sparse, and their effectiveness is unclear. A comprehensive review found 24 studies since 1990, most of which were published before 2011 when NIOSH framed the TWH model (4) The studies examined disparate worksites (for example, manufacturing, health care, and social service) contexts (for example, small vs. large businesses) business sectors (such as health care) and populations (for example, blue vs. white collar) across health outcomes (such as physical activity, worksite injury, diet, and smoking status) The content, approach to implementation, and outcomes are inconsistent across studies. What Are the Known Benefits and Harms of Integrated Interventions? Fifteen studies met methodological inclusion criteria and assessed intermediate and health and safety outcomes (4) Nine investigated health and safety outcomes, whereas 11 addressed intermediate health outcomes assumed to have long term health benefits. Health and safety outcomes included workplace safety, quality of life, physical and psychological well being, self rated health, health symptoms, and stress. Intermediate outcomes included tobacco cessation, decreased use of alcohol and other drugs, body mass index, weight, blood pressure, cholesterol level, physical activity, healthy eating behaviors, hazardous work exposures, and near miss hazard events. Two thirds of the studies had a high risk of bias by using standardized criteria; no studies had a low risk of bias. Outcomes with evidence having a medium risk of bias included quality of life, stress, self rated health, smoking cessation, healthy eating, and physical activity. Overall, the strength of the evidence about all health and intermediate outcomes was low, meaning that the reviewers had low confidence that the evidence reflected the true effect. No studies addressed health care utilization outcomes (for example, primary care visits, delay in seeking needed health care, hospitalization, or emergency department visits) or potential harms (for example, adverse effects on work or family life or violation of privacy) What Are the Characteristics of Effective Integrated Interventions and Programs? With so few effective integrated interventions, it is challenging to describe their key characteristics. The information on intervention development, implementation, and outcomes was limited among studies showing benefits (4) Thus, the feasibility, quality, effectiveness, and scalability (ability to implement interventions in work settings of various size) of interventions were difficult to assess. The few reports on scalability highlighted the common feature that workers participated in the planning, design, development, or implementation of the intervention. The potentially effective interventions were multicomponent, complex, and well disseminated. What Factors Influence the Effectiveness of Integrated Interventions? Given the variety of contexts in which the TWH model can be implemented and studiedwith variation in such factors as employers, work environments, and populationsunderstanding the factors that influence the effectiveness of integrated interventions is important. Although a handful of studies reported on contextual factors (for example, union membership, health insurance, or co occurring worksite safety interventions) no studies included a formal analysis of possible variation in intervention effectiveness according to individual, worksite, organizational, or community factors (4) Thus, no evidence on factors that influence intervention effectiveness and scalability is currently available. Future Directions and Recommendations The integrated intervention studies done before 2011, when NIOSH formally articulated the TWH construct, were retrofitted to the TWH model to inform questions about intervention effectiveness. Hence, it is not surprising to find limited evidence and a lack of peer reviewed empirical studies of the effectiveness of integrated interventions beyond a few studies of medium rigor that show effects on behavioral risk factors (for example, smoking cessation, consumption of fruits and vegetables, and physical activity participation) The current state of the science offers insufficient evidence to determine the overall harms or benefits of integrated interventions. In the absence of this evidence, it is impossible to describe the characteristics of effective integrated interventions or contextual factors that influence effectiveness. Although the paucity of evidence may be discouraging (4) the field of TWH research is young and growing. The presentations, comments, and questions showed the passion, commitment, and engagement of researchers, businesses, labor representatives, and federal agencies. The collective goal was to ensure that future evidence based approaches would optimize the safety and health of U.S. workers. Together, we reached a clear consensus that application of the TWH framework to integrated interventions requires research that extends beyond the lens of individual level behavioral risk factor reduction. Several experts called for studies about optimizing working conditions (for example, chemical exposures or ergonomic factors) and work environment (for example, psychosocial stressors, job demands and scheduling, and familywork balance) to reduce health risks and promote well being. The panel was struck by the similarity among the research needs across the 4 key questions. To accelerate the progress of TWH interventions, we recommend the following overarching strategies. 1. Convene a meeting of stakeholders to set research priorities for integrated interventions. The NIH and Centers for Disease Control and Prevention, along with other funders and stakeholders (for example, private sector organizations and foundations) should engage key stakeholders to identify and prioritize research needs. As part of the strategic planning process to support integrated interve
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