Pronk, Nicolaas P. PhD
In 2004, as part of its “WorkLife” program, the National Institute for Occupational Safety and Health (NIOSH) sponsored the Steps to a Healthier US Workforce symposium. The symposium connected professionals from the occupational safety and health (OSH) and worksite health promotion (WHP) communities with the intention to facilitate progress toward a research, practice, and policy agenda related to integrated worker health protection and health promotion (IWHPP). Growing interest in coordinated efforts toward protection and promotion of health and well-being at the worksite has led to the recent introduction of the NIOSH Total Worker Health™ Program.1
Efforts to integrate OSH and WHP (IWHPP) programs are designed to avoid worker illness, injury, and disability and to promote health, function, and well-being. Functions traditionally considered to be under the auspices of OSH include activities such as compliance with Occupational Safety and Health Administration regulations, safety trainings, ergonomics, blood-borne pathogens, and radiation safety, among others. The focus of WHP has typically been on improving the health of workers through individual behavior change and group-based activities, although more recent efforts have focused on changes in organizational policies that reduce exposures to risks in the physical or psychosocial environment.2,3 IWHPP initiatives create multidisciplinary approaches that operate at multiple levels at the workplace, including the individual-, group-, organizational-, and environmental level. In the context of legal, social, political, and economic factors, IWHPP programs present opportunities for collaboration, integration, and synergy among multiple stakeholders.2
It may be assumed that integrated solutions are more effective than separate efforts to protect and promote health among workers.4 Evidence to support this assertion is needed and, hence, the purpose of this article is to briefly describe IWHPP program characteristics and place them in context, to discuss the rationale for the integration of OSH and WHP programs, to summarize what is known about the impact of these programs on health and economic outcomes, and to offer perspective on the state of current knowledge of this emerging field.
DESCRIBING AND DEFINING INTEGRATED WORKER HEALTH PROTECTION AND PROMOTION
Several conceptual frameworks and descriptive presentations of IWHPP efforts exist in the literature. An early description of an integrated health and safety model compared and contrasted the health promotion and occupational safety and health fields and proposed a model featuring three interactive systems—job demands and worker characteristics, work environment, and extraorganizational influences. This model explicitly recognized the need to address environmental factors in protecting and promoting worker health.5 As a result of the 2010 Towards Better Work and Well-being conference, sponsored by the Finnish Institute of Occupational Health, well-being at work was conceptualized as the interaction among a variety of factors and their relationships to productivity of workers, companies, and the nation as a whole. The critical factors identified in well-being included socioeconomic status, workplace factors, environmental factors, occupational hazards, health, and a host of demographic factors.6 The proceedings of a National Institutes of Health and Centers for Disease Control and Prevention chronic disease prevention workshop describe IWHPP as including the intervention targets of work environment (physical, organizational, and psychological), individual health-related behaviors, and the work–family–community interface in the context of legal, social, political, and economic factors that give rise to opportunities for collaboration, synergy, and integration.2 The American College of Occupational and Environmental Medicine describes components of workplace health protection and promotion programs to include efforts that are strategic, integrated, systematic, and that bring together environmental and safety policies and programs that prevent work-related injuries and illnesses along with activities that enhance the overall health and well-being of the workforce.7 The fusion of worker health protection and promotion was also described by the International Association for Worksite Health Promotion as a coordinated and comprehensive approach that includes programs and policies that address the physical and organizational work environment and promotes personal health among individual workers and their families. This description recognizes multilevel interventions and the roles that leadership, management, and individual employees play in the context of a corporate culture and the broader community.8,9 The World Health Organization introduced a global plan of action for worker health in 2007.10 The framework considers the worksite to be a primary setting for the protection and promotion of health among workers, their families, and the community. It presents an integrated approach to planning, delivery, and evaluation of programs organized around principles of business ethics, a strong business case, and a strong legal case. Finally, the NIOSH defines Total Worker Health as “a strategy integrating occupational safety and health protection with health promotion to prevent worker injury and illness and to advance health and well-being.”1 This program explicitly recognizes that health and well-being of workers is a shared objective by workers, their families, and employers and is impacted by the work environment and nonwork activities.
In an effort to summarize the various descriptions of IWHPP programs, Fig. 1 depicts key words, elements, factors, and characteristics as referred to by these sources into a single illustration that may support the creation of a clear and concise definition of IWHPP programs. The figure is not intended to distill the multiple factors presented down to a small set of basic elements. Rather, the intent is to recognize that many factors need to be considered, many factors interact or are affected by others, and thoughtful consideration of how these factors interrelate and are dependent on each other will likely provide insight in how to conceptualize and define IWHPP approaches. The emerging field of integrated worker health protection and promotion will benefit greatly from a clear and concise, yet open, broad and robust definition; one that will be sufficiently flexible to stimulate innovations and growth.
A comprehensive approach to worker health on the basis of multidisciplinary, multilevel, and integrated methods has been advocated in the literature since the late 1980s.5,11–18 A rationale to support the promotion of integrated programs may cite several reasons.
First, the simultaneous reduction of accidents or injuries and improvement of the health status of the workforce is perhaps the most obvious reason. The idea that an integrated approach can achieve both objectives more efficiently is appealing and makes common sense. Leveraging already available resources (such as safety-related resources and processes to further health promoting objectives) may also be considered good resource stewardship.1,7,18
Second, workers' risk of disease is increased by exposure to both occupational hazards and risk-related behaviors. For example, tobacco smoke contains toxic agents (eg, benzene) that may also be present in certain workplace environments. Workers who smoke may be doubly exposed to these agents because of their exposure to workplace hazards. These exposures may act synergistically when effects go beyond the addition of the two exposures alone, such as in the case of tobacco smoke and asbestos.19,20
Third, workers at highest risk for exposure to hazardous working conditions are also most likely to engage in higher risk behaviors or have recognized health risk factors such as obesity or hypertension. Working-class occupations tend to have more job risk exposures and are more likely to become injured or ill because of workplace hazards than professional employees.21–29
Fourth, integrating OSH and WHP may increase participation, engagement, and success rates (effectiveness) for high-risk workers. The fact that people often place the highest priority on those risks that are outside their personal control, are undetectable, and seemingly unfair30–32 (features associated with job hazards) may lead workers to perceive that reduction of occupational hazards is more important than personal health behavior changes.33 Skepticism about an organizational commitment to protect worker health may reduce employee participation in WHP programs.13,34,35 Conversely, employer efforts to create a corporate culture of trust and respect may enhance workers' receptivity and openness to messages and programs designed to change behaviors and improve health.36,37
Lastly, integrating OSH and WHP may benefit the larger organization through cost reductions or cost savings. Positive economic outcomes cannot be generated without intervention effectiveness. A systematic review by the Task Force on Community Preventive Services noted strong evidence of effectiveness for assessments of health risks with feedback and follow-up interventions.38 Despite some studies reporting mixed results39 or expressing cautious optimism for achieving a positive return on investment,40 evidence of positive economic impact of OSH interventions41,42 and WHP programs43–45 separately is supported by a growing literature. Nevertheless, evidence of cost savings as a result of IWHPP programs is only slowly emerging.4,46
EVIDENCE OF EFFECTIVENESS FOR INTEGRATED WORKER HEALTH PROTECTION AND PROMOTION PROGRAMS
IWHPP programs are those that integrate OSH and WHP components, not those that look at either one or the other. To summarize current knowledge, a literature search (PubMed database; http://www.ncbi.nlm.nih.gov/pubmed) was conducted to identify reports on IWHPP programs by using key words and search strings that were based on the results depicted in Fig. 1. Results were complemented by references identified from previously conducted reviews and committee reports. The health outcomes were conceptualized as changes in health behaviors and health risk factors as well as the impact of preventive efforts on injury and illness reduction. Economic outcomes were conceptualized as changes in productivity losses (ie, reductions in absenteeism- and presenteeism-related factors) as well as changes in health care expenditures. Identified IWHPP program reports were grouped according to the following categories: studies reporting on experimental trial results of interventions among workers, existing reviews or committee reports on IWHPP, and case study examples of intervention results specific to the experience of a single employer.
Eleven experimental studies were identified in the literature that included intervention and control or comparison groups and that provide direct evidence on the impact of integrated worker health programs on health-related outcomes and economic indicators. These studies are presented in Table 1 and include randomized controlled trials and quasiexperimental studies in a variety of workplaces and job types ranging from call centers to construction laborers. Studies included interventions related to tobacco, nutrition, physical activity, and weight loss from a health promotion perspective and office ergonomics, work organization, and employee trainings from a health protection perspective.
Across the 11 studies listed, all reported improvements in health-related outcomes. From an experimental design perspective, 7 of the 11 studies were randomized controlled trials46,48–52,54 and they all showed results in a similar, positive direction. Furthermore, the health outcomes tended to be supported by well-accepted, yet varied, measurement methodologies.
Economic outcomes in terms of productivity-related impact were reported by 5 of the 11 studies.46,47,54–56 The randomized controlled trials46,54 and one quasiexperimental study47 monitored productivity indicators directly using company records and monitoring systems. The remaining two quasiexperimental reports represented pilot investigations with a relatively small numbers of study subjects.55,56 One study56 reported productivity improvements, whereas the other55 did not.
Only one study reported on health care expenditures and found no significant effect.46 This study, a randomized controlled trial, measured health care expenditures through monitoring logs on the basis of the self-report.46
One additional observation of interest was reported by Sorensen and colleagues49 in the WellWorks-2 trial. Results of this study indicated improvement in health promotion program participation. Additional process evaluations have corroborated these findings.50,57,58
Several studies reviewed relate to interventions in the area of ergonomics where sit-stand devices are introduced into the work environment, thereby changing work organization and components of the physical and psychosocial environments.54–56 These studies recognize the contextual impact on psychosocial variables in the workplace and relationships to behavioral variables, specifically physical activity or sedentary behavior.59,60 As such, they integrate ergonomics with behavior change programs into an IWHPP-type application and look for effects on health and productivity-related outcomes. The three studies included in this review represent an innovative and emerging area of research.
On the basis of a review of experimental studies of IWHPP programs, it may be concluded that additional sufficiently powered randomized trials are needed. A consistent observation was the impact on health-related outcomes, but gaps remain related to economic outcomes.
Reviews or Committee Reports
In addition to a review of experimental studies, review articles and committee reports were identified that specifically addressed IWHPP programs. Identified reports are presented in Table 2 and include seven literature reviews and four committee reports that discuss health or economic outcomes. Included are systematic reviews64,65,67 and more general reviews of the literature,61–63,66 an in-depth report from the Institute of Medicine,18 and seminal research articles for the NIOSH Total Worker Health.4,17,68
In general, these reports communicate agreement that IWHPP programs generate positive health outcomes. The IOM Committee to Assess Worksite Preventive Health Program Needs for NASA Employees has presented its recommendations for program evolution at NASA and concluded that sufficient evidence of effectiveness supports the promotion of integrated worker health programs.18 Nevertheless, their recommendations were based on health outcomes only and did not include economic considerations.
Several reports presented positive economic outcomes in terms of productivity indicators.17,62,65–68 Few reports included economic outcomes in terms of health care expenditures, and those that did based their findings mostly on separate OSH or WHP study results.66–68 When the literature was considered in the context of a proposed conceptual model, the evidence base was considered limited for both health and economic outcomes.61
In summary, review articles and committee reports identified indicate mostly positive health-related outcomes. Some evidence suggests positive economic outcomes, mostly limited to productivity loss reduction, although this evidence seems limited to separate OSH or WHP program evaluations. Hence, the economic outcomes may be summarized as promising, but inconclusive evidence of effectiveness. A need exists for additional research specifically focused on the economic impact of IWHPP programs.
Single Employer Case Examples
To support a business case for IWHPP programs, the business community often looks at examples in practice that present a proof of concept. These examples are often referred to as “case examples” or “case studies” and may be helpful to illustrate what is possible and what processes need to be considered for successful adoption in the workplace setting. Several employer-specific case examples are presented in Table 3.18,69–77 It should be noted that this presentation of case examples does not constitute an exhaustive list, but provides benchmarks and best practice examples in support of the characteristics identified in Fig. 1. The case examples presented are generally well recognized in the industry as large, progressive organizations that tend to have a history of moving toward integrated solutions that optimize impact and efficiency.
In summary, the case examples report positive health-related and economic outcomes of IWHPP programs. All tend to have strategic measurement approaches in place that allow for ongoing, long-term reporting on key outcomes and integrate their efforts into management systems. Generally speaking, these best practice examples report outcomes that justify more focused research in the underlying factors and causal pathways for the impact of IWHPP approaches to improve health, reduce costs, and optimize performance at work.
PERSPECTIVES ON CURRENT KNOWLEDGE
On the basis of a review of experimental studies, review articles, committee reports, and best practice examples, it is concluded that sufficient evidence exists in the literature to support the contention that IWHPP programs generate improvements in the worker health status. Although emerging evidence indicates that IWHPP programs may generate positive productivity outcomes, the evidence base for health care cost reduction is considered insufficient.
The best practice examples presented in Table 3 recognize a relatively rich “practice-based evidence” foundation. Nevertheless, because an obvious publication bias regarding positive case examples exists, there is a need to interpret these examples with caution. A strong business case may justify the investment into IWHPP initiatives by employers.78 Legal, financial, and moral reasons represent the major drivers in decision making to invest and implement programs.79 On the OSH side, legal considerations tend to be the driving force behind the decision to implement because the achievement of minimal OSH standards is a regulatory requirement for companies. On the WHP side, studies show associations with low occupational injury rates and occupational illness (eg, asthma and cardiovascular disease)46,47,49,77,80–83 and positive financial impact,45,84 although controversy on financial impact remains.40,85,86 Because investment decisions for WHP are rarely prioritized on the basis of legal or regulatory rationale, financial and moral reasons (eg, Soler et al38 and Pronk87) tend to apply here.
Additional research on IWHPP initiatives has been proposed and recommended by others.2,17 On the basis of the results of this report, emphasis should be placed on high-quality studies designed to show the relationships between integrated programs and economic outcomes. Furthermore, attention needs to be paid to company size and industry type. Large employers tend to be well represented in the research conducted to date. Although some examples exist,88,89 small employers are represented less although most workers find employment in smaller companies.89 In addition, clear differences exist between the needs of companies and workers across various industries, such as manufacturing, construction, or health care. These differences range from the type of health problems most frequently encountered (eg, low back pain vs metabolic profiles) to the risk factors driving health issues, the prevalence of sickness absence, the work organization, and the benefits design for workers and their families, just to name a few.2
The integration of efforts to protect and promote worker health is undoubtedly important. Nevertheless, tools to measure integration remain elusive, which creates challenges for implementation and management. A clear need exists to define, measure, evaluate, and validate integration methods. As stated earlier, integration is more than merely adding worker health protection and promotion efforts together; it reflects shared commitment, goals, and objectives for worker health. Integration reflects strategic and operational activities that extend into deliberate and intentional interactions, partnerships, and interdependencies of efforts to protect and promote worker health. Sorensen and colleagues90 present a discussion on defining and measuring an integrated approach to worker health and outline a set of seven indicators of integration considered along a continuum. Important next steps include the testing and refinement of the proposed measures, the consideration and recommendation of operational implications and guidance, and the dissemination of results to support organizational adoption.
To deliver on the promise of IWHPP programs, it will behoove all stakeholders involved to collaborate more vigorously toward the creation, adoption, implementation, and maintenance of such programs.91 The stakeholders include human resources, OSH, and WHP professionals, but the roles of others such as employee assistance providers, health plan administrators, on-site care delivery providers, and community-based partners should be recognized as well. Whereas incentives such as health care cost containment, improved health and well-being, and reduced financial liability exist for IWHPP programs,91,92 the lack of a compelling business case that justifies resource investment remains a significant challenge.93 Future research should address these concerns and base specific hypotheses on information gathered directly from the stakeholders using both qualitative and quantitative methods.
The integration of worker health protection and promotion efforts is an area of emerging importance. Existing evidence supports an integrated approach in terms of health outcomes but will benefit significantly from research designed to strengthen the business case for employers of various company sizes and industry types.
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