In June 2011, the National Institute for Occupational Safety and Health (NIOSH) launched the Total Worker Health™ (TWH™) Program. This program is the natural evolution of NIOSH efforts that began in 2003 with the creation of the Steps to a Healthier US Workforce Initiative. One of the key events of this early initiative was the 2004 Steps to a Healthier US Workforce Symposium. With the enthusiastic support of NIOSH stakeholders, the “Steps” initiative grew into the WorkLife Initiative, and a second symposium was convened in 2007.
During these formative years, NIOSH focused on funding extramural Centers of Excellence to Promote a Healthier Workforce. Beginning in 2006 and 2007, centers were funded at the University of Iowa's College of Public Health, the University of Massachusetts Lowell/University of Connecticut, and the Harvard School of Public Health. A fourth Center was funded at the Oregon Health and Sciences University in 2011.
With the launch of the TWH™ Program, NIOSH reaffirmed its commitment to the concept of integration of occupational safety and health protection with health promotion and disease prevention activities in the workplace. In addition to continued extramural support, NIOSH turned its attention to intramural research projects and activities with the aim of incorporating TWH™ concepts into the NIOSH portfolio.
This article describes the TWH™ concept as envisioned by NIOSH, key issues related to TWH™, examples of TWH™ in the workplace, and current NIOSH program efforts to advance TWH™.
THE TWH™ CONCEPT
In a typical company, employee health, safety, and well-being are managed in a fragmented arrangement of departments that often operate in independent silos. Examples include traditional safety organizations, group health and disability programs, workers' compensation departments, employee assistance programs, health promotion programs and activities, and occupational health programs. The TWH™ approach is to assure a systematic and organizational linkage of all of these departmental functions to form an integrated whole, with a unified charge—protecting and promoting the total health, safety, and well-being of workers. Thus, TWH™ is a strategy integrating occupational safety and health protection with health promotion to prevent worker injury and illness and to advance health and well-being. This approach eliminates the either/or proposition, overcomes the disconnectedness that exists in many organizations, and provides comprehensive tools and approaches to creating environments where employees thrive.
Since the introduction of the NIOSH TWH™ Program, NIOSH has noted increasing visibility and adoption of the words total worker health. NIOSH actively encourages the use of these words to describe workplace strategies that are consistent with the integration of health protection and health promotion—the foundational element of the TWH™ concept. To overcome concerns that these same words might be used by some to describe programs or activities that lacked any level of integration or that focused solely on health protection or solely on health promotion, NIOSH chose to trademark these words, thus helping establish a specific and enduring meaning to the concept of TWH™. The intention of the trademark is not to prevent others from developing their own TWH™ Programs but rather to ensure a clear and consistent approach to preventing occupational injury and illness while advancing the overall health and well-being of workers.
ISSUES RELEVANT TO TWH™
To illustrate the broad scope of issues that NIOSH believes are relevant to TWH™, an “issues graphic” was created for at-a-glance impact. Issues relevant to TWH™ can be arranged in three categories: workplace, employment, and workers (see Figure 1). The examples in each of these categories represent critical areas of importance to worker health and well-being, but the lists are not meant to be exhaustive. Indeed, the breadth and reach of this program will evolve as the health and safety challenges of workers, the nature of work itself, and the needs of the global economy evolve.
The first group of issues relevant to a TWH™ perspective relates specifically to the workplace and to protecting worker health and safety. Workplace-related issues can be subcategorized as follows: control of hazards and exposures; prevention of injuries, illness, and fatalities; promoting safe and healthy work; and risk assessment and control. Control of hazards and exposures relates to both persistent and emerging challenges. These range from traditional chemical, physical, and biological hazards to the more pervasive, modern-day exposures related to the psychosocial work environment and the organizational demands of work. Prevention of injuries, illness, and fatalities and promotion of safe and healthy work are both issues related to protecting workers in the workplace. Risk assessment and control are tools for identifying and mitigating risks.
The relevance of TWH™ to today's workplace begins to crystallize when current employment-related issues and trends are considered, including new employment patterns, health and productivity, and health care and benefits. The global economy and competition for workers, products, services, and knowledge have created labor shortages for certain jobs and challenge the dominance of American innovation and creativity in the marketplace.1,2 The emergence of new employment patterns and more-common use of previously established employment arrangements, such as precarious and part-time work, has implications for worker health and well-being.3 Shifting population demographics, including increasing diversity and the prevalence of older workers, are changing the face of the American workforce. One of the most pressing examples of this change is the multigenerational workforce now commonplace in many employment settings. For the first time in history, there are four generations of employees working side by side.4 Each generation brings unique challenges to the workplace.
Given these trends, employers are necessarily shifting their focus to preserving human resources through health and productivity management to remain competitive. At the same time, benefits systems are under increasing stress with rising health care costs. Adding to the complexities of health and well-being in the workplace, regulations arising from the Americans with Disabilities Act,5 the Health Insurance Portability and Accountability Act,6 the Genetic Information Nondiscrimination Act,7 and the Patient Protection and Affordable Care Act8 impact the responsibilities of and programs and services offered by employers.
The third group of issues relevant to TWH™ includes those related to workers and the promotion of their health and well-being. Promoting optimal well-being is a multifaceted endeavor that includes employee engagement and support for the development of healthier behaviors, such as improved nutrition, tobacco use cessation, increased physical activity, and improved work/life balance. There are numerous health and well-being assessment tools available in the marketplace to assist with achieving this goal. Older workers, in particular, are concerned with aging productively and preparing for a healthier retirement.
This group of TWH™ issues also addresses populations of workers that may have higher health risks. Younger workers are one such group. They are more likely to be concerned with education and skill-level gaps that sideline them from successful careers, especially given their painfully high levels of unemployment or underemployment. In addition, the modern workplace includes groups who face unique challenges, such as low-income workers, those transitioning from military to civilian careers, and differently-abled workers. Programs that protect compensation and provide support during times of disability are equally important for promoting health and well-being.
EXAMPLES OF INTEGRATION
Programs that integrate occupational safety and health protection with health promotion and disease prevention range from simple to all-inclusive and everything in between. Examples that are relatively straightforward include the following:
- Regular joint meetings of safety teams and health promotion teams
- Combined safety and health promotion workgroups or steering committees
- Respiratory protection programs that simultaneously address tobacco use
- Ergonomic consultations and interventions that also cover joint health and arthritis management strategies
- Stress management efforts that first diminish workplace stressors and then build worker resiliency
- Integrated programs on topics addressing fall prevention, motor vehicle safety, first aid, hearing conservation, stretching and flexibility, and safe lifting for both work and community environments
Examples of more-inclusive programs include the following:
- Comprehensive screenings for work-related and non–work-related health risks
- Full integration of occupational health clinics, behavioral health services, traditional safety protection, health promotion programs, coaching, employee assistance programs, nutrition counseling, disability, workers' compensation, employee benefit programs, and community-based primary care services
- Occupational health combined with a workplace-delivered, patient-centered medical home model
Integration of occupational safety and health protection and health promotion and disease prevention creates improvements in the work environment and the conditions of work that benefit all workers, even for those not actively participating in voluntary programs. A culture of integration increases participation in both health protection and health promotion programs, especially among workers who are often the hardest to reach.9 Ultimately, the potential of integration is decreased injury, illness, disability, and absenteeism rates based on reductions in individual health risks.10 In addition, overall health-related costs decline, including workers' compensation, personal health care costs, and absenteeism- and presenteeism-related costs. From an employer's perspective, a culture of integration contributes to worker productivity. For workers and their families, TWH™ offers a promise of improved health and well-being.
THE NIOSH TWH™ PROGRAM
The mission of the NIOSH TWH™ Program is to examine a broad scope of workplace, employment, and workforce factors to offer to the nation policies, programs, and practices to better protect and promote worker health. The aims of the program are as follows:
- Promote adoption of policies and practices proven to protect and improve worker health both on and off the job
- Motivate transdisciplinary collaboration among investigators focused on preserving and improving the health of people who work
- Overcome the traditional separation of the occupational health and health promotion professional communities, encouraging synergistic interventions
- Encourage and support rigorous evaluation of comprehensive, integrative approaches to TWH™
NIOSH advocacy for TWH™ includes six major areas of focus: national leadership, research, partnership development, marketing and communications, Centers of Excellence to Promote a Healthier Workforce, and development of a TWH™ program for NIOSH employees.
Over the past 2 years, NIOSH leadership for TWH™ has revolved around the institute's convening power. In April 2012, NIOSH cosponsored with the American College of Occupational and Environmental Medicine an invitational summit on Advancing the Understanding of Health Protection and Promotion in the Context of an Aging Workforce. This summit explored issues related to the aging workforce, including barriers to integrating health protection and health promotion programs, and generated recommendations for best practices to maximize contributions by aging workers.11 Later that same year, NIOSH cosponsored (along with the Department of Veterans Affairs, Centers for Disease Control and Prevention, Department of Health and Human Services Federal Occupational Health, US Office of Personnel Management, Department of the Army, President's Council on Fitness, Sports and Nutrition, and the Eagleson Institute) the Healthier Federal Workers Symposium to address TWH™ issues and opportunities within the federal workforce. In May of 2013, the Work, Stress, and Health Conference, jointly sponsored by NIOSH, the American Psychological Association, and the Society for Occupational Health Psychology, featured a subtheme of protecting and promoting TWH™. This international meeting created a forum for worldwide attention to occupational safety and health protection integrated with health promotion and disease prevention. Finally, seminal research articles that were originally commissioned by NIOSH for the 2004 Steps to a Healthier US Workforce Symposium were updated and published as a research compendium, The NIOSH Total Worker Health™ Program: Seminal Research Papers 2012.12
In an effort to build the research evidence for this approach, NIOSH includes TWH™ in its own program portfolio. In fiscal year 2013, two “small” (as defined by funding amounts) National Occupational Research Agenda research projects were funded. One of these projects will examine promising practices for healthy aging, and the other will focus on TWH™ for small businesses. A third project was funded under a different competition and is studying fatigue prevention for commercial pilots. Fiscal year 2014 funding will include support for one new “large” National Occupational Research Agenda research project that will explore the effect of a wellness grant on worker health and safety. To integrate the TWH™ approach into the NIOSH research culture, an institute-wide seminar series was initiated. This series creates an opportunity for extramural scientists to present their TWH™-related work and then engage in scientific discourse with NIOSH researchers.
To advance TWH™ nationally, NIOSH is actively engaged in partnership development. In 2011, NIOSH initiated an annual, invitational TWH™ National Expert Colloquium. Three colloquia have been convened to date, featuring national experts who spent a day sharing their individual perspectives on the intersection of occupational safety and health protection and health promotion and disease prevention. These national experts, including representatives from private industry, academia, labor, and government, help stimulate our thinking about NIOSH programmatic directions. The National Institute for Occupational Safety and Health also collaborates with the Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion on projects of mutual interest. These collaborations include NIOSH contributions to the Centers for Disease Control and Prevention Worksite Health ScoreCard and steering committee membership for the National Healthy Worksite Program.13,14
As the NIOSH TWH™ Program has developed, we have used social media and other on-line communication tools to share and exchange program accomplishments, research, and promising practices relevant to the integration of health protection and health promotion and to expand on-line visibility of TWH™. One of the most widely consumed outputs of our communication efforts has been an electronic newsletter, TWH™ in Action! Published quarterly, this e-newsletter now has more than 50,000 subscribers.15 A popular feature is the regular article, Promising Practices for TWH™, which tells the story of a company or organization that is taking steps to actively engage in integrated health protection and health promotion in its workplace. The NIOSH TWH™ Program is also active on social media channels, such as Twitter (www.twitter.com/NIOSH_TWH) and LinkedIn (www.linkedin.com/groups/NIOSH-Total-Worker-Health-4473829/about). The newly redesigned Web site (http://www.cdc.gov/niosh/TWH/) remains the primary vehicle for keeping information easily available for those who share an interest in TWH™. The Web site is organized around major headings, including essential information about the TWH™ Program, information about the TWH™ research portfolio, how to stay connected, tools and resources, and selected TWH™ topics. Information on the TWH™ Program can also be found on Wikipedia (http://en.wikipedia.org/wiki/Total_Worker_Health).
As previously mentioned, NIOSH currently funds four Centers of Excellence to Promote a Healthier Workforce. The NIOSH Program and the Centers work closely together to coordinate activities and mutual interests through a coordinating committee composed of directors of each center and core team members of the NIOSH TWH™ Program. One of the centers, the Healthier Workforce Center for Excellence at the University of Iowa's College of Public Health, organized and hosted the first “Total Worker Health™ Symposium—Safe, Healthy and Cost-Effective Solutions” in November 2012.
The National Institute for Occupational Safety and Health has also risen to the challenge of “walking the TWH™ talk” by bringing TWH™-related programs and activities to our own employees. The HealthiestYou/HealthiestNIOSH program created a personalized wellness program option for employees, including a health risk appraisal and electronic coaching. Pilot programs are in process for sit–stand workstations and walking workstations. The NIOSH program also targets special events and campaigns aimed specifically at the needs of the employee population.
Faced with ever-increasing challenges to meet stakeholder requests for expanding services and activities, the NIOSH TWH™ Program has focused on selected high-impact future directions. These include the following:
- Leadership to develop a national consensus statement of TWH™ best practices
- National leadership to develop a TWH™ national research agenda
- Intramural TWH™ research program development, targeting priority topics and populations
- Partnership development to include working alongside a super-size employer to explore TWH™ in practice
- Continuation of the annual, invitational TWH™ National Expert Colloquium
- Communication, outreach, and engagement programs for selected media campaigns, coordinated with the Centers of Excellence to Promote a Healthier Workforce, that address TWH™ knowledge gaps
- Ongoing coordination with the Centers of Excellence to Promote a Healthier Workforce in areas of mutual research interest
As we strive to meet current and future challenges related to demands for information and practical solutions to real-world needs, the TWH™ Program mission will remain firm in its commitment. We will continue to focus our attention on the broad scope of workplace, employment, and workforce issues and offer policies, programs, and practices to better protect and promote the health of working men and women.