TOTAL WORKER HEALTH

The National Institute for Occupational Safety and Health (NIOSH) defines Total Worker Health (TWH) 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. Simply put, the TWH approach integrates workplace* interventions that protect workers’ safety and health with activities that advance their overall well-being. The TWH approach always prioritizes a hazard-free work environment that protects the safety and health of all workers. Simultaneously it advocates for integration of all organizational policies, programs and practices that contribute to worker safety, health and well-being, including those relevant to the control of hazards and exposures, the organization of work, compensation and benefits, work-life management, and a health-supporting built environment.

The focus of TWH is on safer, healthier workers and the role of work design and work organization in contributing to adverse health in working populations. For example, the Total Worker Health concept promotes research into how new patterns of employment, and emerging types of work restructuring, affect overall worker health, safety and well-being. This perspective recognizes that new patterns of work organization and nonstandard employment arrangements, and their link to illness and injury, is an important “occupational exposure” that needs investigation. At the same time, NIOSH recognizes that “non-occupational exposures” and “occupational exposures,” can act together to produce worker illness and injury.

By integrating NIOSH’s traditional focus on factors exclusive to work with attention to health conditions, the cause of which may include contributions from work, TWH seeks to enlarge the NIOSH impact to ensure worker health, safety and well-being.

*Work and workplaces in the 21st century are increasingly different from those in the 20th century. Although discussions of TWH refer to workplaces, NIOSH recognizes that a workplace could be a building with an assembly line, an office building, a motor vehicle, a home, the outdoor environment, as well as other settings and circumstances under which work is performed. Use of the word “workplace” is meant to include any physical or psychosocial environment in which work is performed.

To learn more about what Total Worker Health is, visit our webpage at http://www.cdc.gov/niosh/twh/totalhealth.html.

NIOSH coordinates the Total Worker Health Program through Office for Total Worker Health Coordination and Support (hereafter called the Office for Total Worker Health). The Office for Total Worker Health is part of the Office of the Director in the National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services. The Office for Total Worker Health focuses on advancing the safety, health, and well-being of workers by increasing the number of work environments that adopt evidence-based, integrated approaches.

Here are some examples of approaches and interventions that could support a robust Total Worker Health program in your organization (The items are not ordered by importance or priority).

• Control hazards and exposures
• Design work schedules and patterns to reduce stress and increase worker control
• Build safe, healthy environments
• Provide fair compensation and affordable benefits that enhance health
• Cultivate leaders and values that encourage healthy supervision, respect for workers, and responsible business decisions
• Create policies and environments that are inclusive and accepting of workers’ differences
• Create safety and health interventions that will also have community impact

Here are examples of TWH approaches as applied to specific workplace challenges:

• To prevent risk of musculoskeletal disorders, consider:
  • Reorganizing or redesigning how individuals do their work;
  • Providing ergonomic consultations; and
  • Providing education on arthritis self-management strategies.
• To reduce work-related stress, consider:
  • Implementing organizational and management policies that give workers more flexibility and control over their schedules;
  • Providing training for supervisors on approaches to reducing stressful working conditions; and
  • Providing skill-building interventions on stress reduction for all workers.

The following graphic “Issues Relevant to Advancing Worker Well-being Through Total Worker Health^®” illustrates a wide-ranging list of issues that are relevant to advancing worker well-being through a Total Worker Health approach. The list of issues relevant to Total Worker Health was revised, retitled and published in November 2015 with input from stakeholders. This updated list reflects an expanded focus for TWH that recognizes that new technologies, new working conditions, and new emerging forms of employment present new risks to worker safety, health and well-being. Understanding and reducing those risks are important elements of TWH. Additionally, this expanded focus recognizes that there are linkages between health conditions that may not arise from work but that can be adversely affected by work.

Download a PDF of this graphic

Implementing a Total Worker Health (TWH) approach is an ongoing effort in which workers’ safety, health, and well-being are top priorities. In many settings, TWH is a constellation of interventions, policy changes, and practices that create a robust culture of safety, worker protection, and greater health opportunity.

TWH programs are voluntary and participatory, giving workers a voice in the conditions of their work and a say in workplace offerings.

Putting TWH into action often starts with an organizational focus, looking at the challenges to keeping workers safe and healthy. Changes to policy, the built environment, and programs follow. Enduring, system-wide levers for better health take priority over individual-behavior-change programs.

On its Promising Practices webpage, the NIOSH Office for TWH highlights real-life examples of organizations that are moving toward such an approach. In addition, scientists both within the Institute and at the NIOSH-funded Centers of Excellence for Total Worker Health are leading a number of research-to-practice initiatives. Here are some examples:

• The NIOSH Training for Nurses on Shiftwork and Long Work Hours is a free online program that covers the complex relationships between work hours, sleep, and circadian rhythms and associated risks to safety and health from fatigue. Developed by researchers within the Institute, the training provides ways for managers and nurses to reduce risks, such as improving the scheduling and organization of work.
• The Total Worker Health Essentials video series, developed by the NIOSH-funded University of Iowa’s Healthier Workforce Center, addresses development, implementation, and evaluation of integrated approaches in small businesses. The videos show employers innovative ways to support Total Worker Health in their workplaces.
• Home care workers are an isolated and vulnerable occupational group who lack access to traditional safety and health resources. The COMmunity of Practice And Safety Support (COMPASS) program, led by the NIOSH-funded Oregon Healthy Workforce Center, aims to improve social support structures for caregivers. COMPASS combines tactics from peer-led social support groups with scripted team-based programs. Initial findings show that this highly repeatable workplace program improves social resources and prompts safety and health actions, such as talking about hazards with employers, using ergonomic tools, and increasing health-promoting behaviors.
• At a medium-sized manufacturing firm in the Upper Midwest, the SafeWell project (created by the NIOSH-funded Harvard T. H. Chan School of Public Health Center for Work, Health and Well-being) gathered those responsible for safety, health, and well-being. The goal was for them to work together on how each could use their roles and functions to improve worker safety and health.They began to share the initiatives on which they were working and see where they overlapped.The result? Working together saved time and helped them understand and support each other’s initiatives. One program coordinator noted, “It was a light-bulb moment for me...this is exactly what we should be doing. Couldn’t believe we weren’t doing it already.”
• The NIOSH-funded Center for Promotion of Health in the New England Workforce has developed a Healthy Workplace Participatory Program toolkit to assist employers in planning, designing, implementing, and evaluating integrated programs that promote overall safety, health and well-being. The toolkit, which includes worksheets and quick reference guides, draws upon a structured planning process that uncovers root causes to safety and health issues and engages workers in designing solutions.

The TWH approach supports a holistic understanding of the factors that contribute to worker well-being. Scientific evidence now supports what many safety and health professionals, as well as workers themselves, have long suspected—that risk factors in the workplace can contribute to health problems previously considered unrelated to work. For example, there are work-related risk factors for sleep disorders,¹ cardiovascular disease,² depression,^{3, 4, 5} obesity,^{6, 7} and other health conditions.

In recognition of these relationships, the TWH approach focuses on how the workplace environment can eliminate or lessen risks and enhance overall worker health, beyond traditional safety and health concerns. The TWH approach integrates workplace protections with activities that advance the overall well-being of workers. Establishing policies, programs, and practices in the workplace that focus on advancing the safety, health, and well-being of the workforce may be helpful for individuals, their families, communities, employers, and the economy as a whole.

By integrating NIOSH’s traditional focus on factors exclusive to work with attention to health conditions, the cause of which may include contributions from work, TWH seeks to enlarge the NIOSH impact to ensure worker health, safety and well-being.

Related: Visit the Research Perspectives on NIOSH Total Worker Health webpage, which lists scientific papers covering the rationale for a TWH approach.

Just as important as defining Total Worker Health (TWH), it is equally important to stress what TWH is not. TWH approaches are not the same as health promotion programs or newer employee “wellness programs.” Here are some clarifying examples:

• TWH is not a “wellness program” that has been implemented without simultaneously providing safe and healthful working conditions.
• TWH is not a collection of health promotion efforts at a workplace where the very way that work is organized and structured is contributing to worker injuries and illnesses.
• TWH is not consistent with workplace policies that discriminate against or penalize workers for their individual health conditions or create disincentives for improving health.

Rather, the TWH approach recommends that employers and workers collaborate to design safe and healthy workplaces that support all workers, regardless of individual or legal differences (e.g., employees vs. contractors, temporary workers or contingent workers), in both their professional and personal health goals.

Many workplace wellness programs focus on efforts to change individual behavior (such as smoking cessation and weight management) and/or biometric screenings—often with the stated goal of reducing healthcare costs and generating a return on investment for the employer, not the worker. These programs may also place much of the burden of change on the individual without addressing the overall influences of the work itself on worker health (for instance, long work hours & shift work, high work stress levels, unhealthy supervisory practices, ergonomic or trip/fall hazards, and other unhealthy work conditions).

Some current “wellness programs” lack scientific rigor, focus solely or heavily on individual behavior change, can be punitive and discriminatory, and are designed with short-term health insurance cost savings for the employer as their primary goal. Some place far too much emphasis on individually-focused behavior change and completely fail to address the nature, risks, and challenges of work itself on worker health. NIOSH considers the typical “employer wellness” programs to be inadequate because they ignore the contributions that work factors have on worker health and focus largely on medical cost savings.

Concerns have been raised about the potential for wellness programs to even harm worker health and well-being through discriminatory incentives, penalties that shift additional costs to workers through higher insurance premiums, or through incomplete privacy protections. Certain programs may divert resources from essential safety considerations for workers or fail to involve workers in the program design process. Such policies, programs, and practices do not lead to Total Worker Health (TWH).

Keeping workers safe is the foundation upon which a TWH approach is built. Employers and employer-worker partnerships wishing to sustain and improve worker health must make occupational safety and health the priority—the foundation for all other health improvements. A program that uses the workplace just as a platform (as opposed to being a risk factor itself) to improve population health can only be successful if it makes the health of the worker, as a worker, the centerpiece of its efforts. NIOSH believes TWH is the example to follow, not a “wellness” program.

Related: Read NIOSH Director Dr. John Howard’s opening address at the 1^st International Symposium to Advance Total Worker Health

Traditional occupational safety and health protection programs have primarily focused on ensuring that work is safe and that workers are protected from the harms that arise from work itself. Total Worker Health (TWH) approaches maintain this focus but emphasize the benefits of providing additional opportunities to workers to advance their health and well-being. For example, TWH approaches involve the broad spectrum of organizational programs that have a direct effect on the work experience and well-being of workers, such as human resources, organizational design, and disability management. Integrating these different but related functions is crucial to better protecting and advancing worker safety, health, and well-being.

In 2003, NIOSH started the Steps to a Healthier U.S. Workforce Initiative to explore the benefits of integrating the protection of workers from work-related safety and health hazards with efforts to prevent illness and injury, to advance the comprehensive safety, health, and well-being of workers. One of the important outcomes of this initiative was the 2004 Steps to a Healthier U.S. Workforce Symposium, which received overwhelming support from the stakeholder community (Schill and Chosewood 2013). Building on this enthusiastic support, the “Steps” Initiative developed into the WorkLife Initiative, and NIOSH convened a second highly successful symposium in 2007 (http://www.cdc.gov/NIOSH/TWH/history.html).

NIOSH funded two Centers of Excellence to Promote a Healthier Workforce to support program goals in 2005: the Healthier Workforce Center for Excellence at the University of Iowaand the Center for Promotion of Health in the New England Workplace. A third and fourth (Harvard T.H. Chan School of Public Health Center for Work, Health, & Well-being; Oregon Healthy Workforce Center) were funded in 2006 and 2011, respectively.

The Centers of Excellence for Total Worker Health (TWH) are cooperative agreements with the extramural research community to conduct multidisciplinary research, intervention, outreach and education, and evaluation activities related to TWH goals. The Centers play an important role in that they have close relationships with worker populations that can serve as “field laboratories” to elucidate how the new patterns of employment and emerging types of work restructuring affect worker health, safety and well-being.

In 2011, NIOSH renamed its efforts from “WorkLife” to the Total Worker Health Program and committed to further developing its intramural research program and partnership efforts with stakeholders. In 2014, NIOSH created the Office for Total Worker Health Coordination and Research Support to coordinate and advance TWH-related research, practice, policy development, and workforce development. On October 01, 2015, NIOSH released a new Funding Opportunity Announcement (FOA) to further support ground-breaking extramural research. The FOA emphasizes specific areas of particular interest to NIOSH’s enhanced perspectives on TWH, such as new employment patterns and evolving performance management approaches that negatively impact worker health. Also in 2015, the U.S. Patent and Trademark Office granted the mark “Total Worker Health” as an official registered trademark of the U.S. Department of Health and Human Services.

Related: For more on the program’s background, including a timeline, visit the History of Total Worker Health^® page

Illnesses and injuries experienced by working people represent those primarily caused by factors in the workplace and those in which work contributes significantly but only as one of a number of causes. Evidence supporting the role of diverse risk factors in illness and injury causation is frequently not used in an integrated way in developing ways to prevent worker illness, injury and disability (Schulte et al. Am J Public Health. 2012; 102:434-448). By integrating NIOSH’s traditional focus on factors exclusive to work with attention to health conditions, the cause of which work may be a contributor, TWH seeks to expand our understanding of health and to enlarge the contribution that NIOSH can make to overall worker health, safety and well-being.

NIOSH seeks to expand research to include factors exclusive to work with attention to health conditions, the cause of which work may be a contributor, and, “by developing innovative methods, techniques, and approaches” (29 U.S.C. Section 651(b)(5)), fulfill the purpose of the Occupational Safety and Health Act of 1970 “to assure as far as possible every working man and woman in the Nation safe and healthful working conditions and to preserve our human resources…” (29 U.S.C. Section 651(b)).

As a part of the Centers for Disease Control and Prevention (CDC) in the U.S. Department of Health and Human Services (HHS), NIOSH is also mindful that the integration of occupational safety and health protection with efforts to improve the overall health of American workers by preventing all-cause injury and illness, amplifies the efforts of CDC and HHS to promote Healthy People 2020.

For a comprehensive collection of papers considered foundational to the scientific rationale for the integration of health protection with activities that advance the overall well-being of workers, see http://www.cdc.gov/niosh/twh/perspectives.html.

NIOSH supports extramural Centers of Excellence for Total Worker Health to advance its mission to protect and promote the safety, health, and well-being of the diverse population of workers in our nation.

In addition, NIOSH TIC-2 is a searchable database of all NIOSH-funded publications. You may search by keywords “Total Worker Health” or any other terms of interest.

We encourage you to connect with the NIOSH Office for Total Worker Health by following us on Twitter (@NIOSH_TWH), joining our LinkedIn group (NIOSH Total Worker Health), and subscribing to our e-Newsletter, TWH in Action!

There are also a variety of ways to collaborate with the Office for Total Worker Health, including through the NIOSH Total Worker Health Affiliate Program, which bridges partnerships between NIOSH and public and not-for-profit organizations.

You can begin by sending an inquiry to TWH@cdc.gov. We look forward to hearing from you!

Total Worker Health (TWH) builds on NIOSH’s longstanding commitment to establishing the best scientific evidence to protect workers from exposures and hazards, with the increasing recognition that work and non-work factors have complex influences on the overall well-being of workers. In doing so, it complements the work of a number of government initiatives, including these:

• Healthy People 2020, which has established relevant Leading Health Indicators such as Social Determinants, Mental Health, and Environmental Quality.
• The Surgeon General’s National Prevention Strategy, led by the HHS Office of the Surgeon General, which lists Healthy and Safe Community Environments as one of four Strategic Directions designed to guide actions to demonstrably improve health.
• The Centers for Disease Control and Prevention (CDC) Workplace Health Promotion Program, which provides tools for comprehensive worksite health promotion programs.

The Office for TWH routinely collaborates with related CDC, National Institute for Health, and other HHS programs to ensure that the safety, health, and well-being of workers is considered from the broadest possible perspective—one that addresses occupational safety and health protection and integrates a range of other approaches to prevent injury and illness and advance worker well-being.