Total Worker Health : Bridging Worker Exposure and Well-Being

Sara L. Tamers, L. Casey Chosewood,

Heidi Hudson, and Chia-Chia Chang

National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention


The National Institute for Occupational Safety and Health (NIOSH) of the Centers for Disease Control and Prevention (CDC) 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 (NIOSH 2018). The evolving TWH framework has wide-ranging applicability for every safety, health, and well-being issue impacting current and future workers across all occupations and industries, making it relevant to all those who focus on occupational safety and health (Tamers et al. 2019). The NIOSH Office for TWH Coordination and Research Support (Office for TWH) leads and coordinates all activities related to TWH at NIOSH and serves as a conduit for many external TWH efforts.

In this chapter, the authors first describe the main features of the TWH- integrated approach and how it compares to customary siloed approaches in occupational safety and health (OSH) or wellness programs; highlight specific issues relevant to advancing worker well-being; and offer practical, applicable examples and resources. An overview of the 1st and 2nd International Symposia to Advance Total Worker Health® is then provided, followed by advances in TWH research and research-to-practice. Next, the authors discuss essential and progressing work in the areas of cumulative risk assessment (CRA) and total exposure health (TEH), and how these closely align w'ith the TWH paradigm. Finally, this chapter concludes with a review of pivotal partnership and stakeholder collaborative activities, central to all TWH endeavors.

What Is TWH?

The TWH approach prioritizes a hazard-free work environment that protects the safety and health of all workers (NIOSH 2017). Simultaneously, it advocates for integration of all organizational aspects that contribute to worker safety, health, and well-being. TWH tenets focus upon safer, healthier workers, and the important contributions of work design and work organization to the well-being of working populations. It also acknowledges work-related risk factors that contribute to safety and health issues previously considered unrelated to work, such as those that extend beyond the workplace. Establishing workplace policies, programs, and practices that focus on advancing the safety, health, and well-being of the workforce is beneficial for not only the workers but also their families, communities, employers, and the United States as a whole.

Comparing the TWH Approach

The TWH approach is an integrated, comprehensive, holistic one that differs from the more traditional, siloed, stand-alone approaches often found in worksite wellness or OSH programs (NIOSH 2017). Unlike the TWH framework, current worksite wellness programs sometimes lack scientific rigor; focus exclusively or heavily on individual behavior change instead of addressing the nature, risks, and challenges of work itself on worker health; can be punitive and/or discriminatory; and may be designed with short-term health insurance cost savings for the employer as the primary goal.

In contrast to the TWH approach, some traditional OSH programs have solely focused on safety and health by ensuring that workers are protected from the harms, hazards, and exposures that arise from work itself. Many lack integration with other important elements vital to improving worker health, such as human resources, benefits, employee assistance programs, risk management, and occupational health services. Safety reporting and accountability may also be separated from other worker-centered services. Keeping workers safe is the foundation upon which the TWH approach is built. More than that, however, the TWH approach maintains this focus while integrating additional opportunities for workers to advance their health and well-being.

The scientific rationale behind the increased success of integrating OSH protection activities with health-enhancing ones reflects the nature of challenges facing the future workforce, which are increasingly complex, multifaceted, and wide-ranging. These challenges require all-inclusive strategies. The TWH framework supports a holistic understanding of the factors that contribute to worker well-being and focuses on the ways in which the workplace environment can eliminate or lessen risks and enhance overall worker health, beyond traditional safety and health concerns and their associated approaches. More specifically, studies have shown that implementing a TWH approach to jointly and comprehensively address work-related hazards and other exposures addresses the synergistic risks that exist, leading to improved and sustained outcomes (DeJoy et al. 1993, NIOSH 2012, Sauter 2013, Sorensen et al. 2013).

Issues Relevant to Advancing Worker Well-Being through Total Worker Health®

A number of work-related issues impact worker safety, health, and well-being. Some are long-standing challenges, but others have more recently evolved as a result of emerging forms of employment, changes in the demographic distribution of workers, and new technologies, modifying the nature of work and how it is performed. Figure 4.1 depicts a set of salient, but non-exhaustive, issues pertinent to enhancing worker well-being through the TWH framework. It is categorized as follows (NIOSH 2015a): [1]

Issues relevant to advancing worker well-being through Total Worker Health®

FIGURE 4.1 Issues relevant to advancing worker well-being through Total Worker Health®.

To impact the future of work and improve outcomes for the future workforce, it is imperative that these issues be further understood and addressed. This effort involves exploring the linkages between safety and health conditions that may not always arise from work but can be adversely affected by it both directly and indirectly.

What TWH Looks Like in Practice

Worker well-being, which is the overall intended outcome of the TWH approach, characterizes quality of life with respect to a worker’s health and work-related environmental, organizational, and psychosocial factors (Chari et al. 2018). It is increasingly being recognized as a key element that contributes to an organization’s success and, hence, is also of increasing interest to employers (Vitality Institute 2016). In order to advance safety, health, and well-being, careful consideration must be given to the design of work. Jobs must be constructed to protect workers from harm while at the same time providing opportunities for skill utilization and stimulation, positive relationships, flexibility to meet the demands of life and work, and a sense of purpose and meaning (Chalofsky 2010; Day et al. 2014).

More practically speaking, organizations must prioritize multilevel, integrated approaches such as TWH to achieve marked success in preventing safety and health hazards and in promoting worker well-being and productivity. This prioritization must include continued support, commitment, and participation at all levels of leadership. Implementing a TWH approach is an ongoing, day-to-day, transformative, and participatory effort that first and foremost focuses on changes at the organizational level. Workers have a voice in the conditions of their work and are supported in voluntary participation in workplace health-enhancing offerings. Because organizations are not all alike in their size, resources, budget, needs, and workforce, various methods and strategies can help sustain a robust TWH program in any organization. These include but are not limited to

  • • Controlling hazards and exposures, including psychosocial ones
  • • Cultivating leadership norms and values that include expectations of healthy supervision, respect for workers, and responsible business decision-making
  • • Implementing organizational and management policies that offer workers more flexibility and control over their schedules and greater work-life balance
  • • Building environments that support and maintain safety and health
  • • Ensuring fair compensation and affordable benefits that recognize and reward workers and enhance worker health
  • • Creating policies and environments that are inclusive and supportive of workers’ diversity
  • • Using participatory approaches to reorganize or redesign work with reasonable demands
  • • Providing supervisors with skill-building, training, tools, and resources to motivate, engage, and empower workers and to help nurture and navigate employee-to-employee and supervisor-to-employee relations
  • • Offering workers opportunities for career advancement, continual learning, and professional development.

Evidence-based templates of TWH programs in practice across varied occupations and industries are publicly available (CPH-NEW 2019; CWHWB 2012; NIOSH 2015, 2016c, 2016d, 2018b; OHWC 2014) and serve as useful tools and resources.

The 1st and 2nd International Symposia to Advance Total Worker Health®

To introduce TWH to those with a stake and interest in OSH and worker well-being, and to provide a scientific sharing forum for those already immersed, the Office for TWH held the 1st and 2nd International Symposia to Advance Total Worker Health® in 2014 and 2018, respectively, at the National Institutes of Health (NIH) (NIOSH 2018a). The theme of the first symposium was simply “Total Worker Health,” and these were its goals: [2]

  • • Provide resources and strategies for practitioners working to improve the health, safety, and well-being of workers
  • • Inform a future research agenda to expand the evidence base for TWH.

The theme of the second symposium was “Work & Well-Being: How' Safer, Healthier Work Can Enhance Well-Being,” and these were its goals:

  • • Reaffirm TWH dedication and commitment to the safety and health of workers by prioritizing safety in all jobs
  • • Redesign the organization of work to promote a workplace environment that optimizes healthy opportunities through leadership, management, and supervision
  • • Reveal new strategies to redesign work to improve worker well-being through new links and solutions for work and chronic disease risks
  • • Introduce novel research methods and interventions for advancing TWH.

Both symposia brought together numerous partner organizations and more than 350 national and international scientists and practitioners representing academia, labor, industry, nonprofit organizations, and government. Participants and speakers featured those from human resources, employee benefits, employee assistance, workplace health, health promotion, organized labor, workers’ compensation, disability management, emergency response, public health, health policy, health economics, organizational and occupational health psychology, industrial hygiene, and related disciplines. The conference explored areas relevant to the TWH approach, such as TWH framew'orks, research methods, integrated approaches, implementation, and evaluation. Practical toolkits were presented for the fields of construction, transportation, agriculture, firefighting and first response, manufacturing, health care, and law enforcement and corrections. Topics focused on the changing workforce, new employment patterns, physical/built environments, community/ workplace supports, small businesses, vulnerable populations, organizational policies and practices, healthy leadership, ways to enhance the work-life continuum and work design, advances in return-to-work policies, disability and rehabilitation management, work stress and psychosocial factors, obesity, musculoskeletal conditions, mental health, fatigue, and violence.

Subsequent International Symposia to Advance Total Worker Health® are planned. These will continue to build off the previous ones and reflect the growth, development, and evolution of TWH, along with engagement from even more national and international partners and stakeholders.

  • [1] Control of hazards and exposures • Organization of work • Built environment supports • Leadership • Compensation and benefits • Community supports • Changing workforce demographics • Policy issues • New employment patterns.
  • [2] Showcase current research that advances the concept of TWH • Connect stakeholders who share an interest in TWH
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