Advances in Research

Much has been accomplished in TWH research, and future research will continue to build the evidence base and address existing gaps, as was made evident at the first two International Symposia to Advance Total Worker Health®. A seminal literature review in 2015 by Anger et al. (2015), which examined outcomes related to both OSH and well-being, found only 17 articles that met those criteria; the researchers concluded that additional research, particularly in the intervention research space, was warranted. These conclusions were mirrored by those from an independent panel of an NIH Pathways to Prevention Workshop, published that same year (NIH 2015). The independent panel looked at known benefits and harms of integrated research interventions, characteristics of effective ones, and factors influencing their degree of effectiveness. In doing so, they also highlighted the need for increased transdisciplinary research and for studies examining the psychosocial work environment and optimization of working conditions.

National Total Worker Health® Agenda

To advance TWH research and other related domains of the field, the NIOSH Office for TWH published the first National Occupational Research Agenda (NORA) in TWH. entitled National Total Worker Health® Agenda (NIOSH 2016b). Aligned with NIOSH tradition, the goal of the National Total Worker Health® Agenda was to encourage and stimulate varied stakeholders committed to concomitantly protecting workers from hazards in the workplace and advancing their well-being. These stakeholders include OSH practitioners, wellness professionals, labor organizations, employers, workers, researchers, educators, health care providers, and policy makers. The National Total Worker Health® Agenda’s four strategic goals, each supported by a number of intermediate and activity/output goals, are in the domains of research, practice, policy, and capacity-building and reflect stakeholder comments, peer-reviewed evidence (Cherniack et al. 2010; Hymel et al. 2011; Sorensen et al. 2011), and findings from two central TWH workshops (IOM 2014; NIH 2015):

  • 1. Research: Advance and conduct etiologic, surveillance, and intervention research that builds the evidence base for effectively integrating protection from work-related safety and health hazards with promotion of injury and illness prevention efforts to advance worker well-being.
  • 2. Practice: Increase the implementation of evidence-based 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.
  • 3. Policy: Increase adoption of policies that integrate protection from work- related safety and health hazards with promotion of injury and illness prevention efforts to advance worker well-being.
  • 4. Capacity building: Build capacity to strengthen the TWH workforce and TWH field to support the development, growth, and maintenance of 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.

Realization of these goals by partners over the next decade (2016-2026) will better safeguard the safety, health, and well-being of workers, support overall workforce vitality, and foster US economic prosperity.

Total Worker Health Research Methodology Workshop

Motivated by the described research gaps, in 2017, the NIOSH Office for TWH and the Healthier Workforce Center of the Midwest convened the Total Worker Health® Research Methodology Workshop, which assessed methodological and measurement issues for TWH intervention research. The objectives of this workshop were severalfold. Per prior expert recommendations, the first intent was to expand research and evaluation design options to include a range of rigorous methodologies and develop a core set of measures and outcomes to incorporate in all integrated intervention studies (NIOSH 2015). The second was to apply and develop rigorous, standardized methods for TWH interventions, as outlined in the National Total Worker Health® Agenda (NIOSH 2016b). The third was to fill gaps in the TWH intervention research space, as advocated by Anger et al. (2015) and Feltner et al. (2016), by focusing on methodological and measurement issues and creating and prioritizing common and comparable TWH-relevant measures and outcomes. Tamers et al. (2018) published the workshop findings, summarizing TWH research methodological and measurement approaches currently in use and novel ones that experts believe have the potential to advance the field through rigorous and repeatable TWH intervention research (Tamers et al. 2018).

Worker Well-Being Framework

The need to focus on and develop measures that comprehensively assess worker wellbeing and, in turn, advance the TWH scientific evidence base has gained increasing attention. To this end, the NIOSH Office for TWH partnered with the RAND Corporation to develop a framework for worker well-being (Chari et al. 2018). Using multidisciplinary literature reviews and an expert panel, a worker well-being model with five major domains was created:

  • 1. Workplace physical environment and safety climate
  • 2. Workplace policies and culture
  • 3. Health status
  • 4. Work evaluation and experience
  • 5. Home, community, and society.

The framework conceptualizes worker well-being as a subjective and objective phenomenon that is inclusive of experiences both within and beyond the work context. This effort lays the foundation for subsequent well-being measurement activities and will provide useful tools, such as a worker well-being survey instrument (under development), that will prove pivotal in helping to better measure and advance worker well-being.

Centers of Excellence for TWH

Though NIOSH leads the TWH program and conducts associated research, TWH research and related activities are conducted predominantly by six NIOSH-funded Centers of Excellence for TWH (Figure 4.2): Healthier Workforce Center of the

Locations of Centers of Excellence for Total Worker Health®

FIGURE 4.2 Locations of Centers of Excellence for Total Worker Health®.

Midwest (University of Iowa); Center for the Promotion of Health in the New England Workplace (University of Massachusetts Lowell and University of Connecticut); T.H. Chan School of Public Health’s Center for Work, Health, and Well-Being (Harvard University); Oregon Healthy Workforce Center (Oregon Health and Science University); Center for Health, Work & Environment (University of Colorado); and Center for Healthy Work (University of Illinois-Chicago) (NIOSH 2018b). These academic institutions are uniquely qualified to be among the top leaders in TWH research, and they are conduits for research-to-practice efforts that hold promise to impact the safety, health, well-being, and productivity of the US workforce. They use multidisciplinary research projects—including intervention-focused research, outreach and education, and evaluation activities—to improve our understanding of which evidence-based solutions work.

Research to Practice

As the interests of researchers and practitioners in varied disciplines (such as OSH, medicine, psychology, and public health) have converged, awareness has increased of the potential for work to contribute positively to safety, health, and well-being (Chari et al. 2018; Day et al. 2014; Hymel et al. 2011; NIOSH 2016a; Sauter & Hurrell 2017) and for this to be reflected through practical application. Although the scientific evidence base is still evolving, the uptake of the TWH concept has gained substantial traction among leaders and practitioners in OSH and other related fields who are interested in using, adopting, and adapting knowledge, interventions, and resources within the workplace. To respond to this demand, the NIOSH Office for TWH and its partners have developed practice-based tools, promising practices, and frameworks to guide the development and expansion of organizational cultures of safety, health, and well-being (NIOSH 2016c, 2016d). Many more such TWH resources are available than this chapter allows mentioning. Below, the authors highlight two.

Fundamentals of Total Worker Health® Approaches

A practice-oriented document published by the NIOSH Office for TWH in 2016, Fundamentals of Total Worker Health® Approaches: Essential Elements for Advancing Worker Safety, Health, and Well-Being (familiarly known as Fundamentals), is designed to help organizations identify and address job-related factors that may be contributing to health challenges. This unique workbook provides organizations with key practical self-assessment tools and guidance to develop actionable implementation steps that apply a TWH approach. Fundamentals focuses on five defining elements of TWH:

  • 1. Demonstrating leadership commitment to worker safety and health at all levels of the organization
  • 2. Designing work to eliminate or reduce safety and health hazards and promote worker well-being
  • 3. Promoting and supporting worker engagement throughout program development
  • 4. Ensuring the confidentiality and privacy of workers during program design and implementation
  • 5. Integrating relevant systems to advance worker well-being.

Hierarchy of Controls Applied to NIOSH Total Worker Health®

To link traditional OSH and TWH approaches, the NIOSH Office for TWH created a model to augment the traditional hierarchy of controls and provide a conceptual framework for prioritizing efforts to advance worker well-being. The Hierarchy of Controls Applied to NIOSH Total Worker Health® (Figure 4.3) guides researchers and practitioners in implementing workplace safety and health policies, programs, and practices that both protect workers and advance their health and well-being by

Hierarchy of Controls Applied to NIOSH Total Worker Health®

FIGURE 4.3 Hierarchy of Controls Applied to NIOSH Total Worker Health®.

improving the conditions of their work. The emphasis on addressing system-level or environmental determinants of health before individual-level approaches is a key tenet of the TWH approach.

Determining Overall Risk and Exposure for Worker Safety, Health, and Well-Being

Today’s environmental, public, and occupational health professionals have a greater understanding of the health risks associated with multiple stressors encountered, either simultaneously or in sequence, over the life span of individuals. They can also better estimate not only the additive or exponential impact of individual stressors but also the interaction between and among risk factors. Below, we highlight two approaches closely aligned with the TWH framework designed to assess overall risk and exposure.

Cumulative Risk Assessment

The US Environmental Protection Agency defines cumulative risk as the combination of risks posed by aggregate exposures (exposure by all routes and pathways and from all sources of each given agent or stressor) to multiple agents or stressors (EPA 2003). Application of CRA principles in the work setting should result in better understanding of complex exposures and health risks experienced by workers, with the potential to inform more effective controls and improvements in safety and health risk management overall. Such an approach, which parallels the TWH framework, may be especially important for helping employers prioritize the risks facing workers and for aligning strategies that address occupational as well as personal and community risks (Fox et al. 2018). The application of CRA approaches can also result in added appreciation of more complex exposures and, where applicable, assist in assigning or attributing proportions of risk across multiple domains. This has the potential to improve overall safety and health risk management, increase its efficiency, and provide greater insight into the connectedness of work and non-w'ork risks that may lead to earlier detection, screening, and intervention for disease (Fox et al. 2018).

This said, because of the power dynamics of the workplace, employers addressing personal risk factors may inadvertently create additional issues by placing greater onus on workers as more responsibility shifts to controlling risks outside the workplace. The potential for discrimination against certain workers due to personal, genetic, or behavioral risk factors may increase; in addition, employer intervention into personal life carries risks around privacy and autonomy. Supplementary health evaluations, screenings, and monitoring may also result, as risk factors are more readily recognized. Therefore, caution should be taken to ensure that these additional burdens do not outweigh the potential benefits that may accrue for workers through this broadened approach (Fox et al. 2018). The TWH paradigm emphasizes the need to address and modify aspects of the work organization and work itself for improved worker safety, health, and well-being, and is counter to any approach that would shift that responsibility onto the worker or blame the worker for any personal health challenges.

Total Exposure Health

TEH is an approach that assesses workers’ exposure to all hazards at work (environmental and lifestyle) and integrates these with wellness efforts to better safeguard workers’ long-term health (Zielhuis 1985). Exposure, as similarly gauged and evaluated in the TWH framework, is by nature broad and encompassing, accounting for legacy physical and chemical hazards as well as those seen in the evolving economy. Work stress, work organization, less formal and less secure employment arrangements, shifts in benefits provided, emerging technologies, and global and competitive demands all represent growing areas of risk to worker health and well-being. Within the context of TWH, TEH represents the cumulative lifetime experience of risk conditions, influences, and circumstances that impact an individual worker’s health and well-being. It recognizes the potential of well-designed work and secure employment as sources of gain for health and well-being.

Although recognition of and action upon the origins of exposure are important factors to consider, TWH interventions do not artificially divide these between w'ork and non-work. Rather, they recognize the interaction and influences of each on the other and look for integrated solutions to safeguarding work and well-being in a holistic w'ay. This approach also recognizes the frequent uncertainty as to the absolute attribution of exposures or the full causality of outcomes.

In the characterization of total exposure over a lifetime, workplace exposures provide significant contribution to overall health, including important influence on disability and life span. Most workers in the United States vastly underestimate the risks they face related to their work exposures, especially in the domains of motor vehicle accidents, cardiovascular disease, cancer, and respiratory health (Takala et al. 2012). Additionally, each worker brings in her or his own unique exposure history and physiological makeup to work each day, including genetic and epigenetic (the interaction between environmental influences and genetics) factors. These differences in predispositions mean that some workers may be more susceptible than other workers to adverse health outcomes from workplace exposures.


The TWH program, as envisioned by NIOSH, promotes a more integrated approach to worker safety and health and is complementary to the CRA and TEH approaches. As illustrated in this chapter, the TWH framework integrates multiple efforts to advance the health of workers, from the traditional control of workplace hazards and exposures to addressing work organization, compensation and benefits, work-life management, organizational culture and leadership, and the community and built environments (NIOSH 2015). The focus on prevention, inherent in the CRA and TEH strategies, emphasizes system-level or environmental determinants of health before moving to evaluation of individual-level approaches. This is also a crucial tenet of the TWH approach and is fully aligned with traditional industrial hygiene and OSH priorities, as shown on the traditional hierarchy of controls.

The TWH approach advocates that workers are entitled to a fair and complete assessment of the risks and exposures they face during all periods of employment.

This important transparency of the health consequences of work should drive all developments around CRA and TEH estimates and related interventions as well. Workers should have access to comprehensive risk and exposure information from the very beginning of employment and periodic updates, particularly if the facts change over time. Such information should be used in negotiations around conditions of work, hours, shift requirements, wages, and other compensation for higher-hazard duties.

Evaluating total risk and exposure may be daunting in its complexity and immensity, but this does not change the significance of the task and should not impede its pursuit, nor deter organizations from prioritizing it in the workplace. Although more research is needed, emerging CRA models and work in the area of TEH hold valuable promise and currently provide frameworks for the assessment of multiple risk factors emanating from various domains. Ideally, these will enable employers and workers to develop more effective controls and prevention strategies, bridging exposure and well-being—the very mission of TWH.

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