Defining ‘Integration’ for Total Worker Health®: A New Proposal

Abstract

The effects of work and the conditions of employment on health behaviors and intermediate health conditions have been demonstrated, to the extent that these relationships should be addressed in efforts to prevent chronic disease. However, conventional health promotion practice generally focuses on personal risk factors and individual behavior change. In an effort to find solutions to the myriad of health challenges faced by the American workforce, the U.S. National Institute for Occupational Safety and Health (NIOSH) established the Total Worker Health® (TWH) program. Originally organized around the paradigm of integrating traditional occupational safety and health protections with workplace health promotion, TWH has evolved to a broader emphasis on workplace programs for enhancing worker safety, health, and well-being. Among the research programs and approaches developed by investigators at NIOSH Centers of Excellence for TWH and elsewhere, definitions of ‘integration’ in workplace interventions vary widely. There is no consensus about which organizational or individual outcomes are the most salient, how much to emphasize organizational contexts of work, or which program elements are necessary in order to qualify as ‘Total Worker Health’. Agreement about the dimensions of integration would facilitate comparison of programs and interventions which are self-defined as TWH, although diverse in content. The specific criteria needed to define integration should be unique to that concept—i.e. distinct from and additive to conventional criteria for predicting or evaluating the success of a workplace health program. We propose a set of four TWH-specific metrics for integrated interventions that address both program content and process: (i) coordination and interaction of workplace programs across domains; (ii) assessment of both work and non-work exposures; (iii) emphasis on interventions to make the workplace more health-promoting; and (iv) participatory engagement of workers in pivotal ways during intervention prioritization and planning to develop self-efficacy in addressing root causes, skill transfer, building program ownership, empowerment, and continuous improvement. Thus we find that integration requires organizational change, both to engage two managerial functions with different goals, legal responsibilities, and (often) internal incentives & resources, and also to orient the organization toward salutogenesis. Examples from research activity within the Center for the Promotion of Health in the New England Workplace illustrate how these criteria have been applied in practice.

An Integrative Total Worker Health Framework for Keeping Workers Safe and Healthy During the COVID-19 Pandemic

“…Similarly, the Occupational Safety and Health Administration’s (OSHA) proposed injury and illness prevention program (I2P2) includes management leadership, worker participation, hazard identification and assessment, hazard prevention and control, and program evaluation and improvement ( OSHA, 2012 ). Furthermore, other NIOSH TWH Centers of Excellence and TWH affiliates promote organizational systems approaches with similar components, especially participatory approaches and comprehensive and collaborative strategies ( McLellan, 2016 ; Pronk, 2013 ; Punnett et al, 2020 ).…”

Safety and Health through Integrated, Facilitated Teams (SHIFT): stepped-wedge protocol for prospective, mixed-methods evaluation of the Healthy Workplace Participatory Program

“…In a participatory approach, employees are actively engaged in problem identification and prioritization, decisionmaking, implementation, and evaluation of the program. This supports effective program implementation and uptake because employees are well qualified to identify opportunities and obstacles present in their work environment [44,46]. Key features include collaboration, mutual education, and acting on results developed from research questions that are relevant to the community [47,48].…”

“…The U.S. National Institute for Occupational Safety and Health supports a Total Worker Health ® (TWH) research program to examine the combined effects of workplace and non-workplace factors on worker safety, health and well-being [ 40 , 41 ] and to evaluate trials of integrated workplace efforts. Evaluation literature is sparse to date and TWH approaches and goals vary among investigators [ 42 – 44 ].…”

“…New understandings emerge as participants reflect on interventions in light of their first-hand knowledge. Preliminary evaluations have shown high user acceptance and positive process outcomes [ 44 , 52 , 53 ].…”

Using a Mixed Method Approach to Tailor the Implementation of a Participatory Total Worker Health® Program in Public Healthcare Facilities

“…Within the U.S. workforce, more than one-third of adults have at least one chronic health condition, including diabetes, asthma, or depression (3), and the labor force participation rate for workers 65-years-and-older has consistently increased since 1996 (4). These trends have necessitated expanding traditional occupational safety and health focus to include more attention to workplace psychosocial stressors, and to consider the impact of the organization of work on health conditions such as cardiovascular disease, anxiety and depression, and obesity that previously were thought to be unrelated to working conditions (5). To respond to these challenges, the National Institute for Occupational Safety and Health (NIOSH) began promoting a comprehensive, interdisciplinary approach called the Total Worker Health ® (TWH) program (6,7).…”