niosh total worker health (2012)
TRANSCRIPT
10/18/2019
1
CPH-NEW is a NIOSH Center for Excellence in Total Worker Health®
www.uml.edu/cph-new
Total Worker Health®
Integrating Workplace Health Protection with Workforce Well-Being
Laura Punnett, Sc.D., Professor & Co-Directorand the CPH-NEW Research Team:
Univ. of Massachusetts LowellUniv. of Connecticut HealthUniv. of Connecticut Storrs
Univ. of Cincinnati, October 10, 2019
• “Policies, programs, and practices that integrateprotection from work‐related safety and health hazards with promotion of injury and illness prevention efforts to advance worker well‐being.”
• “…. a holistic understanding of the factors that contribute to worker well‐being.…. risk factors in the workplace can contribute to health problems previously considered unrelated to work.”
NIOSH Total Worker Health® (2012)NIOSH Total Worker Health® (2012)
www.uml.edu/cph-new
10/18/2019
2
www.uml.edu/cph-new
Traditional Workplace Programs(Separate “silos” & top-down approach)
Traditional Workplace Programs(Separate “silos” & top-down approach)
Safety and Health
Reducing hazards
and exposures
at work to
prevent injury
and illness
Health/Well-being
Reducing lifestyle
risk factors
to prevent
disease
www.uml.edu/cph-new
Work‐related
morbidity
Non‐work‐related
morbidity
Scientific evidence: The distinction between the 2 silos is not clear
Scientific evidence: The distinction between the 2 silos is not clear
10/18/2019
3
www.uml.edu/cph-new
‐ Removing obstacles to health‐ Fostering positive decision‐making
• “Social health promotion” ‐ activities at the community or societal level
– Environmental conditions that foster healthy behaviors
– Positive human relations at work that foster decision‐making and self‐efficacy
WHO/OMS on Health PromotionWHO/OMS on Health Promotion
[Ottawa Charter, 1986]
• Low‐wage workers (on average): lower decision latitude, more physically strenuous jobs, and more exposure to safety and other workplace hazards.
• WHP programs often have higher participation and effectiveness among higher‐SES employees.
Implications of TWH for socio-economic health disparities
Implications of TWH for socio-economic health disparities
www.uml.edu/cph-new
10/18/2019
4
Study contributions of work to “other” health outcomes; interactions between work & non‐work exposures
Evaluate strategies for integrated workplace interventions
Identify opportunities and obstacles
Key take‐home points:
‐ Work organization as a (preventable) source of risk factors for chronic disease
‐ Participatory intervention processes
‐ The “salutogenic” organization
Center for the Promotion of Health in the New England Workplace (CPH-NEW)
Center for the Promotion of Health in the New England Workplace (CPH-NEW)
www.uml.edu/cph-new
www.uml.edu/cph-new8
“…the way in which work processes are designed and arranged, [and] the broader organizational practices that influence job design.”
WorkOrganization
How often?
Who does what?
When?
How?
NIOSH (2002) The Changing Organization of Work and the Safety and Health of Working People
Work OrganizationWork Organization
10/18/2019
5
www.uml.edu/cph-new9
Work Organization
• Effort required• Frequency • Duration • (Lack of) variation
Physical loading patterns
• Job demands• Decision making• Social support• Job insecurity
Psycho-social
stressors
Work Organization
Work Organization
Who does what?
How often? When?How?
Work OrganizationWork Organization
• Panel surveys:
• Self‐administered questionnaires, distributed and collected at the workplace
• Response rates all 60%‐70%
• Primarily clinical workers (88% RN’s, LPN’s, nursing & medical aides)
vs
Baseline
12 m 24 m 60+ m
Safe Resident Handling
ProCare study of nursing home workersProCare study of nursing home workers
www.uml.edu/cph-new
10/18/2019
6
* Stressors: low decision latitude, low co‐worker support, night work, work‐family interference, perceived toleration of discrimination. Multi‐variable models adjusted for gender, education, region and age.[Miranda et al., 2015]
# of respondents inside bars
<4>
22
34 2614
0
5
10
15
20
25
30
35
0 1 2 3 4 5
Number of work organization hazards
Pre
vale
nce
(%
)
www.uml.edu/cph-new
ProCare: Risk of inactivity in nursing home workers, by number of occupational stressors*
ProCare: Risk of inactivity in nursing home workers, by number of occupational stressors*
*Hazards: low decision latitude, low supervisor support, second paid job, physical demands, workplace assault in past 3 months.All models adjusted for gender, education, region and age (unless stratified)
PR and 95% CI
0,0
1,0
2,0
3,0
All <40 >=40
Pre
vale
nce
rat
io 0
1
2
3
4-5
www.uml.edu/cph-new
ProCare: Risk of current smoking in nursing home workers, by number of occupational stressors*
and age group
ProCare: Risk of current smoking in nursing home workers, by number of occupational stressors*
and age group
10/18/2019
7
* Stressors: low decision latitude, low co‐worker support, night work, lifting heavy loads, workplace assault in past 3 months.
All models adjusted for gender, education, region and age (unless stratified)
PR and 95% CI
0.0
1.0
2.0
3.0
All <40 >=40
Pre
vale
nce
rat
io
0
1
2
3
4-5
www.uml.edu/cph-new
ProCare: Risk of obesity in nursing home workers, by number of occupational stressors*
and age group
ProCare: Risk of obesity in nursing home workers, by number of occupational stressors*
and age group
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
Men Women
Low/low
Low/high orhigh/low
High/high
Job iso‐strain = High job demands,low job control, &Low social support
www.uml.edu/cph-new
Change in waist circumference by job iso-strain group
Change in waist circumference by job iso-strain group
[Ishizaki et al. 2008]
10/18/2019
8
• Review of 22 prospective studies, evaluated on methodologic features
• Resources at work (including job control)
‐ cigs/day; + cessation; ‐ relapse
• High job demands
+ cigs/day; + cessation; + relapse
• Social support
‐ cigs/day; + cessation; ‐ relapse
www.uml.edu/cph-new
Work environment factors and smokingWork environment factors and smoking
[Albertsen et al. 2006]
www.uml.edu/cph-new
Adjusted odds ratio for “healthy lifestyle” (no risk factors*) at follow-up,
by category of work stress at baseline
Adjusted odds ratio for “healthy lifestyle” (no risk factors*) at follow-up,
by category of work stress at baseline
[Heikkilä et al., AJPH 2013]
* Healthy weight, nonsmoker, physically active, only moderate alcohol.
Meta‐analysis of 118 000 working adults in Europe
10/18/2019
9
The traditional HP behavioral targets (exercise, diet, smoking, obesity, etc.) are affected by work organization (decision latitude, social support)
Psycho‐social Stressors
CHD
Health Behaviors
Neuroendocrine mechanisms
32% of the effect is mediated through HB’s
[Chandola et al. Eur. Heart J, 2008]
Job Strain, Health Behaviors, and Coronary Heart Disease
Job Strain, Health Behaviors, and Coronary Heart Disease
• 8 focus groups of lower‐wage workers– Recruited through 2 community NGO’s
– Spanish‐speaking (6 groups)
– English‐speaking (2 groups)
• Topic: how the workplace affects dietary and/or exercise behaviors
• 63 participants
– 65% female; 83% Latino / 22% African/Afro‐American
– Cleaning, restaurants, construction, manufacturing, health care/human services
Obesity and working conditions: Unpacking the relationship
Obesity and working conditions: Unpacking the relationship
www.uml.edu/cph-new
[Nobrega et al., Health Promot Practice 2017]
10/18/2019
10
• Physical workload:
– “I don’t have the desire to do exercise after standing for 15‐16 hours.”
– “You come home and you are so tired that you either don’t want to eat, or you want to eat a lot.”
• Time pressure:
– “The work that three people used to do is given to one person. That creates more stress and eating more…”
• Low control:
– “Working in factories, you have to eat fast or get fired.”
Focus Group Findings:Physical & Psychological Demands
Focus Group Findings:Physical & Psychological Demands
www.uml.edu/cph-new
• Shift work & irregular shifts:
– I used to play football with my friends on Sundays, but now my days off are Tues. and Wed.
• Meal breaks:
– “At 10:00 a.m., they give me a 15‐minute break. I don’t have time to eat healthy food.”
– The mandated 30‐minute break is provided, but divided in two.
– I don’t know when during the work shift I will be permitted to take my break.
Focus Group Findings: Work SchedulesFocus Group Findings: Work Schedules
www.uml.edu/cph-new
10/18/2019
11
www.uml.edu/cph-new
Low decision‐making opportunity at work
is a primary risk factor for chronic
disease.
Thus a program’s process is as important as
its content.
Goals should include worker decision‐
making and empowerment.
www.uml.edu/cph-new
• Increase employee autonomy and decision‐making (“job control,” health self‐efficacy)
• Encourage participation and creativity in problem‐solving
• Structure healthier schedules
• Enhance interpersonal relationships at work
• Promote consistent and constructive feedback, fair recognition, and rewards for good work
Decision-making at work (or not) follows from how work is organized Decision-making at work (or not)
follows from how work is organized
10/18/2019
12
www.uml.edu/cph-new
Image credit: https://www.cdc.gov/niosh/twh/letsgetstarted.html
Hierarchy of Controlsfor Total Worker HealthHierarchy of Controls
for Total Worker Health
www.uml.edu/cph-new24
Employee health self-efficacy
Knowledge from employees’ experience
…to change behaviors …to change conditions…to make decisions …to support co-workers…to sustain the program
…to uncover root causes of physical, social, mental stress…to uncover root causes of unhealthy behaviors…to contextualize solutions
Why a participatory approach?Why a participatory approach?
10/18/2019
13
www.uml.edu/cph-new
www.uml.edu/cphnewtoolkit
Healthy Workplace Participatory Programwww.uml.edu/cphnewtoolkit
www.uml.edu/cph-new
Design Team (DT)Action & feedback
Action & feedback
• Forms DT, provides necessary resources• Invites DT to develop and propose interventions• Selects most feasible/desirable interventions• Helps promote & evaluate interventions
• Identifies & prioritizes health/safety issues• Conducts root cause analysis • Develops ideas for workplace interventions, selects best ideas to propose to SC
• Helps promote & evaluate interventions
Steering Committee (incl. Champion)
CPH-NEW Healthy Workplace Participatory Program (HWPP)CPH-NEW Healthy Workplace
Participatory Program (HWPP)
10/18/2019
14
www.uml.edu/cph-new
A participatory intervention planning method
Intervention, Design, and Analysis Scorecard (“IDEAS”)
Intervention, Design, and Analysis Scorecard (“IDEAS”)
The core of the CPH‐NEW “Healthy Workplace Participatory Program.”
Designing interventions with IDEAS is an iterative process.
[Nobrega et al., Applied Ergo 2017]
www.uml.edu/cph-new
Nurses in rural community hospital
Design Team Case Study #1Design Team Case Study #1
Rated top hospital in New Hampshire for safety and quality service
Winner of Outstanding Patient Experience Award
• Champion: Employee Health Nurse Practitioner/Manager
• Recruited members of Ergonomics Team and Safety Committee to participate
• Goal #1: To reduce patient handling injuries on a med/surg unit
10/18/2019
15
www.uml.edu/cph-new
DT surveyed nurses to identify risk factors for patient handling injuries.Findings: inaccessibility of lift equipment, staffing, irregular rest breaks, lack of exercise, fatigue from inadequate sleep. Engaging the nurses was essential to identify the work organization issues.“We had no clue about the scheduling, the amount of sleep people get, and that these guys don’t actually schedule breaks and coverage for breaks. That turned out to be the biggest issue …., which was a surprise to everyone.”
Design Team Case Study #1Design Team Case Study #1
www.uml.edu/cph-new
Purchased and installed more ceiling lifts. New sling coding, storage and laundering systems.More training on patient handling equipment.All nursing care technicians trained as “super users.” Increased staffing to facilitate rest breaks.
Design Case Study #1Design Case Study #1
0
0.5
1
1.5
2
2.5
3
3.5
4
2013 2014 2015
Year
Patient handling injury rates (per 100 FTEs)
2019: Workers’ compensation experience mod for 2019 is 0.54
10/18/2019
16
www.uml.edu/cph-new
Workers prioritized job stress from work overload• Problems in organizational communication, such as
unpredictable and duplicate work ordersManagement estimated $255K (US) for overtimeWorkers recommended (and helped develop) education for residents and office staff; and policies for the company’s computerized work order system.Allow technicians access to on-line system to manage work orders. Better mobile devices for work order access.
Real estate maintenance technicians
Design Team Case Study #2Design Team Case Study #2
www.uml.edu/cph-new
Qualitative evaluation
Design Team Case Study #2Design Team Case Study #2
Design Team Members: • A useful forum / tool for making improvements
• Solution‐driven: Made change happen
• Interaction‐driven: Improved communication between technicians and management
• Felt engaged and invested in the program
Management:• More aware of workers’ concerns
• Good solutions: resident education materials
• Personal development of DT members: problem‐solving, communication skills, accomplishment
• Wish to see the program continue
10/18/2019
17
www.uml.edu/cph-new
Perceived changes in company climate
Design Team Case Study #2Design Team Case Study #2
0% 20% 40% 60% 80% 100%
Communication between co-workers
Communication between staff andmanagement
)pportunities for decisionmaking
Opportunities to meet and plan
Opportunities to share my opinion
Recognition and rewards
Morale
% said improved
% said same
% said declined
www.uml.edu/cph-new
Corrections officers and supervisors• Mental health (trauma, emotional suppression)• Sleep quality & quantity• Work-family conflict (role behaviors)
Mental health hospital • Burnout
Office workers• Civility
Dept. of Transportation garage workers
Public elementary school teachers
Low-wage workers in primary care• Overweight
Other Design Teams Underway/RecentOther Design Teams Underway/Recent
10/18/2019
18
• Coordinate two functions that have different goals, legal responsibilities, and (often) internal incentives & resources
• Recognize work organization as a (preventable) source of risk factors for chronic disease
• Learn from workers about obstacles to healthy behaviors & feasible solutions
• Seek to create a salutogenic organization
Integration requires organizational change
Integration requires organizational change
www.uml.edu/cph-new
1) Program coordination across traditional silos
2) Assessment of both work and non‐work hazards / obstacles to health and safety
3) Interventions address both work and non‐work risk factors
4) Participatory engagement of all employees
Four essential indicators of “integration:” CPH-NEW criteria
Four essential indicators of “integration:” CPH-NEW criteria
www.uml.edu/cph-new
10/18/2019
19
www.uml.edu/cph-new
University of Massachusetts LowellSandy Sun, Center Administrator
Email: [email protected]: 978-934-3268
CPH-NEW general email:[email protected]
CPH-NEW main website:www.uml.edu/cph-new
Healthy WorkplaceParticipatory Program Website:
www.uml.edu/cphnewtoolkit
University of ConnecticutUConn Health, Farmington, CTUConn Storrs, Mansfield, CT
University of ConnecticutCPH-NEW website:
http://h.uconn.edu/cph-new
The Center for the Promotion of Health in the New England Workplace is supported by Grant Number1 U19 OH008857 from the U.S. National Institute for Occupational Safety and Health. This content issolely the responsibility of the authors and does not necessarily represent the official views of NIOSH.
Contacts & AcknowledgementsContacts & Acknowledgements
Sign up for our newsletter at “Contact Us”
www.uml.edu/cph-new
10/18/2019
20
www.uml.edu/cph-new
Stress -> burnout, depression, poor sleep, disengagement, alcohol, obesity, lack of exercise
Remember the hidden costsRemember the hidden costs
Indirect Costs• Lost productivity• Hiring/training
replacements• Presenteeism• Absenteeism
Non-visible
Costs
Visiblecosts
Indirect costs = 2‐3x direct costs
Direct Costs• Medical claims• Lost wages claims
Step 3The team sets selectioncriteria
These become Key Performance Indicators
“IDEAS” Design Process“IDEAS” Design Process
10/18/2019
21
Step 5Rate each solution by the KPIs; present alternatives to the SC for feedback.
DT develops 3 solutions,Each one as complete as possible
“IDEAS” Design Process“IDEAS” Design Process
Continuous Improvement
Design Team
PassiveSurveillance
Active Surveillance
HazardIdentification
SolutionDevelopment
Training
Monitor, Document, and
Alter
HWPP: “Design Team” ProcessHWPP: “Design Team” Process
10/18/2019
22
• Other metrics apply equally well to any workforce health or safety program, e.g.:
– Management commitment
– Training
– Accountability
– Ethics
– On‐going evaluation
Criteria should be unique to “integration”
Criteria should be unique to “integration”
A systems model for “Total Worker Health”
Corporate
Institutional
Group /Dept.
Interpersonal
Linnan et al., 2001: “individual behavior (e.g., participation in a work‐site health promotion program) is affected by multiple levels of influence.”
Intra‐personal