1. Innovative Worker Safety and Health Solutions: Total Worker Health ® for Small Businesses Thomas R. Cunningham, PhD National Institute for Occupational Safety and Health (NIOSH) Small Business Assistance Program

2. Disclaimer The findings and conclusions in this presentation have not been formally disseminated by the National Institute for Occupational Safety and Health and should not be construed to represent any agency determination or policy.

3. 3 MSHA Department of Health and Human Services (HHS) Department of Labor (DOL) OSHA Research and Authoritative Recommendations Centers for Disease Control and Prevention (CDC) NIOSH Occupational Safety and Health Standards-Setting & Enforcement Federal Government & Worker Health

4. From HR to Safety Traditional thoughts – HR warm and fuzzy, the right thing Increase attendance – Benefits decrease healthcare costs New considerations: – Safety professionals Productivity Control injury rates – Risk Management Control workers compensation costs

5. Comorbidities: Two or more medical conditions NCCI reports – Claims with comorbidities have significantly higher costs (example: obesity, hypertension and diabetes) – Hypertension is the most prevalent Claims left open because of delayed surgery due to uncontrolled hypertension increases the overall claim cost – Untreated medical conditions can result in a slower recovery from work related injuries leading to higher workers compensation costs

6. Small Businesses 35% of the U.S. workforce is in a firm with < 100 employees 89% U.S. businesses have < 20 employees 79% of U.S. businesses have < 10 employees Smaller firms need more external assistance with TWH, and deliver fewer workplace health promotion (WHP) and occupational safety and health (OSH) activities (Linnan et al., 2004; Sims, 2008). Firm size was the best predictor of involvement with WHP (National WHP Survey, 2004). Smaller businesses endure a higher burden of occupational injuries and illnesses (Mendeloff, Nelson, Ko, & Haviland, 2006).

7. The Total Worker Health ® Approach ….policies, programs, and practices that integrate protection from work-related safety & health hazards with promotion of injury and illness prevention efforts to advance worker well-being. 7

8. Focus must be on Fat Jobs….not Fat Workers

9. Total Worker Health ® Keep Workers Safe Invest More in Worker Health Create Worker Well-being

10. Individually-Focused Behavior Change Interventions Not Enough “It is unreasonable to expect people to change their behavior when the social, cultural and physical environments around them fully conspire against them….” Adapted by Dr. Casey Chosewood from M. Marmot/Institute of Medicine Report

11. Employee Wellness ≠ TWH Employee Wellness – No attention to factors arising from work itself that can lead to, or worsen, adverse health outcomes – Entire attention is on health problems of the worker related to lifestyle factors, not on work nor the employer’s responsibility for how work is organized – Primary motivation is medical cost savings Total Worker Health – Attention to factors arising from work itself that can lead to, or worsen, adverse health outcomes Work intensification Mandatory overtime and long hours of work New, more precarious, employment patterns Lack of paid sick leave

12. The Burden of Chronic Health Problems Cancer 1 553,000 deaths, 1.3M new cases/yr $89B in medical costs, $130B in lost work days & productivity Diabetes 1 >23.6M cases, >200,000 deaths/yr $116B for medical issues,$58B for lost work & productivity Cardiovascular Disease 1 80M cases, >870,000 deaths/yr $448B a year Tobacco-Related 1 438,000 deaths $96B in medical costs, $97B in direct costs Obesity Over 68% of Americans ages 20 and over are overweight or obese 2 Annual US health cost of obesity: $147 Billion 3 Aging – Workers ages 55-64 will increase by 36.5% between 2006 and 2016 4 12

13. Work-related RISKS Work design -Role conflict -Task overload, Low control -Difficulty balancing work and personal commitments -Poor interpersonal relationships Unsafe work environment – Extreme conditions (e.g., noise, heat) – Air quality – Machinery

14. Physical Health Consequences Injury – Musculoskeletal disorders – Cuts, burns Fatigue / inactivity Chronic health problems – Obesity – Diabetes – Cardiovascular disease

15. Mental Health and Lifestyle Consequences Burnout Depression Work – life conflict – Work – family conflict – Eldercare issues Lifestyle / health behaviors – Smoking – Alcohol and substance use

16. Organizational Outcomes Lost productivity – Absenteeism – Presenteeism Turnover Healthcare costs – Employees and their dependents

17. Presenteeism/ Absenteeism Occupational Safety and Health

18. From, Glorian Sorensen, 2010; Steven Sauter & Jeannie Nigam, NIOSH, 2011 Comparison of worksite intervention models

19. Integrated Approach EAP Group Health Compensation Programs Presenteeism/ Absenteeism Occupational Safety and Health Disability Workers’ Compensation Health Promotion Demand and Disease Management Adapted from: Liberty Mutual, 2010, Webinar, The Wellness-Work Comp Connection. Goetzel R. Examining the Value of Integrating Occupational Health and Safety and Health Promotion Programs in the Workplace. The NIOSH Total Worker Health TM Program: Seminal Research Papers 2012. DHHS (NIOSH) 2012-146 19

20. Benefits of Integrated Programs Enhance a culture of trust. Employees who feel that their employers are contributing toward a safe and healthy workplace may be more open to changing their personal risk factors. Improvements in employee health will reduce medical care costs AND enhance worker safety, productivity, and organizational competitiveness.

21. Benefits of Integrated Programs Improve effectiveness of occupational safety and health and health promotion programs. In a study of tobacco use cessation for blue-collar hourly workers, the smoking quit rates of workers in integrated interventions were more than double that of workers who had participated only in worksite health promotion programs. Increase participation in worksite health promotion programs. Workers who reported that their employers had taken action to reduce workplace risks are more likely to participate in a worksite health promotion program.

22. Benefits of Integrated Programs Address synergistic risks Occupational and personal risk factors influence each other and may have compounded effects. An integrated approach is important to jointly address work-related hazards and health behavior related risks. Reduce sickness absence and improve return on investment. One study in a manufacturing plant found that integrated interventions created greater reductions in sickness absence and key health risks, including ergonomic and cardiovascular risks and job stressors.

23. What do you mean by integration of health and safety?

24. Examples of Integrated Programs Respiratory protection - tobacco use Ergonomic consultations - arthritis management Stress management - workplace stressors Occupational health combined with a workplace primary care home model On and off the job hazards: falls, motor vehicle safety, hearing conservation, stretching/flexibility/lifting 24 HealthWork

25. Continuum of Approaches to Integration Independe nt efforts Integrated health & safety culture Coordinated Efforts Linked Messages Soresen et al, 2013, JOEM Integrated Evaluation/Data Multilevel Strategies Worker/ management engagement Supportive benefits/incentives

26. Indicators of Integration Organizational leadership and commitment Coordination between WHP and OSH and others Supportive organizational policies and practices Accountability and training Management and employee engagement Benefits and incentives to support OSH and WHP Integrated evaluation and surveillance Comprehensive program content Soresen et al, 2013, JOEM

27. Building on a “Culture of Safety” Culture of Safety Everyone is accountable Trending injuries Tracking near misses Implement Eliminating occupational disability Culture of Health Everyone is accountable Trending ill health Tracking health risks Implement screenings Eliminating all disability Fabius, 2014

28. Start small, scale up How might you do this? Choose one health condition on which to pilot an intervention which addresses organizational and personal risk factors Design a pilot to test the efficacy of the program Look for opportunities to capture encouraging signs of progress in the pilot program

29. Things you can do right now 1.Dedicate a portion of time at meetings for updates from other departments. Share experiences regularly and have routine two-way communications 2.Hold joint meetings between health protection and health promotion. As you make more progress, invite people from other areas, e.g., disability management, human resources, benefits, workers compensation, etc.

30. Things you can do right now 3.Discuss plans for the future so that health protection and health promotion leaders coordinate strategies. Address the shared goal of improving worker safety, health, and well-being by developing shared activities and objectives Encourage cross marketing, e.g., a health promotion initiative to reduce stress could be timed to coincide with presentations on work scheduling and job control 4.Ask employees what factors are getting in the way of their safety, health, work-life balance, or productivity. Employees can be the eyes and ears for safety, health, and well-being. What connections do employees see among the challenges they’ve identified? How can employees help develop or suggest low-cost, feasible solutions to their concerns? Do employees feel their privacy is fully protected?

31. Things you can do right now 5.Sponsor brief lunch-and-learns Share introductory materials on occupational safety and health with wellness staff and vice versa. Ask each group to cross-train others on foundational principles specific to their field 6.Invite staff to share their expertise to address shared goals Invite health protection staff to review health risk assessment (HRA) survey instruments to help make the connection between occupational risks and personal risk factors. Invite health education staff for an occupational risk assessment walk-through to see how improving health risks can reduce occupational risks. 7.Incorporate new information into trainings For example, a stress management workshop could include information on how organizational policies can reduce workplace stressors in addition to education on building employee resiliency

32. Things you can do right now 8.Consider sharing physical resources and space: anything from adjoining cubicles, to a break room, to an office, to the floor of a building. Encourage communication and informal collaboration among staff of health protection, health promotion, and others. 9.Give workers more flexibility and control over their working conditions and schedules whenever possible Ask employees how their working conditions and schedules can better support their safety, health, and well-being 10.Ensure that your built environment, policies, and work schedules enhance safety, health, and well-being Make sure workspaces and job tasks are safe and healthy. Provide paid time and free onsite access to healthier food, physical activity, health screenings, stress reduction resources, and health education

33. Current Project: TWH for Small Businesses in Cincinnati and N. Kentucky

34. Small Businesses Technologies/policies designed to reduce illness and injuries for large don’t work for smalls Workforce has more younger and older workers and is less-educated Smaller business managers report having less experience than those in larger businesses

35. Other Considerations when Targeting Small Businesses Need for ecological approach and multiple levels of intervention to support WHP efforts, including the community level (Faghri et al., 2010; Baker et al., 1996; DeJoy & Southern, 1993). Better approach might be to work with a local business council in a more limited geographic area (O'Donnell, 2012). The “business case” for adoption of TWH must include not only financial cost/benefit, but also personal effort required, time commitment, compatibility with existing systems and behaviors, and expected outcomes (Rogers, 2003; Maddux, 1999).

36. Local Examples of Total Worker Health ® Construction safety manager becoming wellness champion Child care centers adopting new staff wellness policies including ergonomics and stress managment

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39. Discussion What does Total Worker Health look like in your organization?

40. Thank you! Questions? Tom Cunningham NIOSH Small Business Program 513.533.8325 Tcunningham@cdc.gov