Abstract
Dear Editor,
As co-managers of the National Institute for Occupational Safety and Health (NIOSH) Total Worker Health® (TWH) Program, we read the Campbell and Burns article titled “Total Worker Health Implications for the Occupational Health Nurse” published in the July issue with great interest. We are delighted that TWH resonates so strongly with many of our stakeholders, especially occupational health nurses, who, we believe, play a critically important role in the health of working Americans. Therefore, we take this opportunity to more fully describe TWH concepts and expand upon four points to more fully inform all Journal readers about TWH efforts at NIOSH.
First, TWH is not synonymous with wellness programs. This misunderstanding has been so common that recently (July 2015) the definition of TWH was revised to more clearly distinguish the TWH approach from that of wellness programs that focus primarily on worker health-related behaviors. The revised definition is, A Total Worker Health® (TWH) approach is defined 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.
Simply put, the TWH approach integrates workplace interventions that protect workers’ safety and health with activities that advance their overall well-being. The TWH approach always prioritizes a hazard-free work environment that protects the safety and health of all workers. Simultaneously, the approach advocates integration of all organizational policies, programs, and practices that contribute to worker safety, health, and well-being, including those relevant to the control of hazards and exposures, the organization of work, compensation and benefits, work–life management, a health-supporting built environment, and well-being supports.
Just as important as understanding what TWH is, it is equally important to know what TWH is not, especially as a contrast is drawn with many current-day wellness programs. Expanding on the information provided by Campbell and Burns with some clarifying examples,
TWH is not a “wellness program” that has been implemented without simultaneously providing safe and healthful working conditions.
TWH is not consistent with workplace policies that place sole responsibility on the workers for their health and apply punitive measures for individual pre-existing health conditions.
TWH is not a collection of health promotion efforts implemented in a workplace where the very way that work is organized and structured is contributing to worker injuries and illnesses.
Rather, TWH recommends that, in partnership, employers and workers design safe and healthful workplaces that support all workers, regardless of individual differences in their personal health and professional career pursuits.
Second, the TWH approach does not solely or primarily focus on changing individual health-related behaviors. TWH emphasizes changing the environment to support safe and health-promoting choices, not changing the worker. Work environments that, by the very way they are designed, make safe and healthful choices difficult or impossible are not consistent with TWH. Likewise, introducing a “canned,” non-customized wellness intervention into such an environment is not likely to succeed and will not overcome the health deficits caused by unsafe working conditions, hazardous work practices, or poorly designed, health-robbing policies.
Rather, the TWH approach advocates for a holistic understanding of the factors that contribute to worker well-being. Scientific evidence now supports what many workers have long suspected: that risk factors in the workplace can contribute to health problems previously considered unrelated to work (i.e., work-related risk factors for obesity (Champagne et al., 2012; Luckhaupt, Cohen, Li, & Calvert, 2014), sleep disorders (Caruso, 2014), cardiovascular disease (Luckhaupt & Calvert, 2014) and depression (Arcury, Grzywacz, Chen, Mora, & Quandt, 2014; Rayens & Reed, 2014; Wulsin, Alterman, Bushnell, Li, & Shen, 2014). To reiterate, the TWH approach integrates workplace interventions that protect safety and health with activities that advance the overall well-being of workers.
Third, the TWH approach does not emphasize reducing health care expenditures or enhancing return on investment (ROI) as rationale for program implementation. Many workplace wellness programs focus primarily on individual health-related behavior change efforts (i.e., smoking cessation and weight management) and biometric screening, often with the stated goal of reducing health care costs or generating a quick ROI. These programs often place much of the burden for change on individual workers without addressing the overall influences that the nature and conditions of the work itself have on worker health.
Programs that focus primarily on reducing health care expenditures and ROI have the potential to harm workers’ health and well-being through discriminatory incentives or penalties that shift additional costs to workers or through incomplete privacy protections. Others may divert resources from essential safety considerations for workers or fail to involve workers in the program design process. Such practices do not foster a sustainable culture of health within organizations and may even endanger worker safety.
Fourth, although we acknowledge that establishing a workplace culture that consciously focuses on advancing the safety, health, and well-being of the workforce may be advantageous for individuals, their families, employers, communities, and the economy as a whole, we do not consider the TWH focus to be “citizen- and community-centered” (Question 7 of the CE module). Although we appreciate Dr. Sepulveda’s forward-thinking perspective, we frame TWH as a program that is focused on the workplace (i.e., any physical and psychosocial environment in which work is performed), work, and workers—all of which are, of course, vital to healthier communities.
Keeping workers safe is the foundation upon which a TWH approach is built. Employers and employer–worker partnerships wishing to establish effective workplace programs that sustain and improve worker health must first consider the essential, foundational principles of occupational safety and health: keeping workplaces safe and workers protected. Available resources must first address hazardous working conditions. Having these safeguards in place is a prerequisite for a TWH approach. Unfortunately, far too many of today’s workplace health interventions place too little focus on the persistent hazards and difficult conditions of work.
For more information about the NIOSH TWH Program, please see http://www.cdc.gov/niosh/twh/. To stay current with TWH Program developments, register for our e-newsletter, TWH in Action!, at http://www.cdc.gov/niosh/TWH/newsletter/. We also welcome your recommendations and comments on the program at