The Effectiveness of Total Worker Health Interventions: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop

Traditionally, occupational safety and health (OSH) and health promotion (HP) efforts have functioned independently in workplaces (1). Occupational safety and health interventions focus on preventing work-related injuries and illnesses, which can lea... show more

Traditionally, occupational safety and health (OSH) and health promotion (HP) efforts have functioned independently in workplaces (1). Occupational safety and health interventions focus on preventing work-related injuries and illnesses, which can lead to morbidity, mortality, and considerable financial and social costs (24). Health promotion interventions, often called wellness programs, promote overall health and well-being. They often address modifiable behavior risk factors, such as smoking, physical activity, and diet, which are leading causes of morbidity and mortality in the United States (5). In the past decade, interest in integrating OSH and HP interventions has grown substantially (1, 6). This is partly explained by the emergence of evidence supporting the idea that workplace factors contribute to adverse health outcomes traditionally considered to be unrelated to work (such as cardiovascular disease and depression) (7). The National Institute for Occupational Safety and Health (NIOSH), a part of the Centers for Disease Control and Prevention, focused attention on integrated approaches to worker health and safety in 2011 by creating the Total Worker Health (TWH) program. Total Worker Health is currently 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 (8). Earlier descriptions of TWH highlighted the strategic integration of OSH and traditional worksite HP programs (9); NIOSH's current definition is broader and emphasizes work-related factors (such as wages, workload, and stress levels) as important factors in determining worker well-being (10). TWH, a trademarked term, was not commonly used in past studies of integrated interventions. For this review, we use the term TWH interventions to refer to integrated interventions that are consistent with NIOSH's TWH initiative even if they differ in intent, complexity, and approach to integration. For example, an integrated intervention may involve strategic coordination between staff responsible for OSH and HP decision making to develop comprehensive, multicomponent programs to improve worker health and safety. Integrated interventions may also involve single-component interventions (or policies) that simultaneously address OSH concerns and promote healthy behavior. Prior research has outlined indicators and metrics of integration that are important in TWH interventions, such as organizational leadership, data integration, organizational coordination across departments responsible for OSH and HP, and adequate resources (11). However, no research has evaluated these elements separately to determine whether (and to what extent) they contribute to intervention effectiveness beyond other factors, such as intervention content. This article is part of a larger systematic review supported by the Agency for Healthcare Research and Quality (AHRQ) to inform a research agenda for the National Institutes of Health (NIH) 2015 Pathways to Prevention Workshop that focused on TWH. Our purpose was to evaluate evidence on the benefits and harms of TWH interventions. Methods The NIH Pathways to Prevention Working Group provided the initial key questions (KQs). The RTI InternationalUniversity of North Carolina Evidence-based Practice Center (EPC) further refined them and incorporated guidance from a technical expert panel into the final research protocol (see the Supplement). The KQs concerned 1) populations, work settings, intervention types, and outcomes in studies of TWH interventions; 2) benefits and harms of interventions; 3) characteristics of effective interventions; 4) contextual factors potentially affecting intervention effectiveness; 5) research gaps; and 6) future research needs. Detailed methods and data for this review, including the analytic framework, search strategies, eligibility criteria, risk-of-bias (ROB) rating, and strength-of-evidence (SOE) grading methods, are available in the full report (12). Supplement. Evidence-based Practice Center Systematic Review Protocol Data Sources and Searches A research librarian searched MEDLINE, the Cochrane Library, the Cochrane Central Register of Controlled Trials, and PsycINFO from 1 January 1990 (reflecting the timing of increased attention and focus on integrated interventions) to 21 September 2015. We searched for relevant unpublished studies by using ClinicalTrials.gov and Academic Search Premier. To ensure that our database searches had not missed relevant citations, we used reference lists from pertinent reviews and a bibliography that we received from NIOSH listing studies relevant to the TWH program. Study Selection Two investigators independently reviewed abstracts and full-text articles against prespecified eligibility criteria (Appendix Table 1). We included English-language studies of employed adults (aged 18 years) that assessed any integrated intervention that met the definition of a TWH strategy (as defined earlier) (8). To be eligible for inclusion, an intervention had to be designed with the dual objective of improving workplace health and safety and overall health, health behaviors, or risk factors for chronic diseases. To assess the effectiveness and harms of interventions, we considered only studies with a concurrent control group comparing an integrated intervention with usual work practice, no intervention, or an active comparator (for example, an HP-only intervention or another integrated intervention that differed in content). Table. Summary of Key Findings and Strength of Evidence for Total Worker Health Interventions Appendix Table 1. Inclusion/Exclusion Criteria for Studies of TWH Interventions To address KQs related to the benefits and harms of interventions, we included commonly reported outcomes considered to be important measures of worker health and safety (Appendix Table 2). To determine widespread and important ou show less