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Total worker health - an integrated approach to work, health, safety and wellbeing

Musculoskeletal Disorders Symposium 2017

Dr. L. Casey Chosewood

Presented by: Dr L. Casey Chosewood (Director, Total Worker Health, National Institute for Occupational Safety and Health)

Run time: 45:34

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Keynote 1: Total worker health – an integrated approach to work, health, safety and wellbeing

Presented by: Dr L. Casey Chosewood (Director, total Worker Health, National Institute for Occupational Safety and Health)

[Start of keynote 1 transcript]

Madonna King:

So now let's go to our first keynote speaker for today and we are just privileged to have our first keynote speaker fly all the way from America to talk to you this morning. He arrived just on Saturday, and remember you can lodge a question for him also as we go through. Dr Casey Chosewood is Director at the Office of Total Worker Health at the National Institute for Occupational Safety and Health which is part of the Center for Disease Control and Prevention in the United States, and in this role he promotes the protection and improvement of the safety, health and wellbeing of workers around the globe. His office has led numerous workforce protection programs and today Dr Chosewood will discuss the total worker health program and an integrated approach to work, health, safety and wellbeing. Ladies and gentlemen please give a big Aussie welcome to Dr Casey Chosewood.

Dr Casey Chosewood:

Well good morning folks. It's a real pleasure to be here. This is my first trip to Australia. So thanks for already making it very warm, very welcoming and such perfect weather. It's summer in Atlanta, my hometown and pretty miserable if you can imagine. I would imagine sort of like your summers here, so we share that in common.

So thanks for having wonderful weather for my arrival and also the food and wine festival that was just next door. I certainly enjoyed that completely. I'm also feeling quite adjusted to the time zone so I don't think I'll fall asleep on you today but if you want anything later in the day I cannot promise anything, okay?

So first let me say again thanks to Nita and her team for inviting me to this important meeting and also just more generally thank you all very much for the work you do each and every day to support the health, safety and wellbeing of workers. Our institute within the CDC, this public health agency for the US government, is really dedicated to healthier, safer work. We believe very strongly that if you're going to have people home safe at the end of the day, which I know is a major goal of many of the work that you do each and every day, it starts by better job design, the better crafting of work to produce health and safety, not only as an outcome of what workers experience, but the very nature in which a job is created, crafted, designed, organised.

Really ideally you should not just send workers home with the same level of health that they arrived with that morning. Ideally work should be salutogenic. Work should create health. It's not acceptable in the modern age to trade health for wages, and for too many decades that has been the nature of the way work goes. People slowly give part of their existence, their lives, their productivity, their toil and in exchange for wages they have shorter lives, more miserable lives, less enjoyment, less opportunity for health and health expansion throughout their work. That's not acceptable in today's age.

It might surprise you to know that we have some very challenging professions still existing. There are professions in the United States that after you've done that job for a period of time your likelihood of being obese is 70 to 80 per cent. That isn't because when these jobs are open that only obese people sign up to take the job.

This is the very way that job is arranged, organised, created, the very conditions of work produce that high level of obesity which we know will commit people to shorter lifespans which will dramatically increase their risk for diabetes, heart disease, certain types of cancer. So there are tremendous opportunities especially if you influence how jobs are created, crafted, designed and organised, to influence the health of almost every person alive in your country. That vision is what drives the Total Worker Health program.

I mentioned that I'm from the Centers for Disease Control and Prevention. We are the US public health agency. The Centers for Disease Control is about a collection of 10 different activities. We're perhaps best known for our work in infectious disease but actually we have quite a bit of other lines of business as well including chronic disease prevention, after all most of the people in this room and certainly in the United States are not going to die of an infectious disease. They're going to die of a chronic disease. About half of everybody in this room will die of one chronic disease – coronary vascular disease and another big chunk from cancer. So if we're not thinking about the most common ways that people's lives end as a function of employment then we're missing tremendous opportunity to change the focus of the work that we do.

So I want to start with a very picture that's near and dear to my heart and that's of my granddaughter Lily. I think a lot about what Lily will do when she grows up and if you ask her now, 'Lily what job do you want when you grow up?' she quickly mentions 'princess', something about a princess. Okay? It's like, 'I know those jobs are in quite high demand. It's a bit competitive. There are only a fixed number of princesses at any one time in the world. So are there any other things you might be interested in?' I also must say that if you are contemplating grandparenthood, go for it. Okay? It is perhaps one of the best things in the world to see the world and the way it's changing through her eyes. It also reminds me why I get up every day. The future of work, the future of our civilisation of workers, the future of economies, of our security really depends on our getting this issue right.

I mentioned that ideally people go home with the same or better level of health that they come to work with each day. Well that's great for the individual, it's great for their families, it's great for them being able to work a longer life if they wish to do so, or are required to do so based on their financial circumstances. But here's the secret. Those people who go home at the end of the day with more health than when they arrived, they come to the workplace the next day with more health as well and that translates into more productivity, decreased injury and illness rates, better profitability for the enterprise that they work for, better public service, better customer service and that lets our organisations and economy thrive. When it comes to work and employers and workers, it's oftentimes a very contentious space. So it's one of the few win-wins when we take this integrated approach to health, safety and wellbeing.

We're doing quite a bit of thinking about the future of work and if you look very closely to this picture you might notice that this driver isn't actually driving. So this is on the roads in Nevada. Many of you may have been to Las Vegas so not very far from Nevada. The whole state actually allows semi-autonomous big rigs or trucking. This driver is in the truck in case there's an emergency but he's not doing any of the driving. Now it's interesting because motor vehicle accidents are the leading cause of workplace death in the US and very likely here as well. Many of those deaths are not in the transportation industry even though this worker is in the transportation industry and we believe the safety of semi-autonomous driving not only is it going to make that job safer, we're also seeing the obesity rates in these studies in this group decrease as well. Now they're still seated for as long as before, but their stress level is down and with stress in many of our studies going down in any profession, obesity rates go down as well.

Now I mentioned a profession where eight in 10 will get obesity. That's it. That's the profession – big rig driving. So it's important that we look at technology as a way to capture opportunity when it comes to better health at the end of the day. We also know that this – we talk a lot about semi-autonomous driving in other settings too – taxis for instance. Really harsh profession. Taxi drivers in New York City drive the equivalent of between New York and South Carolina every single day. Imagine a job where you would wake up every day and know that you have to drive for 15 hours straight. So their risk for obesity, for sedentarianism which has a host of health problems associated with it, and significant violence also associated with that profession, a real challenge. We need better solutions for those high-risk workers.

We talk about the global pace of change but to be honest with you the word 'global' is not adequate anymore. NASA, the National Aeronautics and Space Administration, just celebrated their hundredth anniversary and I had the opportunity to speak at their hundredth safety conference just a couple weeks ago. We were talking about asteroid mining which is definitely on the drawing board. There are asteroids that are reachable in our solar system today and it's going to be very tempting for companies, for private industry not to reach those asteroids and begin mining. It is hypothesised that reachable asteroids have more gold reserves upon them greater than the GDP of every country on Earth. So keeping people bound to jobs on earth will be increasingly a challenge. What are the implications not only of globalisation of work but of interstellar work? That is something that we have to address if we're going to get it right from the beginning which often times we don't. As new jobs are created we're from a safety standpoint behind the eight ball. We learn by disaster. We only intervene when there's a problem instead of proactively approaching some of the challenges that we face.

I want you to think about the last news story you read. There's a very good chance that a computer wrote that story and not a human journalist. Journalism is a dying profession. What isn't public generated journalism which is definitely a trend of the future, there will be fewer and fewer news article writers. Almost all sports writing in the US is done by computer. They add local colour as they're scanning through the game itself and when the last strike or the last inning or the last out is over, the article is ready for publication.

So, rapidly many jobs that have traditionally been done are disappearing. The real prediction is that about half of jobs that exist today will not be needed in the future. Now in the future, I'm not talking about in a generation from now or half a generation. Ten years from now half of the jobs that we experience today, that are available today, will not be needed in the future.

This is an interesting photo of the interaction between man and machine and when we think about this, this is historically how it's been, that people have been working on machines or working closely with machines to produce something at the end of the day. But the future of that picture really would be most accurate if we flipped it around with the machine working on man and it will start subtlety. It will be the pharmacy aid that's already in wide use in many hospitals delivering medications, filling prescriptions. In fact, all of my last prescriptions were filled by a robotic pharmacy filler.

Hospitals routinely now use mechanics to lift patients, certainly something that impacts MSD risk dramatically. You may also have heard of robotic surgery where a surgeon actually is doing less and less of the work and as the machine learns, the machine is doing more and more of the surgery, far more accurately, more precisely, with fewer errors, with fewer complications and here's the kicker, the surgeon doesn't even have to be in the same room. Heck, he doesn't even have to be on the same continent to do the surgery.

So what will be an interesting change is for us to continue to monitor the interaction of man and machine, something that will happen even in the smallest of workplaces in the future. Already the US Navy is using exoskeletons to build ships 20 per cent faster in one year than they could do the year before. In one year they can build a ship 20 per cent faster. Now that means 20 per cent fewer workers needed to do the same level of production. It also dramatically impacts worker safety and some of these workers with exoskeletons can lift 300 kilograms with movement of the wrist, be very accurate in its placement and positioning.

My question is this though, as we embrace technology are we keeping the needs and the challenges facing workers in these settings front and centre? What if Lee on the left needed to get to the restroom and hurry? Okay? Not so easy I would imagine. So as we find ourselves juxtaposed with the changes that technology is bringing, it's critical that we keep the human element front and centre. It is the worker that we serve not the technology that we serve, and that will be increasingly challenged for our profession as we move ahead, because see in truth while there lots of changes and the future of work is spinning faster than ever and in fact I just love this quote that I heard just a few days ago. 'Change is happening at a pace that's never been seen before … and it will never be this slow again.' Right?

So we are lulled into believing that change occurs at the same pace that we've experienced to date but in truth it's very likely to be an exponential pace of change. So imagine every change that you can imagine for the last 10 years. The rapid growth of social media, Facebook, Instagram for instance, all basically within the last decade, that tremendous change about how we interact with technology, imagine that pace of change occurring in the next one year, and the pace of change in this coming year happening in the next month after that. So it is that pace of change that we're very likely to see. But despite that, Omar in this picture is faced with legacy hazards that still threaten the health and safety of many workers.

So while it may be sexy to talk about the changes that we're going to experience from technology, there's still a tremendous number of workers facing traditional hazards. We cannot forget them because you see, it's people in this workplace setting, the last to have access to technology, the last to see the promise and the opportunity that comes from integration of health and safety programming in the workplace, tends to be the most vulnerable of workers. These workers are the ones that tend to have the off shift, the most hazardous job, the most insecurity in their employment arrangement, the lowest wage and that unfortunate collection is an important reminder that when we are intervening for health and safety there are quick ways to know where the money is, where the priority for intervention is, and a very easy, early way is to look at wages.

Lowest wages workers in general will have the highest health and safety risk. They will come from communities that are least supportive of health. They will have the least security when it comes to long-term employment, the least opportunity for professional development and advancement and obviously wages strongly equilibrated with health outcomes. Perhaps the strongest of all social determinants of health is wage. So it's an excellent place to begin when we're thinking about where to intervene.

We've already mentioned taxi drivers. Here's a set of other jobs that are quite common, that encompass quite a large sector of the workforce. These are workers again, that have lower wages, that have fewer opportunities. It's a good starting place in any workplace to think about people in the, in entry level jobs, low wage jobs, shift working jobs because that's where a tremendous amount of the health challenge lies.

I'd also like to draw your attention to sort of an emerging growing sector of the workforce and it's what I might term 'high consequence workers'. So think people in emergency operations centres, in the military, in security positions, in public safety positions, in high-stakes healthcare. These are workers that have tremendous challenges facing them and increasingly as society becomes global, as the demands on people really span around the clock and around the globe, high consequence workers are really hit with a double whammy. Many of them have prolonged shifts, they have high expectations and very little opportunity for error, very little opportunity to make a mistake. That brings with it high levels of workplace stress.

I hope I'm creating a vision that work is really all encompassing, that work not only is about wages and security and our stress level but work really is very, very difficult to separate from our home life, from the rest of our being. It's inextricably linked to who we are as people and because obviously work is a requirement for most people, we don't have the chance to separate it from the rest of our lives very cleanly and that's especially true as technology keeps us tethered to work 24/7. It's those things along this border, this interface between work and home, that oftentimes create the most challenge for as health and safety professionals. Some of these topics I'm certain you deal with each and every day as cofactors, as influencers, as risk factors for the MSD and other occupational safety and health outcomes that you face. Getting this intersection of work and the rest of life right is critical to a total worker health approach.

I love this, it's a very busy slide, but I love it for showing a couple of things. First of all let me just sort of talk about what's on the top half of the slide above the black bold horizontal line. This is where our perception of risks that we face actually lies. So for instance the big blue circle on your left is our perceived risk of a terrorist attack. Now the actual real risk is the corresponding colour underneath, a very tiny level of risk and you can see how we overestimate in our minds the risk of a terrorist attack.

Now let's move to the other side, the right side of this graph. Take a look at what we estimate our work-related risk to be, the white circle relatively small in size. Compare it to the actual risk down below, the bold orange circle. This says that we vastly underestimate the level of risk that work in and of itself actually faces us with each day. That's an important take away for everyone in this crowd. The people that you're serving do not really fully completely understand the risks that their work entails. So that's something that we must do to continue to remind them.

There are a host of reasons that work is important to our health. We've already talked about wages. One of the ones that I'm really interested in though is this concept of how work especially in the new way work is organised, is really oftentimes a constellation of jobs. We piece together 'gigs' if you will, in order to make a living. Some people have called it 'the Uberisation' of work for instance.

So basically though what that means is that for every job you have, you have twice as many commutes, right, or three times as many if you have three jobs. You have time wasted as you move from job to job. Basically when you have to piece together a number of gigs for full time means of income it leaves no time for anything else. It's a term that's been called 'time poverty' and if I were to ask how many in this room have time poverty, my guess is most of you would say, 'Yes, that's me'. That's especially true for low wage workers who oftentimes have multiple jobs, side gigs, side jobs, even if they have full-time work.

Also even the location that you work is a strong influencer of your health. So the length of your commute translates into how you will spend your time. The nature of your job may determine if you're a cat person or a dog person. So, so many intimate decisions are made about work. If we don't have the promise of permanent employment, so we have what we would call 'contingent work' or 'insecure work'. Then that colours every future decision we make about our future. 'Do we buy a house?', 'Do I buy a car?', 'Do I go in debt for any reason?', 'Do I go to school?', 'Do I get married?', 'Do I have children?'.

If I were to ask how many of you have ever moved to take new work, how many could raise your hand if that applies to you?

More than half of the people in the room have picked up, left their loved ones, left the security of their surroundings and moved to a perhaps relative unknown all for work. Work strongly influences our health.

We talk about long work hours leading to time poverty. It also has a tremendous influence on the type and quality of life we will have, benefits that come from work, extremely influential in many health outcomes. Shift work for instance increasingly common. In fact almost all public safety work and healthcare work involves long hours of work and shifts. We have increasing evidence from our own centres of excellence in research that show shift work is a strong carcinogen. Shift work is obesigenic. Shift work is a diabetogenic condition. We know that shift work in and of itself is detrimental to health.

Now you say, 'Dr Chosewood, we cannot get rid of shift work. We need cops 24/7. We need nurses and doctors who fill our emergency rooms'. You're right. There's some hazards that we cannot get rid of, but we can intervene with more intensity and frequency with pro-health programs in those groups.

For instance would you like to guess how many health fairs in hospitals occur on the third shift? Not very many. Most of those are in the daytime where the healthiest, most well paid, most healthy, most health opportunistic workers already are. The third shift is where we need to have our health fair. So there's a hospital in the States that was concerned about all of their third shift workers, overnight workers having to eat out of the vending machines because the cafeteria was closed. Very common I would imagine in many hospitals across – so what, most workers would do a stop and get fast food on the way to work. This hospital decided to do things differently.

So not only did they open their cafeteria for a meal in the middle of the overnight shift, but they gave that meal for free. Providing it for free did a couple of things. First of all people could leave the fast food behind, right, and they knew they were going to get high-quality food, low cost. So it helped people use their wages for some other purpose. They also could control the quality of that food, the nutritional value of that food. So it was a strong influencer in a third of the calories those workers ate every day. That's a win win. That's tackling the diabetogenesis, the obesigenesis that comes from shift work, a very important intervention.

Would it surprise you to know that the most obese profession in the US is police, firefighters and security guards?

They have more than 50 per cent higher obesity rates than the general population. The people we would expect to run into a burning building, to come help us when there's something going wrong, is the most obese of all professions in the US and this has been shown in another study as well, the Regard Study which looks at risk factors for stroke and vascular disease, again police officers and firefighters. It's the reason that most firefighters in the US do not die of collapse of a burning building or burns. They die of a heart attack in the middle of their duties.

Some people say, 'Well what is it about that work that you know, makes cops so overweight?' and whenever I asked always someone hollers, 'doughnuts,' okay? I think they get pretty bad rap from that. Yes doughnuts might be one factor. Nutritional choices. Certainly we eat more when we have shift work and long hours, there's no doubt about that, well proven.

But our research shows that it's workplace stress levels, it's the high demands of that work, the high public visibility and the inability to make any mistakes coupled with shift work and with long hours of work and fatigue. Many cops do not make enough money to live in the communities they serve. That's increasingly true in city after city in the US. So they have long commutes as well and that leads to time poverty which means no time to pursue health off the job. Cops are also very much into gig work. They oftentimes have multiple lines of work, security work in addition to their regular full time largely because of wages. So it's a real challenge.

This is some dramatic, dramatic study that's basically looking at life expectancy. So what is it about work that threatens how long we actually live, and this is looking at a number of different ethnic groups, men and women, and looking at the disparity between the least and most educated people in that demographic. Then it asks the question, 'What is it about the nature of your work that has such a deficit to your health?' and if you look at the big, bold, orange or red, pretty dramatic. No health insurance. Increasingly in the gig economy in the US workers do not have the guarantee of health insurance coupled with employment. The Affordable Care Act began this separation of employment and health insurance, and this is a significant threat to the health of our workforce, to the health of our nation as a whole. Other big colours – blue there, that represents insecurity. No health insurance and insecurity. Another big one, the lime green – low job control. 'I don't have a say in the nature or the quality of the hours of my work.' Pretty dramatic.

Now those three things together unfortunately are part and parcel of something that's all the more common in the US and that's this issue of contingent work. So I don't have the traditional job that my father had, that my grandfather had, it was with one company for a long period of time. Or full-time work for one company, serially over my lifetime, usually getting better pay from job to job.

So I might ask you what percentage of work in the last decade in the US do you think has made up this brand of work, contingent work? So of the jobs created in the last decade what percentage have been non-standard alternative work arrangements other than full-time? Would you guess 50 per cent of those jobs over the last decade?

You'd be quite underestimating. It isn't 50 or 70. Ninety-four per cent of all jobs created in the US from 2005 to 2015 were non-standard, non-full-time, contingent work. That's dramatically impacting these health metrics.

So in such dire circumstances NIOSH, the National Institute for Occupational Safety and Health thought it was important to take a new approach to the way we craft healthier work. We introduced about 10 years ago this concept of total worker health. It really is about using the workplace, not just a venue for health promotion, but the workplace as an actual place where we can create better health through the design of better jobs. We don't discount physical activity and nutrition programs, tobacco cessation programs. We embrace them but that alone is not enough. How can you actually create more health through the way the work is designed, through the programs, policies and practices that can create worker wellbeing at the end of the day?

So we sort of take three simple steps here. First and foremost, first dollar investment, create safer work. You're not going to have total worker health if people go home with less health than they arrived. It's impossible. They go home with one less digit. They go home with an injury, a debilitating condition, a disability, but that's not enough. So good companies will keep their workers safe but the great ones, the ones the people clamber to work for are the ones that establish additional measures to advance health. Those policies, practices and programs that improve the health of workers, not just the safety of workers but the overall health of workers. This is our integration of the safety piece and the health piece to create worker wellbeing at the end of the day.

We do it by connecting all elements of the workplace and I'm so happy to do some reading about the work of the Queensland Government in this area and the word 'integration' keeps coming up again and again and again. That's music to my ears because we believe that's where the synergy lies.

We also are very much about culture change. This is not a vendor program that you can introduce for one year and then expect everything to be fine. This is about long-term culture building, increasingly difficult when workplace turnover is as we've described. It's unreasonable to expect people to change their behaviour when the social, cultural and physical environments around them fully conspire against them. Take a look at some of those images, right? Poor dog. No one's happy in that picture, certainly not the dog. There's this wonderful set of steps up to the fitness centre. 'No, we're all going to take the escalator up to the fitness centre. That seems like the right thing to do.' For me this quote though says for every behaviour change program I want to put in place like a Biggest Loser contest or physical activity program that I want to introduce, at least for every one of them I need a social, cultural and physical environment change first, because see those are the sustainable things that will allow the behaviour change efforts to actually stick, to actually succeed.

Remember we were talking about Omar earlier? He's not interested in the noonday Tai Chi class, okay? Not his priority. He also reminds us that you cannot overcome eight, 10, 12 hours of difficult working conditions with a 30-minute 'lunch and learn' on any topic. There is no miracle topic for 30 minutes or an hour that will overcome eight, 10, 12 hours of harsh working conditions. This is where the money is. If we want better safety, better health outcomes, better longevity, better economic outcomes for our industry, getting this health quotient right.

The other thing this tells me is he's not interested in Tai Chi but there could be a lot of things that he's interested in and we'll never know unless we ask Omar what he's interested in when it comes to his health. It may not be a health promotion program at all. It may be all about benefits, may be about shifts, it may be about supports for his family, it may be about education but unless we ask the question, what we would term the 'participatory approach' to program design, we'll never know, nor likely will he ever engage.

So you know it isn't, 'if we build it they will come'. It's, 'if they build they will come'. That's the power of the participatory approach.

We're doing a lot of research in a lot of these areas through our network of centres of excellence and we'd invite you to learn more about all of that research by visiting our website. You can see that yes, we still have some traditional programs on here, but we have a lot of others too. Control of hazards and exposure will always be first on our list but we're looking at the health impacts of compensation and benefits, on the role of communities and how that produces healthier workers because basically every worker is part of a much broader community. We're also studying new employment patterns, something that's taking the US by storm and I'm certain it will be here as well.

So is this the future of work? My father had one job in his life. I've had six in mine. My kids are likely to have six at one time. This whole nature of gig work that we've been talking about has health consequences and we're just starting to uncover them. In fact some of the most dramatic ones really apply to this whole issue of uncertainty. Imagine the stress that you and your family would be under if you had no guarantee of an income four weeks or six weeks from now. I can't think of hardly anything more stressful than if that were the case but yet increasingly larger and larger percentage of the workers are facing that very fact, that uncertainty, that insecurity of employment. So we must think about ways to intervene even as these dramatic changes are occurring.

I would also be remiss without mentioning perhaps what is the number one health crisis in workplaces today. It's always on the top of the list when we're asked about challenges that are facing workplaces and that's this epidemic of workplace stress. Now in general there are a number of approaches to workplace stress. In fact you ask companies, 'Well what are you doing already?' when they bring up these challenges, it's very likely that we'll hear about resiliency building programs or employee assistance programs. That tends to be where we hear most of our response. But I would argue that in general resilience is not an adequate approach. Resilience sort of is giving the turtle if you will, a harder shell on the outside, right, so that that turtle can withstand more pressure from above, maybe a stronger hammer to hit the turtle with. Well that harder shell, larger shell comes at a price. It's first of all much more difficult to move, much more difficult to make it through if you're carrying such a hard shell.

See the solution to workplace stress is to get rid of the hammer, to decrease the size of the hammer instead of building the harder shell.

What that means is approaching the way we design jobs, organise jobs, create work so that stress is minimised. We've come up with a number of ways to do that and I'll share those with you, just a few statistics here on is stress an epidemic at work. Two things I'll point out. Almost 80 per cent regularly encounter physical symptoms caused by stress, 73 per cent regularly experience psychological symptoms caused by stress, 60 per cent of US workers said that they would prefer to choose a new career altogether. Talk about lack of engagement in their work, talk about risk for injury and illness translated from that. Well risk for poor customer service or risk for high turnover and looking for a serial employment.

So when it comes to interventions one of the most promising that we found in our research is to retrain the way our supervisors supervise. So I ask often, 'Is it your doctor who is most influential in your health?' and we get a lot, 'Yeah, that's pretty important'. Our research shows that it's actually your frontline supervisor who is far more impactful in your health at the end of the day than your doctor will ever be.

So if we retrain the way we approach supervision, if we give people the skills they need to better understand how to manage with health outcomes in mind, we believe that's where there's tremendous amount of opportunity. What does that look like? Maximising flexibility. Most workers want more flexibility than they want more vacation. So having people have a say when, where, how they do their work. Yes, have the same expectations at the end of the day as you have always had, but between assignment and execution giving as much freedom as possible in that spectrum is a strong predictor of decreased stress, of higher levels of engagement, of more personal fulfilment to the job. People need a voice in the nature of their work.

To the extent that employers can address this growing problem of insecurity it will have tremendous payoff when it comes to engagement and productivity. Even if it's only short term reassurance that, 'Yes, we know times are tough but I can guarantee you a job for six months,' that's certainly better than people not knowing if they have a job from week to week. The participatory approach we've already talked about, providing this concept of meaningful work.

I love this story. There were three brick layers on a job site. Someone walks by and he says, 'Hmm, I wonder what they're doing?' So he asks the first one, 'Can you tell me about your work?' He said, 'Well, clearly I'm a brick mason. I'm putting one brick right on top of the other. You can see what I'm doing'.

The second one was asked, 'Well tell me what you're doing?' and he said, 'Well I'm working hard. I'm making $20 an hour. So it's a good job. I'm providing for my family'.

The third one was asked, 'Well tell me what you're doing?' and he said, 'I'm building a cathedral where my children will get married and my grandchildren will be christened'. They were all doing the same thing but the work meant something vastly different to each of them. Our job as health and safety professionals, you say, 'What? This is not my job'. It is our job to give people meaning to the work they do. That is a health and safety intervention. It will produce lower injury and illness rates at the end of the day. Greater engagement in work is golden when it comes to better health outcomes in this integration of work, home and life, something that will be increasingly challenging as we move ahead.

One study here said that meaningful work should be every CEO's top priority and there's research in our centres that back up this as well.

I'll just speak a little bit about culture. If you don't actively work to build a culture there will be one that develops without you. So it's going to happen one way or the other. In fact every workplace has a culture today. It's part of our job to influence it with health in mind, with safety in mind, with this issue of meaningful work in mind because one will develop, even in the absence of doing anything at all.

What do those PPP's look like? We don't have time to go through every one of these but if you will join me tomorrow and a shameless plug for the two-hour workshop, we will go into great detail on all of these programs, practices and policies because this is where the long term sustainability of programs lay, not in the flavour of the month, the health promotion intervention. It's this enduring long lasting approach that really will produce health at the end of the day.

We have a lot of unanswered questions when it comes to total worker health in this integration of health and safety for the creation of worker wellbeing and here's some of the most important ones that are pressing. I know there's some academicians in the audience. We would invite you to look at these research questions with us.

Perhaps the one that I'm most interested in is this connection between work and chronic disease.

If most people in our countries die from chronic disease how can we use the workplace as a venue to create better opportunity for longer, healthier, more fulfilling lives at the end of the day?

I mentioned we had a number of centres of excellence and an affiliate network around the US. We have not had any international partners yet but based on some of the work that you guys are doing we would love to talk about having an international partnership around total worker health. We see a lot of promise in the approaches that you guys are taking and we're really looking forward to learning more in my two-day visit here.

There are number of ways that you can connect with us. I'd invite you to follow us on LinkedIn, on Twitter and subscribe to our Total Worker Health and Action eNewsletter. We now have 71,000 subscribers. It's one of the most subscribed newsletters in all of the US Government and we would love for you to be 71,000 and 400.

I'll leave you with a picture of Lily and again my sincere thanks for what you do each and every day.

Madonna King:

Wow. So much to take on board Dr Chosewood. Thank you. You know, that idea that a frontline manager can have more impact on a worker's health than their own GP hit me and so did this quote. 'Change is happening at a place we've never seen before and it will never be this slow again.' I'm sure we have lots of questions for Dr Chosewood and you will get the opportunity to do that shortly after our second keynote speaker of the morning.

Before we do that though, can I ask you just to take out your trusty device again? I'm going to ask you three brief questions in relation to the presentation that you have just seen. Remember you can continue to lodge a question for Dr Chosewood in the activity section in Zeetings at any time.

So our first question is how would you rate Dr Chosewood's presentation today?

Of course this is a private response, but just give us some idea for feedback.

Yes, I was going to say Dr Chosewood, you can only vote once.

I'll just get the hands up when we can move on. Thank you.

Our second one is will you change your current approach to managing MSDs in the workplace based on what you have just learned?

Just waiting. Yes, thank you, and our final one is what is your take away message, and for this you know, can you think of a word, a phrase, a sentence? What's the message you'll take away from hearing Dr Chosewood's presentation? I'll just give you a few seconds to answer that and we appreciate you doing this.

Just looking for the hands up before we can move on.

Thank you. Thank you very much for doing that and I'm sure we'll get much quicker as we go throughout the day.

[End of keynote 1 transcript]