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Workshop 5a: Total worker health

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)

Part 1

Run time: 01:10

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Workshop 5a: Total worker health

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

[Start of part-1 transcript]

Janine Lees:

Okay. Well good morning and welcome everybody. I'm Janine. I'm from Workplace Health and Safety Queensland. Welcome back to day two of the Symposium. I hope you all enjoy.

We just have to go through the housekeeping things first. So in the case of an emergency please stay calm and follow the instructions given by the Convention Centre staff who are fully trained for any emergency situation. The amenities are located to the right outside this room near the registration desk. Smoking is not permitted anywhere within the BCEC building. Please ensure all your mobile phones are switched off to silent during the presentation and the workshop. There may be photography and filming taking place, so please let the photographers and Workplace Health and Safety staff know if you do not wish to be photographed.

The sponsors – we'd just like to extend a special welcome to our gold sponsor Safe Work Australia and to our two silver sponsors, AXIS and Connect in the audience today and acknowledge and thank all the exhibitors for partnering with the Queensland Government to ensure the success of this event and all of today's presenters and facilitators for their involvement.

So this morning's workshop is being run by Dr Casey Chosewood. Dr Chosewood is the Director of the Office for Total Worker Health at the National Institute for Occupational Safety and Health, part of the Centers for Disease Control and Prevention in the US. Dr Chosewood's team has overseen a multi-faceted workplace health program providing more than 200,000 encounters, screenings and health opportunities annually. He has presented extensively on the topic of occupational safety and health, biological and laboratory safety, international travel medicine and workplace wellbeing.

Dr Chosewood promotes the protection and improvement of the safety, health and wellbeing of workers around the world. His office has led numerous CDC Workforce Protection programs including all occupational health services, laboratory and biosafety programs, environmental and compliance activities and workplace wellbeing and prevention initiatives.

Today Casey will talk about the total worker health approach, and designing an integrated program. So I hope you all enjoy and please welcome Casey.

Thank you.

Dr Casey Chosewood:

Well hi folks. How is everybody today?

Great. Thanks again for your warm hospitality. I really enjoyed the meeting yesterday. The organisers have done just a bang-up job. So congratulations on a great meeting. Thank you guys very much for making this event so popular today. That's a pretty high standard to live up to, so I will do my best to make this choice worth your while.

My goal for today is at the end for you to have designed one of your own integrated interventions. So that's really where we're going to work toward over the next couple of hours. So in just a few moments we'll pass out a worksheet that will give you an idea of a way to set-up your own integrated intervention. So as we're going through an hour or so of didactic, sort of background information, some applied examples, some practical implications for these programs, be thinking about a challenge in a workplace. It can be your own. It can be one you've consulted in. It can be one that you've just, you know, is theoretical, that doesn't really exist. Think about a challenge that is really begging if you will, for a more comprehensive solution than perhaps is currently the case in your organisation.

We will give you some examples on the way through this first hour that will allow you as a table to come up with a potential problem and then to design as a table an integrated intervention to solve. Then we're going to save time at the end of your table work for a representative from each table to report out on the problem that you chose, perhaps how you decided on that problem and then how you went about designing your intervention and what that integrated intervention is.

So it seems to me appropriate that we would identify a couple of things along the way to get there. First of all talk about integration. Talk about why that seamlessness, that comprehensiveness, that sort of on a continuum approach to solving problems is important, the people that would need to be at the table to help you with your intervention, what kinds of parts of the organisation would come together to best design the intervention and then perhaps we'll look at ways that – examples of things that people have done in the past and maybe some of the evidence base behind some of those integrated interventions. Specifically we'll talk about the concept of healthier supervision. A question came up yesterday, 'What does that look like?' So one of the case examples I will give you is from our own 1,500 member workforce and the design of a two-hour, comprehensive, healthier supervision, intervention for our own team leaders and managers.

Another good example will be from a hospital system in the state of New Hampshire that had very high injury and illness rates, some low engagement, a lot of turnover in their staff, very, very high healthcare costs that in the US are heavily borne by employers, increasingly by people out of their own pockets as well, and we'll talk about how this health care system designed an integrated team-based intervention and some of the results from that.

I think we also have some evidence base around obesity interventions and around tobacco interventions. So that's sort of an overview of where we're going to spend our time together today. It would be helpful if we find out who is in the audience today. So if your background and you could raise your hand more than once as we go through the different sort of professions that tend to make up the audience - if your background is traditional industrial hygiene, safety engineering, pretty much safety is your background in training and work, go ahead and raise your hand.

So that's roughly about maybe a third, 40 per cent of the room. If your background is more traditional health promotion, so moving workplace programs forward through health promotion activities, public health slant of health promotion go ahead and raise your hand.

So maybe a smaller set of people. If you're more occupational health nursing or physical therapy or that sort of background, occupational physician. So a considerable number. Maybe that's about also a third or so of the room. How about human resources, benefits design, sort of on the hiring, the human development side. So maybe about 10-20 per cent of the room. Okay, that's really helpful to know who's in the audience today.

I'll just make sure we have this going.

Having a little trouble advancing with…

I'll advance from here until we can check on that. Okay, yes I did not just forget to leave this slide in from my last speech in Las Vegas, okay? It's not an error. Is it working?

Okay, got it. Great.

So it's not left over from my presentation in Las Vegas. The reason I put this in here is to say that unlike Vegas where what happens in Vegas stays in Vegas, right? You've all heard that saying. What happens at work doesn't stay at work, right? We shuttle those challenges from the workplace home with us each and every day. It can be something blatant like if you work in a lead smeltering facility and you have lead residue on your clothing, it can be taken home to young children in the form of a hug or them playing with the laundry or helping with the laundry and expose children to very high levels of lead. So it can be something very blatant like that or it can be far more subtle.

We talked yesterday about the concept of time poverty and how work takes up so much of time that there's none left over for adequate socialisation, parenting, interacting with the people that we care about, pursuing healthier pursuits like nutrition, physical activity. Work can be so demanding that there's fatigue at the end of the day. You don't have energy to do anything else. Work can interfere with sleep. So we even know, there are sleep studies now and work shift studies that show that long hours and shift work lead to infertility and it's multi-factoral and part of it is time and intimacy, just the ability to develop meaningful relationships when work is so demanding.

So it is definitely, there is a strong connection between work and home. So very much like you shuttle a laptop bag or a lunch box with you back and forth between home and work, those risks are shuttled back and forth as well. So I think we made the case yesterday that there's this intimate connection between home and work. Remember we talked about that interface, where the red and the blue intersect, and how some of those challenges along that interface are some of the most difficult ones, especially when we're trying to help people who have injury and illness and we're trying to help decrease the disability associated with injury and illness and the challenges with return to work. Things at that interface are often times the most challenging. It is this type of problem that lends itself well to integrated interventions.

So as you're thinking about where you would intervene, these kinds of areas are ones where there have been successful examples of people putting interventions in place. So just keep that in mind. This is from Dr Kent Anger who is from one of our six centres of excellence and if you haven't explored our website yet, we have links to all six of those academic centres with great toolkits, video series, webinars that are available. So it's really a great resource. It's also useful for training your own safety and health staff. You can plug in one of our webinars on a number of topics and you have a good 60-90 minutes of training. There's even CEU credits, continuing education credits available with many of them as well.

We talked about some of the most challenging populations. So as you're designing your intervention you may want to think about what subset of your population would be most amenable for you to intervene with? Remember we said that the participatory model, giving people a voice in the challenges they're facing is going to be important. It's also important to know that every single faction of your workplace is not exactly alike. There are some that have relatively low risk compared to others and it's a fallacy to believe that you have to intervene with every single member in your workplace the exact same way. We make most of our programs completely voluntary for that very reason, because some things are going to appeal to some folks whereas they may not have very much appeal to others. So we're not fans in general of making any of our programs mandatory.

Now there are obviously different approaches in the US and in Europe, in Australia when it comes to the role of regulation. In general in this current administration there's a fairly hands-off regulatory environment. Unlike Canada for instance, the EU and I'm pretty certain Australia, there's no like psychological standard in place for workplaces and that is the case here. There's a mental health or psychologically safe work standard here in this country. The US doesn't have that and in fact that's a leading cause of some of the major challenges that we see in workplaces, the major labour employee and employer conflict is around the psychologically healthy workplace or the lack thereof.

So as you're thinking about the population where you would design your own intervention, both for today's exercise and down the road in real life, think about the significant population at risk. A very good proxy for identifying the highest risk workers is wages. That's a very good place to start. Another one is shift work. So if you have people who are on the off shifts or who have the deadly rotating shift where they're constantly changing their shift, even far more health hazard causing than people on a consistent shift. Those would be other areas that you might want to increate the intensity, the frequency, the menu of offerings if you will, when it comes to interventions. So don't think you have to do the exact same thing for everybody, or have the same frequency and intensity of intervention for everybody because you're going to have more value if you go to the highest risk people first.

Also remember we showed that intersection of home and work and many of the things along that border? I would argue that an intervention in any of those areas impacts both home and work. So the hallmark of a total worker health intervention is it's going to have home and work effects by its very nature. Even if it appears at the outset to be only focused on one, the spill over effect that we've been describing, the inextricable link between working conditions and the rest of our lives, by their very nature makes it a total worker health intervention.

We often times get asked the question, 'Well gosh that seems only work-related, it doesn't seem like there's any home association to it?' If it's designed appropriately it will have good spill over effect, send people home at the end of the day with more energy, with less fatigue, with a better frame of mind, with more enthusiasm and that in and of itself, sending home a happier, less stressed employee has positive home effects.

We used an example yesterday of long-haul truck drivers, big rig drivers with the high rate of obesity. We're interested at NIOSH and we have quite a bit of study into transportation workers for this very reason alone. Does anyone know if it also true in Australia, if this is the leading cause of workplace death?

Pardon?

Audience member:

Yes.

Dr Casey Chosewood:

Yes, it is and it's interesting because as you can see, 58 per cent of victims weren't hired as transportation workers. That's what makes it so ubiquitous as a risk in many, many sectors and occupations. So we're interested in the health of drivers because still obviously autonomous driving is very, very rare. Most big rigs and most transportation occurs from drivers who are in full control of the vehicle. Because of their high rates of obesity, because of the sedentary nature of their work, because of the constant vigilance required in the work, it's considered high stress. This also over time tends to be some of the longest shift work of any type of work in general, certainly in the US.

So this is a major focus of NIOSH research and we've been looking at a number of integrated interventions for this population. I'll just give you a couple examples and you say, 'Well gosh, this doesn't seem like it would decrease fatality rates'. I would argue that anything we do to improve the health of the population of truck drivers in general will impact fatality rates because it is conditions like sleep apnoea, so strongly associated with obesity and so strongly associated with daytime somnolence, that is a major issue especially in those people who have very long, uninterrupted drives, not taking frequent breaks, don't have the stops available in some of their locations for adequate breaks, don't have the flexibility in delivery schedules that are actually driving some of these challenges. Not only behind the wheel but in their interaction with other vehicles and pedestrians as well.

So a couple of examples of things that have been done in the US in some of the interventions that we're aware of. There are large transportation companies that hire many, many drivers and in addition to obviously having safety training programs and screenings for sleep apnoea and that sort of thing, they have taken a more proactive approach by packing the lunches and snacks of all of their drivers. So instead of having their trucker stop at truck stops where the choices are few, they have to pay for the food themselves and there's not a lot of healthy options, they pack the healthy foods for their drivers and they've shown some promising changes in behaviour and weight. So that's one intervention we've heard of.

We've also heard of the Trucking Association in certain parts of the country installing fitness centres in trucking stops as well as salad bars, so to increase the availability of fresh fruits and vegetables, so sort of if you will, an infrastructure fix for some of the challenges that these workers face. Other interventions have really relied on in-truck monitoring that give alerts to drivers when they seem to be experiencing drowsy behaviours and certainly with the computerisation and the ability to use remote sensing to look at the driving times, more attention to schedules, stops and breaks is now possible as well with the technology that's available.

I mentioned prioritising certain portions of your workforce. I'll just remind us why low wage work has significant challenges to it. First of all you're all probably familiar with the effort/reward balance if you will that most of us experience. So we get the reward if you will, for the amount of effort that we put into our work and in general if our work is fulfilling, if we're paid well, that's generally a positive balance. But for many low wage workers that tends to be an imbalance, or tends to be a lot of work without necessarily the reward or recognition that they feel they deserve.

There's also an increased risk of job stress, often times because of the lack of control, the lack of flexibility, the lack of ability to sort of arrange their own work, diminish decision latitude – they don't have the opportunity to make very many decisions day in and day out and this whole concept of job insecurity which is increasingly that casualisation of work as it was stated yesterday, is increasingly leading to this element of job insecurity.

Forced overtime is another major issue in the States. Now what does that look like? Well over time is general it's often times seen as a positive in certain settings. It's a way for people to earn more income for less effort because in general overtime by law in the US is at least 150 per cent of base pay per hour, but forced overtime is basically this. 'We need you this number of hours this week. If you can't do it then we don't need you at all, now or in the future.' So it's either choosing between taking the overtime we have and all of it, not just some of it, or you lose your job. So that is a really tough setting for some workers especially if they have home responsibilities, family responsibilities, or increasingly now, the second job. So forced overtime can make them not only lose a primary job but a secondary job potentially as well. Then we know that low wage workers, especially immigrant populations face increased discrimination as well.

What do we know about some of these populations? We talked about shift work being carcinogenic, obesogenic, diabetogenic yesterday.

Here's some of the background and this is from some of our own centres of excellence work. Shift working men are less likely to eat vegetables and fruit. They tend to have higher intake of fast food, of prepared foods, of processed foods. Shift working women get more of their energy intake from fat. Now these are after controlling for other things that might influence diet. This is just looking at the influence of shift work and these are large population studies to be able to draw out this kind of information.

What are some of those potential health effects of contingent work that we were mentioning yesterday? I'm giving these examples as potential areas for you to think about for your interventions. Remember we said total worker health is the three Ps – programs, practices and policies.

So as we're looking at some of these risks that are increasingly common, what are some of the three Ps where we might have interventions that would be useful? The uncertainty in interrupted work leads to a reduction in earnings over time. Lack of many of the benefits that come from traditional employment. So some of our most profound total worker health interventions address the challenge of associated benefits. That's why when you're bringing together a total worker health team, having human resources at the table, people who design benefits, extremely valuable. Negative consequences after injury – one I'll draw specific attention to are those employers who have multi-employer work sites where there is one owner/operator, but tonnes of contractors and sub-contractors beneath, often times there's this distance between information at the lowest level of employment, the sub-sub contract and the owner/operator.

So the owner/operator may have no idea what the injury rate is or the exposure. Exposures are several layers down the chain and they're insulated from any financial risk or penalty from that. So they have no incentive to make changes and they often times use as their defence, no knowledge of what's happening far beneath them. So that's a role for regulators in our view, to look more closely at all of the people, to have a shared responsibility for the health and safety of those workers at every level of the organisation.

I love some of these quotes. 'Work is central to people's wellbeing because it's so vital.' Almost everything that we do has an economic implication to it. Most of us work because it's a necessity of our existence and the quality of that work is going to absolutely impact the extent to which we experience wellbeing or not. 'Decent work sums up the aspirations of people in their working lives.' It's from the ILO.

So just to refresh your memory on what total worker health is. This is the bedrock. Without this there is not a total worker health program because remember we said that bad companies bring their workers to work and they send them home at the end of the day with less health than when they arrived. They're not doing step number one here. That's trading health for wages. Not acceptable in the modern era.

So at the very base of a total worker health intervention you've got to be looking at how healthy are we sending home workers at the end of the day, but it's those good companies that do more than that. They establish those additional workplace PPP – policies, programs and practices that can actually invest in the health of those workers so that at the end of the day they go home with more health than they arrived. Remember we said that that leads to the cyclical benefit for both organisations and employees and their families because those workers that go home with more health, they wake up the next day and they come back to work with greater health. That translates into decreased injury and illness rates, increased productivity, increased engagement, more workability over their working life span, less likelihood for disability. So it is truly a win-win.

Let's talk about this outcome. We struggled actually as we were defining total worker health as to what the right outcome should be. What is a term big enough to encompass what we're trying to sort of lead to through all of these improvements? We settled on this concept of wellbeing. There is quite a bit of interest in defining and sort of characterising what wellbeing in the context of work actually means.

How many of you have heard of the Gallup Wellbeing Survey? Yeah, Gallup if you're not familiar with that, it's a big organisation based in the US but they do surveys worldwide, Gallup G A L L U P, and they actually poll 1,000 people per day, every day around the calendar year, even on holidays, Christmas, New Year's and those 1,000 people are a running sort of measure of the wellbeing of the population surveyed. They ask a lot of questions so that they can sort of correlate what really is causing wellbeing. Quality of work is certainly one of those items. Their income is certainly an element. Their employment, whether or not they have a job is there. Their interaction with families. Their view of the politics in their setting. All of those things are summed up to create a wellbeing score and that tracks so closely with national events. You can see how so many things that are occurring in the atmosphere around people is tracked in this daily wellbeing poll.

So we decided at NIOSH to develop a similar tool that organisations could use to track the wellbeing of their organisation. It can also be used by individuals to see how their wellbeing is changing over time as well. So we've worked over the last three years with the RAND Corporation – another consulting firm that does a lot of study, design, research, development tools to develop a wellbeing instrument in the context of workers and it's being validated right now and we're looking actually for test populations to try out the instrument.

So if you have an organisation that might be interested we'll be happy to talk to you about that. We expect it to be available for everyone free of charge within the next year, but right now it's just in its final design stage. In the US when the government creates a survey we have to go through a number of hoops to make sure that it doesn't tax the public too terribly. The Paperwork Reduction Act requirements and the Office of Management and Budget are all hoops that we have to jump through before we can release a survey and that's the stage where our survey is currently.

Alright, so again here's the full definition, 'Policies, programs and practices that integrate' and here are the two things that we're integrating, separated by the word 'with'. Protection – that's the safety piece from work-related. Work-related safety and health hazards with a broader promotion of injury and illness prevention efforts. So those are the two elements that would make up a total worker health intervention.

Sometimes one thing does both, right?

So for example, a tobacco-free policy in a workplace does both and you say, 'Well how could that be?'

Well, there are places in the US where endorsed smoking is still allowed. Casinos in Las Vegas for example is one good example. Many, many bars and restaurants especially in rural states and in tobacco states still is allowed. So a tobacco-free policy in that kind of setting would serve both purposes. It would certainly encourage people to stop smoking. We know that tobacco-free policies generally lead to lower levels of smoking in that space. That's very well documented. But how does it protect workers?

Well, every place where people smoke indoors is also simultaneously someone's work space. Think about that.

Those casino workers. They don't get to decide when to leave that smoke filled space or not. They're there for eight hours. That is a carcinogen. There's no doubt that secondhand smoke exposure for 40 plus hours a week is a safety hazard for those workers. So that's an example of one intervention that is in and of itself doing both. So you don't have to have two activities necessarily brought together into an intervention for it to be total worker health even though that would also work. Sometimes just one intervention is so powerful that it actually accomplishes both.

Let's talk about smoking. In fact this was one of the earliest total worker health studies ever done by our Harvard Centre of Excellence. It's really what led to the exploration of this area as a research horizon for NIOSH. It basically was a simple randomised controlled trial in a group of construction workers, and you say, 'Well why construction workers?' Well construction workers and miners, outdoor workers in general have the highest rates of tobacco use. Others would be people in the entertainment, so bars and restaurants and low wage health care workers. Those are the most common groups of workers that smoke.

As an aside, the fact that we know that certain workers smoke more than others is a strong, rallying cry for us to change conditions of work, right, to think about how we can intervene, because all other things being held equal, the job you have is a strong predictor of whether or not you'll be a smoker, by more than 50 per cent. So some occupations smoke 50 per cent higher than the average. That's not just an indictment of the workers. That's an indictment of the job that's leading to those differential risks.

So this intervention, randomised control trial, was in a group of construction workers and our researchers went in and they did two things. In one group of workers every morning they would have a tobacco cessation education and motivation session. So that's the one on the bottom. So it was a single intervention of having a training around the challenges associated with smoking, the health risks around smoking and giving people the supports and training they needed to quit.

They also offered nicotine replacement therapy as part of that intervention. You can see the success rate of their intervention in this trial – 5.9 per cent.

When the same activity was combined with a respiratory protection program in that group of workers. So they integrated the messaging, they delivered both in the same setting, the smoking intervention was exactly the same in both but to that they added, 'We care about your respiratory health at work. We're going to tell you what your respiratory risks are here. We're going to offer a respiratory protection program for you. We're going to test your lung capacity.' When they did both together the quit rate doubled. That was shocking to the researchers. They were not expecting that outcome.

They reproduced that study a number of times in other populations beyond construction. This was the beginning of the exploration of the total worker health concept. So what was it about combining these two interventions together that doubled the success rate of a very tough population to help quit smoking?

Well obviously they theorised quite a bit about why that intervention in one setting made such a difference versus in the single intervention alone and it basically was this. 'If my employer is concerned about my health at work, that builds a certain level of trust where I am now willing to listen to them on other health messaging. If I believe that someone is actually genuinely concerned with my wellbeing, I am more likely to follow their advice about other parts of my health, maybe that otherwise I might consider were none of their business, right? Whether I smoke or not is really none of your business.' All of a sudden their attitude changed and that is the theory behind why this intervention worked.

The opposite is, 'Why are you telling me to quit smoking when obviously I have all these risks at work that you're not concerned with, right?' So it just sort of – it doesn't ring true if we're not looking to preserve and extend the health of workers from a work exposure point of view to be talking to them about their own personal behaviours and risks.

Let's take a look at a total worker health approach for musculoskeletal disease. So most traditional health promotion programs would move to the end and look at the personal risk factors that are at play in the musculoskeletal injury illness challenge. So they would look at, 'Gosh, this person's obese. We're going to have to change the way that they're doing their job. We're going to have to give them extra tools, extra accommodations.' They would start there. Or they would say, 'This person has arthritis. That's probably why they got injured in the first place.' They would sort of start on that far right end.

We would ask the total worker health approach to start on the left end. So, 'What is it about the job itself that increases the risk for injury and illness?', 'How can we reorganise the work?'

We learned yesterday that so much of MSDs are related, not necessarily to extreme movements, but the length of exposure, right? The holding in a bad posture for a prolonged period of time. The low intensity but very frequent repetitive motion. Those are all solutions that beg out for reorganisation of the way the work is done. Rotating the job. Taking appropriate breaks. Moving from one task to another instead of doing only one for two hours and then only another for two hours. Do an hour of each one that uses different muscle groups. That is really the beginning of keeping workers safe.

Then customising with ergonomic interventions. What is it about this individual that needs special attention beyond what's useful for everyone? Then lastly, let's give people the information they need to better manage their joint needs on and off the job. We all use our joints at work and away from work. So I would say that any of these three has implications across the home and work spectrum. When you put them all together it's a very nice total worker health approach.

What about for sleep and fatigue? You can see we start with staffing levels as being the most important intervention here. Most of our research in sleep and fatigue and there is an extensive amount on the NIOSH home page, so if this is an area of interest to you, especially in healthcare and we've chosen healthcare to do much of our sleep research because it's such a – first of all it's now one fifth of the US economy. It's almost where tremendous amount of job growth has been over the last decade in the US and it will continue to have strong growth. We heard that yesterday for Australia as well. Healthcare and education will continue to be very rapidly growing sectors of the economy.

We have studied health care in the context of sleep and shift work and fatigue, and staffing approaches are really the long-term fix. You cannot make people resilient enough to overcome the staffing challenges. So staffing shortages are really at play here.

There are also some countries that are especially in healthcare settings, trying to introduce naptime in the middle of the night shift. Did anyone have that intervention here in a healthcare setting that you're aware of? Yeah, it's been quite common in South America where workers who are on the night shift will have one hour of sleep in the middle of the shift and it will begin at hour three and go through hour six, staggered one hour per person as the shift rotates. It's actually been shown to have some positive health impacts, that sort of napping in the middle of the night shift. But you can see the total worker health approach here would be safe staffing, health supporting policies like the ones that we just mentioned and then sleep hygiene education, so giving people the skills they need to manage working at off shifts.

Here's the quote that I shared yesterday from Sir Michael Marmot and he's sort of the modern father of the social determinants of health and to me this really sends home the point that we can't start just by behaviour change interventions.

When total worker health was first introduced can anyone guess who our major critics were in the US, who the major – really the only critic in the US? Anyone want to guess?

What was that? Government? No. Labour. Labour was our primary critic. So organised labour and it was because they were worried that employers would delve into the private lives of individuals with this kind of approach. It would draw attention perhaps to the obesity, to the behavioural issues, to the aging-related challenges that were coming with the aging workforce, all of the personal behaviours and elements. Like tobacco, like nutrition, physical activity, underlying middle health conditions, that would lead to potential discrimination or invasion of privacy of workers.

It became very clear to us very early on that we really needed to have some protections for the privacy of people's own personal medical information in this kind of environment where you're looking at individual risk and workplace risk, home challenges and work challenges, privacy obviously important. It's why we really encouraged all these programs to be voluntary for those people who felt that their privacies weren't actively protected.

It also made it clear to us that we really needed to make the research case that total worker health had to be beyond just the traditional wellness program intervention which for the most part stuck with nutrition, physical activity, tobacco and sometimes employee assistance programs, so help with stressors, that sort of thing.

So we really started looking for the evidence base around where is the value in social, cultural, physical environment change over individual behaviour change, and that is where we put the emphasis in the program design and development.

A couple more background – we talked about some examples already for sleep and fatigue.

Let's take a look at smoking. This was an interesting study that was featured in Fortune and it basically looked at wages, benefits and EAP – and we're going to specifically look at the issue of wages here from that puzzle piece, as well as a policy around tobacco. It's interesting what they found.

Their analysis found that overall smoking prevalence was lower in states with higher minimum wages or higher rates of unionisation. Their recommendation was that if we want people to smoke less then we need to concentrate on wages. Now it's quite interesting as to why that might be happening.

Their theory is that if you raise wages you decrease stress and stress-associated smoking. Sort of the solution that often times people have from feeling high levels of stress is to turn to substance, to turn to alcohol, that it would decrease and this is after controlling for other factors that might be influencing smoking rates. So it's an interesting twist here. This is not NIOSH research. It's not research that we have reproduced but we did find it interesting at that intersection of wages and behaviour.

This example though is from NIOSH-funded research. I mentioned we have six centres of excellence. This is the one that we have in New England and it basically looked at the risk of obesity in workers who were facing certain levels of workplace stress. Basically their findings showed that if you have a number of the stressors listed here and they included low decision latitude, poor co-worker support, heavy lifting – so this is also related to the job duties itself – work at night, work-associated physical assault during the past three months; those were the stressors that they identified.

If you have a significant number of them your risk for obesity goes up. This was after controlling for baseline physical activity level, age, sex, gender and education level. You can see other things there they controlled for. Basically they found that if you had five or more of these stressors you were four times more likely to be obese than your co-workers. So a huge association between work stress and obesity.

This was in a group of low wage nursing home assistants. So these were people who were healthcare providers on the lower wage spectrum in long-term care facilities.

Just a couple of warnings about what total worker health isn't and here again pushing the focus on organisational changes over individual behaviour changes. It's not your traditional wellness program, okay, especially one that's been implemented without simultaneously providing safe and healthy working conditions. Remember yesterday we said you cannot overcome a full shift of difficult working conditions with a, you know, a 30-minute lunch and learn or just having access to a free health fitness centre. It's just not possible. The two exposures are not equivalent, so you cannot advantage one by just adding, tacking on the other.

So it's not an add-on collection of health promotion efforts at a workplace where the very way the work is designed contributes to worker injury and illness. It's not consistent with policies that discriminate against or penalise workers for their health conditions, or create disincentives for improving health. This element really was a move away from what was a trend in HR for many, many years in the US and that was incentivising people to have healthier behaviours. I don't know if those policies are common here but it was very common for people to be given a certain amount of money if they would stop smoking, or a certain amount of money, maybe US$50, or US$100 dollars. Some companies were giving up to $900 if you jump through a series of health promotion hoops – doing biometric screening, taking a cholesterol reduction education class, attending smoking cessation seminar. You could earn up to $900.

Basically research showed this. As long as you were dependent on extrinsic motivations eventually they stopped working. You couldn't pay people enough to become healthy. It just wasn't possible. You had to find a way to move from an extrinsic to an intrinsic motivator if you wanted to sustain changes over time. So we really did not see any promising research in the incentive space and we do not really advocate incentives as a particularly effective means of moving people forward.

Now that doesn't mean that extrinsic, rather intrinsic motivation, trying to find a way to motivate people and to educate people about their own health and wellbeing is important but we would say that's only successful if the conditions of work are amenable to that sort of engagement, to that sense of wellbeing as a baseline.

It's not a wellness program that does not ask employees for their input. Remember it's not, 'if they build it,' or 'if we build it they will come'. It's, 'if they build it they will come'. I think in every single workshop, the two breakout sessions yesterday and two of the keynoters were all talking about the extreme value of their participatory approach. That is certainly part and parcel of our research.

One of our centres of excellence that does research is in the participatory ergonomics model that you heard yesterday. They do all of their work design in participatory approaches. They have some excellent tools to help you design your own programs as well.

We had gone through a few of the puzzle pieces in the last example and here's sort of the nine different areas where we believe they're sort of right for total worker health interventions. Under each of those nine puzzle pieces there's a number of ideas where you may think about where we could intervene in our own space. I know some of you are struggling to see the slides. These will be made available as the keynote slides. They will be available for you as soon as they're posted online. I'm certainly fine for you to have the slides.

Remember we talked about the PPPs. Let's take a look at what some of those PPPs are and I would say this is a really great slide to think about when you are developing your own intervention for the middle part of the workshop. Worker centred operations – that's the participatory model again – especially in workplace problem-solving and remember yesterday we heard that the main benefit there is if they had a role in coming up with the challenge, understanding it, experiencing it, they're going to be most intimately familiar with it and if they are involved in solving it, more likely to buy into the solution and to carry it out, to sustain it over time.

Paid family and sick leave, paid medical benefits. Is it a law in Australia that paid sick leave must be available for every worker? Yes.

Audience member:

Except casual.

Dr Casey Chosewood:

Except casual employment, yeah. That's not the case in the US. Even workers in full-time standard jobs may not have access to paid sick leave which is disastrous and it's certainly something that we've been trying to shed light on the health impacts of that kind of short-sighted decision making. We have very strong economic research at NIOSH that shows that companies that offer paid sick leave not only have better engagement, obviously retention of workers, attraction of workers, here's the kicker, they have low work injury and illness rates. Now some people would say, 'Oh, I would thought just the opposite. You offer someone a benefit, you're going to see more uptake of that benefit'. The opposite is true.

There's a huge amount of workers' compensation data and study by our economists that show acute injury and illness rates and this is in the manufacturing population specifically, have a lower occupational injury and illness rates. So it's certainly a lesson that we could take from your success.

Policies that intervene around discrimination, harassment and violence prevention also shown to have positive health impacts. The whole issue of work intensification prevention, this is both a risk with the technological changes that are occurring and also this drive to do more with less staffing. So we see work intensification happen especially around those times when there are economic downturns. So after 2008 there were a lot of layoffs, a lot of lack of new hires, so a lot of attrition without rehiring behind folks. We saw a lot of work intensification. So the average worker instead of working 44 hours was up to 48 hours or 55 hours, throwing away vacation, not taking vacation as much as possible, or even when you're on leave, continuing to work at home, and that work intensification strongly associated with a number of health risks.

This whole idea of recognising work factors as potential causes of chronic conditions. There are two main surveillance systems in the United States that look at the health of the American people. One is the National Health Interview Survey and one is the Behavioural Risk Factor Surveillance Survey. The National Health Interview Survey is interesting because it's a group of mobile vans that travel around the United States and they pull into parking lots in Walmarts and Target stores and community centres. They have people come in and they answer health questionnaires and they draw their blood to look for exposures, to look for cholesterol, to look for all sorts of diseases and conditions, and they weigh them as well, and they measure their height. So we know how big and how small the population of the US is getting by direct measurement.

We also compared that to what people's report is about their height and weight, and you can imagine that people are shorter than they report and they're heavier than what they actually weight, right? No surprise there. But the fact is these are representative. So we're collecting enough samples to be able to make predictions about all of the US by congressional district, right? That's the National Health Interview Survey and the National Center for Health Statistics, part of CDC does that.

The other major surveillance system in the US is the Behavioral Risk Factor Surveillance program – BRFSS, and that basically is just self-reported behaviours that have health implications – so, 'How much do you smoke?', 'How much physical activity do you get?', 'Tell me about your diet', 'Tell me about your health seeking behaviours', 'Tell me about how often you get a preventive physical exam or a prostate screening, breast cancer screening,' that sort of thing. So those two major surveillance systems in the United States were for decades what we relied upon to understand the health of the American population.

Guess the one question that wasn't asked in either surveillance system? 'What the heck is your job?'

So for decades that information was collected without asking what we would argue is one of the biggest exposures that people have.

So for the last 6/7 years we've been adding in occupational modules to both surveys and it has uncovered a wealth of information about people's behaviours and their health outcomes, and their weights, and their cholesterol levels in relationship to work. For the first time ever we can now associate certain industries, occupations, certain jobs down to the makes code, down to the very detailed description of what you do.

We can show how that exposure, the work exposure actually does lead to some of the behaviours and some of the health outcomes. That led to the information I shared yesterday about firefighters and police and security guards. It's led to a better understanding of the risk factors for stroke, for diabetes, for certain types of cancers. There is an overwhelming evidence now, indisputable, that work is a major influencer of health and health opportunities. So for us this is just a brand new horizon of information we can use to develop and track the success of workplace interventions for chronic disease prevention.

Let's talk a few minutes about integration and could I have a time check? How are we doing on time? Okay, we're halfway through. Great. I'm going to finish up in the next five minutes so that we can shift to some table work and let's just quickly go through these remaining slides. We won't go to the end because I will have some resource slides for you at the very end.

So what do we mean by integration? The goal is to align all initiatives focused on worker health to reduce duplicated efforts. This will help save money obviously. It will utilise limited resources more appropriately, amplify the impact of all programs involved and bring together those people who actually have a voice, have a role in determining the outcome, the success of workers. That means your safety staff, your health staff, your occupational medicine staff, your human resources people, your employee assistance program. Any of those people who have a role in the way work is done should be present at the table. Just review, share budgets, reduce cost, share programming, avoid duplication.

Most people who are starting down the path of total worker health put together a community, a committee rather, and we call it 'safety and health community', a 'total worker health community' in some settings, but basically here's some of the folks that are involved. We feel strongly that you should have worker representation. So the dark blue on the left, a worker representative whether that's a union official, or a leader elected by the workforce, or a strong advocate for workers, they should be involved. You can see some of the other folks that we would bring together at the table to discuss what interventions we're going to choose as a group.

So why implement an integrated approach? Workers may perceive changes in health behaviours as futile in the face of significant occupational exposures. That's why we would argue that you need to be focused on creating better worker conditions. That was the argument behind why the first intervention in the construction workers in tobacco was not successful. Management efforts to create a healthy work environment may increase workers' motivation to modify their own personal health behaviours and foster trust that may support workers receptivity to messages that are coming from the employer.

Here's some of the benefits that our early research has shown – injury and illness, worker satisfaction, better culture, less stress, reductions in workplace injuries, reduction in healthcare costs. Healthcare costs are a tricky one in the US because things are not being held constant. So it's very hard to compare healthcare savings over time through any workplace intervention because the healthcare cost environment is rapidly changing. There's a lot more cost-sharing which means that people have to pay more out-of-pocket. That intrinsically changes demand. That changes the cost at the end of the day for the employer which is how most of these things are tracked.

So in general we move away from talking about a hard number ROI when it comes to healthcare costs because the environment is changing so rapidly that it's hard to make year over year comparisons.

With that said though we have some very good track record of large companies like Johnson & Johnson, American Express, Caterpillar, Coca-Cola that have had long-term integrated interventions that have saved a lot of money according to their own company press releases and articles, research findings. So we do believe there is significant cost reductions that can be had in healthcare costs.

I mentioned two studies. We'll just quickly talk about Dartmouth-Hitchcock. They're an academic medical centre, 8,500 employees. They're in New Hampshire as I mentioned. Here were their problems - very high healthcare costs, sidelined programs. So their safety department never had any interaction at all with their occupational health department. Their employee assistance program in HR completely separated. The workforce was sicker than benchmarked organisations. So they had a higher absenteeism rate, they had more turnover and patient safety concerns. They had a high level of needlestick especially in the operating room setting. It was one of their most worrisome exposures.

So what did they do? They worked over the course of several years to create a sustainable culture of health model that would support both occupational and larger health goals of their workforce and they started with an organisational assessment – two types. They did an employee viewpoint survey. So they asked, 'What do you like about your job and what do you don't?' They didn't just drill down to, 'What are your safety concerns or not?' That was part of the question. They asked broader issues – 'What do you love about your job?', 'What would you like to see differently?' They asked broad questions that would allow them to think more from a cultural standpoint and then they developed a program called 'Live Well Work Well' that basically took the feedback from their organisational assessment and their employee viewpoint survey and turned it into program interventions.

First of all they did a much better job of collecting injury data. So they started with electronic reporting of injury and illness data and usually within the same day they started their investigation process. So they fine-tuned their approach to safety. They developed SWAT team - Safety Wellness Action Teams which were very integrated. So you can see they had a variety of people as part of that team – both the safety officer, an operational health person, an employee assistance person, an organisational psychologist – all that were part of the team that would go into hotspots in the organisation, both that either had high injury and illness rates, or proactively in those that sort of triggered worrisome findings on the employee viewpoint survey. They would go in and they would do interviews. They would say, 'What are your challenges?', 'What would you like to see differently?' Then they developed a fuse committee which was stakeholder representatives from the work unit and they provided peer assistance to those hotspot areas. So it was pretty comprehensive.

Here are some of their interventions at the group level - supervisor training. Remember we talked yesterday about the importance of the GP, almost tiny compared to the importance of the supervisor when it comes to health at the end of the day. They did some team and resiliency building, chaplaincy, lifestyle coaching and benefits design. So they used their employee viewpoint survey to redesign benefits to better align with the needs of the population. They changed their access to healthier foods. They improve their work scheduling – something difficult to do in healthcare settings. They also had some individual level interventions including some self support surveys. These worked to alert people as to all of the benefits that were available to them and to test if they were aware or not if they were available, and then provided employee assistance, behavioural health, workability programs and primary care disease management. These were all voluntary programs.

I mentioned to you yesterday the concept of healthier supervision. This is a program that we put in place in NIOSH and it basically shows you know, some of these stats here show the importance of that supervisor when it comes to so much of your engagement and enjoyment of work. The way we did it was also by starting with an annual survey and every year in May we have a survey. We get about 70 to 75 per cent participation. So it's a pretty good handle on the challenges that our workforce faces. We ask what your challenges are in that survey and we use that feedback to design our healthier supervision training. It basically identified three or four things.

Our supervisors need better coping skills with problem employees. They need to develop sort of better ways to manage those hotspots if you will, from an employee standpoint. They need to do a much better job of rewards and recognition. That's something that we heard again and again and again. They need to have a variety of tools available to do rewards and recognition from on the spot awards, financial awards, newsletter recognition, all hands meetings with recognition that way. Supervision by walking around was another big portion of our training, so have people out of their offices. You know, a group of scientists tend to be fairly insular, behind their desk, amongst their work. We really talked about supervising by walking around.

We required our supervisors to have eight hours of training on interacting with their staff, eight hours of training per year. So every supervisor and above must have eight hours of training and these are on topics like better communication skills, offering feedback, workforce development training. So it's not just sort of the technology. It's not just like, 'This is personnel law'. No we wanted really the occupational health psychologist leading much of this training. Resiliency building was another component.

Those were the elements that we built in to our own healthier supervision training and our employee viewpoint survey continues to improve every year. So we're really encouraged by the healthier supervision training.

Our own internal total worker health program at NIOSH is called 'Healthiest NIOSH' and just to give you an idea of some of the things that we do in addition to the healthier supervision training, we're also offering a financial wellbeing seminar right now. We're offering retirement preparation as part of our health intervention and we're also offering coping with change seminars. It's been a real challenge going through the administrative upheaval of moving from one administration to another and we got early feedback that our staff wasn't coping with these changes at all, quite well.

So we developed a four-part training on coping with change and that's been very successful. We've had hundreds of people coming to our webinars. We archive all our webinar material, so it's available for people who can't attend live and also after the fact.

There are five essential defining elements of total worker health and I'll just go through those quickly as we get ready for your exercise. First of all demonstrate leadership commitment. So your intervention should talk about how you will engage leadership. Design work to eliminate or reduce safety and health hazards. So talking about and thinking about work design is a critical component of improving total worker health – important, essential we would call it, fundamental. Promoting and supporting worker engagement. So this is the participatory component again. Ensuring confidentiality and privacy. So if you're going to be collecting information as part of your intervention – surveys, biometric screenings, any kind of collection of data, having some plan to make sure that the confidentiality and privacy of those workers is protected.

See most people worry that, 'My supervisor will know about something that I don't want them to know about', or, 'That information will be used against me to not allow me to progress, to get a promotion, to get a new job, to not even be hired in the first place'. Then lastly that this concept of integration, addressing both either risks that are integrated and meaning the risks apply to both home and work, or the intervention itself can have implications for home or work and certainly anything that influences wellbeing is going to impact home and work.

How many of you in the room have heard of the traditional hierarchy of controls? Almost everybody. It's part and parcel of traditional industrial hygiene. Get rid of the risk first by eliminating it when you can. If you can't do that, substitute something less harmful and if you can't do that, then build in an engineering control to try to separate the risk, the hazard from the person. Then lastly use administrative controls like training or limiting exposure time, and then lastly PPE. So removing down the hierarchy because the top one is most efficient, most effective at securing the health of the individual. The bottom rung is the last choice, right?

We would argue that most interventions that are traditional wellness programs go for the very last bottom of the rung first, right? They look at the individual. 'How can we change you?' you know, instead of thinking about the system and its impact on those outcomes or those behaviour choices.

So we developed a total worker health hierarchy that mirrors the other and this is really – I think I'll leave this up for your exercise because this is really talking about eliminating working conditions first. When you can do that substituting current policies for those that enhance health, redesigning the work environment and then moving to individual interventions – education and encouraging behaviour change, encouraging prevention behaviour. In that order. If you start with the bottom first we believe you'll be less successful.

Policy change is powerful. There was one policy in Vietnam that reduced their head injury rate by 50 per cent overnight. Overnight the whole country's head injury rate went down 50 per cent. Anybody want to guess what it was?

Helmet laws. You could have had television campaigns about wearing your helmet for years and never had a 50 per cent reduction. Overnight, in a compliant society where they follow the law and quickly wore helmets as was required by law, the head injury rate dropped dramatically.

I mentioned the wellbeing project that we're doing with RAND. This is basically the centre of it. The survey will look at the physical environment and working climate. It will look at work evaluation experience from the worker standpoint, their health status and the policy environment they perceive. In the context of the external which is their community, their home, their family and it will give us a single summative score that can be measured over time. It can be done before a total worker health intervention and after to look for impact. It can be done annually to look at sort of the pace of change of an organisation. This is the tool that we'll be happy to share both as a test bed if you have a population, as well as eventually it will be open source for everybody.

Then my last formal slide before we move into the activity is the article that I referred to yesterday about better performance in the stock market. So these were companies that were compared to their peers to see how well they performed in the stock market and it looked at the average company versus those that scored well on a culture of health award program. The award winners have significantly increased market performance. So this is a pretty strong study done by the American College of Occupational and Environmental Medicine that we put a lot of faith into as showing some of the return or value of investment from these kinds of interventions.

Okay, so you're already broken into groups. How many of you have the handout already? So that something that you have? Great.

The goal is to choose a real-life worksite, identify key factors and risks at that worksite and you can use one of your own at the table or come up with one, choose one to two risk factors that you'd like to target and then come up with a plan. We're going to spend – how about we say we spend about 20 minutes as a group, only about 20 minutes as a group so we'll have some time for report outs. So as you're developing your own intervention also sort of develop or pick a spokesperson as well .

[Audience completes activity]

[End of part-1 transcript]

Part 2

Run time: 28:35

Download a copy of this podcast (MP3, 16 MB)

Workshop 5a: Total worker health

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

[Start of part-2 transcript]

Dr Casey Chosewood:

Great. Okay, let's go ahead and get started. We would love to get through as many of the report outs as possible. We're also going to whiteboard all of the interventions. So we're going to write them up on the board here and take a photo, and we can include this photo in your slide set as well, so you have a listing of all the interventions that folks came up with.

We will be able to get through the majority of the tables if everyone takes about three minutes. Now I know that's going to be kind of a tough way to summarise 20 minutes or so of work but if you can do your best to have your spokesperson just speak for about three minutes and you can focus on the intervention, the population you chose, your approach, the integration element. You can choose what you think is the most important information to share in the report out. Okay?

We can go just start on one end and go to each table. I'd like to take volunteers first. So if there is someone who would like to lead off and start sharing the group from their table, or the work from their table, please go ahead.

Alright, perfect. Let's also see if we need a microphone. Let's see if we can hear or if we'll need a microphone. Do you want to start?

Audience member:

Yeah, I've got a pretty loud voice. Basically we couldn't decide who we were going to concentrate on so we made something up, and what we looked at was ground crew in the airlines. Obviously the baggage handlers and all the different roles that keep planes in the air. So we went through the whole sort of context space.

Now I've got you, and obviously all the stuff that came out was shift work, manual tasks, noise, the work environment, exposures. Wages and conditions was the chat we had around that space and particularly obviously the psychosocial piece for the workloads and the timeframes etc. We made an assumption having watched a lot of ground crew work that they're sort of middle-aged to ageing workers. So there was a consideration there. Eventually we narrowed down probably the environment was the interesting one to make an intervention around. The majority of these people would probably drive a fair distance to come to the airport, would have a travel home. Obviously during the day there's little downtime parts but not a lot.

So we took on board your suggestion about using the supervisors. We thought that was a really powerful piece. Now we've got 10 minutes guys. Let's do a health intervention. So empowering them was a big part of that. The other thing that we discussed was using some technology and obviously every ground crew person's probably got a phone in their pocket. So some of the communication, consultation, working group type staff we'd probably do via SMS type messaging and things like that, a bit like what we saw yesterday.

Yeah other than that, that's as far as we got.

Dr Casey Chosewood:

Great. I love that. Thank you. Super.

(Applause)

I especially love the use of the SMS text messaging that has and in some studies has been shown to be quite effective. A generational thing. The younger population is far more interested in that kind of intervention than older populations. Okay. Who's next? It's great. Got it.

That was exceptional. Good job in such a short time.

Audience member:

Hi there. We identified working alone yardsmans at school. So we identified those people as being generationally mature people who tend to come from backgrounds of plumbers, builders, you know, labour-intensive roles and this is usually towards the twilight end of the years. We identified that they on weekends sometimes have to work alone. We identified that they were low pay, limited resources, that their work is their identity. So when they become injured they've got the psychosocial kind of issue that comes about.

Some of our solutions we looked at were you know, taking a pool of those people and talking to them about identifying the particular risky behaviours, working at heights, working with vibration tools, those sort of things and then forming like toolbox education for that group of workers.

Some of the things we identified were the same as the other gentleman which was use of technology. So these people have a mobile phone that they can do JSAs on to look at each individual task as they do them and having weekly catch-ups with their supervisors, making sure that their supervisors were educated enough to identify when things are going wrong.

Dr Casey Chosewood:

Great, super.

(Applause)

Love the focus on population at higher risk and you know, one of the other things that's been very promising with an older workforce is to do training around groups of medications that are quite common. So if you know your population or even have insight into the pharmacy benefit management, so you know what prescriptions are being filled, you can target specific education to the most common medications in use and talk about the safety implications of broad classes of medications. Those have been some of the most popular educational offerings that we've had and we tie them to broader prevention messages as well.

Ready?

Audience member:

I'm getting handed notes here.

Dr Casey Chosewood:

The pressure's on.

Audience member:

Okay. We identified new recruits in the Defence Force, that their expectation is at a certain level of what the job's going to be and when they join it certainly doesn't meet their expectations at times. Then they can experience some stress and get bullied, and also they tend to have absenteeisms from field work and things like that. We identified that this could be through a lack of communications through their supervisor/manager and maybe a lack of control from when they're going into a new job they think, 'Okay, I have some say,' and that mightn't necessarily be the case. Also they are used to maybe playing their PlayStation games and shooting people and think, 'Oh, okay, it's just going to be like that'.

So the solution, the integrated solution that we decided to approach this with is provide a comprehensive induction about what the job entails and also providing mentoring or a buddy system so that they have that person that they can talk to, that maybe was lacking with their supervisor or manager or someone. They feel like they can approach a buddy more so than they can approach their manager or supervisor if they're having issues about that. Is there anything else you wanted me to say here? Excellent.

Dr Casey Chosewood:

Perfect, great.

(Applause)

I love the focus on new employees and onboarding employees, a couple reasons why. We've done a really good pilot of developing an onboarding process for our own workers in NIOSH. It's been one of the most successful interventions. Not only do we tell people about the resources that are available but we give them information about how to order a sit-stand workstation, how to access the walking workstation intervention that we have, to let them better understand where they go to if there's a problem, if they need assistance with any kind of workplace problem where they – we fill in all our new folks on that information.

Two of your most vulnerable working populations – older workers we spend a lot of time talking about. There's a tremendous amount of emerging research about the first year of employment being extremely high risk. So those new workers, new to a site, new to a new task have a lot of occupational health and safety risk. Definitely the onboarding process helps dramatically with that. Great idea.

Another? Yes, sir. You guys are doing a wonderful job. These are excellent. You would think that I'm out of a job soon. My goodness.

Audience member:

Okay, we elected to look at the road construction and maintenance industry of which there is an ongoing problem with an aging workforce which I hear is a common factor amongst the tables here. We focused specifically on manual handling as the maximum reasonable consequence with an aging workforce that encounters a strain or sprain goes up as a result of a decline in physical strength and ability.

We looked primarily at identification. In order to get identification we needed to speak to people on the ground that spoke to a committee, not unlike what the presentation listed as a SWAT I believe was the acronym?

Dr Casey Chosewood:

Right.

Audience member:

Bringing in a supervisor, your HSR or OHS rep, field staff in consultation with the project manager but not necessarily always with the project manager or with senior management such as an operations or resource management area. Taking that SWAT – incidentally if I go off book, someone please pull me back in – taking that SWAT team we have a team that is dedicated to looking at a worksite, going on to the worksite, identifying manual handling risks from a perspective a step back but also with some experience. If we're able to target the aging workforce and identify those risks not only do we nip something in the bud, but addressing the younger workforce concerned where they draw the example from is typically from people who have spent 10, 15, 20 years on the job.

So if we can teach them, the aging workforce, how best to identify and eliminate these risks, they pass those learnings down to those who are coming into the workforce for the first time.

Dr Casey Chosewood:

Love it. Thank you.

(Applause)

You know, I especially love your intergenerational comments. We introduced a program at NIOSH called 'Coach Approach' and it's interesting. We have all of these older people talking about topics that the younger folks could benefit from like research methods, how to write for a scientific journal article, that sort of thing, but we have all of our new employees teaching the older employees the public health value of Twitter or LinkedIn or social media. So it's really been empowering on both ends of the spectrum that intergenerational sort of benefit. Some people see it as a major drawback. We've tried to turn it into a positive for our own workforce and love that approach.

I saw hands. Yes? Thank you.

Audience member:

Okay. Can everyone hear me?

We decided to look at an importing business. So this company works – well, people contact this company when they went to import something from overseas such as when the Australian dollar was good I was working with them. So a lot of people were buying Harleys from overseas and lots of different American style cars and the packaging, and they'd come in in shipping containers and sometimes there was no control over the way the shipping container was actually packed at the source.

So at this end the shipping container would turn up. It would go through the Customs process and the fumigation and things. Then it would be unpacked by a workforce here in Brisbane.

The main things we looked at as well was engaging mainly management to start off with, so getting their buy-in to everything and also engaging the supervisors and the workers in the process as well. So it's probably not much to add to what most other people have done but the main difference as well is there was a large – the population of people that work within the organisation are from Polynesian backgrounds and they tended to work really well in groups together and have that real mateship culture and look after one another. So we thought we could really buy into that as well to try and engage them in the interventions and things and get that mateship really working towards the intervention, like positive outcomes of the invention.

Is there anything else anyone wanted to add? That's right, the other thing was the system. So whether we could actually – they could get some contracts happening with a specific company overseas so that they had some more control over how things were packaged and also when they come back here systems involved to actually ensure they had the right equipment to unpack rather than just using the brute force of the workforce.

Dr Casey Chosewood:

Great. Thank you.

(Applause)

Really love bringing in the cultural and diversity aspects of these sort of integrated interventions. One of the things we found in some of our NIOSH locations was that they weren't very diverse populations. So a good example is we have 500 workers in Morgantown, West Virginia. It's a very isolated, insular community, not very diverse. Those managers and trainers really benefited a lot from diversity interventions, sort of cultural educational opportunities that we brought as part of the Healthiest NIOSH intervention. You think, 'Well there's no health and safety implications'. There's a tremendous amount of employee engagement, value that comes from a more broader global sense of who you are in relationship to the world around you. So we saw positive benefits from that kind of intervention.

Okay.

Audience member:

Okay. We decided to actually look at an actual case that happened within the Queensland Police. A general duties officer was tasked with removing a dead body from bushland. As a result this officer has suffered a back injury and later had a secondary psych because the back injury has meant that he couldn't maintain his fitness and possibly couldn't be a police officer. This person has actually gone on and put a Common Low claim in against the QPS.

So, when we discussed it as a group straight away the first question from people that didn't work within the QPS was, 'What's your training like?' Well guess what? Training for removing a dead body isn't really something that you can actually go and do a 101 on if you know what I mean, because dead bodies can be in a house. They could be in the water, wherever. Interestingly yesterday when we were at that other lecture and he was saying, 'Manual handling, don't waste your time,' we're sort of going, 'Alright, what do we do?'

But anyway we discussed and we said, 'Well no, there isn't so much actual training for removing dead bodies. The word that we like to throw around in the QPS is 'risk assess'. So presumably these two officers, because there was two, they would have performed the performed risk assessment. 'Yes, we can remove this body.' Obviously not. He's ended up with a back issue.

So we further talked about it and there's a definite gap between what training we provide, what legislation requires and also what the QPS's OPM or Operational Procedure Manual tells you to do. So doing a gap analysis but when you do your gap analysis we're going to have to have the unions, executive, sergeants, connies, health and safety, HR – all of those people in the room to say, 'This is the gap'.

I'm sure you can appreciate the gap for any police officer and the tasks they're to do every day, it's something that we meet every day because a police job isn't easy. You can have a day where you don't have any issues at all, you can have a day where you've got 55 drunk people smashing each other and you're there and you've got to try and, you know, resolve that issue. So we basically said that it's all about a consultative approach. You identify your risks. You then take your policies and you go with your board of management and your executives and the unions and you obviously prioritise levels that you need to try and reduce this risk first. But I'd be really interested with the manual handling to get some advice and help from anyone that can give us some information on how we can do this for the QPS because it's an area that we're really not being targeted, but it is an area that you can't say, 'Oh, just use a lifting device'. You can't do that with people punching on that are knocked out and you've got bystanders on. So it's a really difficult area.

Richard who used to be a firey, he said, 'The SES actually have devices that can go into remote bushland and extract that'. So maybe we need more communication with other departments as well. I don't know, but that's another area that we'd need to look at.

Dr Casey Chosewood:

Great. Well thank you.

(Applause)

It strikes me as a challenging job on so many fronts. You and I were having an offline conversation yesterday about how police used to be viewed by the public as heroic, as sort of coming to the rescue, as being this sought-after profession that people wanted to grow up to become and increasingly they're in this scenario where they're oftentimes held to a higher than normal level of scrutiny. They're seen as a negative influence in so many communities and that certainly has a huge draw, a huge pull you know, on the psyche, the engagement, the community there. So that's really a tough spot. It really strikes to the need to have a very comprehensive program to help prepare them for the huge variability of the exposures that they see.

Great. How are we doing on time? Okay and then that will be the end? Okay, so let's do – let's do two more reports and then I have just a couple more slides to show you. Over here on the wall.

It sounds like from Game of Thrones, 'From the wall', right?

Audience member:

Thanks Casey. We looked in the utility sector. One of the issues that had been identified was the increasing obesity rates. We've got a blue collar workforce, predominantly working out in the field, working at heights and in confined spaces. There was quite a significant number of people that were at a weight that was beyond the limit of the harnesses that we've been using.

Yet the culture and the systems that were in place just enabled people to continue using that, a workforce that was continually, you know, the same sort of people had been in the workforce 20, 30, 40 years. It was an aging workforce as well which we've mentioned numerous times, and the culture existed, 'Just let them go. Let them just keep using the harnesses'.

So even though there was the policy in place around it, literacy levels both with supervisors and individuals didn't even look – HR, typical process. It was all online. Go and look at the policies, look at the practices, read them. Most of the people couldn't read.

There was issues around the shift work and people being between all the multiple shifts about the education around safety or the time that they had because they weren't getting paid to be able to come along and actually find out what was required, and again the focus was predominantly on safety, not around the health and wellbeing of the workers.

Some of the plan that we probably looked at and some of the stuff that's been developed as more of a health and wellbeing focus around the individual and what can be put in place to support them when they go home, after work and the culture that exists around that. Looking at providing more time around the shift work and overlap between them to have the conversation and the communication. Reporting to the executive around some of the issues around the lifestyle factors and the due diligence required from the executive to be aware that people are operating and using equipment out of its boundaries and the weight zones and the risks associated with that, but how do we shift the focus not from the risk, but to the lifestyle of those individuals so that you ensure that they go home safe at the end of the day to their family and friends. That some audits need to be done by senior executive because if the supervisors and middle management are allowing this practice to happen, how do you get the senior executive to go and actually demonstrate to the culture that that's not acceptable, that it's their responsibility that they can't dissolve their responsibilities just all the way down, that they actually also have to take ownership of that as well, but also the individuals have to take ownership of their own lifestyle factors.

Some of the programs that have been put in place is health and wellbeing programs, so the exercise physiologist, psychologist, nutritionist to help those that are overweight and to put not only programs in place for them but their family members. So taking a more holistic approach and providing healthy eating options for breakfast at those times when they couldn't probably access nutritional food or activities as part of their health program.

Dr Casey Chosewood:

Great, thanks.

(Applause)

Good job.

I like the focus on taking care of the harness issue and the sort of safety issue staring you in the face first and then moving to individual level intervention second. Whenever I see high rates of obesity I really think the first focus needs to be, 'What's the level of workplace stress?' because some of the most physically demanding jobs in the US, think hotel cleaning, hotel workers, think people who are on their feet all day long, bending, lifting, stooping are some of the most obese. So it's more than just opportunity for physical activity or exertion. It's the working conditions more broadly, the stress levels that come along with that low decision, low latitude, kind of high stress, high demands environment.

Okay, we have time for one more short report and then we will wrap up.

Audience member:

Okay, we chose musculoskeletal disease as an area for intervention and our target group were mail room staff, mail room teams. The risk factors we identified as well as the physical demands, the physically demanding aspect and the sedentary aspect of the job were low wages, work pressures like quite strict times because mail had to be delivered, so start time, finish time and break times, low decision making, could even be environmental issues, the design of vehicles, the design of trolleys, parking distances and staffing levels in general.

In terms of who we would get involved we identified that senior management was key to get on board. So senior manager of the area, someone with budget authority and authority to actually maybe bring in casuals or other people to allow their team time to participate in this program. Other stakeholders would be area managers, staff themselves, injury management team, safety reps, union reps, HR in terms of recruitment, could be pre-employment screening or things like that and occupation health teams if you've got them. Otherwise you could use external agencies if you need to.

In terms of our baseline data and stuff, information that we try and look at to identify key problem areas, we'd look at the job description, look at task analysis, risk assessments, our incident and workers' comp data, look at their own KPIs in terms of delivery of service and see if there was anything that we could change around that or work in with that because obviously productivity is still important. We would do observations and get staff involved in those observations and identifying the risks themselves. Maybe issuing things like discomfort surveys because we recognise that just because things aren't reported doesn't mean they might not be experiencing current levels of discomfort – aches and pains and musculoskeletal problems.

Then other interventions – we know we need budget commitment first, but could be equipment upgrades, so to the actual trolleys and equipment that they're using, be a good design as I mentioned, but getting the staff to identify, 'These are the problem areas. These are the things that aren't working,' and getting them even identify which trolley might be best and trialling that equipment.

Different types of training in different areas and it could be just body and musculoskeletal awareness as well as maybe using the new equipment and better ways of manual handling practice. Maintenance programs for the environment and the equipment that they use. Even maybe reorganisation of work, so delivery to the end point instead of it all coming to a central mail room for them to source out and then have to work out how to deliver across campus or across location. Yeah, I think that's it.

Dr Casey Chosewood:

Great, thank you.

(Applause)

I really love the comprehensiveness of your approach. That was really great to see.

Okay, let's just finish up with a reminder of the resources that you have available. Also remember you're going to get both of the lectures from yesterday and today, the slides and please feel free to reach out to me if there's any specific resources or research article maybe that I've mentioned that you'd like to see. I'm happy to share that.

This is just a quick overview of our website. Remember you can get there just by googling 'total worker health' and we specifically highlighted some publications and reports, some total worker health events and a couple of events that I want to draw your attention to. We have this ongoing webinar series. Because of the time zone change please join by the archive version as opposed to live unless you're really, yeah, unless you're up late at night it might be a challenge, but the archive has access to all of our webinars and they're usually 60 to 90 minutes on a number of topics, many of which you guys have brought up today. Then there's also the 'contact us' button, if we can help with anything at all.

We also have three documents that I really want you to take a look at if you're interested in developing your own programs, the essential elements, the ideas you can implement right now. So it's kind of the very earliest low hanging fruit that you can start and then a series of worksheets to help you get started on program design and implementation, and evaluating your success.

We also have a number of assessment tools that are available online. The ones that are in red are the ones that are used most avidly, most commonly. CDC has a worksite health scorecard that NIOSH and other parts, the Chronic Disease Center part of CDC have worked jointly on. I think it's really exceptional because it does a great job of looking at risks from a broad standpoint, not only safety risk, not only chronic disease risk, but the overlap of the two.

Then these are some deeper, more what I would say are academic guidelines for the total worker health approach. The third one is from our Harvard Center of Excellence. The first one is from a similar organisation to the sponsor of this meeting from the state of California. So it's going to have a regulatory sort of approach to the language combined within it, and the Healthy Workplace Participatory Program which is really a deep dive into participatory ergonomics and design of solutions for all of these challenges. Remember we have twitter, we have LinkedIn. Both, I have a personal one, Casey Chosewood, as well as we have a total worker health one. So definitely please sign up for both if you have that opportunity and join our total worker health in action eNewsletter.

With that, thank you for your attention today. Great job.

(Applause)

Janine Lees:

Okay. Thank you Casey. If everyone would just like to go and make your way out now for brunch and then just select your rooms and your topics for this afternoon. So most are being repeated but it will be a new topic in this room.

Thank you.

[End of part-2 transcript]