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Total Worker Health in Action

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Volume 8 Number 2 June 2019

Director’s Buzz

L. Casey Chosewood, MD, MPH

In this issue, we are pleased to share exciting updates from our Office and stories of collaboration with partners across the country and world. First, we are enthused to announce that a 17-chapter edited book, Total Worker Health, published by the American Psychological Association and edited by NIOSH leadership, is now available for pre-order and will be released on July 9, 2019. With contributions from over 60 researchers and practitioners at the forefront of the Total Worker Health field, the book brings together the state-of-the-science knowledge on integrative prevention strategies that safeguard and ensure the health and well-being of workers. Read more about the TWH book in New Publications and Resources.

This issue’s TWH Exclusive feature, on TWH initiatives in Brazil, is from Serviço Social da Indústria (SESI) in collaboration with the Harvard T.H. Chan School of Public Health Center for Work, Health, and Well-Being. In another collaborative effort—involving NIOSH, the American Heart Association, the AHA Centers for Workplace Health, and the National Heart, Blood and Lung Institute (NHBLI)—the Workplace Health Research Session convened to focus on improving employees’ cardiovascular health and overall well-being. Read more about this recent effort in News from NIOSH TWH Affiliates and Partners. Transforming organizational policies, programs, and practices to improve worker safety, health, and well-being at home and abroad is more important than ever as challenges facing today’s workers continue to evolve and grow more complex.

In light of the changing nature of work in today’s modern workplaces, NIOSH is embarking on a new initiative around the Future of Work. By taking a TWH approach to this initative, NIOSH will consider conditions of work as well as emerging issues confronting employers and workers. Read more about the new NIOSH initiative in this issue’s Updates from the Office for TWH.

Shining the light on important topics around TWH continues to be a focus of the NIOSH TWH Webinar Series. I’m pleased to share news on two upcoming webinars. The first, happening in June, will feature a refresher on the concept of TWH, including the evolution of the program from 2011 to the present. It will be perfect for those of you who are new to this field or for those who want to get a refresher on TWH basics.  The second webinar, planned for July, will focus on the research behind how evidence-based practices, interventions, and policies are effectively translated to and used in the workplace. It’s an ideal exchange for our academic partners, researchers, and practitioners looking for the latest approaches to ensure successful implementation of our evidence-based science.  I hope you will join the TWH community for these informative webinars on foundational topics for TWH research and practice. Learn how to register and join in Updates from the Office for TWH.

Don’t forget, you are welcome to join the conversation on Twitter (@NIOSH_TWH), on the NIOSH Total Worker Health LinkedIn Group, or by email at to stay up-to-date on the latest Total Worker Health news, research, events, and more.

Total Worker Health Exclusive

Bringing Integrated Approaches on Worker Safety and Health to Brazil

What is SESI?

Brazil, a country of vast industries and businesses, promotes and supports those entities with the National Confederation of Industry (Confederação Nacional da Industria, or CNI). CNI represents Brazil’s 27 state-level federations of organizations and 1,245 sectorial employer’s unions, which are affiliated with almost 700,000 businesses. One of the organizations that CNI directly administers is Social Service of Industry (Serviço Social da Indústria, or SESI). SESI aims to improve employees’ well-being and to promote healthy and safe work environments (

Because of its interest in future occupational health trends, SESI has created nine Innovation Centers in different regions of Brazil that approach various issues related to health and safety at work. The Innovation Center for Psychosocial Factors (CIS-FPS) works with organizations to develop solutions tailored to their specific needs. The CIS-FPS method for assisting a company involves (1) listening to problems; (2) prototyping solutions; (3) testing in the workplace; (4) adjusting the solutions; and (5) replicating the solutions with other organizations.

people in classroom setting listening to instructor

Group participating in the
Professional Education program

Total Worker Health® Approaches for SESI-Supported Organizations

Recently, organizations in Brazil have expressed interest in systemic and integrated approaches to the management of health, safety, and well-being. Many organizations realize that an emphasis on worker health equates with an emphasis on business health. However, simultaneously creating positive outcomes in both areas can be challenging.

To fill this gap between worker health and business health, the CIS-FPS team sought an effective solution that could be applied to various types of businesses in Brazil. They considered a TWH approach most appropriate because of its emphasis on creating policies, programs, and practices that integrate protection measures with efforts to advance worker well-being.1

CIS-FPS turned to the Executive and Continuing Professional Education program of the Harvard T. H. Chan School of Public Health for initial TWH training. Using an approach laid out in its recently published guidelines2, the Center for Work, Health, and Well-being (CWHW) (a NIOSH Center of Excellence for TWH) at Harvard developed training customized for the needs of Brazilian firms. The resulting four-day program featured CWHW faculty and trained 30 CIS-FPS staff members and three representatives from client organizations. Juliano A. Colombo, regional superintendent of SESI-RS, noted that the “TWH approach inspired us. It can be used as a base methodology to promote potential reductions in occupational injury and disability rates in Brazilian companies.”

After the training, CIS-FPS partnered with two Brazilian enterprises to translate their learnings into practice. These two application case studies are discussed here.

Case 1

The first case involved a plastics manufacturer in the capital of Rio Grande do Sul with about 500 employees. CIS-FPS worked with the organization to determine the following scope of activities in the pilot study:

classroom in a circle style setting listening to instructor

Participants attending
a presentation

  1. Create an integrated committee comprising six stakeholders at every level of the organization, including employees and representatives of organized labor. This committee worked together with the CIS-FPS team at all stages of the pilot study.
  2. Analyze organizational programs and policies by sharing current initiatives and health and safety programs with the CIS-FPS team.
  3. Conduct workshops. CIS-FPS conducted four workshops to identify opportunities for enhancing worker safety and well-being, based on the views of employees and leaders. The workshops were divided so that employees and leaders met separately. Afterward, they came together for “listening workshops” to hear what each group developed, and they jointly developed solutions to address problems and improve workflow.
  4. Create an action plan. After the four workshops, all initiatives were categorized and the committee defined priorities for actions that could be addressed with available resources.
    workshop style classroom

    A workshop group
    engaging in discussion

The organization determined that the small initiative they conducted was an effective strategy for identifying opportunities to implement an integrated approach and to enhance a culture of trust. Furthermore, involving workers in this initiative was a concrete first step for instituting a holistic approach within the organization. Additionally, results from a worker perception survey conducted at the end of the project indicated participating staff believed that this initiative contributed to:

  • Creating a stronger health and safety environment
  • Improving worker satisfaction
  • Enhancing work climate
  • Improving communication between leaders and employees

Case 2

The second case study involved a manufacturer of trailers and semi-trailers in Latin America. It is among the largest such manufacturers in the world, and its worksite in Rio Grande do Sul has approximately 1,500 employees. The manufacturer requested CIS-FPS support in planning an integrated approach to improve safety and health conditions among all levels of employees.

These were the pilot activities:

  1. Define the goal. CIS-FPS helped the manufacturer focus on “starting small.” Because this organization had abundant structured
    health data and defined performance indicators, there were many opportunities to review valuable information.
    group photo

    Group photo of planning meeting

  2. Build integrated planning. While this organization already had a committee designated for new initiatives, it still needed to get buy-in to use an integrated planning approach. The committee and CIS-FPS then analyzed existing health and safety data. The manufacturer requested additional survey questions to focus on psychosocial and health conditions. The tool was administered to 185 randomly chosen workers, resulting in an action plan. Analysis of the strengths, weaknesses, opportunities, and threats (SWOT) helped define priorities, specifically to improve communication among leadership and employees about the importance of using an integrated approach to maintain interest, build further support, and stimulate more participation in the initiative.
  3. Monitor and support the initiative. CIS-FPS and the manufacturer committee held monthly meetings for 3 months after implementation. Through this process, the business evaluated its needs and focused on addressing working conditions, especially encouraging participation of employees in this new approach. The organization established a strategy to regularly share
    the results and findings with leaders and workers, thus contributing to optimized communication.
    group discussion

    Small group discussion


These two cases show it is possible to tailor the CWHW guidelines to implement two different processes while using policies and practices to influence workers’ safety, health, and well-being. In addition, the exchange of knowledge among CIS-FPS, Harvard T.H. Chan School of Public Health, and CWHW was helpful for enabling all parties to learn and adapt TWH approaches for different communities. Learning and implementing TWH approaches contributed to development of the CIS-FPS team and also helped the pilot organizations build their own initiatives for safer and healthier work environments in their individual contexts.

Finally, the CIS-FPS team is able to support other Brazilian industries to build an approach which focuses on safety, health, and well-being and emphasizes psychosocial factors management. Using the Total Worker Health approach brought innovation to SESI not only for working with its industries but also for improving its own internal process.


  1. CDC (Centers for Disease Control and Prevention), National Institute for Occupational Safety and Health (NIOSH) [2018]. What is total worker health?
  2. McLellan D, Moore W, Nagler E, Sorensen G [2017]. Implementing an integrated approach weaving worker health, safety, and well-being into the fabric of your organization. Boston, MA: Harvard T.H. Chan School of Public Health Center for Work, Health, and Well-being,

Editor’s note: Serviço Social da Indústria (SESI) is a Brazilian not-for-profit entity which appreciates the importance of new research and knowledge in developing and applying preventive measures in occupational safety and health. To demonstrate the organization’s commitment to the protection of workers, SESI has been in a formal partnership with NIOSH through a memorandum of understanding since 2014.

NIOSH Responds to the Opioid Crisis: Vital Information for Workers and Employers

Editor’s note: In this and future issues, TWH in Action! will highlight the latest research, resources, and news around the opioids crisis and work. You may learn more about opioids and work by visiting the NIOSH Opioids Topic Page. If you or someone you know needs assistance with mental and/or substance use disorders, prevention, and recovery (in English or Spanish), please contact SAMHSA’s National Helpline at 1-800-662-HELP (4357) or visit

What Workers’ Compensation Data Tells Us About the Opioid Epidemic

Workers’ compensation systems were established to provide partial medical care and income protection to employees who are injured or become ill from their job. These systems may also provide incentives to employers to reduce work-related injury and illness. A majority of employers buy workers’ compensation insurance coverage through private insurers or state-certified compensation insurance funds. Larger employers may also have the option to self-insure. These systems are complex and governed by state laws. Workers’ compensation claims data can be used to estimate the numbers of work-related injuries and illnesses by cause, industry, and occupation.

  • A significant share of workers’ compensation opioid prescriptions are associated with injuries that occurred several years prior to the prescriptions. Analysis of data from 40 states as of 2016 showed that 15% of workers’ compensation claims with at least one prescription for opioids had a date of injury that was 6 or more years prior (year 2010 or earlier), 30% had a date of injury that was 2 to 5 years prior, and 55% had a date of injury that was less than 2 years prior.
  • Opioid dispensing rates within the workers’ compensation system differ by industry, company size, injured worker age, injury type, and county-level factors. A recent NIOSH-funded study by the Workers’ Compensation Research Institute (WCRI) found significantly different opioid dispensing rates within the workers’ compensation system in relation to several factors.
  • Workers’ compensation opioid dosing guidelines may significantly decrease chronic and high-dose prescription opioid use among injured workers. For example, the mean monthly prevalence of opioid use among all workers with open claims* declined by about 25% between 2004 (14%) and 2010 (11%) after guidelines were instituted in a large study that included 161,283 workers receiving opioid prescriptions in Washington State.

Find these and other data by visiting To learn more about correlates of opioid dispensing in workers’ compensation, view the recent NIOSH TWH Webinar presented in conjunction with the NIOSH Centers for Workers’ Compensation Studies and WCRI.

Updates from the NIOSH Office for Total Worker Health

NIOSH Future of Work Initiative

In today’s modern world, technological innovations, digital transformation, and globalization accelerate the speed at which we live and work. Such forces have an impact on workers and organizations in the United States and around the world.

These new realities are driving multiple efforts to examine the Future of Work (FOW) and broaden the approach to worker safety, health, and well-being. As part of this collaborative initiative, the Institute is framing FOW on the basis of the multidisciplinary Total Worker Health approach. The initiative promotes worker well-being by encouraging collaboration across the spectrum of organizational policies, programs, and practices that have an effect on the safety and health of workers, their families, communities, employers, and society as a whole. Readers can soon learn more about this new NIOSH initiative on the upcoming Future of Work Topic Page.

NIOSH Total Worker Health Webinar Series

Two Upcoming Installments in the NIOSH Total Worker Health Webinar Series

Understanding TWH

Would you like a refresher on the basics of TWH principles? Do you have colleagues you’re hoping will join you in TWH approaches? Join the NIOSH Office for TWH for a webinar titled “Understanding Total Worker Health: Where We’ve Been and Where We’re Going” on Thursday, June 20th, at 12 pm EST. Hear directly from NIOSH researchers and practitioners pushing ahead the science and practice of TWH. Dr. Sara Tamers, CAPT Mary O’Connor, and Chia-Chia Chang will explore the evolution of the TWH concept, current research, and practical examples applying TWH approaches in organizations. The webinar will be strongly reflective of content featured in this recent journal article. Join us to deepen your understanding of TWH. Register now!

Applying Dissemination and Implementation Science to TWH

Please join us Tuesday, July 2, 2019, for a webinar on “Applying Dissemination and Implementation Science to Total Worker Health Research and Practice: What We Need to Know,” brought to you by the NIOSH Office for Total Worker Health and the NIOSH Centers of Excellence for Total Worker Health. The webinar will focus on the research behind how evidence-based practices, interventions, and policies are effectively translated to and used in the workplace. Featured speakers include Dr. Ross Brownson, Dr. Tom Cunningham, and Pamela Tinc. Dr. Ross Brownson will provide an overview of dissemination and implementation science, including information on strategies for researchers and practitioners. Dr. Tom Cunningham will discuss the NIOSH Translation Research Framework and how various contexts influence TWH dissemination strategies. To conclude, Pam Tinc will share her own experience implementing a National Rollover Protection System Rebate Program, sharing lessons learned and areas for future research. Registration is now open, and free continuing education is available.

Updates from the NIOSH Centers of Excellence for Total Worker Health

Oregon Healthy Workforce Center (OHWC)

OHWC has launched its TWH education effort for practitioners. The Total Worker Health 101 Curriculum is designed to provide actionable steps to implement TWH within an organization. The curriculum was piloted last fall at the Western Pulp and Paper and Forest Products Safety & Health Conference and was launched at the Oregon Governor’s Safety & Health Conference (GOSH) in March 2019. OHWC and NIOSH TWH Affiliate SAIF Corporation staff led the training session.

In addition to the TWH 101 half-day training, OHWC conducted a follow-up TWH Workplace Solutions session. The follow-up training offered further practical steps and specific examples to help put NIOSH’s TWH Hierarchy of Controls into action. This session was also co-led by OHWC and SAIF Corporation staff. The TWH trainings are a key effort of the Oregon TWH Alliance between the Oregon Institute of Occupational Health Sciences (OHWC’s home), SAIF Corporation, and Oregon OSHA. Each session saw about 50 attendees and an enthusiastic and engaged audience. Both courses will be taught next in Seattle, in collaboration with the University of Washington ERC Continuing Education Program, through the Northwest Center for Occupational Health and Safety. The courses will be repeated regionally through 2019, including with the Oregon SHARP Alliance. The target audience includes safety, health, wellness, and human resources professionals and practitioners.

Registration is open for OHWC’s spring symposium, Workplace aggression: Best practices to prevent, identify and safely mitigate aggressive behavior and violence. This day-long event in June will highlight stressors at work, particularly aggression, bullying, and violence. Using case studies from healthcare, education, and social services, the symposium will focus on preventing, identifying, mitigating, and managing risk factors for violence and promoting a safe work environment.

Editor’s note: There are many ways that you can advance TWH practice. You can find out more about professional development opportunities in support of Total Worker Health at NIOSH and our Centers of Excellence here.

News from NIOSH TWH Affiliates and Partners

American Heart Association

Of the 157 million workers in the United States, roughly 1 in 5 has a diagnosed mental health disorder and many live with comorbid conditions, such as hypertension and diabetes, which raise their risk for heart disease and stroke. Improving employees’ cardiovascular and general well-being is vital, inspiring the Workplace Health Research Session, which drew over 100 guests to Houston. Sponsored by NIOSH, the American Heart Association, the AHA Centers for Workplace Health, and the National Heart, Blood and Lung Institute (NHBLI), this one-day summit was held in collaboration with EPI | Lifestyle. Attendees learned about funding workplace research, leveraging data science, increasing physical activity, and optimizing mental health.

Mount Sinai Entities

On May 1st, in honor of the International Labor Day and World Day for Safety and Health at Work, the International Labor Organization (ILO) and the International Commission on Occupational Health (ICOH) held a special event on “Safety and Health and the Future of Work.” The program featured Dr. John Howard, NIOSH Director, and Dr. Roberto Lucchini, Director of the Division of Occupational and Environmental Medicine, Icahn School of Medicine at Mount Sinai. The webinar is archived here.

New Publications and Resources

From CDC and NIOSH

Total Worker Health book cover

Edited Volume on Total Worker Health. The 17-chapter volume, Total Worker Health, published by the American Psychological Association, is now available for pre-order and will release on July 9, 2019. Edited by NIOSH’s Heidi L. Hudson, Jeannie A. S. Nigam, Steven L. Sauter, L. Casey Chosewood, Anita L. Schill, and John Howard and authored by over 60 thought leaders in the areas of work and well-being, it has something for everyone interested in the TWH concept. The book provides an overview of the historical development of the concept and field of Total Worker Health. The volume summarizes the seminal theory and research that underpins the case for integrative workplace prevention strategies, addressing the interplay of occupational risk factors and risks beyond the workplace. The book’s chapters discuss applications of organizational approaches for integrated interventions and evidence of their effectiveness in various occupational and industry contexts. Chapters also describe the design of Total Worker Health programs targeting specific health and safety risks of central concern in occupational and public health today, such as chronic diseases, aging, fatigue and sleep, and work-life conflict. The volume has application as a state-of-the-art reference on integrative prevention strategies for academicians; a handbook for practitioners in occupational safety and health, public health, and business; and a textbook for students in the growing number of academic courses and programs in the United States and abroad that address worker health, safety, and well-being. For more information, including an excerpt from the book, go to the APA Books website.

The association between job insecurity and engagement of employees at work. Researchers from NIOSH examined the association between workers’ perceived job insecurity and their job engagement by using data from the Gallup-Sharecare Well-Being Index national telephone survey. Results indicate that perceived job insecurity was associated with reduced engagement but may be moderated by supervisor support.

Trust in the work environment and cardiovascular disease risk: Findings from the Gallup-Sharecare Well-Being Index. NIOSH and Iowa HWCMW researchers explored the connection between trust and seven cardiovascular disease risk factors, using data from the U.S. Gallup-Sharecare Well-Being Index national telephone survey. Results indicate that lack of trust was associated with increased risk of having many of the cardiovascular risk factors. Workers whose supervisors created a mistrustful environment had more than 20% odds for having four or more of the seven cardiovascular risk factors.

Five New Publications and Resources from NIOSH Centers of Excellence for Total Worker Health

Availability and use of workplace supports for health promotion among employees of small and large businesses. Iowa HWCMW researchers examined the availability and utilization of workplace health supports by employees of small and large-sized employers. Results indicate that large employers (>100 workers) offered more supports than small employers (<100 workers), but workers at small employers were more likely to utilize supports when available.

Generalizability of Total Worker Health® online training for young workers. OHWC researchers assessed changes to knowledge and behavior between two groups of young workers (<25 years old), following online TWH safety and health training. The researchers collected information on the workers’ demographic characteristics, knowledge, and self-reported behaviors of workplace health and safety. Results indicate that training programs based on TWH improve the safety, health, and well-being of young workers.

Job satisfaction and the psychosocial work environment: Does the relationship vary by hospital patient care workers’ age? Researchers at Harvard T.H. Chan School of Public Health Center for Work, Health, and Well-being examined the association between psychosocial work factors and job satisfaction and how these factors might be influenced by age for hospital patient care workers. The results show that most situational determinants of job satisfaction may not vary significantly by age.

Paradoxical impact of a patient-handling intervention on injury rate disparity among hospital workers. Harvard T.H. Chan School of Public Health Center for Work, Health, and Well-being researchers tested effectiveness of a comprehensive safe-patient handling intervention for higher-wage healthcare workers (nurses) versus low-wage healthcare workers (patient care associates). Results demonstrate that although the intervention changed self-reported perceptions of safe patient handling in both healthcare worker groups, injury reductions were observed among only the higher-wage workers.

Testing the associations between leading and lagging indicators in a contractor safety pre-qualification database. Harvard T.H. Chan School of Public Health Center for Work, Health, and Well-being researchers evaluated the relationship between safety management systems for construction contractors and injury rates on job sites. Safety management systems include leadership commitment, regular and frequent hazard recognition and controls, employee training, safety communications, and program evaluation. Results indicate that higher scores for safety management systems are linked to lower injury rates.

Conferences, Webinars, and Trainings in Support of NIOSH Total Worker Health


18th to 23rd— OHWC scientist David Hurtado will be presenting Application of Social Network Analysis to Inform an Occupational Health and Safety Program in Healthcare at the XXXIX International Conference for Social Network Analysis, in Montreal, Canada.

20th— The NIOSH TWH Webinar Series will present “Understanding Total Worker Health: Where We’ve Been and Where We’re Going” at 12 pm EST. Hear directly from NIOSH researchers and practitioners pushing ahead the science and practice of TWH. Register now!

26th— The International Association for Worksite Health Promotion will feature Office for Total Worker Health Director, Dr. Casey Chosewood, in a free webinar titled “A New Paradigm for Keeping Workers Safe and Health.” Register now!

28th—Dr. Glorian Sorensen of the Harvard Center will present “Measuring Best Practices for Workplace Safety, Health, and Well-Being,” as part of the Work Wellness and Disability Prevention Institute webinar series, at 2:00 pm Eastern time.


2nd—The NIOSH TWH Webinar Series will present Applying Dissemination and Implementation Science to Total Worker Health Research and Practice: What We Need to Know, brought to you by the NIOSH Office for TWH and the NIOSH Centers of Excellence for TWH. Register to attend.

8th to 10th—The International Labour Organization’s 6th Annual Regulating for Decent Work Conference will take place in Geneva, Switzerland.

31st to Aug 1st— All NIOSH TWH Affiliates will meet face to face in Washington, DC for two days of collaboration, sharing successes, and the latest NIOSH updates. NIOSH leadership from some of our most active program areas and representatives from the TWH Centers of Excellence will also be on hand to enrich the connections. To find out more on becoming a TWH Affiliate, click here.


1st—The 2019 National Symposium on Corrections Worker Health will take place in Boston, Massachusetts. The symposium will bring together correctional leaders, industry practitioners, labor representatives, and researchers to discuss solutions and collaboration possibilities to improve correctional worker health and well-being. Visit the CPH-NEW Corrections Officer Health Resource page for information about prior national symposia events and registration for 2019.


September 4–7

The Association of Occupational Health Professionals in Healthcare (AOHP) Annual Conference will take place in Baltimore, Maryland.

September 26

The Heartland Center for Occupational Health and Safety and local trade partners, with support from the Iowa HHWMW, will host its Hawkeye on Safety symposium for construction managers and workers, union representatives, safety professionals, human resources professionals, administrators, wellness administrators, and other individuals interested in improving the health, safety, and well-being of construction workers.

November 6–9

The 13th International Conference on Occupational Stress and Health, “Work, Stress, and Health 2019: What Does the Future Hold?” will be held at the Sheraton Philadelphia Downtown. Preconference workshops and opening events are planned for November 6. This conference is organized by the American Psychological Association, NIOSH, and the Society for Occupational Health Psychology.


Editorial Board

L. Casey Chosewood, MD, MPH, Executive Editor

CDR Heidi Hudson, MPH, Editor-in-Chief

Reid Richards, Managing Editor

Sarah Mitchell, Associate Editor

Seleen Collins, Copy Editor

Steve Leonard, NIOSH Web Publisher

Please send your comments and suggestions to us at

This newsletter is published quarterly via email by the National Institute for Occupational Safety and Health Total Worker Health® Program to inform members of the public health community as well as interested members of the general public of program-related news, new publications, and updates on existing activities and initiatives.