Small + Safe + Well: lessons learned from a Total Worker Health® randomized intervention to promote organizational change in small business.

BACKGROUND: Leadership commitment to worker safety and health is one of the most important factors when organizations develop and implement a Total Worker Health® approach. We aimed to assess the effectiveness of a Total Worker Health ("TWH") leadership development program that targeted owners and other senior-level leadership positions on changing organizational and worker outcomes from baseline to one-year later. METHODS: The Small + Safe + Well study included small businesses from a variety of industries in the state of Colorado, USA that were participating in Health Links™. We designed a randomized waitlisted control comparison design (RCT) to evaluate the added benefit of a TWH leadership development program. An employer assessment tool was used to assess TWH policies and programs, and an employee health and safety survey was used to assess safety leadership and health leadership practices, safety climate and health climate, safety behaviors and health behaviors, and well-being. We used a linear mixed model framework with random effects for business and employee to assess the impact of intervention on the outcomes of interest. RESULTS: Thirty-six businesses (37% retention) and 250 employees (9% retention) met the RCT study inclusion criteria and were included in the analysis. Businesses improved their TWH policies and programs score from baseline to one-year later, regardless of leadership intervention group assignment. Neither intervention group demonstrated improvements in employee-reported outcomes. CONCLUSIONS: This study sought to address a gap in the literature regarding small business senior leadership development for TWH. Our study demonstrates many of the challenges of conducting studies focused on organizational change in workplaces, specifically in small businesses. When designing TWH intervention studies, researchers should consider how to best engage small business leaders in interventions and implementations early on, as well as methods that are well matched to measuring primary and secondary outcomes longitudinally. Future research is needed to test the feasibility and sustainability of TWH interventions in small business. TRIAL REGISTRATION: The trial was retrospectively registered with ClinicalTrials.gov ( ID U19OH011227 ).

Profiles of total worker health® in United States small businesses.

BACKGROUND: The Total Worker Health® (TWH) approach is a best practice method to protect and promote worker safety, health, and well-being. Central to this approach is leadership support and health and safety climates that support day-to-day use of health and safety policies and programs. There is some research that supports these relationships, but there is limited research amongst small businesses. Furthermore, it remains to be shown what role TWH business strategies, as reflected by organizational policies and programs, play in this process. The purpose of this study is to characterize small businesses by their organizations' TWH approach and assess the relationship of these approaches to employee health and safety behaviors. METHODS: We utilized cross-sectional data from 97 businesses participating in the Small+Safe+Well study. We collected data using a business assessment tool, Healthy Workplace Assessment™, and an employee assessment tool, Employee Health and Safety Culture Survey. We used latent profile analysis at the business level to identify subgroups of businesses based on a set of characteristics from these assessments. Linear regression analysis at the employee level was used to determine profile association with employee safety and health behaviors. RESULTS: There were two profiles characterized by the lowest (33% of all businesses) and highest (9%) levels of the indicators. There were also two profiles with higher scores on two of the different foci on either TWH business strategies (27%) or leadership and climate (31%). Employees working for a business with a profile that focused on leadership and climate, in addition to having a business strategy, reported the best safety and health behaviors. CONCLUSIONS: Our study demonstrates that employee engagement in TWH will be highest when businesses have a strategy for how they implement a TWH approach and when they demonstrate leadership commitment to these strategies and foster positive safety and health climates. Our results offer suggestions on how to use TWH assessments to develop interventions for small businesses. More research is needed to understand whether small businesses can improve upon their profile overtime, whether these changes depend on contextual factors, and whether TWH interventions can help them improve their profile.

A pilot study of changes in Total Worker Health® policies and programs and associated changes in safety and health climates in small business.

BACKGROUND: There is little longitudinal research on whether changes to Total Worker Health® (TWH) policies and programs are associated with changes in health climate and safety climate. We hypothesize that as TWH policies and programs change, employees will report changes in safety climate and health climate from baseline to 1 year. METHODS: Twenty-five diverse small businesses and their employees participated in assessments completed approximately 1 year apart. The exposures of interest, TWH policies and programs, were measured using the business-level Healthy Workplace Assessment™ which collects information on six benchmarks. The outcomes of interest, employee perceptions of safety climate and health climate, were measured via an employee survey. We employed paired t-tests and simple linear regression to assess change over a 1-year period. RESULTS: The mean Healthy Workplace Assessment overall score changed by 11.3 points (SD = 11.8) from baseline to Year 1. From baseline to Year 1, the mean scores of each benchmark changed in a positive direction within this sample. The mean safety climate score and health climate score changed by +0.1 points (SD = 0.2) and +0.1 points (SD = 6.4) from baseline to Year 1, respectively. The associations between changes in the overall Healthy Workplace Assessment score and health climate and safety climate scores were negligible [ß = 0.01 (95% confidence interval [CI]: 0.002, 0.02), and ß = 0.01 (95% CI: 0.002, 0.02), respectively]. CONCLUSION: Our study suggests that when small businesses improve upon their TWH policies and programs they experience marginal measurable improvements in employee perceptions of their workplace safety climate and health climate.

Evaluation of heat stress and cumulative incidence of acute kidney injury in sugarcane workers in Guatemala.

OBJECTIVE: Agricultural workers worldwide exposed to heat stress could be at the risk of kidney injury, which could lead to chronic kidney disease of an unknown origin (CKDu). Hydration has been promoted as a key measure to reduce kidney injury. In the presence of a hydration intervention, the incidence of acute kidney injury (AKI) was calculated in a sugarcane worker population in Guatemala and several risk factors were evaluated. METHODS: We measured kidney function at the beginning and end of the work shift at three time points in 517 sugarcane workers. We defined AKI as an increase in serum creatinine of 26.5 µmol/L or 50% or more from the pre-shift value. Associations between AKI and risk factors were examined, including interactions with hydration status. RESULTS: The prevalence of dehydration post-shift (> 1.020 specific gravity) was 11% in February, 9% in March, and 6% in April. Cumulative incidence of AKI was 53% in February, 54% in March, and 51% in April. AKI was associated with increasing post-shift specific gravity, a dehydration marker, (OR 1.24, 95% CI 1.02-1.52) and with lower electrolyte solution intake (OR 0.94, 95% CI 0.89-0.99). CONCLUSIONS: Dehydration and insufficient electrolyte consumption are risk factors for AKI. However even well-hydrated sugarcane workers routinely experience AKI. While hydration is important and protective, there is a need to understand other contributors to risk of AKI and identify prevention strategies with these workers.

Effect of an opioid management program for Colorado workers' compensation providers on adherence to treatment guidelines for chronic pain.

OBJECTIVE: The aim of this study was to examine adherence of state guidelines for Colorado workers' compensation physicians/providers treating individuals as injured workers with chronic pain after initiation of an opioid management program and provider incentives. METHODS: A retrospective cohort of chronic, non-cancer pain claims was constructed from the Colorado's workers' compensation database. Adherence to treatment guidelines and opioid prescribing practices were evaluated during implementation of a new billing code to incentivize adherence. RESULTS: Overall, less than 33% of claims showed evidence of opioid management. Comprehensive opioid management was observed in only 4.4% of claims. In 2010, after implementing the new billing code, the ratio of long acting opioids to short acting opioids decreased from 0.2 to 0.13; returning to 0.2 in one year. Similarly, morphine equivalent doses declined for a short period. CONCLUSIONS: Incentivizing physicians to adhere to chronic pain management guidelines only temporarily improves prescribing practices.

An overview of health and safety in the Colorado cannabis industry.

BACKGROUND: Understanding worker health and safety in the rapidly growing legal U.S. cannabis industry is important. Although little published research exists, workers may be exposed to biological, chemical, and physical hazards. This study investigated the Colorado cannabis industry workforce and both physical and psychosocial hazards to worker health and safety. METHODS: Two hundred and fourteen Colorado cannabis workers completed an online survey after in-person and online recruitment. Participants answered questions about their occupation, job tasks, general well-being, occupational health and safety, cannabis use, and tobacco use. RESULTS: Colorado cannabis workers were generally job secure and valued safety. However, they regularly consumed cannabis, expressed low concerns about workplace hazards, reported some occupational injuries and exposures, and reported inconsistent training practices. CONCLUSIONS: Working in the cannabis industry is associated with positive outcomes for workers and their organizations, but there is an imminent need to establish formal health and safety training to implement best practices.

Health risk factors as predictors of workers' compensation claim occurrence and cost.

OBJECTIVE: The objective of this study was to examine the predictive relationships between employee health risk factors (HRFs) and workers' compensation (WC) claim occurrence and costs. METHODS: Logistic regression and generalised linear models were used to estimate the predictive association between HRFs and claim occurrence and cost among a cohort of 16 926 employees from 314 large, medium and small businesses across multiple industries. First, unadjusted (HRFs only) models were estimated, and second, adjusted (HRFs plus demographic and work organisation variables) were estimated. RESULTS: Unadjusted models demonstrated that several HRFs were predictive of WC claim occurrence and cost. After adjusting for demographic and work organisation differences between employees, many of the relationships previously established did not achieve statistical significance. Stress was the only HRF to display a consistent relationship with claim occurrence, though the type of stress mattered. Stress at work was marginally predictive of a higher odds of incurring a WC claim (p<0.10). Stress at home and stress over finances were predictive of higher and lower costs of claims, respectively (p<0.05). CONCLUSIONS: The unadjusted model results indicate that HRFs are predictive of future WC claims. However, the disparate findings between unadjusted and adjusted models indicate that future research is needed to examine the multilevel relationship between employee demographics, organisational factors, HRFs and WC claims.

Integrated approach to health screening of former department of energy workers detects both occupational and non-occupational illness.

BACKGROUND: The National Supplemental Screening Program (NSSP) uses a Total Worker Health(TM) approach to address U.S. Department of Energy (DOE) former worker health. This article provides the design of the integrated occupational health screening and promotion program. METHODS: The NSSP implemented a web-based relational health records system to process demographic, exposure, and clinical data. We present medical findings for 12,000 DOE former workers that completed an initial NSSP medical screening between October 1, 2005 and October 4, 2013. We discuss the DOE former worker participant population and the exposure-based and non-occupational medical screening tests used. RESULTS: The NSSP identified potential occupationally related health conditions in 40.5% of those screened. Notably, we identified 85.8% of participants with addressable non-occupational health conditions, many of which were previously undiagnosed. CONCLUSION: The NSSP demonstrates that the identification of potential occupational health issues in conjunction with addressable non-occupational health conditions provides former workers with information to more effectively manage health.

Occupational exposures in the oil and gas extraction industry: State of the science and research recommendations.

The oil and gas extraction industry is rapidly growing due to horizontal drilling and high volume hydraulic fracturing (HVHF). This growth has provided new jobs and economic stimulus. The industry occupational fatality rate is 2.5 times higher than the construction industry and 7 times higher than general industry; however injury rates are lower than the construction industry, suggesting injuries are not being reported. Some workers are exposed to crystalline silica at hazardous levels, above occupational health standards. Other hazards (particulate, benzene, noise, radiation) exist. In this article, we review occupational fatality and injury rate data; discuss research looking at root causes of fatal injuries and hazardous exposures; review interventions aimed at improving occupational health and safety; and discuss information gaps and areas of needed research. We also describe Wyoming efforts to improve occupational safety in this industry, as a case example.

Engaging oncology and occupational medicine to inform design of a Total Worker Health® intervention to address employment, financial, and well-being outcomes in cancer survivors.

OBJECTIVES: Few Total Worker Health® studies, and fewer interventions, examine well-being in the work context of cancer survivorship. We investigated the possibility of occupation and oncology professionals working together to address employed survivors' work-associated needs. METHODS: We employed a community-based participatory research (CBPR) approach to examine the educational, contextual, and workflow needs of oncology care team members to inform intervention design. Focus groups were conducted with oncology care team members and occupational medicine physicians. Key themes from each group were then examined. RESULTS: Themes included oncology care team's role in helping patients navigate resources, providing psychosocial support, and educating patients. Major themes for ways to better provide employment-related support during treatment included referring patients to employment experts and providing education on employment support. CONCLUSIONS: Occupational health professionals in collaboration with oncology clinics could play an important role in assisting cancer survivors' ability to navigate employment challenges.

Integration of Total Worker Health ® Training for Occupational Health and Safety Professionals With Efforts to Promote Worker Health, Safety, and Well-being in Mexico.

OBJECTIVE: We sought to test whether a 2-week Total Worker Health (TWH) training mapped to TWH education competencies could be administered to a Mexican audience of occupational safety and health professionals and could lead to positive changes to knowledge and behaviors. METHODS: This study used robust program evaluation methods collected before and after each of the nine training days and at the end of the course. RESULTS: Overall course quality received a mean score of 4.6 (SD = 0.6) and 98.8% of participants agreed that their TWH knowledge increased. All participants intended to make at least one change to their professional practice, most frequently helping companies assess their organizational culture to support health, safety, and well-being. CONCLUSIONS: This TWH training was well received and led to positive self-reported increase in knowledge and abilities to influence workers' health, safety, and well-being.

The Relationship Between Stress and Sleep Sufficiency in the Context of Varied Workplace Social Support.

OBJECTIVE: Sufficient sleep is essential for well-being. We examined the relationship between work-related social support, work stress, and sleep sufficiency, predicting that workers with higher social support would report higher sleep sufficiency across varying levels of work stress. METHODS: The data set analyzed in the present study included 2213 workers from approximately 200 small (<500 employees) businesses in high, medium, and low hazard industries across Colorado. RESULTS: Perceived social support variables moderated the relationship between work stress and sleep sufficiency such that employees reporting higher levels of social support reported higher sleep sufficiency when work stress was low or moderate but not high. CONCLUSIONS: Although preventing work stress is optimal, in cases where employers cannot apply primary interventions to prevent stress (eg, eliminating/reducing night shifts), employers should attempt to increase social support or other more relevant resources for employees.

Leveraging an Implementation Science Framework to Measure the Impact of Efforts to Scale Out a Total Worker Health® Intervention to Employers.

The role of dissemination and implementation (D&I) science is critical to the translation of Total Worker Health® into practice and to the success of interventions in addressing current and future implications for worker safety, health, and well-being. D&I frameworks can guide researchers to design Total Worker Health ("TWH") delivery approaches that use flexible implementation strategies to implement the core components of programs for employers with varying contextual factors, including small/mid/large-sized businesses and different industry types. To date, there have been very few examples of applying implementation frameworks for the translation and delivery of interventions into organizational settings that require adoption and implementation at the business level to benefit the working individuals. We present a TWH case study, Health Links™, to illustrate an approach to applying an existing implementation framework, RE-AIM, to plan, design, build, and then evaluate TWH implementation strategies. Our case study also highlights key concepts for scaling-out TWH evidence-based interventions where they are implemented in new workplace settings, new delivery systems, or both. Our example provides strong support of key implementation planning constructs including early and consistent stakeholder engagement, tailored messaging and marketing, flexibility, and adaptations in implementation strategies to maximize adoption, implementation, and maintenance among participating businesses.

Evaluation of a Total Worker Health® leadership program for small business leaders.

Leaders play a critical role in the development and execution of Total Worker Health (TWH). Small businesses, in particular, can benefit from strong leadership support for TWH as the burden of work-related injury, illness and fatality, as well as poor health and well-being is high in this population. In the present study, we conducted a program evaluation of a TWH leadership development program for small business leaders using the RE-AIM framework. The goal of the program was to help change leaders' behaviors around health, safety and well-being practices following the theory of transformational leadership. Two leaders from each business participated in pre-training activities on their own, a 6-hour in-person training, and three months of access to virtual training transfer activities, including coaching and goal tracking. Our results suggest that the TWH leadership development program is effective at improving leaders' self-reported TWH leadership practices and that the in-person training was implemented successfully. However, leaders did not report improvements in their personal health and in fact reported increased levels of work stress after the program. We also observed some challenges when implementing our training transfer strategies. Our study suggests that leaders may benefit from attending TWH leadership trainings alongside other colleagues in their organization to facilitate a shared vision and goals for TWH in their organization. As a next step, it will be important to determine the program's effectiveness in changing business TWH policies and practices, employee perceptions of TWH and leadership, and employee health and safety outcomes.

Total Worker Health® and Small Business Employee Perceptions of Health Climate, Safety Climate, and Well-Being during COVID-19.

The COVID-19 pandemic created workplace challenges for employee safety and health, especially in small enterprises. We used linear mixed-effects regression to examine changes in health climate, safety climate, and worker well-being, prior to the pandemic and at two timepoints during it. We also examined whether employees at organizations that had received a TWH leadership development intervention prior to COVID-19 would better maintain pre-pandemic perceptions of climates and well-being. The final study cohort consisted of 261 employees from 31 organizations. No differences were observed in mean outcome scores between the leadership intervention groups at any of the survey timepoints. We combined intervention groups to examine the difference across timepoints. Perceptions of health and safety climates remained stable across all timepoints. However, employee well-being scores declined between the pre-pandemic period and subsequent COVID-19 timepoints. These findings suggest that while small organizations continued to be viewed as supporting employees' health and safety over the course of the pandemic, well-being scores declined, indicating that other factors contributed to decreased well-being. The findings from this study have implications for small business leaders as they navigate the impact of the COVID-19 pandemic on the health, safety, and well-being on their organizations and employees.

The Importance of Small Business Safety and Health Climates During COVID-19.

OBJECTIVE: This study examines employee perceptions of safety and health climates for well-being during the COVID-19 pandemic in a sample of small businesses. METHODS: We evaluated changes to employees' work and home life resulting from COVID-19 and perceptions of safety and health climates. Cross-sectional relationships were assessed using multivariable linear regression models for a sample of 491 employees from 30 small businesses in Colorado in May 2020. RESULTS: Employee perceptions of safety and health climates were significantly related to their self-reported well-being during the first wave of COVID-19, even when there were changes to childcare, the ability to work, and limited social contacts. CONCLUSION: Safety and health climates may influence employee well-being even when other disruptions occur, suggesting that during emergencies, small businesses with strong climates may be better prepared to maintain employee well-being.

Impact of Advising on Total Worker Health Implementation.

OBJECTIVE: Little is understood about the mechanisms for improving the adoption and implementation of Total Worker Health® (TWH) in workplace settings. The primary objective of this study was to identify whether the delivery of TWH advising is associated with subsequent changes in TWH in small-to-medium sized businesses. METHODS: We conducted a longitudinal study of a TWH intervention in 200 organizations completing Health Links Healthy Workplace Assessments™ between October 2016 and December 2019. Organizations were offered consultation via telephonic and live web-based advising sessions. RESULTS: Organizations exhibited non-significant albeit positive change in assessment scores from baseline to assessment 2. Businesses receiving advising showed significant score improvements from assessment 2 to 3, versus those without advising. CONCLUSIONS: TWH consultation may enhance adoption of organizational behaviors that promote worker health, safety, and well-being over time.

International Total Worker Health: Applicability to Agribusiness in Latin America.

Total Worker Health® (TWH) is a framework for integrating worker and workplace safety, health, and well-being, which has achieved success in European and US settings. However, the framework has not been implemented in Latin America or in agricultural sectors, leaving large and vulnerable populations underrepresented in the implementation and evaluation of these strategies to improve safety and promote health and well-being. This study presents a case study of how a TWH approach can be applied to a multinational Latin American agribusiness. We describe the process and adaptation strategy for conducting a TWH assessment at multiple organizational levels and in multiple countries. We follow this with a description of a TWH leadership training that was conducted based on the results of the assessment. Finally, we describe our methods to make corporate recommendations for TWH policies and programs that were informed by the TWH assessment and leadership trainings. With this case study we aim to demonstrate the importance and feasibility of conducting TWH in Latin America.

Small Business Employees' Perceptions of Leadership Are Associated With Safety and Health Climates and Their Own Behaviors.

OBJECTIVE: Leadership is an important factor in creating a safe and healthy work environment. Little is known about its influence in small organizations. This study assessed the relationship between leadership, climate, and employee behavior in organizations with less than 500 employees. METHODS: We examined organizational factors and worker perceptions of leadership and safety/health behaviors in an analysis of 1271 employees in 53 Colorado small organizations. Cross-sectional relationships were assessed using multivariable linear regression models. RESULTS: Perceived leadership commitment to safety was associated with safety climate (ß = 0.67) and safety behaviors among employees (ß = 0.45). Perceived leadership commitment to worksite wellness was associated with health climate (ß = 0.66) and health behaviors (ß = 0.42). CONCLUSIONS: Leadership plays an important role in creating a positive work environment around safety and health.