In 2011, the National Institute for Occupational Safety and Health (NIOSH) introduced Total Worker Health^® (TWH) as a comprehensive approach to promote the health, safety, and well-being of all workers. TWH is defined as the “policies, programs, and practices that integrate protection from work-related safety and health hazards with promotion of injury and illness-prevention efforts to advance worker well-being”.¹ As such, the TWH approach unites traditionally distinct occupational health and safety and workplace health promotion domains to offer a more holistic, integrated, and interdisciplinary perspective.^2,3 Whereas occupational health and safety interventions traditionally focused on reducing work-related health and safety risks and associated outcomes (e.g., occupational injuries and fatalities, hazardous exposures), TWH approaches incorporate broader efforts, both within and beyond the workplace, to improve worker well-being.⁴ TWH similarly builds on workplace health promotion efforts (e.g., wellness programs) by advocating for working conditions that support worker health and safety.⁴ TWH thus represents a paradigm shift in how researchers and practitioners approach worker health and safety.⁵

Sorensen and colleagues developed a conceptual framework to help researchers and practitioners interested in embracing a TWH perspective.⁶ The first version of the framework, published in 2016, was developed to clarify relationships between workplace policies and practices, worker characteristics, the conditions of work, and outcomes for workers and employers.⁷ It focused especially on documenting the relationship between working conditions and worker health, safety, and well-being outcomes. The second version of the framework, published in 2021, expanded the first by situating conceptual relationships specified in the original model within the larger “socio-political-economic environments” in which work occurs.⁶ According to the authors, such environments affect the nature of the workforce, the organization of work, and labor relations.

The breadth of TWH and associated framework constructs⁶ require corresponding measures and tools to accurately assess a diverse set of exposures and outcomes across levels of measurement. Moving toward the identification of “consensus measures” (also sometimes referred to as “common outcome sets”) may address this need. Consensus measures are agreed upon, standardized approaches for assessing a construct of interest intended to be used by researchers and practitioners across different studies and settings. Consensus measures support evidence building by facilitating cross-study comparisons, integrated data analysis, and validation studies, which can enhance the generalizability and applicability of research findings. Consensus measures also help their users operationalize complex and multidimensional concepts such as work-related stress, organizational culture, or worker engagement. The National Institutes of Health’s PhenX Toolkit⁸ and the Core Outcome Measures in Effectiveness Trials (COMET) initiative⁹ are examples of existing efforts to establish common measures

The purpose of this study is to conduct a scoping review¹⁰ to identify existing measures and measurement tools that can be used to assess TWH outcomes and factors associated with those outcomes. Although measures and tools are defined separately—measures referring to specific metrics and methods to assess a defined construct, and tools to the instruments used to capture data across measures—we aim to capture both, owing to the relative novelty of the field. We searched for measures and tools that cover a range of domains relevant to TWH, including indicators for assessing the conditions of work; worker safety, health, and well-being; and enterprise policies, programs, practices, and outcomes. We also focused on measures and tools that can be completed by or about workers or workplace representatives without the need of specialized biological, physiological, laboratory, or environmental data capture. Candidate measures and tools thus align with data collection using surveys, interviews, checklists, and other self-report or observational methods. We intend for the findings to help researchers and practitioners who are interested in designing, implementing, and/or evaluating TWH interventions across settings and populations. Researchers can use the measures and tools to select appropriate indicators for their research questions, hypotheses, and designs, as well as to identify gaps and opportunities for developing or improving measures and tools. Practitioners can use the measures and tools to assess the needs, strengths, and challenges for their organizations and workers; to monitor and evaluate the progress and impact of their TWH interventions; and to inform their decision-making and strategy. The broader vision for this scoping review is that we will facilitate the national TWH agenda by advancing rigorous, standardized methods for studying TWH^11,12 and inform future consensus building needed to establish common measures for TWH.

We conducted a two-phase scoping review¹⁰ to identify TWH measures and tools. Phase 1 consisted of a systematic search of bibliographic databases. Phase 2 entailed a targeted review of key TWH websites.

We identified a total of 102 measures and tools from 100 sources. The number of sources differs from the number of measures and tools because some sources contained information on multiple measures and tools, and some measures and tools were evaluated across multiple studies. Figure 1 summarizes the results of our systematic literature search. We screened 1,997 titles and abstracts; 1,833 did not meet our inclusion criteria. Of the 160 remaining titles and abstracts, 82 articles reporting on 88 unique measures and tools were deemed eligible after full text review. From the 11 websites we scanned (the CDC’s “assessment tools” page and those of the 10 TWH Centers for Excellence), we identified an additional 14 measures and tools.

Table 3 provides descriptive information regarding the 102 measures and tools we identified. Although our inclusion criteria allowed for a variety of data collection modes, all but six of the 102 measures and tools (94%) were designed exclusively for survey data collection. About three-quarters of the measures and tools (N=79) were assessed at the worker level. Nearly all the measures and tools (82%) were publicly available in the articles we reviewed and/or via an external website, but in some cases (N=15, 15%), it was unclear. The measures and tools contained between two to over 100 self-report items, with most (N=71, 70%) containing fewer than 50 self-report items. For 16 measures and tools, different versions varying in length were assessed within and across articles. Most of the measures and tools (N=63, 62%) were designed for general use across workplaces and/or workers. Of the measures and tools designed for more targeted use (N=39, 38%), they were intended for a specific occupation or industry (N=22, 56%; mostly construction/healthcare), health risk or ailment (N=13, 33%), or type of work (N=4, including lone workers, office workers, and remote workers). Five measures and tools were assessed for use with workers from specific cultures or who spoke specific languages (mostly Hispanic workers).

Table 3 also identifies the number and percentage of measures and tools for which we found evidence of validity and/or reliability assessment. As the table reflects, close to three-quarters of the measures and tools were assessed for construct validity (N=79, 74%). Assessments of content validity (N=70, 69%) and internal consistency (N=63, 59%) were also common. Fewer than half the measures and tools were evaluated for criterion validity (N=17, 15%) or test-retest agreement (N=18, 18%). Only 10 measures and tools were introduced or assessed in the sources we reviewed without any evidence of psychometric evaluation.

Table 4 lists each of the 102 measures and tools we identified organized using Sorensen et al.’s conceptual model for integrating worksite health protection and health promotion.⁶ In total, 18 measures and tools relate to enterprise policies, programs, and practices; 34 relate to the conditions of work; 30 relate to worker safety, health, and well-being; 17 relate to enterprise outcomes; and 3 measures and tools cut across the categories. Table 4 also shows subcategories that we developed inductively within the Sorensen model, which we suspected may be of interest to future researchers. We used symbols to signify level of measurement for each measure and tool and we found evidence of validity or reliability assessment.

In this paper, we identified 102 measures and tools that can be used to assess TWH outcomes and factors associated with those outcomes, including indicators for assessing the conditions of work; worker safety, health, and well-being; and enterprise policies, programs, practices, and outcomes. We used Sorensen’s conceptual model for TWH⁶ to organize the measures and tools for researchers and practitioners who are interested in designing, implementing, and/or evaluating TWH interventions across a variety of workplace settings and worker populations.

Our analysis revealed many strengths of existing measures and tools. Most are publicly available and can be accessed by researchers and practitioners at no charge. Most measures and tools identified were also designed for general use across various types of workers, workplaces, and industries, suggesting ample opportunities for adoption. Substantively, the measures/tools addressed the subset of categories of Sorensen et al.’s conceptual model of an integrated approach to worker health⁶ that we identified as relevant to this review. Consistent with their conceptual framework, measures and tools associated with the conditions of work comprise a relatively high proportion of those we identified. And, critically, all but 10 of the measures and tools were evaluated for validity and/or reliability using the indicators and criteria we defined – most commonly for construct validity, content validity, and internal consistency.

Our analysis also points to several limitations of the measures/tools available, with implications for both research and practice. Over half of the measures and tools we identified contained 20 or more unique self-report items, and 15 percent contained 50 or more. Although lengthy measures and tools may help researchers who are interested in a comprehensive and robust assessment of some underlying construct (e.g., the NIOSH WellBQ¹⁰⁹), they can also be excessively burdensome for study participants. Compounding this issue, in our experience, studies focusing on TWH commonly entail assessment of multiple constructs, and researchers/practitioners designing studies may need to make concessions with respect to measure burden to keep data collection manageable. For situations where burden may be a concern, we see opportunities to develop more concise tools and additional short-form measures. Several authors associated with the sources we reviewed were already proceeding in this way.^18,19

We also found uneven substantive coverage of the measures and tools identified. For some topics, we identified many measures and tools with the same goal and felt it could be challenging for researchers/practitioners to select from among them – especially in the absence of an established gold standard for evaluating the underlying constructs. For example, we identified seven measures and tools designed to provide overall assessments of employers’ policies, programs, and practices relating to worker health, safety, and well-being. Similarly, we identified ten measures of worker well-being. Future researchers might consider using theory or the results of psychometric evaluation to evaluate the strengths and limitations of these measures and tools in relation to each other, as we observed some authors doing.^69,70 This work to identify the best measures and tools for a particular construct could be part of defining common measures for TWH.

In contrast, some substantive topics seemed to have comparably limited measures and tools. For example, the measures and tools used to assess enterprise outcomes focused exclusively on productivity, which is just one of many outcomes that employers hope to improve when implementing TWH interventions.¹¹² Although alternative enterprise outcomes may be easily monitored using data sources and indicators beyond the purview of this work (e.g., human resource records on absenteeism, days away from work, recruitment, retention), there nevertheless seem to be opportunities to develop new measures/tools aligned with this category. These might include proxy measures and tools designed for use at the worker level, which may be easier to integrate into TWH studies that do not directly engage employers.

Another limitation was that although just ten of the measures and tools we identified were not evaluated for any of indicators of validity or reliability that we assessed, some forms of psychometric assessment were less common than others. Only 15 percent of the measures and tools were assessed for criterion validity, which may make sense in the context of lacking gold standards for many key constructs associated with TWH. Without gold standards against which new measures can be developed, it can be difficult to determine which measures and tools should be promoted over others focusing on the same underlying construct(s). We also found limited evidence of test/retest agreement, perhaps due to overreliance on cross-sectional research designs. Expanded use of longitudinal data for reliability assessment can help address this limitation.

Considering the overwhelming number of measures and tools designed for survey data collection, we see opportunities to standardize measurement practices when using qualitative or observational approaches. The Consolidated Framework for Implementation Research (CFIR) website provides an example of how this might be accomplished. The CFIR website provides questions for qualitative interview guides that align with each construct in CFIR.¹¹³ Sharing these interview questions along with the construct definitions and supporting evidence helps align users’ thinking and data collection strategies.

There may also be opportunities to develop or assess additional measures and tools that are tailored for specific uses. Just over a third of the measures we identified were designed to focus on specific occupations, industries, health risks/ailments, or types of work, which could improve the precision of data collected and the perceived relevance of the measure or tool to study participants. We also identified a small number of measures and tools that had been assessed for use with workers from specific ethnicities, cultures, or linguistic preferences, and see value in continuing such efforts as to reflect the diversity of workplaces.

In combination with the gaps noted here, NIOSH’s National Occupational Research Agenda for Healthy Work Design and Well-Being¹¹⁴ may help researchers identify the most critical measures and tools needed to advance TWH. Experts prepared this agenda to establish priorities for occupational safety and health research based on the existing literature. The agenda identifies topics such as non-standard work, advancing technology, fatigue associated with shift work and long hours, worker well-being, quality of work life, and work/nonwork balance as requiring new measures or measurement approaches. For example, the introduction of artificial intelligence into the workplace could pose new risks to workers¹¹⁵ and thus imply opportunities for research and measurement to better assess those risks. Although we identified measures of worker well-being as part of this review, the remaining topics may be ripe for measure development.