Approximately half of Americans live with a chronic disease and about one-fourth report residual effects from their chronic diseases.¹ Chronic diseases, including heart disease, cancer and stroke, are the leading causes of death in the United States (US).² Disparities in chronic disease exist by race/ethnicity and socioeconomic status, with minorities and lower income groups having a higher prevalence of heart disease, cancer and stroke, and multiple risk factors for these conditions.^3–5 Of additional concern, the prevalence of chronic diseases is higher in the US than in other developed countries.^6–8 There are more than 81 million people with cardiovascular disease (CVD) in the US, with an estimated cost of $503 billion in 2010.⁹ In 2005, over 1.3 million people were diagnosed with cancer, with costs in 2007 estimated at $219 billion.¹⁰ Almost 24 million Americans have diabetes, at a cost of $174 billion in 2007.¹¹ Approximately 67% of American adults are overweight or obese,¹² with a projected cost of $147 billion for 2008.¹³ In addition, non-fatal chronic conditions, such as musculoskeletal disorders ¹⁴ and psychological disorders,¹⁵ are major sources of disability.¹⁶

Worksites provide a venue to address multiple individual risk factors and risk conditions through worksite health promotion aimed at changes in individual behaviors, worksite health protection including occupational safety and health interventions, and efforts to address unhealthy work-family conflict.^17,18 As a venue for delivering chronic disease prevention efforts, worksites provide a ready channel for reaching the large segment of the population that is employed. Worksite conditions also contribute to the development of chronic diseases, for example through hazardous job exposures, high job demands, and inflexible work schedules.

Individual health behaviors contribute significantly to these chronic disease outcomes. In 2000, 435,000 deaths (18.1% of total deaths) were attributed to tobacco use, 365,000 deaths (15.2%) were attributable to a combination of poor diet and lack of physical activity, and 84,000 deaths (3.5%) were related to alcohol misuse.^19,20 These four individual health behaviors collectively accounted for approximately 40% of all deaths in the United States in 2000. ²¹ Worksite health promotion provides an effective way to enhance health-promoting behaviors, to reach a large segment of the population, and to reduce chronic disease risk factors. Comprehensive worksite health promotion has been recommended by the American Heart Association, the American Cancer Society, Healthy People 2010, the National Institute for Occupational Safety and Health, the National Institutes of Health, and the Centers for Disease Control and Prevention (CDC).^22–25

In 2006, US healthcare spending was reported to be over 2 trillion dollars²⁶ and employers on average paid more than one-third of this cost.²⁷ A meta-analysis of the literature on costs and savings associated with worksite health promotion programs reported that medical cost reductions of about $3.27 are observed for every dollar invested in these programs.²⁸ This number has been corroborated by recent systematic reviews and economic analysis conducted by the Task Force on Community Preventive Services, which reported an annual savings of $3.20 for every dollar invested.^29,30 Other benefits of worksite health promotion include reduced absenteeism^28,30 and improved employee attitudes towards work.³¹

The work environment, encompassing the physical, psychosocial, and organizational environments, directly shapes employee health, safety, and health behaviors.²² In 2008, over 5,000 workers died from occupational injuries,³² and work-related illnesses account for 49,000 deaths annually.³³ Over 4.6 million workers experienced non-fatal occupational injuries or illnesses in 2008; about half of these non-fatal injuries and illnesses resulted in time away from work due to recuperation, job transfer or job restriction.³⁴ Employers and insurers spent approximately $85 million in workers’ compensation costs in 2007,³⁵ although this figure is only a portion of the costs borne by employers, workers, and society overall for the costs associated with work-related illness and injury. In 1992, the total economic costs to the nation from occupational illnesses and acute injuries was estimated to total between $155³⁶ and $171 billion, ³⁷ figures that are similar to those for all cancer or all cardiovascular disease in this time period.^36,38

Worksite health protection initiatives include efforts to improve occupational safety and health, address organizational factors at work that influence worker health, and support work-life balance. Compliance with safety and health standards were mandated by the passage of the Occupational Safety and Health Act of 1970. OSHA rules, such as those pertaining to cotton dust, inorganic lead, and blood-borne pathogens, have resulted in reduced exposures and illnesses.³⁹ Efforts by government, labor, management and health professionals have also led to reductions in exposure to biomechanical risk factors at work, which contribute to work-related musculoskeletal disorders, the most common category of occupational disease reported to OSHA.¹⁴ Labor-management health and safety committees and worker compensation insurers have reported that OSHA’s support of prevention through regulation and training have contributed to the prevention of work-related injuries and illnesses.⁴⁰ It is also possible for worksite initiatives to redress sources of stress at work including inflexible work schedules, low job control, and excessive job demands, ^41,42 which lead to negative health outcomes for employees and their families.

The combination of health behavior change programs with work environment changes may be synergistic and when integrated, may enhance their effectiveness.^22,43 Beyond using the worksite as a platform to promote changes in individual health behaviors, such as smoking, dietary intake, physical activity, and weight control, a more integrated approach recognizes that the workplace acts as both an accelerator and preventer of chronic disease and as a key determinant of individual health behaviors, through physical, social, organizational and psychosocial mechanisms. Simply stated, workers may perceive changes in their individual health behaviors as futile in the face of significant occupational exposures that have considerable bearing on their health. Conversely, management and labor efforts to create a healthy work environment may contribute to workers’ motivations to modify their personal health behaviors, and may foster a climate of trust that may support workers’ receptivity to messages from their employer regarding individual health behavior change.^44–46 This principle of integrating worksite health protection with worksite health promotion was recently endorsed by the American Heart Association for cardiovascular health promotion.⁴⁷

In light of the importance of chronic disease prevention at the workplace, the National Heart, Lung, and Blood Institute (NHLBI), the National Institute of Occupational Safety and Health (NIOSH), the Centers for Disease Control and Prevention (CDC), the National Institute for Child Health and Human Development (NICHD), and the National Cancer Institute (NCI), convened a workshop to identify research needed to develop effective programs that reduce chronic disease risk and support worker and family health through effectively promoting healthy and safe individual behaviors, reducing physical, psychosocial and organizational risks at the worksite, and promoting work-life balance. The workshop, held on May 21–22, 2009, was co-chaired by Dr. Barbara Israel, Professor of Health Behavior and Health Education, School of Public Health, University of Michigan, and Dr. Glorian Sorensen, Professor of Society, Human Development and Health, Harvard School of Public Health. The panel, selected by the workshop sponsors to reflect a range of perspectives on chronic disease prevention in the workplace, consisted of specialists in epidemiology, sociology, occupational and preventive medicine, organizational psychology, occupational health psychology, health education and health behavior, environmental and occupational health, economics, exercise physiology, ergonomics, pediatrics and human development. Their interests were varied and included individual behavior and organizational change research, family and community health research, public policy, intervention design and evaluation, translation and outcomes research, participatory action research, and health disparities (see list of participants in Appendix A).

The workshop objective was to develop a comprehensive and coordinated research plan to build the evidence base around effective chronic disease prevention for working adults and their families through worksite interventions. To achieve this objective, the workshop had three main informational sessions: 1) promoting individual behavior change, 2) changing the work environment (physical, psycho-social and organizational), and 3) intervening to influence the work-family-community interface. Each session was guided by eight areas of discussion: 1) research strategy, 2) current state of the science, 3) conceptual models, 4) research design, 5) practices and policies, 6) cost-effectiveness, 7) barriers, and 8) specific populations. This report presents three parallel worksite approaches to preventing chronic disease – through promoting individual behavior change, changing the work environment, and addressing work-family-community interface – and explores opportunities for coordination and integration of these approaches. Further details about these recommendations are presented in Table 1.

Figure 1 depicts the conceptual framework that guided the workshop discussions. The three circles illustrate the three intervention targets that were the workshop focus: individual health behaviors, the work environment, and impacts on the work, family and community interface. A focus on individual health behaviors, such as smoking, dietary patterns, physical activity, and weight control, may occur singly or as a multiple risk factor approach, and typically utilizes the workplace as a platform for program delivery; changes in the work environment may be implemented to support health behavior changes. Components of the work environment that may influence worker and family health include worksite culture; organizational policies and practices; hazardous chemical, physical and biological exposures; psychological job demands; job control; work schedule and control over work time; work-related rewards; organizational justice; work norms and social support; and union status. Additional attention must be paid to the impact of the interrelated work, family and broader community systems, given the importance of psychological and behavioral spillover and crossover between work and family lives. The conceptual model also acknowledges the roles of economic, legal, political and social factors, which may influence worker health, job insecurity, access to health insurance, and worker and family stress.¹⁸ Overlap of the circles shows opportunities for collaboration, integration, and synergy, thereby strengthening the potential for impact on chronic disease prevention at the workplace.

Workshop participants referred to the Healthy People 2010 Objectives for a definition of “comprehensive” worksite health promotion, which includes several core components: health education programs, a supportive social and physical environment, “integrated” programs (e.g., budget, staffing, resources), screening (including treatment and follow up as needed), and linkage to other assistance programs.²⁵ Worksite health promotion programs also include a needs assessment, individualized health messages, encouragement of self-care, use of incentives, social support, and sufficient duration to enhance implementation and maintenance.⁴⁸ Through Healthy People 2010, CDC has recommended that at least 75% of worksites offer a comprehensive worksite health promotion program.⁴⁹ The most recent National Worksite Health Promotion Survey found, however, that only 7% of worksites do so.⁵⁰ Although larger worksites are less numerous that smaller ones,⁵¹ worksites with 750 or more employees were over six times as likely to offer comprehensive worksite programs than those with 50–99 employees.⁵⁰ Larger worksites also offered more variety in programs such as physical activity, tobacco, fitness and nutrition, and screening services, compared to smaller worksites.⁵⁰

Barriers to worksite program implementation include low employee participation, lack of employee interest, limited staff resources, cost, misalignment of incentives among different stakeholders, and insufficient management support. ^50,52 Workshop participants discussed strategies for increasing employee participation, including peer and management support and incentives, as well as implementing and maintaining a respectful partnership with stakeholders (e.g., employees and their families, labor, management, health professionals, insurance companies, government agencies).

Physical activity provided a useful example of a health behavior that can be effectively influenced through multi-level worksite health promotion. Only about 32% of U.S. adults report engaging in regular leisure-time physical activity, with rates even lower among ethnic minority, low income and other underserved populations;⁵³ rates are also lower when activity is objectively monitored.⁵⁴ Several studies have demonstrated the potential impact of brief, socially obligatory structured group exercise breaks on paid time.^55–58 Future studies may explore the use of physical activity breaks in increasing participation in physical activity and enhancing sustainability, as well as identifying the organizational benefits of exercise for injury prevention.^59–63

Participants discussed the challenge of sustaining health promotion programs after implementation, and of the tendency of some programs to degrade from evidence-based models over time. A framework for implementing, sustaining, and evaluating effective programs, such as the RE-AIM model, can be a helpful guide for program planning and evaluation. The RE-AIM framework addresses both employee and organizational interventions by considering the reach and representativeness, as well as efficacy, adoption, implementation and maintenance of comprehensive worksite health promotion programs.^64,65

The physical, psychosocial, and organizational work environments are important contributors to chronic disease. Cancer is the leading cause of workplace fatalities worldwide, accounting for about one-third of all workplace fatalities.⁷⁶ The World Health Organization and others have estimated that 8–16% of all cancers are caused by preventable exposures to workplace hazards.^76,77 Shift work may also lead to increased cancer risk.⁷⁸ Workplace risk factors for cardiovascular disease include chemicals such as carbon monoxide, carbon disulfide, solvents, and lead; organizational factors such as work schedules, including long work hours and shift work; and psychosocial stressors, such as high demand-low control work (job strain), high job efforts combined with low job rewards (e.g., income, support, respect and job security), and organizational injustice.^15,79 Estimates of the proportion of CVD due to these work-related factors range from 15% ⁸⁰ to 35%.⁸¹ Work schedule factors and psychosocial stressors contribute to obesity, smoking, heavy alcohol use, and lack of exercise;^82–84 as well as to musculoskeletal disorders;⁸⁵ psychological disorders, such as depression, anxiety and “burnout”,¹⁵ and work-family stress and conflict.^86,87 Workplace risk factors for musculoskeletal disorders include repetition, force, awkward postures, vibration and temperature. Each year, these disorders affect about 1 million workers and cost the nation between $45 billion and $54 billion in compensation expenditures, lost wages, and decreased productivity.¹⁴

Risks posed by the work environment do not affect all workers equally. Workshop participants discussed older workers, noting there has been over a 100% increase in the number of workers aged 65 or older between 1997 and 2007, compared to a 59% increase in total employment during that decade.⁸⁸ Chronic disease is more prevalent in older than younger workers. Research using the work-ability index (WAI),^89,90 which captures workers’ assessment of their individual ability to be productive in the job given their current health status, has shown older workers consistently score lower on work-ability compared to younger workers. Although average WAI decreases with age, factors such as improvements in ergonomics, reductions in work stress and work demands, improved supervisor support, flexible work schedules, teamwork, individual lifestyle health promotion (e.g., physical activity), and building workers’ skills and competencies can improve the WAI. ⁹¹ Both chronic musculoskeletal disease and low work-ability are highly predictive of disability. ^92–94 Participants discussed the utility of the concept of work-ability and other measures to capture an important interplay between health status and efforts to change health and work. Workplace interventions that integrate improved workplace safety and health conditions with personal health promotion or individual interventions may be effective in preserving work-ability, reducing disability and preventing or helping people to manage chronic illnesses as they age.^56,95

Risks posed by the work environment also vary by employee socio-economic position, as illustrated by the differential impacts of work stressors, and their relationship to health behaviors and chronic diseases.⁹⁶ Work stressors associated with chronic disease include work organizational practices and characteristics (e.g., downsizing, restructuring, privatization of public services); production characteristics (e.g., piece-rate incentive pay systems, electronic surveillance, inadequate staffing); task-level psychosocial stressors (e.g., job strain, low job control, long hours, shift work); and other work-related factors (e.g., organizational injustice, job insecurity, safety and health hazards).^97,98 Workshop participants noted evidence that socioeconomic position and work stressors interact. For example, blue-collar workers experiencing job strain are more likely than white collar workers with job strain to have heart attacks (among Swedish men),⁹⁹ and elevated blood pressure (among New York City men).¹⁰⁰ The workgroup discussed the growing socioeconomic disparities in cardiovascular disease¹⁰¹ and its risk factors, with risk increasing for lower status (blue collar) workers relative to higher status (white collar) workers.¹⁰² Relative to other workers, workers from lower socioeconomic status also face more hazardous physical and psychosocial workplace exposures, and have less access to health promotion programs at work.¹⁰³ Participants suggested that labor market trends and related changes in working conditions of lower income workers may contribute to chronic disease disparities. These trends include stagnant real income and growing income inequality, the decreasing proportion of the U.S. labor force in unions, increases in precarious or contingent work, deregulation, and privatization of government services.^15,97

Work also influences health through its interface with workers’ families and their communities. Workshop participants discussed the changing nature of work-family dynamics, the resulting impact of workers’ exposures to stressors at home and on the job, the potential effects not only for workers’ health but also for the health of their families, and the implications for workplace interventions to help reduce work-family stress.

Attention to the work-family interface has increased over the past 30 years with increasing numbers of women working outside of the home, a corresponding increase in dual earner families, delays in childbirth, and an increasing percentage of workers who are caring for both children and aging parents.¹⁰⁸ These socio-demographic changes reduce family time, and contribute to work-family stress and broader changes in family members’ roles.^109,110 With increases in service sector employment coupled with increases in technology and the global economy, workers are being required to operate in a 24/7 work environment. Many workers occupy low wage, high demand service jobs, requiring them to have second jobs to make ends meet. Work-family conflict, or the stress and interference of engaging in both work and family roles simultaneously, has been linked to mental health problems such as depressive symptoms and psychological distress, lower self-reported health,^111–116 more chronic physical symptoms, and higher sickness absence.^117,118 Work-family conflict has also been related to higher work stress, family stress, and substance abuse,^86,87,119 as well as to decreased healthy eating behaviors.¹²⁰ Work-family conflict may also result in decreased organizational commitment and job satisfaction, absenteeism, and increased intentions to leave the job.⁸⁶

While workers’ families and communities clearly may support workers through mechanisms such as positive spillover and social support,¹²¹ much research in the area of work and family has identified the detrimental effects of integrating multiple roles on worker and family health.⁸⁶ These detrimental effects have primarily been examined among white-collar workers with greater access to flexible work schedules and control over work hours. Workshop participants speculated that the impact of work-family conflicts and stress may be more pronounced for lower wage workers due to the lack of workplace support and higher levels of psychosocial stressors such as demanding supervisors, excessive work hours, and unpredictable work schedules.

Formal workplace supports, benefits, and policies that are aimed at reducing such work-family conflict include providing dependent care support via subsidies, resources and referral, alternative work schedules, and increased worker control over when, where and how work is performed. Informal support comes from organizational and management culture. Research has demonstrated that the success of formal supports in impacting worker and family health and well-being is dependent on the level of organizational and managerial informal support for work and family.¹²² Furthermore, a recent quasi-experimental study of grocery workers and their supervisors found beneficial effects of a supervisory training and a self-monitoring intervention to improve supervisor support for work and family on worker job satisfaction, turnover intentions and self-reported physical health symptoms.¹²³

While there is substantial research indicating that the psychosocial characteristics of the work environment, such as supervisor support, work role demands, and control over work-time, spill over to impact health of workers, there is also evidence that the work environment can impact workers’ family members. This crossover, or the transmission of stress and strain from one individual to another, occurs between workers and their family members.^41,42 When considering chronic disease prevention in the workplace, workshop participants recommended a systems perspective to study the effects of workplace prevention programs on the family in addition to the effect on workers, and evaluating the impact of family characteristics on how workers respond to such interventions at work.¹⁰⁸ Workplace interventions addressing workers, their family members, and the community are needed to prevent or diminish adverse work-family conflict and crossover effects.

This workshop explored not only the parallel paths of these three approaches to worker health, but also the potential avenues for synergy, coordination, and integration as a means of strengthening chronic disease prevention efforts at the workplace, increasingly supported by of scientific evidence.^{22,43–46,128} This approach aims to attend to individual health behaviors and to the work organization and environment, including hazardous exposures, work stressors, and organizational policies and practices, as well as work-family demands.^18,129 Research has demonstrated that blue-collar workers are more likely to make health behavior changes, such as quitting smoking, when worksite health promotion programs are coupled with workplace hazard assessments and changes in the work environment.^128,130,131 Research is also exploring the links between the physical and psychosocial conditions of work, and a range of musculoskeletal, cardiovascular and mental health outcomes.^43,132

National initiatives are now underway to further research in this area. The NIOSH WorkLife Initiative is a broad-based effort aimed at sustaining and improving worker health through worksite programs, policies and practices that promote and protect worker health at the organizational and individual levels.¹³³ NIOSH has identified core “essential elements” of effective workplace programs and policies for improving worker health and wellbeing, as described on the weblink.¹³⁴ The Work, Family, and Health Network, funded jointly by the Centers for Disease Control and the National Institutes of Health, is another example of a worker health research initiative; the Network is aiming to develop and evaluate the effects of worksite work-family policies and practices that impact health of workers and their families.¹³⁵

Workshop participants discussed challenges to the development of a shared research agenda aimed at reducing risk of chronic disease among workers and their families. Convening multi-disciplinary teams as a foundation for a trans-disciplinary approach requires surmounting barriers among scientific disciplines, including developing pooled bodies of knowledge based on shared language and jointly developed methods.^136,137 These diverse disciplinary perspectives rely on communications through different journals and professional meetings, and on funding mechanisms that cut across NIH Institutes and the CDC. Our diverse backgrounds have contributed to differing perspectives about worker health. For example, the premise that worker health begins with individual behavior change sets in motion a different set of intervention strategies from the legal formulation in the Occupational Safety and Health Act, which starts from the assumption that management bears primary responsibility for worker health and safety on the job. Overcoming the segmentation of these fields ultimately will require an inclusive, comprehensive model of work and health, providing for an understanding of our differences in assumptions, vocabulary, research methods, and intervention approaches. It is possible to expand communication to support inter-disciplinary strategies, for example, through shared journals, shared symposiums, or shared funding opportunities.^22,126

Based on the presentations from the three panels, the workshop participants outlined a framework for a research agenda addressing chronic disease prevention that integrates health promotion and heath protection approaches in the workplace, and that takes into consideration the broader work-family-community interface. Workshop participants identified cross-cutting research themes and priorities for future research, with particular attention to research priorities for coordinating and integrating the three parallel targets influencing worker health. After the workshop, participants further developed these themes in a series of conference calls; the writing team consolidated these priorities, which were then vetted by the full group of participants.

As illustrated in Table 1, we identified six broad recommendations for future research:

Prevention of chronic disease among workers requires a partnership among federal and state public policy makers, employers, workers, labor union representatives, health professionals and the surrounding community. In the face of an increasing chronic disease burden, rising health care costs and health care reform, it is critically important that part of the solution involves addressing the health of workers. Promising evidence points to the important role that the workplace may play in chronic disease prevention and control. It is important that these prevention efforts also acknowledge the potential impacts of work-related factors on individual health behaviors through physical, social, organizational and psychosocial mechanisms, and potential exposures to hazards on the job that may directly influence work, family and organizational health outcomes. It is critical that rigorous scientific evidence be the cornerstone of the next generation of research on chronic disease prevention in the workplace. Articulation of a research agenda to enhance worker health in the context of healthy workplaces will require the engagement of policy, research and funding organizations. This research will benefit from the contributions of scientists across disciplinary boundaries, including researchers focused on health behaviors and worksite health promotion, occupational safety and health, the work-family-community interface, and the intersections between work and other sectors of workers’ lives. This workshop stimulated a dialogue across these disciplines and identified critical research that may ultimately promote and protect worker health. Systematic implementation of this research vision and effective dissemination of new models of interventions to support worker health outcomes is needed to address chronic disease prevention.