National Academies Press: OpenBook

Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention (2014)

Chapter: Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide

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Page 1
Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Suggested Citation:"Part I - A Transit Workplace Health Protection and Promotion Practitioner's Guide ." National Academies of Sciences, Engineering, and Medicine. 2014. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention. Washington, DC: The National Academies Press. doi: 10.17226/22322.
×
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Part I A Transit Workplace Health Protection and Promotion Practitioner’s Guide

1TRANSIT OPERATOR HEALTH T Transit Operator Health: Introduction and Explanation The Background ransit sector employees, and bus operators in particular, are more likely to have certain serious and chronic health problems, compared to other workers (Witters 2013). Research suggests that there is a connection between transit employment and metabolic syndrome, diabetes, stroke, musculoskeletal disorders, digestive prob- lems, fatigue, and sleep disorders (Tse et al., 2006). Most of the health problems identified in bus operators are affected by a combination of factors: lifestyle choices, genetics, and workplace and environmental conditions all contribute. Possible work factors include air pollution, sedentary work, schedule stress, and unhygienic and unsafe eating and restroom facilities. In addition, transit workers are often older and from groups that are at increased risk for cardiovascular disease, diabetes, and other health problems. Transit employers recognize the importance of health and wellness, as do transit workers and the unions that represent them. Health plan costs and retention issues drive much of the concern. Operator health is also likely to affect customer service, performance, and safe operations. The bottom line is that too many people are affected by problems that can be reduced or prevented. Workplace health protection and promotion (WHPP) has been recognized as an important path to improving operator health and reducing costs. In 2004, TCRP published TCRP Synthesis 52: Transit Operator Health and Wellness Programs, which reported on existing wellness program “An important tenet of Total Worker Health™ is that risks and our responses to them must be proportional. Highest risk occupations and workers require more frequent and more intense workplace health interventions on both the health protection and the health promotion fronts. The higher risks of shift workers and low-wage workers are great examples. These folks often have riskier jobs, more personal health risks, and less access to health care. They may come from higher-risk communities and are frequently at risk for incomplete worker protection programs on the job. Increasing the number of health interventions, supports, incentives, and protections in these higher- risk populations is critical if we are to achieve Total Worker Health™ for all working Americans. Health and safety programs are not only for the day shift or the well-compensated.” Chief Medical Director Total Worker Health™ National Institute for Occupational Safety and Health

activities in the transit industry. TCRP Project F- 17, “Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention,” updated and extended that knowledge. This Guide and the Planning, Evaluation, and Return on Investment (ROI) Template are the results. They can be downloaded from the Transportation Learning Center (www.transportcenter.org) and TRB (www.trb.org), along with the project research report. Exploring Current and Best Practice for Bus Operator Health Protection and Promotion From 2011 to 2013 the F-17 research team investi- gated common and best industry practices for health protection and promotion, particularly how transit WHPP programs integrated health and safety approaches with traditional health promo- tion activities, and how WHPP in transit differed from other industries. This study was designed to catalogue and assess the WHPP practices, goals, and models implemented by transportation organizations. The program data collection includ- ed an extensive review of health and business literature, a survey targeting 238 transit agencies and unions in the US and Canada, detailed case examples developed through follow-up with survey respondents, and six in-depth case studies. The invitation to participate in the 32-question survey was distributed via email by industry groups and by international unions. Follow-up discussions were held with 40 sources from 26 agencies to clarify the survey findings and expand on the experience of labor and management. In-depth case study interviews were completed with six agencies whose practice illustrated core concepts in designing, implementing, and assessing integrated WHPP programs. A subject-matter expert team of working bus operators, union representatives, and agency safety and wellness staff provided ongoing input. Responses from 68 agencies across the US (52) and Canada (16) were received, and from 40 agencies represented by 44 local unions (eight Canadian and 36 US), for a total of 94 different agencies, about 40% of the targets. Additional information was collected from the in-depth review of health research and business literature, and expanded descriptions and detailed case examples developed through follow-up with survey respondents. The panel of subject-matter experts (SMEs) from agencies and unions in the US and Canada helped assess the information. They contributed to the development of this Practitioner’s Guide and the Planning, Evaluation, and ROI Template. The State of Transit Industry WHPP The Transportation Learning Center’s research team and academic consultants worked over the course of more than a year to identify and analyze the programs and activities that agencies reported as helpful in operator health, absenteeism, medical disqualification, turnover, health care costs, the work environment, and other outcomes related to operator health. WHPP programs and activities are common but not universal in transit operations. Programs are run by human resources, safety, and operations departments but typically not by experienced bus operators. All survey respondents took the issues of bus operator health, wellness, and safety seriously. Work organization and the work environment were recognized as important to operator health. But they were often not addressed by the programs. Effective program action was hampered by silos of data and limited access and influence for the program staff. Only half of the transit agencies responding to the survey had current workplace health promotion programs for bus operators, 2

3TRANSIT OPERATOR HEALTH and only one out of three among smaller agencies. (Organizations with programs may have been more likely to respond to a survey on the topic, so the actual proportion of transit agencies with programs could be lower.) This is less than the national average for other industries: A recent Kaiser Foundation survey showed that 63% of all employers who provide any health benefits also offer some health promotion resources to their employees, and usually to families as well (Claxton et al., 2012). Another 10% of the F-17 survey respondents plan to start or restart a program. In comments and interviews, support for a WHPP program that addresses transit-specific health protection and promotion was strong. Of course, all agencies have some kind of safety program that may in part protect worker health. The majority of transit agencies with active programs follow a traditional health promotion program design. This health promotion consisted of a few isolated activities rather than being integrated with other related areas and policies such as occupational safety and health protection or scheduling. Limited financial resources were a major constraint to starting or broadening a program. Even transit agencies with the will to begin or expand sometimes lacked a systematic approach in preparing the organization and planning the process. They described narrowly focused programs that may not do what the agencies want and expect. The common thread: Bus operators are harder to reach than less mobile transit agency employ- ees. Unions and management assess the programs differently. Each tended to report that they supported health activities more than the other party. All respondents felt strongly that joint action was essential in getting operators and other workers the resources they need to stay healthy and safe at work, and to go home the same way. Management respondents were much more confident that the organization’s policies and actions supported health than union respondents. The data collected from managers, operators, health promotion and safety staff, and unions shows that keeping workers healthy demands organizational support, adequate resources, data-based and collaborative planning, and ongoing evaluation and improvement. To be effective, programs will address both health promotion and workplace health and safety concerns. Examples of the many ways that transit agencies and unions can integrate health protection and promotion make up the body of this Practitioner’s Guide. Where the Results Lead This project has produced a catalogue of the common and innovative practices in transit workplace health protection and promotion— WHPP. The F-17 research team has established the outlines, targets, and effective actions for a comprehensive WHPP framework for transit organizations. It is based on the models seen in practice and those described in the wider health promotion literature and practice. The framework is laid out in this Practitioner’s Guide. The investigation has already had an impact. During data collection, agency and union respon- dents have recognized potential improvements or have been inspired by the discussion to reinvigorate their own programs. Several have increased collaboration and co-sponsorships. Sharing ideas has helped them grow.

The Practitioner’s Guide The Practitioner’s Guide is built around six chapters, each made up of best practices and elements that illustrate how to achieve them, as shown in Figure 8. Each chapter and element is accompanied by real transit agency practice examples by tools, links, and resources and by references to journal articles and other sources. (The electronic version of the Guide includes hyperlinks to online resources.) The Guide is supported by the Planning, Evaluation, and ROI Template, a set of spreadsheets for documenting and showing the value of your program. These can be downloaded from the TCRP website and the Transportation Learning Center, with a summary roadmap. The Practitioner’s Guide is designed for anyone interested in creating health protection and promotion in the transit workplace. That could be the top executive ready to commit for the entire organization, human resources or benefits management staff looking to reduce costs or increase retention, a union leader representing members in an employer’s program or setting one up within the union, a safety professional trying to introduce a new approach or, ideally, all of those together. The Practitioner’s Guide contents are based on a model of health and change developed by top researchers, health agencies, and on-the-ground practitioners. It follows national recommenda- tions for workplace health protection and promo- tion and applies these concepts to the practical realities of the transit workplace. The main focus is on bus operators because of the established health risks and demanding working conditions. The concepts, however, can be used throughout transit operations, maintenance, and other areas. This approach does not replace a safety management system. The goal is to bring together the issues across transit workplaces that affect health, safety, and well-being, and the people who can make a difference. The bottom- line impact ideally is to improve working conditions, control health care costs, increase operations efficiency, and decrease absenteeism. These changes will help employees and the organization as a whole. WHPP programs have been shown to pay off. A combined analysis of the worksite health promotion literature found that on average, reported medical costs fell by $3.27 for every dollar spent and absenteeism costs fell by $2.73 for every dollar spent (Baicker, Cutler, and Song, 2010). A review of over 70 worksite wellness programs showed an average annual ROI (return on investment) from 150% to almost 2,000% (Chapman, 2008). An actuarial study identified wellness programs as potentially affecting approximately 25% of health care costs for working populations (Bolnick, Millard, and Dugas, 2013). The average ROI reviewed in more than a dozen traditional worksite wellness programs was 300% (Chapman, 2012). Of course, positive findings and successful programs are more likely to be reported, but just breaking even can represent an overall advantage when factoring in the benefits that are less easy to quantify. Chapters 1 and 5 will help you define and keep track of these. Many of these programs and ROI analyses were carried out in office settings or white-collar occupations, so it is likely that methods and outcomes could be different in transit organizations. Chapters 3 and 4 focus on target- ing and implementing transit-specific programs and activities. 4

The Model According to the World Health Organization (Burton, 2010), a healthy workplace is one in which workers and managers collaborate to continuously improve, protect, and promote the health, safety, and well-being of all workers. This is achieved by • Addressing the health and safety concerns in the physical work environment. • Meeting the health, safety, and well-being concerns in the psychosocial work environment, including organization of work and the workplace culture. • Allowing access to personal health resources in the workplace. • Providing opportunities for participating in the community to improve the health of workers, their families, and others. A comprehensive workplace health protection and promotion (WHPP) program goes well beyond individual health concerns and health promotion targets. Figure 1 illustrates that worker health depends on individual behavior and resources (the right corner of the triangle) but also on the sum of the organizational polices, programs, and practices that affect health (left side), and on the conditions of the physical environment (top of triangle). The SafeWell model, originally developed for health care work places, shows how workers are affected by health promotion, the psychosocial work environment, and occupational safety and health. WHPP is firmly set in the context of organizational and community policy. The Suggestions Improving workplace health protection and promotion is a national and world-wide goal. The US National Institute for Occupational Safety and Health (NIOSH), along with the Centers for Disease Control and Prevention (CDC), provides support and information for employers, unions, workers, and health care providers, by way of the Total Worker Health™ model. The elements of Total Worker Health™ use the resources of the workplace to improve the work environment, work organiza- tion, and individual health. They are laid out in Figure 2 and detailed in Appendix A. 5TRANSIT OPERATOR HEALTH

6 FIGURE 2 Total Worker Health™ ESSENTIAL ELEMENTS OF EFFECTIVE WORKPLACE PROGRAMS AND POLICIES FOR IMPROVING WORKER HEALTH AND WELL-BEING Organizational Culture and Leadership 1. Develop a “human- centered culture.” 2. Demonstrate leadership. 3. Engage mid-level management. Program Design 4. Establish clear principles. 5. Integrate relevant systems. 6. Eliminate recognized occupational hazards. 7. Be consistent. 8. Promote employee participation. 9. Tailor programs to the specific workplace and the diverse needs of workers. 10. Consider incentives and rewards. 11. Find and use the right tools. 12. Adjust the program as needed. 13. Make sure the program lasts. 14. Ensure confidentiality. Program Implementation and Resources 15. Be willing to start small and scale up. 16. Provide adequate resources. 17. Communicate strategically. 18. Build accountability into program implementation. Program Evaluation 19. Measure and analyze. 20. Learn from experience. Total Worker Health™ is based on a comprehen- sive view of health that integrates programs, policies, and practices in an overall health and safety management system. This Practitioner’s Guide applies the Total Worker Health™ elements to the transit workplace. The Practitio- ner’s Guide also relies on policies and practices that have been developed and applied around the world. Links to some of those programs are provided in the Tools and Resources section in each chapter. The Practical Approach In traditional health promotion, the workplace can function as a convenient place to get access to individuals rather than an integral component in the human health equation. Workers have health problems, which they need to have diagnosed and treated. The health problems may result from factors beyond their control such as genetics or aging. The health problems affecting bus operators are commonly regarded as preventable through health-enhancing choices and decisions they alone can make. That is, what people are and what they do have a health impact, and the impact leads to undesirable outcomes for the individual or the organization. The WHPP model recognizes that the environment – what the working conditions are, and how the organization functions – also affect health directly. If you define and recognize the variety of contribu- tors to health problems, you can develop a map that points to where the organization, individuals, and other resources fit in correcting or controlling them. Figure 3 shows the basic map for identifying the range of influences on health. Figure 4 shows the filled-in map for a common health concern of bus operators, musculoskeletal disorders (MSDs). The workplace contributors to MSDs are well known among operators: bus vibration, hitting potholes, wrestling with wheel chairs or windows, extended sitting, and work stress can all be linked to strain, pain, and injury. MSDs can develop because of individual habits (sedentary lifestyle leading to stiffer tissues, for

7example) and leisure activities (powerlifting, for example, frequently causes back strain). MSDs are more common as we age. So a comprehen- sive WHPP program would seek to work with the city to eliminate potholes, improve workstation ergonomics in the bus procurement process, encourage exercise and rest, and recognize the costs and challenges of an aging workforce. In this and other areas, the payoff of adapting conditions and demands is not limited to older workers: Improvements in work organization (hours of work, rest) and work conditions (correcting slips and falls conditions, ergonomics Seated work Accidents Wheelchairs Vibration Outside activities Sedentary life Age MSDs Availability accommodations) are of value to the entire workforce and can improve retention and performance across the organization (Silverstein, 2008). Workers’ compensation costs FIGURE 4 MSD MAP What the environment is and does What people do What people are IMPACT Outcomes The map for hearing loss, Figure 5, is interesting because it shows how a health problem (hearing loss) can lead to another health risk factor, and possibly to safety concerns. Transit workers may be exposed to short or continued high noise levels and suffer work-related hearing loss. There are other contributors to hearing loss in this workforce: Many are aging, quite a few are veter- ans, and some use firearms or go to loud concerts. An operator with enough hearing loss will not pass a commercial driver’s license (CDL) medical exam. Hearing loss could be a factor in accidents. In addition, hearing loss even at lower FIGURE 3 MAPPING HEALTH PROBLEMS levels will make communication difficult with passengers and with family members, leading to stress and possibly conflict. So an effective hearing conservation program will increase safety and health at work and home by controlling workplace sources of noise, encouraging hearing protection at work and home, and helping those with hearing loss get treatment and support. TRANSIT OPERATOR HEALTH

Maintenance and vehicle noise Leisure activities Past work exposures: Veterans Other trades HEARING LOSS Safety and operators working afternoons or nights frequently have “dinner” at times that increase insulin resistance. Occupational health hazards come into play as well, as work at night and sleep disturbance have been linked to diabetes (Szosland, 2010), schedule stress raises blood pressure (Greiner et al., 2004), and diesel exhaust affects the heart (Mills et al., 2007). Finally, there are the many stressful aspects of work organization: working alone, dealing with the public, limited access to restrooms that can discourage opera- tors from taking hypertension medications that Passenger communications Stress CDL FIGURE 5 HEARING LOSS MAP cause frequent urination, and work-family conflict. The experience of all these factors can vary enormously among agencies, employees, and even routes or days. When it comes to wide-spread health problems such as metabolic syndrome (the combination of medical disorders that increase the risk of devel- oping cardiovascular disease and diabetes), the map is more complicated but the analysis is the same, as shown in Figure 6. These health problems are increasing across industries, although they seem to be more common in bus operators (Witters, 2013; Bushnell et al., 2011). A sedentary lifestyle and less than healthy food choices lead to hypertension, overweight, and insulin resistance. Schedule stress Diesel work at night Toilet access Sleep disturbance Sedentary habits Food choice METABOLIC SYNDROME Access to food on the road Eating at night Gender, race, age, genetics Healthy worker Other selection This has a direct effect on operational concerns and CDL medical disqualifications. Health plan costs rise and there is concern that vehicle accidents could be increased. Although diagnosis, treatment, and control have reasonably gotten a lot of attention in transit agencies, individual behavior is not the only cause of metabolic disorder. Operators may be older or of ethnicities with increased risk of metabolic disorder, and gender is a complicated factor in the equation. Conditions of work contribute: It can be hard to find healthy food, Commercial driver’s license Health plan costs Vehicle safety? FIGURE 6 METABOLIC SYNDROME MAP This complex of contributors may seem daunting. It can also be seen as a strength, because it provides a wide range of intervention points for health protection and promotion. Workers may believe that they are responsible for the choices they make, and they also recognize that work is where they spend more than half of the waking day (or the 24-hour day, for some). An example of 8

an integrated approach is to address concerns about asbestos or diesel exposure at the same time as providing support for quitting smoking. Respecting workers’ concerns is more likely to be trusted and more likely to lead to health improvements. The program potential for reach and effective- ness can be assessed using this practical model (see Figure 7). Ask yourself: What is the current status of the workplace, the parallel to what people are. Is there trust? Is confidentiality a given? Are resources limited? Then, what do people do in your program? How are all parties involved in planning and integration of the program’s vision? Do they participate in specific activities, or do they find them irrelevant? And finally, how does environment contribute? For the program, that could be the challenging conditions of work that make your planning harder, and have to be taken into account. Hours of service and a mobile workforce are just two of many characteristics. These factors will have an effect on your program success. They will influence the health targets you are able to achieve, as well as other important outcomes such as support from union leaders, supervisors, and others. Involvement in planning Summary The Transit Workplace Health Protection and Promotion Practitioner’s Guide is based on the NIOSH Total Worker Health™ approach, and informed by theory-based practice models such as the SafeWell Integrated Management System for Worker Health and the World Health Organization Healthy Workplace Framework and Model. Most existing programs in the transit industry focus on individual health issues and describe themselves as wellness or health promotion. The growing consensus among research, government, and public health practitioners, however, is that the best practice encompasses workplace health protection and promotion. The shorthand for this concept used throughout the Practitioner’s Guide is WHPP. The Guide also reflects practice and policies that have been developed and applied around the world. Links to many of these are provided in the Tools and Resources section in each chapter. Hours of service Mobile workforce Relevance Integration Trust Confidentiality Limited resources REACH EFFECTIVE- NESS Health outcomes Value to management Labor support FIGURE 7 EXAMPLE OF A WHPP PROGRAM MAP 9TRANSIT OPERATOR HEALTH

Transit Workplace Health Protection and Promotion Roadmap Preparing the Organization and Making the Commitment • Culture of health and safety • Organizational needs assessment • Organizational resources • Meeting needs with resources Setting Targets in Transit Health Protection and Promotion • Setting priorities • A comprehensive health risk focus • Effective components • Transit-specific programming Building the Team • Taking the lead • Putting the team together • Management support • Labor support • WHPP committee • Champions and ambassadors • Vendor integration Implementing and Integrating an Effective Transit Program • An inclusive range • Transit-specific implementation • Effective communications • Training supports the program • Equitable incentives Evaluation, Return on Investment, and Ongoing Improvement • Evaluation framework • Integrated data management • Process measures • Impact and outcome measures • Cost-benefits and return on investment • Data-driven ongoing improvement Maintaining Effectiveness with Growth • Maintaining • Growing • A realistic perspective FIGURE 8 THE PRACTIONER’S GUIDE MAP The Practitioner’s Guide relies on the practical examples provided by US and Canadian transit agency staff, union leaders, and bus operators. Enormous thanks are due to all those who provided their information, opinions, and input to make the F-17 research project and this Guide possible. You will find that elements from different chapters overlap at times. The elements are steps, but cannot properly be numbered or taken in a strict order because the conditions in which they are applied will vary. You will want to take the steps in the order that makes sense to your organiza- tion. The best approach is to read through the Practitioner’s Guide entirely, probably flagging important areas, then go back to the beginning to build your effective workplace health protection and promotion program. 10

Chapter Background Operator Health Bushnell, P. T., J. Li, et al. (2011). “Group medical claims as a source of information on worker health and potentially work- related diseases.” J Occup Environ Med 53(12): 1430-1441. Greiner, B. A., N. Krause, et al. (2004). “Occupational stress- ors and hypertension: a multi-method study using observer- based job analysis and self-reports in urban transit opera- tors.” Social Science & Medicine 59(5): 1081-1094. Mills, N. L., H. Törnqvist, et al. (2007). “Ischemic and Throm- botic Effects of Dilute Diesel-Exhaust Inhalation in Men with Coronary Heart Disease.” New England Journal of Medicine 357(11): 1075-1082. Szosland, D. (2010). “Shift work and metabolic syndrome, diabetes mellitus and ischaemic heart disease.” Int J Occup Med Environ Health 23(3): 287-291. Tse, J. L. M., R. Flin, et al. (2006). “Bus driver well-being review: 50 years of research.” Transportation Research Part F-Traffic Psychology and Behaviour 9(2): 89-114. Witters, Dan (2013). “U.S. Doctors Lead in Wellbeing, Trans- portation Workers Lag.” www.well-beingindex.com/, Accessed March 27, 2013. Health Protection and Promotion Burton, J. (2010) World Health Organization Healthy Workplace Framework and Model: Background and Support- ing Literature and Practices www.who.int/occupational_health/ healthy_workplace_framework.pdf. Claxton, G., M. Rae, et al. (2012). Employer Health Benefits 2012 Annual Survey. Henry J. Kaiser Family Foundation and Health Research & Educational Trust. Menlo Park. McLellan, D., E. Harden, et al. (2012). SafeWell practice guide- lines: An integrated approach to worker health. Version 2. Boston, MA, Dana-Farber Cancer Institute. centerforwork- health.sph.harvard.edu/images/stories/SafeWellPracticeGuidel ines&ExecSumm_Sept2012.pdf. NIOSH. (2013). What is Total Worker Health™? www.cdc.gov/niosh/TWH/ totalhealth.html, updated 2/10/13, accessed 5/30/12. Poulsen, K. B. (2004). “The Healthy Bus project in Denmark: need for an action potential assessment.” Health Promot Int 19(2): 205-213. Poulsen, K. B., K. Drewes, et al. (2005). Reflections on interven- tions. Copenhagen, National Institute of Occupational Health. Silverstein. B. (2008). “Meeting the Challenges of an Aging Workforce.” American Journal of Industrial Medicine 51:269–280. Return on Investment Baicker, Katherine, David Cutler, and Zirui Song. 2010. “Workplace wellness programs can generate savings.” Health Affairs 29(2): 304-311. Bolnick H, Millard F, and Dugas JP. “Medical care savings from workplace wellness programs: what is a realistic savings poten- tial?” Journal of occupational and environmental medicine. American College of Occupational and Environmental Medicine 55:1 2013 Jan pg 4-9. Chapman, Larry S. 2008. Proof Positive: An Analysis of the Cost-Effectiveness of Worksite Wellness, Chapman Institute; 6th edition. Chapman, Larry S. 2012. “Meta-Evaluation of Worksite Health Promotion Economic Return Studies: 2012 Update.” American Journal of Health Promotion 26:4, TAHP- 1-TAHP-12. 11TRANSIT OPERATOR HEALTH

13GETTING STARTED Chapter Getting Started: Preparation and Commitment CHAPTER MAP CULTURE OF HEALTH AND SAFETY The organization maintains a healthy and safe culture based on leadership and organizational commitment. • Recognize the importance of WHPP for the agency. • Establish top leadership buy-in and commitment. • Leadership takes an active role. • Articulate the vision and mission statement. ORGANIZATIONAL NEEDS ASSESSMENT The organization identifies workforce health status and needs, and understands the sources of health problems. • Evaluate bus operator health status separately, as well as other titles or the whole workforce. • Understand the varied sources of operator health problems. • Consider demographics and other health factors. • Identify potential sources of support for and barriers to an effective WHPP program. ORGANIZATIONAL RESOURCES Program planners identify resources including staffing, finances, programs, structures, and internal and external partners. • Are there qualified and motivated staff? • What resources are found in the work environment? • How can existing structures and programs contribute? • Who are the internal partners? • Who are the external partners? • Where are the financial resources? MEETING NEEDS WITH RESOURCES The organization develops a plan to provide effective health assessments, a healthy and safe environment, and targeted and population-based intervention programs for all employees. • Draft a long-term program plan. • Plan to grow, including developing new resources. • Develop program components that match the needs identified. • Design a practical program.

14 Just as each organization has a culture of safety, positive or negative, the culture of health is formed by the environment, polices, practices, and participants. Are health problems considered an individual responsibility, or do work conditions figure in? Is blame, support, or action most common? How does the environment help or hinder health? Recognizing the organiza- tion’s characteristics, strengths, and weaknesses helps to plan and implement an effective workplace health protection and promotion program. A healthy culture starts with leadership commitment to the workplace health protection and promotion agenda. This is what the NIOSH’s Total Worker Health™ model calls organizational culture and leadership. It includes understanding the current health culture and defining a vision for the future. Whoever initiates the workplace health protection and promotion (WHPP) program—the general manager, an assigned or self-identified staff person, union leadership—will require a clear understanding of the organization’s needs, resources, and constraints. This will define how the WHPP program will fit in. Most often, wherever the impetus, the program details will need to be drafted and justified by someone in the middle of the organization. To lay a solid foundation for advancing health and well-being and preventing injury and illness for bus operators and other transit workers, you will need to solicit input from across the transit agency, identify workforce health needs, research the agency’s experience with related programs, and find and recruit partners. This chapter explains how to do this. BEST PRACTICE The organization maintains a healthy and safe culture based on leadership and organizational commitment. Culture of Health and Safety An effective WHPP program requires commitment from senior manage- ment, Boards of Directors, and labor leaders. Leadership commitment to the health and well-being of front-line employees is demonstrated concretely by recognizing and improving policies and practices that affect workplace health culture. Commitment means providing funds for staff, equipment, vendor services, supplies, and incentives, and allowing time for the program during the work day. It is reflected, with the Board’s support, by incorporating workforce health and safety into the transit agency’s strategic plan and making it a key operating principle for which leaders are held accountable. Unions may sponsor distinct programs for their members, as well as participate in employer-supported programs. Just as union support is important for the success of an employer’s program, the union program will do better if the agency is informed about and supports it. As you begin to plan a WHPP program, you need

15GETTING STARTED United Transportation Union—Los Angeles County Metropolitan Transit Authority Wellness Program: Organizational Leadership and Commitment The United Transportation Union—Los Angeles County Metropolitan Transit Authority (UTU-LACMTA) Trust Fund joint labor-management collaboration began in 2007 focusing on ways to control escalating costs without reducing benefits. The Board of Trustees asked its benefits consultant, Rael & Letson, to develop a wellness and health care cost containment strategy to improve member health and to control health plan premium rates and self-funded costs. Strong senior labor and management support was obtained, including the General Union Chair, all Local Union Chairpersons, MTA Chief Operating Officer, MTA Chief Financial Officer, MTA Director of Human Resources, and MTA Benefits and Safety Directors. The UTU Trust Fund, which negotiates health insurance rates, decided when they observed the impact of the wellness activities to fund the program manager position after the pilot was completed. The manager directs program activity and coordinates planning with management and the other unions. The program initially focused on prevalent issues of presenteeism, upward trends in workers compensation claims, and avoidable accidents. Following the initial pilot in two divisions, the wellness program expanded to involve most agency divisions and unions. A Wellness Committee was developed in 2008, composed of UTU-LACMTA Trustees, union leaders, MTA transportation and human resources department staff, and health plan repre- sentatives. A local union chairperson was initially appointed as the wellness committee chair. Extensive health plan involvement was also obtained, including financial, staffing, and resource support from all health vendors (insurance, dental, vision, etc.) and community organizations (American Diabetes and Heart Associations, etc.). The Trust Fund manager, the 5 UTU divisional chairs representing the operators, and repre- sentatives of other unions participate actively in planning and supporting program focus and activities. An agency-wide wellness committee meets monthly; participants include the union team, human resources, and health-related vendors. Corporate Safety remains supportive of the program but defers to the WHPP committee and manager as it has focused on system safety.

16 to understand clearly the organization’s culture of health and safety and what support there is across the organization. Assess the organizational culture: The initial organizational assessment identifies the current health protection and promotion culture, and suggests ways to improve it. A culture assessment, by showing needs, strengths, and weaknesses, helps target initial steps and define long-term goals. Tool 1.1 is a brief self-assessment instrument for the organizational health culture, including organizational support for health and readiness for a WHPP program. Positive scores (above 0) demonstrate stronger health cultures, and the basis for effective WHPP programs. The results from the F-17 study showed that labor and management can see the same program differently, so it is important to spread the survey widely to get a good view of what people understand to be going on. The Tools and Resources section provides links to other checklists for gauging the organizational culture and readiness for workplace health protection and promotion. Instructions for using Tool 1.1: Ask employees throughout the organization to check the answers that best describe the current status of the organization. Tabulate the results in a spreadsheet, and calculate the average score for each question. The seven point scale can be simplified into a “yes” and “no” checklist, and the numbers coded as -1 and 1. A positive health culture will be indicated by more scores above 0 (neutral) and a higher average score. By repeating the survey at intervals you can use this tool to track the overall impact of the program on the workplace health and safety culture and other factors you may identify. Topics in the questionnaire are covered in the chapters indicated in parentheses following each question. (If there is no union, for question 2, use “The workforce as a whole supports and participates in the workplace health protection and promotion program.”) Recognize the importance of WHPP for the agency: Rising costs of health care and operator absenteeism and turnover are a serious challenge to transit agencies. Transit agencies may not yet see how a comprehensive WHPP program can help contain costs and improve operator health and safety. A good argument for management buy-in includes agency data such as health care costs, absenteeism and turnover rates, and costs for occupational injuries and safety accidents. Figure 1.1 lists some of the potential benefits for employees, transit agencies, and unions that can be used to support a WHPP program.

17GETTING STARTED TOOL 1.1 RATING THE HEALTH PROTECTION AND PROMOTION CULTURE How would you agree with the following statements about your organization’s worksite health and safety culture? (If you do not know, mark “Neither agree nor disagree.”) NEITHER STRONGLY SLIGHTLY AGREE OR SLIGHTLY STRONGLY STATEMENT DISAGREE DISAGREE DISAGREE DISAGREE AGREE AGREE AGREE 1 Upper management has made employee health protection and promotion a top priority (Chs. 1, 2) -3 -2 -1 0 1 2 3 2 Union leadership supports and participates in workplace health protection and promotion (Chs. 1, 2) -3 -2 -1 0 1 2 3 3 Employee health promotion has been integrated with other operational and administrative policies and procedures (Chs. 1, 2, 4) -3 -2 -1 0 1 2 3 4 There is a person identified who has the primary responsibility for the WHPP (Ch. 2) -3 -2 -1 0 1 2 3 5 Others in the organization take active responsibility for WHPP (Ch. 2) -3 -2 -1 0 1 2 3 6 An effective committee leads or supports WHPP activity (Ch. 2) -3 -2 -1 0 1 2 3 7 Health is linked with other organizational areas, for example, occupational health and safety, benefits, etc. (Chs. 1, 2, 4) -3 -2 -1 0 1 2 3 8 9 Workplace data is used to determine WHPP direction (Chs. 1, 5) -3 -2 -1 0 1 2 3 WHPP activity has a long-range (3-5 year) strategic plan (Ch. 1) -3 -2 -1 0 1 2 3 10 WHPP planning responds to changing needs (Chs. 1, 3, 5) -3 -2 -1 0 1 2 3 11 Management allocates adequate resources for WHPP (budget, space, etc.) (Ch. 1) -3 -2 -1 0 1 2 3 12 Managers actively promote participation in health protection and promotion activities (Chs. 1, 2) -3 -2 -1 0 1 2 3 13 Front-line employees are actively involved in WHPP activity development and implementation (Chs. 2,4) -3 -2 -1 0 1 2 3

18 FIGURE 1.1 WORKPLACE HEALTH PROTECTION AND PROMOTION ADVANTAGES TRANSIT WORKER EMPLOYER UNION • Increased knowledge about factors affecting health • Increased opportunity to take control of health and medical treatment • Improved health and quality of life through reduction of risk factors • Increased morale because of organization’s interest in health and well-being • Increased opportunity for support from coworkers and environment • Reduced presenteeism related to productivity loss • Reduced out-of-pocket medical costs • Reduced pain and suffering from illness and injuries • Informed and health- conscious workforce • Healthier and safer work environment • Improved labor-management relations • Support recruitment and retention • More productive workforce • Improved morale • Positive public image • Opportunity for cost savings via: • Reduced sick leave absenteeism • Decreased overall health benefit costs • Decreased health care utilization • Reduced disability claims • Reduced workers’ comp • Reduced premature retirement • Fewer accidents and on-the-job injuries • Lower casualty insurance costs • Improved health and quality of life for members • Improved occupational safety and health of members • Increased participation in joint decision making • Improved labor-management relations • Reduction of health care premiums or fund costs • Increased opportunity for workers to influence health, safety, and medical treatment Establish top leadership buy-in and commitment: The connection between operator health and transit services that are safe and reliable should be acknowledged by leaders and communicated widely. It is important to keep management and labor leadership involved to maintain momentum. Union leaders who get involved and encourage members to participate can influence the program and increase success by showing that it is not solely a management initiative. Leadership takes an active role: A leadership steering group should oversee the strategic direction of the WHPP program. Draw this team from top management, middle management (for larger agencies), and local union leaders, and make sure it includes people who are strong advocates for the health, safety, and well-being of front-line workers. The steering group is distinct from the working groups, such as joint health and safety committees, that already exist or are formed to implement the WHPP activities. The steering group sets the vision and goals of the

19GETTING STARTED WHPP program, makes budget and resource decisions, and addresses organizational and collective bargaining issues, but does not run the program. The steering committee meets on a regular basis and contin- ues to assess progress and adapt goals and strategies as necessary. Articulate the vision and mission statement: Worker and workplace health and safety should be included as part of the organization’s mission, vision, and values. To maximize success and impact, the vision of a culture of health needs to apply consistently to the entire workforce. Through presentations, memos, the intranet, and other communication vehicles, leadership can stress the links between health and safety and the well-being of workers and the organization. Organizational Needs Assessment Anyone reading this Practitioner’s Guide is likely to be working in a transit environment and committed to worker health, probably with a good insight into common health problems and concerns. This is not the same as possessing all the information required to implement a useful and effective WHPP program, or even to support starting one. In particular, general knowledge about costs, health, and program manage- ment does not mean you know what the operators need. The needs assessment looks at conditions in the workplace, current health and safety data, and detailed differences among groups as well as trends in the industry. Evaluate bus operator health status separately from other titles or the whole workforce: Issues and problems are probably very different between office staff and bus operators, for example. Define employee health from multiple sources of information. Existing data sources you can draw on are presented in Figure 1.2. You should also collect new information as you did with the organizational culture assessment. (Getting and using data is described in greater detail in Chapter 5.) BEST PRACTICE The organization identifies workforce health status and needs, and understands the sources of health problems.

20 USING DATA TO SET TARGETS In one active agency with an individual health focus, the main data drivers for deter- mining the program’s focus each year are group data on blood pressure, glucose, cholesterol, and diabetes; a pharmacy report on the categories of medications prescribed; dental and vision plan summary data; cause of death data (listing the five main causes of mortality); and aggregate data from voluntary health risk assessments and quarterly biometric screening. FIGURE 1.2 EXISTING SOURCES OF DATA Note: All health data collected or reviewed must be treated as confiden al. Aggrega on and de iden fying is recommended. In addi on to the legal concerns, par cipa on will be limited if employees do not trust that the informa on they provide is secure. HEALTH STATUS/RISKS, HEALTH CARE UTILIZATION, AND HEALTH RESOURCES Health risk assessments (HRAs): Individual assessments for health status and risk may be offered by health plans. The plan data manage- ment team can provide you with aggregate-level information on what health problems are common, what risk factors need attention, and the level of participation in supportive health programs they offer. Some employers hire a vendor to do the assessment independently. Health care and medication claims: The plan may provide analyses of common health diagnoses and procedures and the associated costs, even to the level of depot, and can review the impact of family health care use on plan costs. Health benefits: The union or management benefits administrators can report on the type of coverage and covered services employee receive under the health plan; vacation and sick leave; access to health promotion programs and related benefits. OCCUPATIONAL SAFETY AND HEALTH DATA SOURCES Lost time that can be related to health: sick time, disability, workers’ compensation. Occupational injury and illness records: Occupational Safety and Health Administration (OSHA) 300 logs and equivalents, incident reports, and safety and health data analyses and summaries. Mine these for the problems related to employee health and the health and safety culture. OPERATIONS INFORMATION SOURCES Availability problems including driver disqualification Vehicle accidents Passenger complaints WHPP history and experience Employee health programs data collected on participation, satisfaction, or outcomes Existing policies related to health protection and promotion activities and related areas such as assault reporting, use of restrooms, route schedule problems

21GETTING STARTED Qualitative approaches to assessing need can be especially useful in under- standing the work environment. Carry out site walkthroughs and observa- tions of the workplace to identify health risks and health-promoting charac- teristics. This should include safety surveys and checklists that flag health and safety hazards as well as good practice. The organization may have a work hazard checklist that is used for the maintenance and other work areas, as well as pretrip inspection forms and protocols. The bus routes are also the work environment for operators, and Tool 1.2 Bus Operator Route Checklist is an operator inspection checklist to assess and report on that working environment. The Tools and Resources section links to additional formats and widely used tools for assessing the physical, psychosocial, and organizational environment. They are not transit-specific, and none combines these three areas completely, although WHPP practitioners around the world are collaborating on more comprehensive instruments. Other qualitative approaches include interviews with managers and employees to discuss health attitudes and beliefs, and employee surveys for health satisfaction and interest. Links to other useful worksite assessment instruments and tools you can adapt to your work setting are found in the Tools and Resources section at the end of the chapter. Understand the varied sources of operator health problems: Many factors influence worker health. The integrated approach to workplace health protection and promotion looks at three areas, as described in Figure 1.3. How to identify and address the ways that transit worker health can be protected and promoted in these three domains is covered in detail in Chapter 3. Consider demographics and other health factors: The makeup of the targeted employee population can provide insight into potential health problems and solutions. How old are they—young enough to have small children that affect sleep, old enough to be at higher risk of diabetes? What are the cultural factors that might affect food choice or disease risk? The gender distribution can influence health problems, health care use, and the kinds of activities that will be most effective. Identify potential sources of support for and barriers to an effective WHPP program: As a last step in assessing need, make a list of what existing characteristics will help your program develop and what could get in the way. Supports might be a cooperative labor environment, a directive from your health service provider to focus on worker health, or a health-promoting physical environment. Hindrances might include information or work culture divisions, funding problems,

22 TOOL 1.2 BUS OPERATOR ROUTE CHECKLIST ROUTE DATE TIME NAME/BADGE LOCATION/ DESCRIBE THE PROBLEM, INCLUDING ACTUAL HAZARD TIME OR POTENTIAL HEALTH OR SAFETY IMPACT Roadway issues (ex. potholes) Visibility hazards (ex. trees) Issues affecting schedules (ex. construction, traffic jams) Changes in passenger load Limited access to toilet facilities Assault or conflict concern Weather hazards (ex. flooding, ice) No recovery time Limited access to food Ergonomics concerns Other Other Other

23GETTING STARTED personality or power conflicts, a run-down physical plant, or a stressed or mistrustful management or hourly workforce. These problems need to be taken into consideration as you go forward. FIGURE 1.3: INDIVIDUAL FACTORS, ORGANIZATIONAL FACTORS, AND ENVIRONMENTAL FACTORS WHAT CONTRIBUTES TO OPERATOR HEALTH PROBLEMS Environmental Factors: elements of the physical environment. This encompasses work facilities and workstations, workplace hazards, psychosocial stressors and health promot- ing or discouraging environmental factors in and beyond the workplace, such as access and opportunities for healthy activity and eating. Organizational Factors: elements of the workplace or community structure, culture, practices, and policies. Factors that affect health include work schedule, work-family conflict, health and other benefits, and support for a healthy work culture and healthy behavior. Work organization interacts with the individual and social network including relationships with managers, coworkers, and family that provide support or impede health. Individual Factors: elements of an employee’s health, such as current health status, health risk factors such as overweight or obesity, physical activity, or personal challenges. Organizational Resources The needs assessment, in addition to finding gaps, also charts what resources the organization has available to support a WHPP program. Organizational resources include staffing, finances, related programs and policies, physical plant, and internal and external partners. Are there qualified and motivated staff? The most effective WHPP programs described by transit agencies rely on a dedicated staff member, full or part time. This person oversees the program, regularly convenes the WHPP committee, and is supported by an ongoing budget and the organizational support discussed earlier. The characteristics of the lead staff are explored in Chapter 2. What resources are found in the work environment? Look for health-enhancing space. The layout of the workplace can be a resource: Physical activity programs will be supported if there are gyms on the property, space that can be converted, or open areas around the facilities for walking or sports. The canteen and vending machines influence food availability and choice. Dedicated rest or quiet space can assist with fatigue and stress. Also consider if the workplace is well- maintained, seasonally cooled or heated, clean, and safe. BEST PRACTICE Program planners identify resources including staffing, finances, programs, structures, and internal and external partners.

24 How can existing structures and programs contribute? Many transit agencies have safety and health committees or location subcommittees. However, these committees are not often organized to address the full range of operator health issues as a priority. The various functional divisions of the organization—operations, maintenance, human resources, safety, risk management, labor relations, employee health, or employee assistance—are all typically engaged in activities that directly affect health. Without necessarily acting together they may have implemented overlapping initiatives that can be coordinated or consolidated in the comprehensive WHPP program. Who are the internal partners? Who has an interest in employee health, and what are they doing about it? In addition to the depart- ments, titles, and projects that overlap with the workplace health protec- tion and promotion program, find the people who are interested. The employees who can support as well as benefit from the program may be the most important group of internal partners. Union representatives are generally strong advocates for the health and safety of operators and are important resources and partners. Use Tool 1.3 Charting the Organization and Finding Partners to make this list. You may not be able to or need to fill each area as you start out. This step will be useful again when you work on building the program team as discussed in detail in Chapter 2. Who are the external partners? Workplace health protection and promotion is a growing area, and there are many free and inexpensive resources as well as excellent vendors. Take advantage of resources from local and national voluntary and government agencies. Collaborate with community organizations to conduct health programs such as smoking cessation programs. And look for cooperative vendors who will help you provide services that suit your specific needs. Remember that you will probably need to bring outside partners up to speed on the realities of transit work. The potential partners listed in Figure 1.4 usually take either a health promotion or a health protection approach. You will need to alert them of your interest in coordinating the two.

25GETTING STARTED TOOL 1.3 CHARTING THE ORGANIZATION AND FINDING PARTNERS DEPARTMENT WHPP-RELATED CONCERNS RELATED PROGRAMS CONTACT AND RESOURCES AND POLICIES Communications Internal and external newsletters, Other: Data management Access to health and injury data, Other: Facilities Planning and construction, Other: Human resources Hiring, Work-family, Employee Assistance Program (EAP), Disability, Return to work, Benefits, Other: IT Employee dashboard, Other: Labor relations Benefits negotiations, Other: Occupational safety and health Fatigue, Stress, Ergonomics, Accident, Heat/cold/weather, Other: Operations Availability, Vehicle safety, Scheduling, Other: Public relations Passenger interactions, Community support for transit, Other: Purchasing Costs, Vendor contracts, Other: Risk management Worker’s compensation, Vehicle safety, Other: Union Knowledge of workforce, Union Assistance Programs, Health activities, Other:

26 FIGURE 1.4 EXTERNAL WHPP PARTNERS GROUP WHAT THEY CAN CONTRIBUTE Health insurance providers HRAs, data, health coaching, funds, care management, classes Disease and case management For-fee support Occupational health clinics Diagnosis, treatment, and referrals for work-related illness and injury, group screenings, interface with researchers, consultation Physical fitness vendors Programs at work or offsite, ideally adapted to the transit workforce Primary care centers Disease management and health care directed at your workforce’s needs Vendors for health risk appraisals and other health evaluations Targeted data collection and reports to build your case and track success Behavioral health vendors (e.g., Employee Assistance Programs, work-life) Services for specific problems identified Local health and wellness consultants Programs tailored for your situation Local and state government: Department of Health Training materials, workshops, special events Community organizations Social service opportunities Area transit agencies Shared experience, partnering on developing a transit-specific program Local business community and nearby businesses Support for developing healthy food choices, exercise areas, and other health-friendly local changes National agencies: CDC, NIOSH Training, research, materials Educational and research institutions: universities, hospitals Partners in identifying and addressing workplace health issues, in a controlled research collaboration Health promotion associations (Wellness Council of America) Up-to-date information and ideas Riders—associations or individually Community support for agency initiatives Where are the financial resources? Some agencies have initiated WHPP programs without a budget, but it really makes sense to allocate start-up and operating money to a program that is likely to produce ongoing value. These funds may be justified based on health premium savings that you negotiate with your health plan or expect to see shortly, and on other identified program benefits. Funding for staff is especially important, but staff time may be hard to carve out. Additional funding can be developed from large and small sources: in one agency health plan and services vendors contribute most of the funds needed for health fairs, materials, and meetings; in another, the union

27GETTING STARTED contributes incentive items; several transit agencies have received public grant funds from local, state, or national sources. Some transit agencies explicitly commit the savings derived from the WHPP activities to supporting and expanding the program. Meeting Needs with Resources The organizational health needs and resources assessments set the stage for the programs, policies, benefits, and environmental supports that make up the workplace health protection and promotion program. Building a program that is based on the assessed needs of the employer and employees will put the WHPP program on solid footing and enhance participation and long-term sustainability. Program planning should be strategic, including long-term strategies to achieve program goals. It should also be tactical, involving the specific actions and steps necessary to implement and evaluate the program’s efforts. This Practitioner’s Guide focuses on the areas of planning that are particular to health protection and promotion in the transit workplace, so you will probably continue to refer to other health and program planning resources. Draft a long- term program plan: Plan ahead, as health change takes time. The program plan should establish a reasonably ambitious vision of what needs to be accomplished. It sets the fundamental, long-range direction. Although the long-term plan can be adjusted over time, it is important to maintain consistency so the program activities are not designed in reaction to temporary needs, concerns, or available topics. You can use the framework provided in the Overview worksheet from BEST PRACTICE The organization develops a plan to provide effective health assessments, a healthy and safe environment, and targeted and population- based intervention programs for all employees. EXTERNAL PARTNERS IN WHPP In one Canadian transit agency, occupational safety and health staff work closely with the city- wide wellness committee to share information and implement health and wellness initiatives. the Planning, Evaluation, and ROI Template to document and track your activities, as illustrated in Figure 1.5. Generate a short- term plan and establish priorities: Because resources at public transit agencies are limited, you will also want to set short-term goals and objectives to focus on selected high-priority issues revealed in the health needs assessment. Targeting high-impact areas can build momentum and lead to early success. Do this by considering the potential health impact, the proportion of employees who might benefit, and, where reasonable to do so, the cost-effectiveness of the activity. Short-term targets include increasing exercise, reducing tobacco use, achieving high levels of flu vaccination, and eliminating toxic chemicals used in cleaning or maintenance. Some objectives will focus on participation and morale. A medium-sized agency partnered with a community- based program, funded by the Centers for Disease Control and Prevention and created by the County Health and Human Services Department, to design a comprehensive health and wellness plan for transit employees. An agency with an active health risk assessment focus gets technical assistance on program evaluation from a local university.

28 Program Name Agency Worksite Health Protection and Promotion Program Program Year 2013 Mission Statement The mission of the WHPP program is to improve employee health and wellness, improve morale and work productivity, and reduce health care and other related costs by building a positive workplace health culture and establishing and maintaining activities, policies, and environmental supports that foster a healthy workforce. Long-term Goals— Health, Safety, and Wellness Long-term Goals—Work Organization and Environment Improve employee health, safety, and wellness, including reduce CDL medical disqualifications and bus operator MSDs by 20% per year. Establish a strong health culture by implementing policies and environmental supports that foster a healthy workforce and employee involvement. Long-term Goals— Business Outcomes Limit health plan annual premium rate increases to less than the regional healthcare trend. EXAMPLES OF PRACTICAL PLANNING TO GROW FIGURE 1.5 DOCUMENTING PROGRAM GOALS A large agency program is guided by explicit and quantita- tive 4-year strategic plans defin- ing targets, activity, evaluation, and outcome goals. The Wellness Committee establishes strategic plans covering 3-4 year periods. Yearly goals are set after looking at health plan data, other health indicators, partici- pation by divisions, and available resources. Targets are based on the current strategic plan and annual plan, previous year health fairs outcomes and evalu- ations; the program tries to maintain activities with good participation and at the same time keeping the offerings fresh. Initiatives are also identified in quarterly meetings of site SHORT-TERM OBJECTIVES: EXAMPLES FROM A MEDIUM-SIZED AGENCY champions and ambassadors. Aggregate health risk assess- ment data is used to target site- specific activity. Through the years, one medium- sized agency has gradually expanded its program to include a comprehensive menu of complementary components. Each program activity is planned based on the needs expressed by employees through opinion surveys and supportive data such as demographics and • 15% participation in worksite fitness programs/contests over six-month period (Get Fit Club, walking, gym utilization, etc.). • 15% participation in annual health fairs at all locations. Health fairs to include education, screenings, wellness coaching, and referral to year- round wellness programs (web-based programs, exercise, weight loss, and seminars). • 15% participation in various seminars (stress management, vendor sponsored events). • Respond to all requests for ergonomics assessment within one week. health claims. Plan to grow, including developing new resources: Planning and designing programs that produce results at different intervals will allow program staff to generate data to assess and to share results quickly and frequently. For example, weight loss challenges and flu vaccines are two examples known to produce strong results in the short-term, and the Société de Transport de Montréal has seen immediate and ongoing results from their comprehensive Sécuribus program, receiving the APTA

29GETTING STARTED Gold Award for Bus Security in 2013. Typically, cost outcome savings from sustained individual health risk factor reduction are seen in the long term. Rolling out successive activities while maintaining the long- term targets allows the program to continue to achieve important short- and long-term targets that justify program costs. Develop program components that match the needs identified: As helpful as best practices or proven plans are, they cannot be directly applied in a one-size-fit-all fashion to address the specific concerns of a transit agency or its operator workforce. Although there are many excel- lent generic health resources available, success will depend on activities that are tailored to match the specific workplace and the diverse needs of workers. Transit agencies vary in size, location, health and safety experience, resources, and health practices. Bus operators as an occupational group share some characteristics, and the work leads to common health concerns. At the same time, needs also vary within the workforce. Also, ask yourself how interested the employees are in participating in the proposed activity. You will need to identify operators’ interest and availability, and match program activities to their goals as well as the organization’s. Successful programs recognize this variation and are designed to meet the needs of individuals, the specific work location, and the agency as a whole. Effective programs respond to and attract a diverse range of participants. Design a practical program: It is important to assess realistically how hard it will be to implement the planned intervention or strategy, what it will cost, and the time needed to plan and conduct it (both staff time and the duration). The next two chapters should help you take steps to develop a program that meets felt needs and continues to attract and challenge participants. Summary Building a successful WHPP program requires leadership, resources, and hard work. The initial assessment of the workplace helps demonstrate the importance of the program to upper management and other leaders, and to the organization as a whole. As you map out problem areas, you will find your earliest targets and at the same time highlight areas of potential growth. Done right, the contacts you made to begin with will ensure an easier transition into the critical aspects of building a team to take on integrated workplace health protection and promotion. EXAMPLES OF PRACTICAL PLANNING TO GROW At a large agency with a combined fitness and ergonom- ics focus, yearly goals and activi- ties are based on evaluation, experience, and practical consid- erations: health areas known to be of concern including those identified through health plan data, the results of employee surveys following challenges, and the content of topical workshops and resources made available by the health plan and other resources.

30 TOOLS + RESOURCES Workplace Culture Assessment Safewell Practice Guidelines. An Integrated Approach to Worker Health. centerforworkhealth.sph.harvard.edu/images/ stories/SafeWellPracticeGuidelines&ExecSumm_Sept2012.pdf Wellness Council of America. Cultural Wellness Assessment Self-Test. This is a simple tool for assessing organizational culture and readiness for a wellness program. Absolute Advantage. 2006. p. 33. www.welcoa.org/freeresources/pdf/ aa_v5.4.pdf Assessing the Environment CDC National Healthy Worksite Program (NHWP) All Employ- ee Survey: This instrument assessing work organization, the health culture and some aspects of the work environment will be made available through NIOSH’s Total Worker Health™ website in mid-2013. www.cdc.gov/niosh/TWH/. CDC Tool for Observing Worksite Environments. This tool to conduct an environmental assessment at the workplace includes components to assess the worksite building, parking, and grounds environments; fitness center; nutrition and information environments; and the surrounding commu- nity. www.cdc.gov/nccdphp/dnpao/hwi/downloads/swat/ SWAT_observing_worksite_environment.pdf OSHA Small Business Handbook (2005). This extensive self- inspection checklist covers all areas or workplace health and safety and the components of a safety management system. It is not a compliance document, but can be used to design an inspection protocol relevant to any workplace. www.osha. gov/Publications/smallbusiness/small-business.pdf PRIMA-EF (Psychosocial Risk Management Excellence Frame- work) Consortium (2008) Monitoring Psychosocial Risks at Work. This factsheet produced by the PRIMA-EF Consortium and supported by the World Health Organization explains how to select and use the categories of exposures and outcomes most relevant to your workplace, and develop a checklist suitable for the specific demands of your transit agency. www.prima-ef.org/uploads/1/1/0/2/11022736/08_ english.pdf Organizational Needs CDC Swift Worksite Assessment and Translation (SWAT). This is a rapid assessment evaluation method for worksite weight maintenance and loss activities. www.cdc.gov/nccdphp/ dnpao/hwi/programdesign/swat.htm CDC Workplace Health Assessment Data Matrix. This table of qualitative and quantitative sources can be adapted to your organization to conduct a comprehensive workplace health assessment. www.cdc.gov/workplacehealthpromotion/ pdfs/AssessmentDataMatrix.pdf CDC Workplace Health Promotion: Assessment. 2011. This page defines the process of worksite assessment and provides links to tools. www.cdc.gov/workplacehealthpromo- tion/assessment/index.html Wellness Council of America. What to Look for During a Wellness “Walk-Through.” Absolute Advantage: The Workplace Wellness Magazine. 2006. p. 35. Sample Health Risk Assessment (HRA) tools Wellstream: www.getwellstream.com/ Summit Health: www.summithealth.com Employee Interest Surveys Wellness Proposals: www.wellnessproposals.com/pdfs/ employee_interest_survey.pdf WELCOA: www.welcoa.org/freeresources/pdf/ni_survey.pdf Organizational Resources CDC Writing SMART Objectives. This guidebook is aimed at helping states develop realistic and measurable goals and objectives for their heart disease and stroke prevention programs. It is also useful for other settings. Available at www.cdc.gov/dhdsp/programs/nhdsp_program/evaluation_ guides/docs/smart_objectives.pdf Texas Department of State Health Services. Worksite Wellness Index. The Worksite Wellness Index is a self-assess- ment and planning guide adapted from the Center for Disease Control and Prevention (CDC) School Health Index: A Self-Assessment and Planning Guide (2004). Available at : www.dshs.state.tx.us/wellness/resource/wwibody.pdf Wellness Council of America. Planning Phase Checklist. The checklist can be used to help organizations complete the planning process for their employee wellness programs. Absolute Advantage: The Workplace Wellness Magazine. 2006. p. 38. www.welcoa.org/freeresources/pdf/aa_v5.4.pdf Leutzinger, J. (2005). Building Your Wellness Budget. WELCOA’s Absolute Advantage Magazine, 4(10), 2-5.

31GETTING STARTED Chapter Background Baicker, Katherine, David Cutler, and Zirui Song. Workplace wellness programs can generate savings. Health Affairs 29(2). 2010. pp. 304-311. Centers for Disease Control and Prevention. Leadership Support. 2011; www.cdc.gov/workplacehealthpromotion/ planning/leadership.html Chapman, S. Proof Positive: An Analysis of the Cost- Effectiveness of Worksite Wellness, Chapman Institute; 6th edition, 2008. Leutzinger, J. (2005). Building Your Wellness Budget. WELCOA’s Absolute Advantage Magazine, 4(10), 2-5. McLellan, D., E. Harden, et al. (2012). SafeWell Practice Guidelines: An Integrated Approach to Worker Health Version 2 Boston, Harvard School of Public Health Center for Work, Health and Wellbeing. NIOSH. Essential Elements of Effective Workplace Programs and Policies for Improving Worker Health and Wellbeing. 2011. www.cdc.gov/niosh/twh/essentials.htm

33BUILDING THE TEAM Chapter Building the Team: Coordinating Health Protection and Promotion CHAPTER MAP TAKING THE LEAD The organization designates dedicated staff to coordinate and implement the workplace health protection and promotion program. • Identify an onsite staff person with WHPP knowledge and skills. • Support the WHPP program lead. • Supply adequate organizational support. • Make sure that the WHPP lead person and other staff understand the operator work environment and demands. • Set up ways for the program lead and staff to respond to the workforce needs and input. • Ensure ongoing staff education and training. • Provide feedback and supervision for WHPP staff. PUTTING THE TEAM TOGETHER Input is gathered from across the organization. • Identify organization partners. • Lay out a map of the organization in the context of WHPP. • Do outreach across departments. • Make planning and participation attractive and relevant for the WHPP team. MANAGEMENT SUPPORT Senior and mid-level management support workplace health protection and promotion initiatives as evidenced by documented communications, infrastructural initiatives, and health-focused policies • Upper management approves the program. • Involve senior and mid-level management in planning and implementation. • Identify conflicting motivators such as scheduling, budgets, availability, management models. • Communicate support throughout the organization. LABOR SUPPORT Union leadership and other representatives have influence on and support the workplace health protection and promotion goals and content. • Explore union interest and perceptions. • Identify conflicting motivators: e.g., contract, seniority, and discipline concerns. • Establish a direct role in the program for union leadership or designees. • Maintain communication with leadership, not solely designees or volunteers.

34 CHAPTER MAP (continued) WHPP COMMITTEE The organization sets up and supports a group to take action on workplace health protection and promotion. • Communicate with the safety committee. • Identify and recruit interested and effective committee members from management and labor, including operations, HR, procurement, occupational safety and health (OSH). • Observe protocols for joint committees. • Add location committees to meet more frequently. • Establish a regular meeting schedule suited to the teams. • Plan ahead to make meetings effective. CHAMPIONS AND AMBASSADORS Employee skills support and contribute to planning and implementation. • Identify management and operator champions and ambassadors in locations. • Recruit skills—health, safety, training, food, community organizing—not simply interest. • Provide champions and ambassadors with training on the concepts and practices of WHPP. • Define responsibilities. • Provide champions and ambassadors with schedule flexibility. • Sustain champion and ambassador role. VENDOR INTEGRATION The organization enlists health care providers and other vendors as partners in and contributors to the WHPP program assessment, planning, and implementation. • Find out what data is available and ask for data that fits your needs. • Educate vendors and providers about the workforce and transit work demands. • Involve vendors in planning, evaluation, and implementation. • Promote use of vendor programs. • Enlist vendor support for health fairs.

35BUILDING THE TEAM Employees’ health is important to all areas of a transit organi- zation. Despite this, in the TCRP F-17 Bus Operator Health, Wellness, and Retention survey, less than a third of the transit agencies said that their programs used resources from or influenced other departments or programs. Most of the programs described were run from the human resources department. In about half, responsibility was shared with operations, safety, or health divisions. Most of the transit agencies with programs identified a person responsi- ble, but half of these spent 20% of their time or less on their workplace health protection and promotion (WHPP) responsibilities, and only six were full time. Figure 2.1 shows the title categories of the leads, mostly administrative, such as HR or benefits; 20% were defined as wellness staff. The lead person was identified as operations or safety staff in only 17% of the programs. FIGURE 2.1 WHPP TITLE CATEGORIES

36 Respondents realized that better coordination across departments would be valuable, but they typically did not take advantage of their available resources to make that possible. Many described organizational silos, with the WHPP program isolated from important decision makers, sources of information, and the operating staff. This, along with the limited time, may explain why a majority of the agencies reported that more dedicated resources would make the program better, and one-third felt the program lacked support and integration with other organizational activities. At the same time, there was often overlap in areas, and an interest in making the programs relevant to the full range of workplace health protection and promotion. The most effective teams call on resources from all these areas, and include procurement, risk management, and others. Building that team means deciding: • Who is going to take the lead? • Who will be active on the team? • The WHPP committee. • Other contacts in relevant departments. • Supervisory, management, and labor champions. • Ambassadors and activists. • What support will they get from others? • How will outside partners be involved? BEST PRACTICE The organization designates dedicated staff to coordinate and implement the workplace health protection and promotion program. Taking the Lead Identify an onsite staff person with WHPP knowledge and skills: Although responsibilities can be shared, it is important to designate a WHPP program lead or contact person. The person who will lead and manage the WHPP program should have a health education and promotion background along with practical knowledge of the work environment. According to the Wellness Council of America, desirable skills include communications, project management, budgeting, record- keeping, vendor management, negotiation, and evaluation. Social traits might include confidence, a spirit of inclusiveness, and a desire to help others. The key staff person may be a self-identified person who cares about and pushes the issues, someone selected by leadership from existing staff, or a new staff person recruited from outside the organization.

37BUILDING THE TEAM Dallas Area Rapid Transit Wellness Program: Building the Team Dallas Area Rapid Transit (DART) is a good example of how an agency can make chang- es within a program to bring people together and start a team. It has created a team focused on implementing effective program components and increasing program participation. The wellness specialist is responsible for implementing the wellness program for all employees (transit and non-transit) and running the wellness and communication committees. When the wellness specialist was hired, she found a committee made up of mostly female administrative staff. She worked to make it represent the entire DART population. The new committee now has more men, front-line workers, cultural and ethnic diversity, and members who participate in the health and wellness program activities. The wellness committee is active in planning and implementing the health and wellness program and the communication committee is charged with the dissemination of information about the program to employees within their departments. Support the WHPP program lead: To ensure that the program remains a top priority, WHPP responsibilities and time commitment can be written into the job description. Upper management and union leadership help the program lead by showing confidence and support. Supply adequate organizational support: An effective program leader needs an operating budget and space. Other staff in the agency are also key resources. Helpful skills can be found in HR, benefits, safety, occupational health, finance, IT, operations, and labor unions. Their time should also be formally released whenever possible. Make sure that the WHPP staff understand the operator work environment and demands: Staff responsible for the WHPP program need to know what it is like to work as an operator, and especially how the organization of work (e.g., schedules, sedentary nature) can be a barrier to participation and success. Recognizing the challenges of work demands and the environment helps identify health targets, select useful activities, and structure the program to make it accessible to operators despite varied and tight work schedules. DESIGNATING DEDICATED STAFF In one large agency the full-time wellness coordinator, based in human resources, integrates her communication and wellness teams with other departments within the organization. Another large agency program is run by a full-time wellness manager supported by the union health trust fund. A Canadian municipality has a full-time Workplace Wellness Specialist who runs the program for all city agencies, providing program resources to the trans- portation division. continued

38 DESIGNATING DEDICATED STAFF continued A small agency contracts out the wellness coordinator position. It reports increased participa- tion due to fewer concerns about confidentiality and the coordina- tor’s more flexible schedule. Programs at many small- to medium-sized agencies are coordinated by human resources staff who report committing 5-100% of their time to WHPP activities. GETTING INFORMATION FROM THE WORKFORCE A Canadian program collects operator feedback through a comment box in the fitness room and satisfaction forms following activities. One agency surveys employees every year to help determine what areas they should target. At a small agency the WHPP program team brainstorms and develops program ideas with input from all members. BEST PRACTICE Input is gathered from across the organization. Set up ways for the program to respond to workforce needs and input: Encourage buy-in and participation at all levels of the organization. Set up methods for employee input (for example, identified point person solicits input, front-line worker surveys, suggestion forms, representatives on the WHPP committee from all locations and shifts). Define a timeframe for employees’ needs and concerns to be addressed. Inform employees of progress and resolu- tions of suggestions. Arrange ongoing staff education and training: Keep WHPP staff current with health knowledge and initiatives and additional skills needed to implement the program. Important areas include disease management and prevention, health and safety regulations, what works and what doesn’t in health protection and promotion, health risk assessments and how to use the results, health education, and effective communication. This could be in-house training from your own skilled resources, in-service presentations from external partners such as the American Heart Association, regional or national health protection and promotion conferences, webinars, books, or subscrip- tions to periodicals. Health specialists from hospitals, occupational health clinics, universities, or from your health plan provider are good resources for information and training for the staff. You may have access to health and wellness materials via local public or university libraries, voluntary health organizations, local public health depart- ments, and state or national government agencies. Provide feedback and supervision for WHPP staff: Leadership and operations management needs to let the WHPP staff know how they are doing, rather than allowing the program to exist as another silo. This oversight should include assessing the impact and value of the program from the outside, as well as the internal program evaluation described in Chapter 5. Putting the Team Together A successful WHPP program needs input from throughout the organiza- tion. Managers, supervisors, front-line workers from all departments, and professional and administrative staff can all make a valuable contri- bution to the planning, design, and implementation of the WHPP program. A barrier at any of these levels can block progress even when the WHPP program is welcomed by participants and endorsed by top management. Involving the organization’s various interests and divisions

39BUILDING THE TEAM in the program should help integrate it into the workplace culture, policies, and procedures. Identify organization partners: Resources could be people who can bring a needed skill set to the program or departments that can develop products and activities to be included in the program. Build on the list of internal and external partners that were identified in Chapter 1. Lay out a map of the organization in the context of WHPP: Who is responsible for related health areas, resources, and communication paths? If you haven’t done this already, use Tool 1.3 Charting the Organization and Finding Partners to list the people, departments, and resources that need to be involved in the planning and implementation of the WHPP program. Take into account skills and expertise that are needed, as well as resource availability. Define on the organizational map the skills and expertise that each resource can bring to the program. Do outreach across departments: Contact the identified resources to find out who is interested and has time to help. These representatives will assist with the coordination and integration of the respective programs into the WHPP program. Be sure to include labor representatives from all titles participating in the program. Make planning and participation attractive and relevant for the WHPP team: Team members need to feel that their input is valued and used. Roles and responsibilities should be clearly defined and communi- cated. Keeping team members actively engaged and contributing allows for buy-in and commitment to the success of the program. Celebrate milestones achieved and small successes with team members. See Figure 2.2 for an illustration of how the WHPP committee can actively contribute to the development of the WHPP program. ORGANIZATIONAL SUPPORT AND INTEGRATION A medium-sized Canadian agency has dedicated transit health and safety specialists who work with the municipal wellness committee to disseminate infor- mation and implement initia- tives. The city-wide program is expanding to address worker safety, ergonomics, and other occupational concerns, and to adapt the program initiatives to the transit work environment. In another, an HR-based wellness program works with an ergonomist to focus on high- injury areas by analyzing equip- ment issues such as seats, breaks, and maintenance challenges on a weekly basis. LEARNING ABOUT THE WORKPLACE In a medium-sized midwestern agency, all employees in the operating departments are required to hold a commercial driver’s license whether or not they drive a bus. A union WHPP manager trained in health promotion spent many hours riding buses and in the locations talking with operators to better understand their work demands.

40 FIGURE 2.2 WELLNESS PROGRAM COMMITTEE PROJECTS DEVELOPMENT: AN AGENCY EXAMPLE The 2012 Wellness Committee Project plan was developed to support Wellness initiatives. Each project should state what is proposed for the 2013 Wellness Program. Each project should contain to the following characteristics: novelty, necessity, and innovation. Projects should be submitted in document form and include timeline, budget, staffing, marketing, and materials needed. The deadline for project proposals is October 30, 2012. COMMUNICATION Project—New or Improved Communications System for 2013 Project Details: Communication system project should propose a new or improved system for the Wellness Program to get information out to employees. Plan should include a Social Media element. RECRUITMENT Project—Plan for Increasing Enrollment by 10% Project Details: Recruitment plan should propose a way for the Wellness Program to increase recruitment. PARTICIPATION/ENGAGEMENT Project—Plan for Increasing Participation Project Details: Plan should include at least three suggestions for increasing participation and employee engagement in Wellness Program. Plan should focus on areas where employees have a low participation record. FITNESS Project—Fitting Fitness into Work Schedules Project Details: Plan should include fitness center implementation, fitness events, and classes. DISEASE MANAGEMENT Project—Addressing High-Risk Medical Issues Project Details: Based on Wellness health initiatives, provide a plan that suggests ways to address high-risk medical conditions so employees may better manage their diseases and conditions. Plan should also include suggestions to reduce unnecessary emergency room visits. FEEDBACK Project—Wellness Survey Project Details: Identify three main concerns employees have as a whole through a survey and include suggestions to specifically address these concerns. POLICY Project—Documentation Guidelines Sheet, Fitness Center Disclaimer Posters Project Details: Project plan should include possible conflicts in Wellness Program rules and possible policy issues.

41BUILDING THE TEAM FIGURE 2.2 WELLNESS PROGRAM COMMITTEE PROJECTS DEVELOPMENT: AN AGENCY EXAMPLE NUTRITION Project—Nutritional Health Assessment Project Details: Project plan should include suggestions to find out why good nutrition and a balanced diet are not being achieved by the majority of employees. PRODUCTS Project—Select Threshold Prizes and Kick-Off Items for 2013 Project Details: Provide suggestions for Wellness Program products that will help employees become healthier. PROCESSES Project—Assess Current Wellness Tools and Processes Project Details: Assess current Wellness processes and tools and propose improvements. RECOGNITION Project—Recognition Plan 2013 Project Details: Submit a comprehensive plan to recognize all Wellness involvement. The plan should include contests, events, and participation levels. Management Support Management commitment is a well-recognized cornerstone of program success and of safety and health culture. Virtually all top managers contributing to the F-17 project described how strongly they supported health and safety across the board. However, research shows that organizational policies that present contradictions between operational concerns and health or safety are likely to be interpreted in favor of operations (Zohar, 2013). Top management has the power to make the program succeed, by issuing unequivocal statements of support, by making sure the rest of the organization agrees, and by providing resources. Upper management approves the program: Senior level management will ideally be advocates of the program, supporting the WHPP staff, motivating supervisory staff, encouraging participation from front-line workers, and allocating adequate resources to implement the program. They show support through interdepartmental memos, agency policies and procedures, personal communications with employees, and management participation in wellness activities. BEST PRACTICE Senior and mid- level management support workplace health protection and promotion initiatives as evidenced by documented communications, infrastructural initiatives, and health-focused policies.

42 OPERATIONS MANAGEMENT INVOLVED IN PLANNING In a large western agency, Division Manag- ers actively participate in their division-based Health and Wellness committees. While this is a requirement, it also helps them influence and tailor activities to limit any conflicts with operational demands. REDUCING CONFLICT BETWEEN OPERATIONS AND WHPP ACTIVITIES One agency, recognizing that front-line operator involvement is a challenge given the work schedules of the operators, collects operator feedback through a comment box in the fitness room and satisfaction forms following activities. Program planners make an effort to schedule activities to maximize operator participation. Involve senior and mid-level management in planning and implementation: Mid-level management and supervision help convey information between employees and upper management in a supportive way to demonstrate commitment for the WHPP program. The supervisory level is key. Supervisors can invest in workplace safety and health, promote safe workplace environments, serve as role models by participating in programs themselves, and offer front-line workers flexible access times and benefits that support health initiatives. Together, this instills a culture of health in the organization where workplace health issues are integrated into daily managerial practices; front-line workers can clearly see the dedication, encouragement, and importance of the program to management and the organization as a whole. Without this, the program can seem to be a tool for getting hourly workers to change without changing the organization. Identify conflicting motivators such as scheduling, budgets, availability, and management models: Knowledge of the work environ- ment is essential here. Identify barriers to management support that are created by the work environment, work schedules, common practices and, most critically, operations demands. The management and safety cultures may not be quite in sync with the health goals and culture being developed. You can use surveys, dedicated meetings (like focus groups), and even informal conversations to explore barriers, initially and as the program develops. Any conflicts should be raised and addressed, both directly with the responsible management level and in the program plan. Communicate support throughout the organization: Management strengthens the program by establishing effective and consistent communication that supports a culture of health and ensures that the benefits and activities of the program are communicated to all levels of the organization. Many organizations create a written statement endors- ing the program goals and objectives and defining the WHPP process and management and supervisory roles. Top management and other organization leaders further legitimize the program by speaking at, attending, and participating in program events, and by encouraging a culture of health within the organization. Leadership participation and support shows organizational commitment to the program. Front-line workers who perceive this commitment to a healthier and safer workplace should be more willing to participate in program activities.

43BUILDING THE TEAM Labor Support Union leadership can effectively influence policies, programs, and front- line workers. Union input and opinions are valuable to the members, and the union is a forum for important concerns and information about front-line worker health. WHPP is an important area of bargaining and can help leaders enhance their representation of the members. Despite taking the health problems facing bus operators equally seriously, both agencies and unions surveyed in the F-17 process felt that unions had limited confidence and involvement in WHPP programs. This was attributed by the union respondents to a lack of management commitment to issues of interest to the union leadership and members, and by agency responders to lack of interest or time on the part of the union. Union leadership that is consistently involved in planning and implementation will foster a sense of ownership in the program. Union endorsement and word-of-mouth promotion will support program activities as well as facilitate member participation. Explore union interest and perceptions: Union leadership’s first- hand knowledge about health and safety issues on the front line provides valuable input to the discussions on practical and effective strategies for the program. Union approval of the program encourages union member participation. Some union leaders will participate directly; others will want to select designees for committee work and activities. Identify conflicting motivators such as contract, seniority, and discipline concerns: Management should avoid program activities or recommendations that are in violation or competition with existing union contract clauses and procedures. The union may be interested in BEST PRACTICE Union leadership and other representatives have influence on and support the workplace health protection and promotion goals and content. REDUCING CONFLICT BETWEEN OPERATIONS AND WHPP ACTIVITIES continued To address schedule concerns as a motivator that could conflict with health and safety commit- ment, a scheduling department sets up tables to get input about scheduling problems in each division eight times a year. discussing issues such as alternative shift times to reduce work-family conflict that do not conform to the contract. There may be ways to mitigate the conflict in a way that will allow both sides to benefit from the implementation of the program. Establish a direct role in the program for union leadership or designees: Union leadership needs a seat at the table that will allow proactive involvement and the building of trust between labor and management. Union leaders can provide access to hard-to-reach and high-risk workers and can overcome some program barriers by promoting the program and acknowledging its value. The union can often contribute to the selection process of outside vendors or partners. Most agencies in the F-17 survey recognized that operator schedules and work demands are major barriers to program success.

44 Maintain communication with leadership: If union designees are selected for the WHPP committee or other program roles, they should have regular contact with the elected leaders to make sure that support and input continue. Union representatives sitting on committees and involved in program plans and activities should communicate all program progress (or failures) to union leadership. Union leadership should review program activities and outcomes at meetings with senior management. BEST PRACTICE The organization sets up and supports a group to take action on workplace health protection and promotion. UNION LEADERSHIP IN HEALTH PROTECTION AND PROMOTION One of the most extensive programs described is run independently by a union trust fund, which administers the health and wellness benefits for agency bus drivers and also negotiates health insurance rates. Union officers are closely involved with the program. Many unions reported playing an active role in occupational health, safety, and related operations concerns, but less so in health promotion. Following conversations related to the F-17 project, one midwestern union met with management to reintegrate health concerns into their already strong joint safety process. WHPP Committee The WHPP program committee may be a freestanding committee or report to an existing Safety and Health Committee. Among agencies in the F-17 survey with WHPP committees, HR and bus operators had the greatest representation on the committees; other titles included line managers, top managers, safety staff, union representatives, consultants, and health care providers. The makeup of the committee is important. It should include people who are excited about the program, those that have the skills and expertise needed to implement the program, and even skeptics to get all perspectives. Use the committee structure to seek and receive input about all aspects of the program, positive and negative. Other work groups can support WHPP programs and activities, for example, a communication committee to promote the program, a finance group focused on health care cost savings, or a few IT and data specialists creating the data structures described in Chapter 5. The upper-level management team addressing strategic wellness issues was described in Chapter 1 as the critical initial level of support. A WHPP charter establishes the committee’s: • Purpose: State committee goals and objectives, and a strategic plan • Structure: Lay out who is on the committee and how they are selected (that is, volunteers, appointed, nominated, by seniority) • Roles: Define the roles and responsibilities of the committee, includ- ing tasks and activities to be carried out by committee members • Schedule: Establish the committee meeting schedule and location • Planning process: Outline the method for establishing and revising wellness activities and targets • Timeframe: Set how long each committee member sits (that is, two years, the length of specified project, permanently) Figure 2.3 illustrates an example of a committee charter.

45BUILDING THE TEAM FIGURE 2.3 COMMITTEE CHARTER: TRANSIT AGENCY EXAMPLE PURPOSE The 2012 Wellness Committee will focus on the program initiatives of the current year. MEMBER ESTABLISHMENT Membership on the committee is voluntary and shall be established by written invitation and acceptance by December 31 of the previous calendar year. TERM OF SERVICE The term of service for each committee member shall be from January to December. REQUIREMENTS FOR WELLNESS COMMITTEE MEMBERSHIP Must be a full-time employee (no contractors or part-time employees). Must have accumulated at least 100 points within the program year. Must have approval of supervisor to serve on the committee. EXPECTATIONS FOR WELLNESS COMMITTEE MEMBERSHIP Volunteer for one of the 2012 Wellness Program projects and complete the project by May 31, 2012. Recruit at least seven new members during one-year term. Attend pre-scheduled committee meetings for the year or arrange for backup. Volunteer to take meeting notes and distribute them for at least one committee meeting within the year. Volunteer for and help to coordinate at least two wellness events at own location and at least one other location. Identify and motivate at least two other employees at the committee member’s respective facility to help support wellness initiatives. Give at least one wellness presentation during the program year. Actively participate in committee meetings and events in a professional manner while contributing in a productive way. I agree to the terms of membership for the Wellness Committee. Signature of Wellness Committee Member Date: Signature of Supervisor Date:

46 COMMITTEE EXAMPLES The 14-member wellness committee represents all departments, with at least three transit operators. The committee charter provides members details about the meeting schedule and the roles and responsibilities of the members. Their work is supported by a 25- person wellness communication committee tasked with enhancing communication about the program. The agency includes operations managers, OSH consultants, and union representatives in their legally mandated OSH commit- tee, which implements wellness and health and safety initiatives influenced by the safety team and supported by the city-wide wellness program. Wellness is a subcommittee of Safety and Health. The subcommittee is drawn from safety, scheduling, vendor selection, and bus procurement. The WHPP committee is diversi- fied, with union and manage- ment health plan trustees, department managers, divisional chairpersons representing operators, and health vendor representatives; corporate safety has a seat but defers to the committee. The targeted wellness commit- tee includes line managers, HR, bus operators, mechanics, and administrative staff. Communicate with the occupational safety and health committee: In some cases it will make sense to establish a WHPP subcommittee. Whatever the structure, the occupational safety and health program and the WHPP program need to communicate frequently to discuss overlapping issues. The two areas should hold regular joint meetings to discuss the progress and activities of each committee and to review issues that need to be addressed in coordinated initiatives or policy. Identify and recruit committee members from management and labor, including operations, HR, procurement, and OSH: Include management, union representatives, front-line workers, and operations supervisors if possible. Leverage each person’s strength and talents. Those selected for the committee should be dedicated, participating individuals who will move the WHPP program forward. Observe protocols for joint committees: The expected format for such a committee may be established by practice, contractually or legally (as it is for safety committees in many jurisdictions). In some organizations joint committees will have equal numbers of management and union members. Often the committee chairperson switches off between labor and management, which helps both parties feel a shared sense of responsibility for the success of the committee. A WHPP staff person may be the leader of the program, but the committee will function better if peer relations are maintained and all members have responsibilities. Add location committees to meet more frequently: In larger organizations, depot committees may be set up to do the ground work on agency-wide projects, or to implement local program tasks and activi- ties. They can adapt the program to the needs and limitations of the location, provide a two-way communication system between manage- ment and front-line workers, and help identify and develop champions. Subcommittees should meet as a group across locations or report back to the main committee regularly. Establish a regular meeting schedule that works for all: Keeping in mind the hours of operation of the agency, schedule meetings that committee members can reasonably attend. For some, this will mean more than one meeting time, or rotating the times or locations. This may require sign-off from upper management, mid-level management, or supervisors for front-line workers to attend. It could mean that 9-5 staff will need to flex their schedules to participate in late or early meetings.

47BUILDING THE TEAM Plan ahead to make meetings effective: A focused agenda that is sent to team members in advance will allow time for review and sugges- tions, and to collect more information from the field if needed. Minutes should be kept and circulated after each meeting to confirm next steps and actions items and document program progress. Champions and Ambassadors Champions and ambassadors help move the WHPP program forward. These are the program’s main supporters, who understand the importance and the benefits of workplace health protection and promotion. They adopt program initiatives and lead by example, while carrying out and modifying program activities to suit their locations. Ambassadors are tasked with promoting the program to front-line workers, scheduling and leading program events and activities, recruiting participation, and soliciting input on the program. They are the face of the WHPP program and are responsible for sharing information among the workforce, WHPP staff, and upper management. Identify management and operator champions and ambassadors in locations: Recruit enthusiastic people to develop support for the program, encourage participation, and solicit input from front-line workers about their interests and concerns. These champions help keep program activities new and relevant. Recruit skills—health, safety, training, food, community organizing—not simply interest: Identify skills or traits that potential champions can use to enhance the WHPP program. While interest is important, champions should also have skills and social characteristics to help successfully implement and sustain the program. Provide champions and ambassadors with training on the concepts and practices of WHPP: Educate champions about workplace health protection and promotion and the WHPP program and planned activities so that they can share information and skills with others. Regular training will ensure that information is current and correct, and it will keep the champions and ambassadors engaged. Providing training on paid time demonstrates its value to the organization. Define responsibilities: Champions’ responsibilities should be explicitly defined in writing so that they know what is expected from them, and other workers can refer to them as needed. Ideally the roles reflect their potential to contribute, not simply require them to push a prepackaged program. BEST PRACTICE Employee skills support and contribute to planning and implementation. ACTIVE CHAMPIONS In one large agency, champions and ambas- sadors help plan the program, implement the activities, and get input from workers about health needs and concerns. The Wellness Ambassadors are hourly workers who define and lead local activities. The Wellness Champions are Division Managers tasked with aiding the base ambassadors and actively participating in their division-based committees.

48 Provide champions and ambassadors with schedule flexibility: Management should schedule paid release time for champions to partici- pate in and promote WHPP program activities and events. The champi- ons are the face and the boosters of the program, so it is important that they have the flexibility to actively support and promote the program. Sustain champion and ambassador roles: Continue to recruit champions and ambassadors. Redefine the role if needed as your program grows. Maintain champions’ skills development and longevity through consistent training and involvement in program planning. Encourage participation through recognition and incentives. BEST PRACTICE The organization enlists health care providers and other vendors as partners in and contributors to the WHPP program assessment, planning, and implementation. Vendor Integration Health plans, service providers, and other vendors can be instrumental in planning and implementing the WHPP program. In particular, the employee health plan has data on the current health status of the workforce. They know how to sort it in ways that can help you identify targets and define program activities. Because improved health is in their interest as well, they may be willing to support funding of the WHPP program. In transit agencies surveyed, the health plan was often involved in the programs, but what data and support they offered varied widely by agency even with the same provider. Other types of vendors and allies may be underutilized. Figure 2.4 lists some of the ways external partners can provide support, data, and resources to the WHPP program. Some may be provided without charge, and others you will need to pay for. MAKING TIME FOR CHAMPIONS A large agency covers release time for 18 ambassadors every other Wednesday for four hours. Divisional managers have the discretion to release ambassa- dors for longer. An East Coast agency provides designated walk-around repre- sentatives with one paid day a month for health and safety meetings and inspections in each base and crew area. FIGURE 2.4 WHAT VENDORS CAN PROVIDE Aggregate reports of health data Comparison with other employers Workshops and classes Coaches—online or onsite Prizes Mobile health or dental units Financial support for program activities Training and informational materials

49BUILDING THE TEAM Find out what data is available and ask for data t h a t you need: When partnering with health insurance vendors, talk to them about the kinds of data that will help target your WHPP program strategy and activities. Define a consistent schedule for information to be made avail- able to you, the contact person that the data should be released to, and how to discuss any changes to the data that is to be provided. Getting and using vendor data is discussed in Chapter 1 and in more detail in Chapter 5. Explore vendor resources: Do your research to identify vendors that will actively contribute to your WHPP program. You may be required to issue a request for proposals (RFP) to solicit vendors, and you can use this to find out those with experience related to transit workplace, a proven track record on integrated or targeted h e a l t h interventions, or a willingness to accommodate to your needs. The questions in Figure 2.5 will help with vendor selection and contracts even if you do not use a formal RFP process. Educate vendors and providers about the workforce and transit work demands: Vendors should be made aware of the operational needs and demands of the workforce so that they can appropriately plan and implement activities or resources that suit transit workers. They can learn about the workforce through tours of the worksite and riding on the buses, information sessions where the vendor interacts with the front-line workers, or organization educational materials, for example. The tables in Chapter 4 and factsheets such as the one in Appendix B are good ways to educate providers and vendors about the transit environment and the needs of the workforce. Involve vendors in planning, evaluation, and implementation: Vendors may have staff with a lot of experience in health protection and promotion, and they can bring good ideas and insight to the WHPP program. It is important to let them know of your interest in addressing both health protection and promotion, as most are likely to have a tradi- tional health promotion focus. In some transit workplaces, vendors participate on WHPP committees. They may have a defined role and responsibility that include providing specified information at meetings, and sponsoring functions or events such as classes, health fairs, or health risk assessments. USING VENDOR INFORMATION A mid-sized agency has recently targeted weight reduction and healthy eating based on a meeting with health care providers to review employee utilization of health services. A small agency uses regular meetings with the health insur- ance company to target wellness activities based on health care claims and the type of ailments that operators seek treatment for. AGENCIES BENEFITTING FROM PARTNER RESOURCES An agency in a medium-sized city contracts with businesses along bus routes to allow transit employees to use their restrooms, if needed, while driving their route. A large agency solicits vendor contributions to cover incentive programs, health fairs, program supplies, travel, printing and copying, program shirts for ambassadors, and meeting costs. One health insurance vendor provided free classes and mobile medical services. However, these were cancelled if fewer than 20 operators showed up. This left the WHPP program in the lurch, along with the operators who had planned to participate, when traffic jams or other scheduling problems made the group smaller than hoped for. continued

50 Promote use of e x i s t i n g vendor programs: Useful examples of specialized vendor programs include HRAs for high-risk individuals, online health coaches, and onsite or mobile health services. During the F-17 research project it became clear that employees and even WHPP program staff are not always aware of the resources that are available. You may want to advertise coaches, discounts, and other benefits offered by the health insurer. If they are not being used, talk with the workers and with the vendors to see what can be improved. Enlist vendor support for health fairs: Health fairs appeal to people if they offer new information and give-aways along with familiar health protection and promotion activities. Fairs provide new and established vendors a chance to show their value to the organization while promoting their programs. The best vendors should be willing to participate in off-hours events to accommodate transit workers. Summary Carefully building a strong team will help your agency set up a successful workplace health protection and promotion (WHPP) program and make use of available resources. Recruit internal and external partners with different skills and expertise to plan and implement the program. Respon- sibilities of the WHPP team include: • defining program goals, objectives, and a strategic plan that are in alignment with the organization’s needs and priorities; • developing a mission and vision statement that exemplifies the program direction; • assisting in carrying out the program’s operational plan; • guiding the adaptation of the plan to specific departments’ needs; • recruiting program involvement throughout the organization; and • soliciting input. The process of developing and defining the team helps promote the program throughout the organization. This sets the stage for the team to identify the health targets for the program. AGENCIES BENEFITTING FROM PARTNER RESOURCES continued A small campus transit system receives and distributes weekly wellness newsletters and educa- tional posters from the Regional Medical Center. An urban agency arranges for a market vendor to sell fresh fruit and vegetables at the worksite.

51BUILDING THE TEAM FIGURE 2.5 QUESTIONS TO ASK VENDORS Customer Service How quickly are questions answered? How much does the vendor support implementation and delivery process? How are complaints handled? Will there be a designated person assigned to the account? Are there hidden costs? What is the turnaround time on reports and documents? What are the customer service hours? Experience Pricing What is the average number of years staff has been involved in programming? How many clients does the vendor work within a year? How long has the vendor been in business? Does the vendor have subcontractors that deliver part of its services? What are staff credentials? How are field staff trained? Are there customer service satisfaction and performance statistics? What is your experience with transit workplaces? With other similar workplaces? Can we contact your clients? What programs or activities do you most commonly provide? Can you adapt your services to our workplace—type of work, health needs, schedule? Can you provide services outside of regular hours? What services are available at no charge? What are your prices for onsite activities? What are your prices for data and reporting documents? What kind of incentives (monetary or other) can you provide for us contracting with your company? Do you offer any special program discounts? Is a contract required? If so, is there a mandatory minimum contract term? Confidentiality and Liability Is the vendor HIPAA compliant? What processes are in place for handling and storing personal information? How does the vendor handle communication of personal information at screenings to ensure confidentiality? How does the vendor transmit personal information? Satisfaction (participant and customer) What type of participant satisfaction documentation does the vendor have? How satisfied have other clients been with performance? What methods do you use to allow clients to provide feedback? What is the process for handling client complaints and concerns? Metrics and Evaluation What kind of evaluation does the vendor provide for the program? Will the vendor work with other vendors, insurance brokers, and others to integrate information? What data can the vendor provide? Account Management What is the account manager’s experience? How much guidance does the manager provide? Who supports the manager? As presented in SafeWell Practice Guidelines - Adapted and summarized from Kruse, Mary M. “From the basics to comprehensive programming” in ACSM’s Worksite Health Handbook: A guide to building healthy and productive companies. 2nd ed. Pronk, N (Ed). 2009. Champaign, IL: Human Kinetics.

52 TOOLS + RESOURCES Who is going to take the lead? Partnership for Prevention (2001). Healthy Workforce 2010 (p. 31-65). www.prevent.org. This list of resources can be used to help provide ongoing training and education for worksite staff. Management Support The Leading by Example Commitment. Example letter of management commitment to a healthy productive workforce. Partnership for Prevention Leading By Example. The Value of Worksite Health Promotion to Small- and Medium-Sized. (2001) (p. 4). www.prevent.org/data/files/initiatives/lbe_smse_2011_final.pdf Health Management Initiative Assessment for Small- or Medium- Sized Employers. An assessment of the health culture within your organization. Partnership for Prevention Leading by Example. The Value of Worksite Health Promotion to Small- and Medium-Sized Employers. (2001). (p. 5). www.prevent.org/data/files/initiatives/lbe_smse_2011_final.pdf The Wellness Council of America Wellness Leadership Survey Assessment of senior level support of your health promotion program.. Absolute Advantage: The Workplace Wellness Magazine. Capturing CEO Support (p. 17) 2007. www.welcoa.org/freeresources/index.php?category=11 The Wellness Council of America. Capturing CEO Support Absolute Advantage: The Workplace Wellness Magazine. 2007(p. 50). www.welcoa.org. Communication plans. www.cdc.gov/workplacehealthpro motion/planning/communications.html Vendor Integration WELCOA Checklist for Selecting Health Promotion Vendors. www.welcoa.org/freeresources/pdf/vendor_checklist.pdf WELCOA: Guilty Until Proven Innocent: In-depth article on choosing a health risk assessment vendor. Remember to check if your health insurer can do the same thing. www. welcoa.org/freeresources/pdf/aa_7.7_guilty_until_proven_ innocent.pdf Selecting Vendors: Topics and Questions. A summary of potential topics and tools that you can ask vendors. Safewell Practice Guidelines. An Integrated Approach to Worker Health. centerforworkhealth.sph.harvard.edu/images/stories/ SafeWellPracticeGuidelines&ExecSumm_Sept2012.pdf Committees Absolute Advantage. Volume 6. Number 3. (2007). The Wellness Council of America. Creating Cohesive Wellness Teams.(p. 54). Guide to Effective Joint Labor/Management Safety & Health Committees (reprinted 2008). Eaton, A and M. Egarian. This handbook describing the process of working effectively together was produced for the New Jersey Public Employee Occupational Safety and Health Program by Rutgers University Labor Education Department. www.state.nj.us/health/ peosh/documents/jlmhsc.pdf A plan for change: Safety and health committees, SEIU Training Fund: This OSHA-funded outline for an effective joint labor-management safety committee can be adapted for the WHPP committee www.osha.gov/SLTC/healthcarefacilities/ training/activity_7.html Chapter Background Grossmeier, J., P. E. Terry, et al. (2010). “Best Practices in Evaluating Worksite Health Promotion Programs.” American Journal of Health Promotion 24(3): TAHP1-TAHP9. The Wellness Council of America. Creating Cohesive Wellness Teams. Absolute Advantage: The Workplace Wellness Magazine. 2007. www.welcoa.org/freeresources/ index.php?category=8 The Wellness Council of America. Planning Wellness Getting Off to A Good Start. Absolute Advantage: The Workplace Wellness Magazine. 2006. (p. 21). www.welcoa.org/freere- sources/index.php?category=8 Vaag, J. et al. (2013) The Sound of Well-Being: Choir Singing as an Organizational Intervention to Improve Well- Being in a Norwegian Municipality. Protecting and Promot- ing Total Worker Health: Work, Stress, and Health 2013, 10th International Conference on Occupational Stress and Health, Los Angeles. Zohar, D. (2013). Reducing Policy-Practice Decoupling to Improve Safety Climate and Performance: A Randomized Intervention Field Study. Protecting and Promoting Total Worker Health: Work, Stress, and Health 2013, 10th International Conference on Occupational Stress and Health, Los Angeles.

53SETTING TARGETS Chapter Setting Targets: Effective Transit Health Protection and Promotion CHAPTER MAP SETTING PRIORITIES The organization establishes what matters and what can be done with available resources. • Use planning and needs assessment data to define program targets to match the organization’s strategic goals. • Estimate the challenge. • Combine assessments of need, severity, and challenge to set your priorities. A COMPREHENSIVE HEALTH RISK FOCUS The organization identifies and targets multiple contributing factors to operator health problems and conditions. • Establish clear prevention and promotion principles. • Understand what contributes to operator health problems and conditions. EFFECTIVE COMPONENTS The WHPP program activities are based on feasible and effective practices that address the identified program targets. • Understand and apply what has been successful in workplace health protection and promotion. TRANSIT-SPECIFIC PROGRAMMING The program planning and content address transit-specific risks, exposures, and conditions. • Target areas and plan activities that are relevant to transit workers. • Be realistic about the results you expect.

54 Bus operators and other transit workers experience some of the highest rates of health problems of any industry, as discussed in the introduction. There is not complete agreement on what the biggest problems are: As shown in Figure 3.1, agencies in the F-17 survey consistently reported the top health concerns of bus operators to be chronic diseases and musculoskeletal problems, followed by achieving healthy behaviors and general wellness. Labor representatives were more concerned about what the work environment does to health, and slightly less concerned than management about individual health behaviors. Most of the health activities described by transit agencies focused on giving the individual information and tools for identifying, treating, and 80 76% 70 60 50 65% 60% 70% 55% Agency Union 49% 50% 40 40% 40% 30 21% 20 10 13% 6% 0 Chronic Diseases (hypertension, diabetes, cardiovascular, lung, reflux) Musculo- skeletal Problems (back injury, tendinitis, other pain) Achieving Desired Physical Activity (diet and/or tobacco use status) Wellness (such as stress and fatigue) Occupational Injury/Illness Work Environment (accidents, work-related injuries or illnesses, assaults) FIGURE 3.1 WHAT ARE THE TOP 3 HEALTH ISSUES AFFECTING BUS OPERATORS AT YOUR AGENCY?

SETTING TARGETS Edmonton Transit System: Moving Toward Integrated Health Protection and Promotion A key element in transit workplace health protection and promotion is the range of contributors to operator health. Edmonton Transit System (ETS) demonstrates how occupational safety and health staff and committees can help promote health and wellness. The Edmonton Employee Safety and Wellness section employs a corporate health promotion specialist, an industrial hygienist, occupational health nurses, and an ergonomist. WHPP activity has emphasized fitness and exercise, stress, and obesity. Major initiatives include sponsored fitness center membership (available to all city residents), educational events and health fairs, and work hazards assessments and consults. Each city department, including ETS, has dedicated occupational health and safety (OH&S) staff, called consultants. Among other OH&S responsibilities, the consultants disseminate information and implement initiatives from the city-wide wellness committee. Health promotion targets are established for the city as a whole and for each division. Current transit-relevant targets include sleep apnea and obesity, encompassing health, design, and procurement issues. The OH&S committees identify and respond to transit health protection and promotion needs, and carry out campaigns dealing with wearing seat belts and slips, trips, and falls prevention. Each of four bus facility OH&S committees consists of representatives from management, occupational health and safety, operators, and inspectors. The OH&S committees analyze worksite hazard assessments, incident reports, and seasonal changes to define what health and safety problems should be targeted. A facility inspection is carried out monthly, and findings and recommendations are submitted to the facility operations committees and then to the directors meeting for approval. Twice a year, the facility committee co-chairs, supervisors, and management meet to discuss the improvements made as well as areas of future improvement. In ETS the OH&S committee and the OH&S consultant bring together observed problems, complaints, incident reports, and knowledge of health and safety issues that are common in the transit industry to propose and implement activities for the following year. Although at the city level health promotion activities are not fully integrated, the transit OS&H consul- tants and committees interact with the Safety and Wellness section for health protection and promotion initiatives. 55

56 avoiding illness. But to protect transit workers’ health, organizations must also acknowledge and address contributing factors in the work environment. Worker representatives in the F-17 survey showed less confidence in employer programs that did not cover the work conditions. Workplace health concerns might stimulate program participation: in one study, motor freight workers who felt that workplace stress and schedule demands were a problem were more likely to participate in smoking cessation programs (Sorensen et al., 2010). To be successful, WHPP programs need to define and support a healthy culture, at work and away. In traditional worksite wellness programs this can mean promoting safety at home along with safety at work in educational materials or tool-box talks. The NIOSH Total Worker Health™ Essential Elements of Effective Workplace Programs cites improving the work environment as fundamental to health promotion: Eliminate recognized occupational hazards. Changes in the work environment (such as reduction in toxic exposures or improvement in work station design and flexibility) benefit all workers. Eliminating recognized hazards in the workplace is foundational to Total Worker Health™ principles. This approach also improves productivity and absenteeism, according to a recent study of 19,121 employees from five employers (Shi et al., 2013). This chapter of the Practitioner’s Guide describes ways to understand and tackle the combined environmental, organizational, and individual contributors to the major health targets faced by bus operators. The following chapter defines how to carry out WHPP activities that suit the transit workplace. BEST PRACTICE The organization establishes what matters and what can be done with available resources. Setting Priorities The program initiation steps outlined in Chapter 1 and the baseline evaluation measurements explained there and in Chapter 5 should tell you what issues are important to your organization, in terms of frequen- cy, seriousness, and financial impact, and what matters to the bus opera- tors. It will take some more discussion to determine what targets are feasible. Limited resources may force a choice even among important issues and effective and popular activities.

57SETTING TARGETS Use planning and needs assessment data to define program targets that match the organization’s strategic goals: Target priority should be based on an assessment of the number of operators affected and how severe the impact is on worker health, on organizational success, or on finances. Tool 3.1 can help you prioritize your targets by comparing this information. The first column includes a list of the most common health issues of concern in transit agencies. For each that may be prevalent in your organization, identify as well as you can the number of operators that are or may be affected (second column). Judge if the impact is serious, medium, or low, and circle that in the third column. E s t i m a t e t h e c h a l l e n g e : There are also pragmatic considerations, because some success or improvements can be hard to achieve. The expected value for the effort required is important to consider (fourth column). It is smart to collect some low-hanging fruit to develop confidence and test your program. At the same time, tough health issues are often the program drivers, so the organization may be pushed to take on important but more challenging targets in the early stages of the WHPP program. The program components that can have the biggest impact may need to be introduced early as they take longer to develop and to meet important goals. Combine assessments of need, severity, and challenge to set your priorities: You will want to target serious problems, and ones that affect a lot of people; these may or may not be the same. There will be overlap, and some issues can be addressed together. Whatever you decide to do, keep the filled in Tool 3.1 as documentation of how you have examined and selected targets over the course of your program. You will be able to reach for more challenging targets as the program grows. SETTING PRIORITIES At a Canadian agency, health protection and promotion targets are defined by the OSH committee and the OSH consultant bringing together observed problems, complaints, incident reports, and knowledge of health issues that are common in the transit industry. Seasonal and annual targets are set and each month two topics are selected to cover with educational materials and activities.

58 TOOL 3.1 SETTING PRIORITIES Health problem Number of How severe How hard will it Priority Notes operators is the impact be to achieve im- affected (on health, provement? operations, finances) Cancer Serious Medium Low Easy target Some challenge Hard to reach Top Near future Postpone Cardiovascular disease (heart disease and stroke) Serious Medium Low Easy target Some challenge Hard to reach Top Near future Postpone Diabetes (Type 1, Type 2, gestational and insulin resistance) Serious Medium Low Easy target Some challenge Hard to reach Top Near future Postpone Digestive problems (reflux disorder, ulcer, irritable bowel) Serious Medium Low Easy target Some challenge Hard to reach Top Near future Postpone Hypertension (high blood pressure) Serious Medium Low Easy target Some challenge Hard to reach Top Near future Postpone Metabolic syndrome (insulin resistance, fat location, blood pressure) Serious Medium Low Easy target Some challenge Hard to reach Top Near future Postpone Musculoskeletal disorders Serious Medium Low Easy target Some challenge Hard to reach Top Near future Postpone Occupational injuries Serious Medium Low Easy target Some challenge Hard to reach Top Near future Postpone Sleep and rest (fatigue, sleep apnea, circadian rhythm disruption) Serious Medium Low Easy target Some challenge Hard to reach Top Near future Postpone Substance use (tobacco, alcohol, OTC medications, illegal drug) Serious Medium Low Easy target Some challenge Hard to reach Top Near future Postpone Other: Serious Medium Low Easy target Some challenge Hard to reach Top Near future Postpone

59SETTING TARGETS A Comprehensive Health Risk Focus Extensive research and the practical experience of agencies, bus operators, and health care providers demonstrate how closely connected the individual, the organization of work, and the home and work environments are when it comes to common health problems. An effective WHPP program uses this evidence to establish a comprehen- sive approach. It is widely recognized that the health conditions bus operators and transit agencies are dealing with—notably, high blood pressure, cardiovascular disease, diabetes, sleep apnea, and metabolic syndrome—are all influenced by genetics, weight, physical activity, and food choices. But these individual characteristics are not the only contributors. Research shows that stress can be a cause or an aggravating factor in all these problems. Stress comes from schedule demands, work-family conflict, and workplace health and safety concerns such as assault or access to restrooms. The experience of stress is influenced by the support available to the worker, by individual responses to demands, and by other life factors. Some of the health problems feed each other. For example, sleep disturbance is connected to diabetes, cardiovascular disease, and reflux, and in turn these disorders can contribute to sleep disturbance and fatigue. Health status can drive choices about eating, sleeping, and substance use. So a person with sleep apnea, which could be related to reflux disease, overweight, or stress, may mistakenly drink alcohol at night BEST PRACTICE The organization identifies and targets multiple contributing factors to operator health problems and conditions. HOW THE WORK- PLACE CAN CONTRIBUTE TO OPERATOR HEALTH PROBLEMS Musculoskeletal disorders (MSDs) may be more likely for people who are sedentary outside of work, but driving a bus exposes workers to known risk factors such as vibration, awkward postures, and stress that can increase the risk of MSDs. to try to get to sleep, or reach for high fat and sugary food for energy. An operator with hypertension might avoid diuretic medication and drink less water because of limited access to toilets, but this could aggravate the hypertension as well as lead to health problems. Critically, workplace conditions and hazards can combine with other risk factors to cause disease or make it worse. The traditional approach to health promotion focuses on individuals with diseases or risk factors, providing support to reduce the risk factors or manage the disease. Organizations with a traditional approach will typically use educational materials, HRAs supported by health coaching, and activities, policies, and incentives that encourage healthy decisions and actions. Some expanded programs will include supports to deal with stress or work-family conflict or social events to increase morale. WHPP programs have enhanced the health environment by installing Diesel exhaust has a direct harmful effect on cardiovascular functioning. Operators may avoid taking medications such as diuretics if they are concerned about access to toilets on the road.

60 gyms, walking trails, showers, and bike racks. These activities are all parts of an effective WHPP program, but they do not reduce the occupational components of risk. A comprehensive workplace health protection and promotion program creates a physical and organizational work environment that eliminates or reduces occupational hazards and promotes health, incorporating health supportive policies and practices to enhance health and safety at work and beyond. It might seem obvious that the comprehensive approach is most likely to succeed. At the same time, it requires more commitment of time and resources and greater cooperation around the organization. Establish clear prevention and promotion principles: Start by defining your approach. Will you focus on people with diseases and recognized risk factors—the traditional health promotion model? Will you also try to improve health and well-being by developing policies and a work culture that encourage and reward healthy exercise, food choice, and stress response? Will you develop a comprehensive workplace health protection and promotion program? The decision may depend on the workforce priorities, the organizational readiness, and the resources available. Whatever you start with, you can grow to the next level as you develop your program and enhance the organizational health culture. Understand what contributes to operator health problems and conditions: Figure 3.2 summarizes the major contributors to common health problems of transit workers. Understanding these contributors will help avoid, resolve, or manage important health problems for transit workers. Here is just one example: Bus operators have higher rates of hypertension, cardiovascular disease, and diabetes. Is this caused by their behavior? They report less physical activity than other workers, and are also more likely to be overweight and to smoke. Is this because their hours are so challenging, making it hard to eat and exercise at healthy times and in healthy ways? Or is it because of other work conditions? For example, some operators report not taking diuretics prescribed for hypertension because they do not have a reliable place to use the restroom. For many, going home after an evening shift possibly after hours of effective solitude or schedule stress can make it hard to get to sleep, and disturbed sleep patterns have been linked to diabetes. So where does the health problem start, and how can any program hope to take on all these challenges? The good news is that many interventions will help reduce more than one health problem. Diet and activity adjustments can improve blood pressure, diabetes, digestive problems, and mood. It turns out that even

61SETTING TARGETS a small weight loss can improve insulin response and increase energy. Improving access to healthy food at work can help control the precur- sors to heart disease and diabetes and improve sleep. Improving workplace conditions can reduce absenteeism and improve morale as well as keep people safer and healthier. Appendix B is an example of explaining a significant health problem affecting bus operators (sleep disturbance) to show specifically how transit work as well as individual behavior can affect operator health, and what employers and workers can do about it. FIGURE 3.2 HEALTH PROBLEMS AND RELATED FACTORS IN TRANSIT WORKPLACES RELATED FACTORS HEALTH PROBLEM INDIVIDUAL PSYCHOSOCIAL AND ORGANIZATIONAL ENVIRONMENTAL High blood pressure Genetics Medical care Shift work Work-family conflict Schedule pressure Stressful work conditions Cardiovascular disease Diabetes Metabolic syndrome (insulin resistance, fat location, blood pressure) Digestive problems (including GERD) Fatigue Sleep disruption Sleep apnea Sedentary habits Food choices Weight Weight Sleep hygiene Individual coping mechanisms Sleep disturbance Timing of meals Shift structure Work stress Work-family conflict (such as assault) Diesel exhaust Working at night Access to restrooms may discourage proper medication use Working at night Overtime Musculoskeletal disorders Outside activities Overall fitness Age Work stress Fatigue Seated work Work station design: seat position, pedal position, and force Whole body vibration Forceful contact with seat (disk compression) or steering wheel (carpal tunnel syndrome) Forceful motions—wheelchairs, windows Cancer Genetics Tobacco, alcohol Early diagnosis Night work Diesel exhaust Asbestos Substance use (tobacco, alcohol) Genetics Habits Sleep disturbance Work-family conflict Break schedules Hours of work Work stress

62 REDUCING CONFLICT BETWEEN OPERATIONS AND WHPP ACTIVITIES One agency, recognizing that front-line operator involvement is a challenge given the work schedules of the operators, collects operator feedback through a comment box in the fitness room and satisfaction forms following activities. Program planners make an effort to schedule activities to Figure 3.3 shows how you can apply this information to your health concerns and targets, as explained in detail in the Practitioner’s Guide introduction. The mapping process defines the individual behaviors (what people do); individual characteristics that rarely change (what people are); the work, home, and community influences (what the environment is and does); and the impact the health concern has on the health of the individual or on the organization (the impact and outcomes). What maximize operator participation. To address schedule concerns as a motivator that could conflict with health and safety commit- ment, a scheduling department sets up tables at each division every 6 weeks to get input about scheduling problems. What the environment is and does people do What people are IMPACT Outcomes OPERATIONS MANAGEMENT INVOLVED IN PLANNING In a large western agency, Division Manag- ers actively participate in their division-based Health and Wellness committees. While this is a requirement, it also helps them influence and tailor activities to limit any conflicts with operational demands. FIGURE 3.3 MAPPING TRANSIT WORKER HEALTH PROBLEMS So for a certain health problem (such as metabolic syndrome – illustrat- ed in Figure 3.4), we know that what people do (sedentary habits or food choice) is very important. Some individual characteristics that rarely change are age, gender, race, and genetics. The environment has a recognized impact on metabolic syndrome (schedule stress affects blood pressure, diesel exhaust exposure affects heart function, working at night affects insulin response). How work and home life are organized (what the environment does) affects metabolic syndrome by driving when and what people eat or how they exercise. Other environmental factors are less obvious—not having access to bathrooms is a stress on its own, and it may discourage people from taking their medication; sleep disturbance related to schedule stress and work- family conflicts can be made worse by health problems and can make them worse. The result: a health impact and negative outcomes for the person and the organization.

63SETTING TARGETS Where you start filling in the map does not matter—you may know people have a health risk and want to explore what impact it might have or how you could limit its effects, or you might have an organizational issue such as commercial driver’s license (CDL) disqualification and want to work out what is contributing to it. What matters is to ask all the questions: What do people do that affects their health, what do the organization and environment contribute, what are the impacts and the outcomes? The map can show you what is important and where you can intervene. The relationships between these can be even more complex than the drawings suggest. REDUCING CONFLICT BETWEEN OPERATIONS AND WHPP ACTIVITIES continued Most agencies in the F-17 survey recognized that operator schedules and work demands are a barrier to program success. Schedule stress Diesel (CVD) Work at night Sedentary habits Food choice Access to food on the road Eating at night Gender, race age, genetics Toilet access Sleep disturbance METABOLIC SYNDROME Commercial Driver’s License Health plan costs Vehicle safety? FIGURE 3.4 MAPPING METABOLIC SYNDROME FOR BUS OPERATORS Effective Components It may seem obvious to say that you should choose activities and set policies that have a chance of affecting your targets. But the F-17 research process suggested that a surprising amount of health promo- tion activity is done because it is appealingly packaged, people have liked it in the past, or an attractive campaign has been carried out elsewhere. Not all popular WHPP activities are effective, and not all will suit every group of workers. Understand and apply what has been successful in workplace health protection and promotion: The CDC Task Force on Community Preventive Services reviews the research literature on BEST PRACTICE The WHPP program activities are based on feasible and effective practices that address the identified program targets.

64 workplace health promotion on an ongoing basis. Figure 3.5 lists the intervention methods that the Task Force has determined to be reliable. It reports strong evidence that environmental and policy approaches can increase physical activity, by creating or improving access to places for physical activity combined with informational outreach. Workplace obesity programs have had some success; however, the obesity research reviewed focused on the white collar workforce and may not apply as well in the transit environment. More important for people looking to research for guidance, this extensive analysis could not determine what among the many educational, fitness, or other health promotion components was having the observed effects on obesity. Overall, workplace smoking cessation programs seem to work. Onsite flu vaccination programs are also effective. As is common, the Task Force analysis focused strongly on dealing with individual health and wellness and did not cover occupational health protection or safety. Another clear message of this national Task Force was that health risk screening or health risk assessment (HRA) alone is not enough. Following HRA results with health education, referrals, and activities does improve health outcomes. Health education following HRAs can have an impact on tobacco, alcohol, and seatbelt use; blood pressure and cholesterol; days lost; and appropriate health care utilization, as well as total number of self- reported risk factors. Health education after HRAs does not have a proven impact on fruit and vegetable intake, body composition, or overall fitness. (This may be because it is hard to show statistical significance for small changes that may be important to health at the individual level, or because the measured interventions were not well executed, or because they do not in fact work.)

65SETTING TARGETS FIGURE 3.5 TASK FORCE ON COMMUNITY PREVENTIVE SERVICES RECOMMENDATIONS AND FINDINGS INTERVENTIONS TO PROMOTE SEASONAL INFLUENZA VACCINATIONS AMONG NON-HEALTH CARE WORKERS Onsite, Reduced Cost, Actively Promoted Vaccinations Recommended 2008 Actively Promoted, Offsite Vaccinations Insufficient Evidence 2008 ASSESSMENT OF HEALTH RISKS WITH FEEDBACK (AHRF) TO CHANGE EMPLOYEES’ HEALTH AHRF Used Alone Insufficient Evidence 2006 AHRF Plus Health Education with or without Other Interven- tions Recommended 2007 PREVENTING CHRONIC DISEASE Skin Cancer Prevention: Education and Policy in Outdoor Occupational Settings Insufficient Evidence 2002 Diabetes Prevention and Control: Self-Management Educa- tion at the Worksite Insufficient Evidence 2000 Obesity Prevention: Worksite Programs to Control Overweight and Obesity Recommended 2007 PROMOTING PHYSICAL ACTIVITY Point-of-Decision Prompts to Encourage Use of Stairs Recommended 2005 Creation of or Enhanced Access to Places for Physical Activity Combined with Informational Outreach Activities Recommended 2001 Smoke-Free Policies to Reduce Tobacco Use Among Workers Recommended 2005 INCENTIVES AND COMPETITIONS TO INCREASE SMOKING CESSATION Incentives and Competitions when Used Alone Insufficient Evidence 2005 Incentives and Competitions when Combined with Additional Interventions Recommended 2005 Source: www.thecommunityguide.org/worksite/index.html, accessed May 6, 2013

66 BEST PRACTICE The program planning and content addresses transit-specific risks, exposures, and conditions. Transit-Specific Programming There are many excellent health promotion packages available from local or state health departments and nonprofit health groups, and WHPP program managers may find it efficient to adopt generic health information and activities. But best-practice agencies describe how their success depends on using content and activities that address the work realities, schedule demands, shifts, and preferences of transit workers. This means recognizing specifically how operators in the organization are affected. It requires understanding the overlap of contributing individual and work factors. The challenge lies in selecting approaches that are feasible and effective for the work setting. Target areas and plan activities that are relevant to transit workers: Many operator health issues such as diabetes and hypertension are also found across occupations. However, just as the transit working environment can cause or aggravate common health problems, it can also make it harder set up and run an effective WHPP program that reaches every one and achieves health targets. Tailor the program to the transit workplace and the specific conditions at your agency. Figure 3.6a-g lists overall goals to support transit worker health, the objectives that can be set to achieve those goals, and the approaches that have been used by F-17 survey respondents and others active in WHPP, supported by best-practice examples.

67SETTING TARGETS Health Protection and Promotion Targets and Transit-relevant Practices FIGURE 3.6A Goal: To help diagnosis, treat, and manage health problems Objective Approach Best-Practice Examples Help workers identify health problems early Health risk assessments and supportive follow-up Health professional consults Screening HRA with follow-up from health system—may be coordinated by health plan Schedule a nurse at locations monthly to answer questions confidentially Improve retention and availability CDL concerns (high blood pressure, diabetes, sleep apnea) Arrange with health plan to provide full coverage and waive copays for CDL-related health issues Campaign of CDL-supportive health promotion activities and rewards participants who requalify Improve treatment Educate physicians about how work affects wellness and health decisions Work with health plans to identify operator health issues and share with care providers Hold meetings to discuss treatment implications of diuretics with plan physicians Enhance access to care Screenings and care provided on paid time or at the workplace New York State law requiring time off for mammograms and prostrate screening publicized by employer Mobile MD allows operators to schedule physician visits Arrange for a mobile dentist at locations Prevent infectious diseases Decrease illness Decrease transmission at work Flu vaccine provided at work Accommodating sick leave policy does not penalize ill workers or encourage coming to work ill (Department of Homeland Security recommendation)

68 FIGURE 3.6B Goal: To improve safety and health at work and at home Objective Approach Best-Practice Examples Vehicle safety Safe driving Investigate red light run-throughs and other infractions as indicator of schedule problem Left hand turn training Driver safety training and refreshers discuss car as well as bus safety Winter driving program Noise and hearing Screening, diagnosis, and treatment Screen at health fairs and special outreach programs with vendors, for employees and family members Training and information Work and home exposures are addressed in training Hearing protection provided for use at home Comprehensive hearing protection program Screening, follow-up and protection provided for all workers exposed at or above 85 dB Reduce noise at work Improve maintenance practices to limit bus noise Include internal and external noise specification in bus design and procurement Shield operators and others from noisy maintenance practices Chemical exposure Eliminate or reduce toxic chemical exposure Training on material safety data sheets and labels Recycling and waste disposal programs collect home waste Worksite green cleaning program Mental Health Improve mental health, treat disease, and accommodate workers Canadian workplace standard covers comprehensive approach to integrate prevention, diagnosis, treatment Substance use Eliminate illegal drug use WHPP program supports and promotes Union Assistance Program and Employee Assistance Program Eliminate tobacco use (smoking, snuff, and chew) No smoking policy applies to workplace and events Tobacco cessation support programs, including patches Tobacco cessation incentives Referral to health plan, community groups, or health department for tobacco cessation support Promote safe alcohol use “Driving Buzzed Campaign” around holidays and Super Bowl reminds drivers how a little alcohol can have a large impact No alcohol at agency or union-sponsored events

69SETTING TARGETS FIGURE 3.6C Goal: To improve healthy food access and choice Objective Approach Best-Practice Examples Nutrition education Illustrate relevant healthy food choices Explain the impact of food choice on health Provide information about food timing and insulin response/discourage night-time eating Develop nutrition programs for transit workers Hold nutritional workshops that focus on cooking in a culturally relevant way Nutrition coach available to respond to questions Recipes and healthy food promotion in newsletters Improve food access at locations Provide and subsidize healthy food choices in vending machines, cafeterias Subsidize healthy food in machines and cafeteria Help operators carry healthy food Make it easier to carry healthy food Provide healthy bag lunch options in cafeteria in early morning so operators can carry them on route In bus-cab design process, provide space to store food and other personal items (discussed in the development of the European “Recommendation for a code of practice of driver’s cabin in line service buses”) Improve food access on routes Identify healthy food outlets (stores, restaurants, and trucks) Partner with outlets to develop healthy food options that are convenient for operators Arrange with food outlets to make operators priority customers Researcher June Fisher MD recommends a celebrity chef campaign with trucks and restaurants Support healthy food choice Schedule group meetings to support food choice at times and locations operators can meet Popular weight loss program geared toward the work environment (success reported mainly with female office workers, as operators found it hard to attend group meetings) Popular weight loss program online and geared toward men provides a helpful perspective Nutrition program that lists convenient but healthy and appetizing choices Nutrition program adapted for truck drivers Support employees who have food-related health problems Provided one-on-one nutrition coaching— varied hours or by phone Provide health care providers with information about food access considerations for operators, including night eating Wellness trainer certified to provide general nutrition coaching Group health plans provide nutrition counseling by phone for people with diabetes Educate workers with reflux disorder to talk to their physicians about transit work demands

70 FIGURE 3.6D Goal: Increase physical activity Objective Approach Best-Practice Examples Improve individual exercise opportunity Make exercise opportunities available for all work schedules Bicycle loan program Hula-hoops and jump ropes onsite Exercise DVDs and a player are freely available so people can fit their exercise in Identify safe and interesting exercise and walking circuits at the workplace and stopover areas Encourage group activity Provide access to classes, gym, and coaches onsite and within the work schedule Gym with trainer 4 days/week at each base 24-hour access to gym Popular exercise classes are provided by a motivated champion Walking clubs are run by operators to match schedules, swing shifts, etc. Make exercise part of the regular day Identify and take natural opportunities—stairs, along the route, house, or yard Stair access and stair competition (but many transit buildings are not multilevel, and security concerns can block stair access) 10,000 steps campaigns Exercise while working Seated exercises for upper body and cardiovascular fitness Resistance band exercises have been developed for use on the road by truck drivers Increase resilience and recovery Provide opportunities for stretching and improved circulation Operator stretch and exercise handouts and palm card Yoga classes Transit safety manual includes stretches and exercises using the bus Using the built and outdoor environment Identify and plan outdoor exercise External example: 101 things you can do on a park bench www.youtube.com/watch?v=tNBUWXQuCfI Cable car operators developed a set of exercises to do while waiting for a turnaround

71SETTING TARGETS FIGURE 3.6E Goal: Improve ergonomics and reduce musculoskeletal disorders Objective Approach Best-Practice Examples Improve work environment Driver’s seat and controls Vibration Safety team involved in pedal and wheelchair seats redesign Wellness, operations, and maintenance redesigned control toggle based on tendinitis cases. Operators and ergonomists worked together to develop improved seat design A peer assessor observed operators while they drove, and provided support and input about adjusting equipment and working more comfortably Workstation assessment of operators with MSDs or concerns by trained ergonomist; shared with others and used in training Improve work practices Assess and improve how tasks are done Signs, mirrors, windows Wheelchairs Maintenance An ergonomist evaluated work processes, and used ergonomic assessment to produce manual of good practices for operator tasks. Individual operators can request input and ergonomics assessments FIGURE 3.6F Goal: Prevent and manage fatigue Objective Approach Best-Practice Examples Provide education Understanding circadian rhythms and the impact on health Provide training on biorhythms as part of OSH program Improve work organization Designing schedules that promote health and rest Operator schedules allow 10 hrs. between shifts Work environment Quiet rooms Quiet rooms provided for workers on split shifts Reduce work-life conflict Accommodating the life cycle Young people Parenting Aging Illness Dependent care funds and policies to help parents of young children Personal calls are allowed at school let out times so parents can check in with their children Flexible leave time use to cover family need

72 FIGURE 3.6G Goal: Eliminate or reduce the impact of hazardous and stressful working conditions Objective Approach Best-Practice Examples Develop coping skills Public work Passenger interaction Screening and recruitment alert applicant to intense public contact Classes on public interaction, including “Reality training” developed to help operators prepare for customer conflict situations Create contact points for WHPP Provide access despite solitary work Telephone health consults and coaching provided by phone in addition to work locations to enhance use by mobile workforce Schedule routes to reduce stress Identify and correct problem schedules Informally, schedulers at various agencies reported including restroom access time and looking at routes that operators bid out of to adjust schedules Eliminate stressors Restroom access Establish policy to assure access to convenient, clean, safe restrooms Limit trauma Policies that protect workers from trauma after an accident or assault Comprehensive workplace violence program includes treatment and support for operators involved in accidents or assaults Find and eliminate hazards Proactive safety plan Confidential near-miss reporting system Inspections to include road hazards as well as vehicle safety and onsite Be realistic about the results you expect: When selecting the components and activities to make up your program, you may find success with methods that have not been proven scientifically. Still it is best to choose activities that will reasonably achieve your goals. For example, a race or walk for a cure is not likely to lead to weight loss on its own, and does not promote individual health. These activities can increase workplace morale and health consciousness. They may set an expectation for group exercise and improve the public image of the agency. It also makes sense not to expect too much of any one activity. For example, it is very difficult to maintain weight loss. A short-term “Biggest Loser” competition may attract participation, and even lead to a measurable loss of pounds. But the losers and others will need ongoing support and you should keep measuring to make sure it did what you planned. You can use the Planning Worksheet from the Planning, Evaluation, and ROI Template to document and track your program components, as illustrated in Figure 3.7.

73SETTING TARGETS FIGURE 3.7 MATCHING ACTIVITIES TO GOALS AND OBJECTIVES: AN EXAMPLE USING PHYSICAL ACTIVITY Goal: To increase activity among bus operators Sample Description Timeframe Measurable Objective 1 50% of operators exercise one or more times a week Jan-Dec Measurable Objective 2 25% of operators participate in work-based exercise Jan-Dec Planning Locations Activity 1 Identify safe, attractive walking area around each base Jan-Feb Activity 2 Contract outside health center for family pass Jan Activity 3 Provide hoops, bands, and weights for on-base activity September Programming Participation Activity 1 Weekly walking group April-Oct Activity 2 Family exercise passes Jan-Dec Activity 3 Lunchtime exercise class Nov-Mar Summary According to the Senior Medical Officer of NIOSH’s Total Worker Health™: It is not enough for all of our health efforts in the workplace to be focused only on individual behavior change programs. These are expensive, time-consuming, and often have limited success. We must work to change the work environment and the culture of our workplaces. Health- enhancing policies, built environments, and social supports make real health progress possible and more sustainable. Collaboration between labor and management in a participatory fashion in program design and execution is equally critical. The transit-specific WHPP program sets targets based on the measured health need, on the resources available, and on what participants find important and effective. Assessing the range of contributors to transit health problems means looking at individual, organizational, and workplace factors. The next chapter covers how to construct an effective program using these building blocks.

74 TOOLS + RESOURCES Driver Health Spotlight on Sleep Apnea. The Federal Motor Carrier Safety Administration (FMCSA) provides guidance on sleep apnea for drivers, including the CDL concerns. www.fmcsa.dot.gov/ safety-security/sleep-apnea/sleep-apnea.aspx FMCSA Medical Programs. This webpage maintains up-to- date links and information on CDL-related health issues. www.fmcsa.dot.gov/rules-regulations/topics/medical/ medical.htm Driving Healthy is a website with information and resources produced for commercial truck drivers, also relevant for transit workers. www.drivinghealthy.org/ Mental Health Psychological Health and Safety: An Action Guide for Employers. Provides a practical application approach to the Canadian standard on mental health in the workplace. www. healthyworkplaces.info/wp-content/uploads/2012/10/ Workforce_Employers_Guide_ENG.pdf Chapter Background Brown, T. (2012). Bus Operator Restroom Use, Transportation Learning Center. www.transportcenter.org/images/uploads/ publications/Bus_Operator_Restroom_Use_(interac tive)_1.27_.pdf BNQ-CSA Group Technical Committee on Psychological Health and Safety in the Workplace (2013) CAN/CSA-Z1003- 13/BNQ 9700-803/2013 - Psychological health and safety in the workplace—Prevention, promotion, and guidance to staged implementation. Alberta. Chosewood, Casey (2013). "An Industrial Hygienist’s Guide to Total Worker Health™." in AIHce2013: Montreal. Department of Homeland Security (2008). Pandemic Influen- za Preparedness, Response, And Recovery: Guide for Critical Infrastructure and Key Resources, Mass Transit Sector Annex www.dot.gov/sites/dot.dev/files/docs/OIS_MASSTRANSIT_ FLU.pdf, last updated 3.24.08, accessed 5.30.13. European Bus System of the Future, Recommendation for a code of practice of driver’s cabin in line service buses. Report D2.2.4 – Appendix D, International Association of Public Transport. 2011-10-24 Shi, Y., L. E. Sears, et al. (2013). “The Association Between Modifiable Well-Being Risks and Productivity: A Longitudinal Study in Pooled Employer Sample.” Journal of Occupational & Environmental Medicine 55(4): 353-364. Sorensen, G., A. Stoddard, et al. (2010). “Tobacco use cessa- tion and weight management among motor freight workers: results of the gear up for health study.” Cancer Causes Control 21(12): 2113-2122. Task Force on Community Preventive Services (2010). “Recommendations for Worksite-Based Interventions to Improve Workers’ Health.” Am J Prev Med 38(25): S232-236.

Chapter Implementing and Integrating: Balanced Workplace Health Protection and Promotion CHAPTER MAP• AN INCLUSIVE RANGE The WHPP program offers varied activities and resources. • Set up activities to engage the range of needs and interests of the workforce. • Organize team and individual challenges. • Provide access to exercise facilities and coaches. • Integrate health risk assessments and other individual activities with the overall program. • Understand what occupational safety and health (OSH) and other issues are important. • Involve families. TRANSIT-SPECIFIC IMPLEMENTATION The implementation structure is adapted to suit the mobile workforce, multiple base locations, and varied schedules including evening, night, early morning, and split shifts. • Identify convenient access times. • Plan activities, events, and classes to accommodate schedules, including events for early and late shifts. • Provide information and training on paid time. • Identify resources that are shift-specific and even along routes, to encourage wider participation. • Create operator-friendly points of contact for training, activities, and reporting. • Protect workers’ health information. EFFECTIVE COMMUNICATIONS Set up a strategic, comprehensive, and integrated communications plan with multiple communications pieces and delivery channels that are tailored to the transit population. • Keep the whole organization informed. • Assess the impact of the communication modes you use. • Recognize the value and limitations of electronic communications. • Provide online education and reporting systems that are accessible outside of work. • Facilitate safe and confidential use of computer stations. • Engage recipients with written materials. • Keep leadership informed about program progress and impact. • Establish two-way communication. 75IMPLEMENTING AND INTEGRATING

76 I CHAPTER MAP (continued) TRAINING SUPPORTS THE PROGRAM Training is designed to promote the program goals, not just deliver information, and is integrated into other agency training. • Plan initial training to cover the program orientation, access, and concepts as the WHPP program is rolled out. • Develop and carry out topical training events relevant to operators and supported by other program activities. • Schedule training at times and places accessible to operators. • Make refresher training available to maintain involvement and address questions. EQUITABLE INCENTIVES The organization utilizes equitable, nondiscriminatory incentives that encourage active involvement and a healthy workplace culture. • Aim incentives at desirable and feasible targets. • Reward positive steps rather than punishing current health status or health problems. • Analyze the incentives for the effect of schedule, family demands, and other potential inequities, and take work challenges for bus operators into account. • Negotiate incentives for group premium cost reductions and other insurance-related incentives. • Award ideas for best practice not just individual progress. • Consider alternative reward structures. mplementing and integrating an effective transit workplace health protection and promotion (WHPP) program uses assessments of organization needs and resources, the environmental conditions, and employee health and safety needs to plan program activities including: • a variety of approaches, • targeted activities based on the population’s health needs, • schedules that allow for maximum participation, and • transit-specific activities designed to encourage operator participation. You will also need to make use of or develop an effective communica- tion system to disseminate information to the workforce efficiently and make sure that both WHPP training and other organization training support the program. Many programs include an incentive structure, which should be practical and equitable.

77IMPLEMENTING AND INTEGRATING Orange County Transportation Authority (OCTA): Organizational Support OCTA aims for transit-specific implementation of its WHPP program by addressing physical activity and health education along with work conditions: • Scheduling: recovery time built into the schedules. • Safety Policies: Workstation evaluation to determine the demands of and best methods for loading and unloading wheelchairs, promote stretching, and including micro breaks during shifts. • Vendor Selection/Bus Procurement: Evaluate bus equipment to deter- mine the strain/stresses placed on the body in order to prevent back injuries and reduce workers compensation claims. OCTA has also worked well with their vendors. They negotiate with the vending machine supplier to maintain a percentage of healthy beverages, snacks, and foods in their machines and they work with the health care provider to track aggregate employee health status and to target behaviors that affect health. The program offers a point-based incentive system to encourage healthy behavior, learning, and fitness activity via a web-based portal. Employees record daily physical activity and education to win health-related prizes such as hand weights or sports clothes. There are four fitness centers, three with part-time exercise specialists who also provide health indicator measurements, coaching, and consultation. Other activities include quarterly health workshops for operators and health awareness/behavior change programs such as weight challenges, including a holiday “Maintain Don’t Gain” program. OCTA negotiates health club membership fee reductions and other health benefits. Some employees participate in competitive races outside the agency. The OCTA wellness program and Health, Safety & Environmental Compliance program plan to continue to contribute to the development of a transit-specific culture of health at OCTA that can bring workers together.

78 BEST PRACTICE The WHPP program offers varied activities and resources. An Inclusive Range A successful program provides a wide enough variety of activities to interest the range of people in the organization, with differing health needs and varied ability and interests. Intervention strategies should allow employees in all shifts and schedules to participate. According to a Canadian assessment of WHPP programs, larger organizations were more successful in promoting health probably because they were able to support a wider variety of interventions and services [The Health Communication Unit (THCU), 2004]. F-17 survey participants made it very clear that how content and servic- es are delivered can have a big effect on how well they are received, and on their impact. For example, exercise trainers and champions often are healthier and more fit than the people they want to recruit. While this can be an inspiration, people can also feel that the bar is set too high, or that the trainer cannot understand the barriers they face. In F-17 interviews it was not uncommon for WHPP exercise champions to focus on the willpower of the operators who did not participate. Research has found that the organizational focus on a specialized or elite activity can leave some people worse off than before, even though participants do better (Vaag, 2013). For many people, a less competitive model of fitness enhancement makes them feel more welcome. Especially for shift-challenged and stressed bus operators, activities, advice, and services conflict with the need to go home, to relax, to be with the family. Activities have to be appealing as well as challenging. Designing a program that suits the organization’s unique needs and resources can mean: • Developing culturally relevant menus and understanding variations in how people buy, cook, and enjoy food to support healthy food choice. • Taking advantage of seasonal changes and regional health culture differences. • Subsidizing family access to gyms to reduce the competing claims of fitness and family life. Set up activities to engage the range of needs and interests of the workforce: Offer different levels of exercise classes, competitions and incentive programs, discussion groups, informational classes, and a variety of other activities to appeal to the participating population. Solicit employee input through surveys, during meetings, and by other methods to ensure that you are addressing their needs.

79IMPLEMENTING AND INTEGRATING Include workplace inspections that look at occupational health and safety as well as the health-promoting environment. Figure 4.1 lays out many of the activities reported by US and Canadian transit agencies in the F-17 study, and by other key informants. Organize team and individual challenges: Worksite competitions that provide incentives for individuals are very popular. However, they may tend to recruit people who are already most likely to succeed. This could leave an important part of the workforce behind. It makes sense to plan team challenges that promote cooperation, as well as individual challenges that are easier for the solo bus operator to achieve. Provide access to exercise facilities and coaches: Exercise rooms and coaches were among the most popular of the interventions reported in transit work locations. If the budget and space allow, invest in an onsite fitness facility that provides a fitness coach or trainer to help individuals obtain their fitness goals. Employees can engage in fitness activities during their lunch break or around their work schedule without having to travel to a separate location. It also gives them the benefit of a personal trainer without a direct cost. While the more fit tend to take greater advantage of the resources, the site, trainer, and related classes can be leveraged to involve those less likely to exercise. In addition to onsite exercise facilities, arrange access at a local gym for employees and their families. If the agency cannot cover the cost of the entire membership, at a minimum negotiate a discounted rate. Family discounts should make exercising more attractive. One agency held a walking at work program for teams to compete in a walking challenge. The 300 participants all received a T-shirt to promote involvement and group morale. PROGRAMS THAT SUIT THE ORGANIZATION At one large agency, depot ambassadors are encouraged to organize activities that match the location’s interest AND their own skills. An ambassador who was a certified popular exercise instructor ran successful classes. Another with business and cooking skills prepared meals for sale and used the proceeds to purchase exercise videos and other equipment for the depot. Integrate health risk assessments and other individual activities with the overall program: Health risk assessments (HRAs), which help people identify their own level of risks and health care needs, can encourage participation into the program activities, and they can tell you what resources may be needed. Confidential HRAs followed by health counseling have been shown to improve health outcomes. Screening and testing are not considered effective as stand-alone activities. F-17 respondents typically said that HRA participation was much greater in management and office staff than in operations. Transit workers and their representatives mistrusted HRAs that were required for receiving full health benefits, and wondered if screening results could be used against employees. Management’s motivation was sometimes questioned in agencies where HRAs were not clearly introduced and negotiated as a fair and sensible way to improve care and reduce costs. Confidentiality and voluntary participation are keys to success. In addition, screenings may not find all the serious cases of illness – for example, blood pressure A small agency set up a financial wellness library, mandatory trainings from a retirement plan specialist, one-on-one consultations with a financial planner, and mandatory training on personal finance management. They based the project on a financial wellness assessment (like an HRA) and saw a decrease in workers taking loans against pensions and an increase in saving plans. In one medium-sized agency in an urban area, a fitness consul- tant held weekly workshops with operators, mechanics, and administrative employees, on topics such as diabetes, back pain, or weight management.

80 FIGURE 4.1 F-17 INDUSTRY PRACTICES Health target Activity Disease management and prevention • “Ask A Nurse”: blood pressure checks, stroke risk assessment, and health questions. • “Tri-Fit Summer Tour” ( mobile biometric testing and incentives) • Mobile physician’s hours • Paid time for cancer screening Ergonomics/MSDs • Annual required training: body mechanics, stretching/exercise, and healthy behaviors • Evaluation of bus equipment • Evaluations to determine body mechanics for loading and unloading wheelchairs • Onsite pain management vendor treatment • Chair massages • Onsite acupuncturist • Chiropractor training • Counseling from kinesiology intern Financial health • Financial health evening classes for employees and spouses • One-on-one consultations with financial planner • Financial wellness library • Financial wellness vendors (banks) Fatigue and sleep • Operator hours of service scheduled to allow 10 hours between each shift and not more than 16 hours on staff or 14 hours on the road. • Training on circadian rhythms and sleep disruption. • Covering costs of sleep studies and paid time for diagnostic visits • Traveling Fatigue Awareness program • Quiet rooms for rest Fitness/exercise • Fitness training at no charge to employee • Bike loan program • Group participation in diabetes “Bike for the Cure” • Classes: stretching, core strengthening, boot camp activities, aerobics, popular exercise program, yoga • Onsite fitness facility at locations • Subsidized access to fitness facilities • Health Fitness Specialist or personal trainer in fitness center • Intramural sport activities • Physical therapist training on ergonomics • Stretching and micro breaks during shift Health and wellness • Bathroom access policy • Contracts with businesses to allow operators to use their restrooms • Coaching sessions with wellness provider • Education on healthy lifestyle in light of shift work • Health fairs • Online health education and quizzes Infectious disease control • Flu shots • Hepatitis B vaccine • Provide alcohol-based hand rubs and virocidal wipes

81IMPLEMENTING AND INTEGRATING Health target Activity Medical self-care and medication management • Blood donation & typing • Health coach • Holistic wellness vendors • Registered nurse on site • Wellness consultant lunch and learns • Wellness mobile: biometric screening, health risk assessments, and telephone follow-up Mental health • Counseling service for employees and family members • Onsite EAP training • Peer support for mental health following accidents or assaults Nutrition • 30 days nutrition training • Fresh fruit and vegetable market • Organic food display at health fairs • Healthy cafeteria and vending machine programs • Onsite nutritionist for consults and advice • Subsidized access to healthier food • Healthy cooking demonstrations • Healthy menu coupon program Responsible alcohol use • Drunk and buzzed driving campaigns • No-alcohol policy at agency events Safety • Reduce distracted driving campaign • Monthly injury prevention and disease management presentations • Onsite CPR Training • Walk-around representatives identify and help resolve safety and health hazards • Recovery time built into the schedules • Slip and fall campaign • Safety training enhanced to emphasize health and wellness, and shift work • Fatigue Smoking/tobacco product cessation • No smoking policy • Tobacco cessation class for employees and family Stress management • Incentive contests for stress management • Stress management seminars • Stress screening from insurance provider Threat assessment and management/violence prevention • Safety rules on bus operator/customer interactions to enhance operator safety • Fare policies to eliminate conflicts • Workplace Violence Policy • Comprehensive workplace assault program • Training on operator-customer conflict minimization • Bus cab barriers Weight management • Weight loss challenges • Weight loss programs (onsite, offsite, and online)

82 ACCESS TO FITNESS One agency has two onsite 24 hour fitness centers with free personal training and health assessments Another has a trainer available at the fitness center during lunch hours four days a week, providing individual assessment and training plans along with nutritional advice. The trainer provides help to employees to achieve a safe blood pressure before participating in demand- ing activities. A small southern agency pays for employees to go to a gym facility and to have a one-time consultation with a nutritionist to set up a healthy diet and exercise plan. can be lower in the doctor’s office or at lunch, and higher when driving. Some researchers recommend blood pressure measurement over the work day to find this “masked hypertension.” (Landsbergis, 2013) Understand what occupational safety and health (OSH) and other issues are important: Wellness initiatives can conflict with or overlap other conditions of work that may be covered by the bargaining agreement. To be successful, the WHPP program must address the complex set of issues related to health concerns. This is discussed in detail in Chapter 3, Setting Targets. At a minimum, the organization should document a procedure for addressing overlapping issues in the OSH and WHPP programs. If there is no WHPP committee, include health issues in OSH meetings and discussions. Ensure that whether issues are addressed in the OSH or WHPP committee (or both), resolutions are communicated to workers and management. Involve families: Family involvement is important, but only one-third of transit agencies surveyed open some program activities to families. Lack of family participation can have a direct impact on health plan costs. One large agency was informed by its service provider that although the WHPP program has had a measurable impact on worker health, family health costs—and especially childhood obesity—continue to rise, making the family a critical unit in health promotion and cost containment. Family involvement also recruits the partner and other household members to support the worker in health initiatives. It can encourage participation by not separating the worker from the family in leisure time. “Our program includes family member and community participation. We recognize that health issues often begin or are exacerbated at home.” Agency WHPP program manager Figure 4.2 lists how F-17 survey participants involved family members in their WHPP programs. Some were limited to health plan activities, a few of those were required or incentivized. Other programs made health resources available, and a few planned special activities to bring families together.

83IMPLEMENTING AND INTEGRATING FIGURE 4.2 INVOLVING FAMILY MEMBERS: TRANSIT EXAMPLES UTU-LACMTA’s wellness program has initiated a pilot six-week family exercise plan. Employees who commit to exercising weekly receive a basket full of exercise aids and encouragements, paid for by the group health vendor: basketballs and soccer balls, fitness bands, MP3 speakers to allow the family to exercise to the same music, a jump rope that counts calories, a paddle ball that doubles as a chess and backgammon board, sticky mitts and cloth balls to let the little ones join in. The employee reports how many family members participate, how long they exercise, what activities they do, and estimates the calories burned. The plan is to add access to health clubs and other facilities as the program is rolled out. ACTIVITIES AND RESOURCES OPEN TO ALL FAMILY MEMBERS Smoking cessation classes. Access to EAP including psychologists, social workers, legal advice, and financial advisors. Recreation programs. Health and wellness communication material and resources. Weight loss programs. Invited to participate in all wellness activities. e.g., sports activities, health fair, classes, EAP, etc. Health risk assessments, work with a health coach, and access online education. Eligibility for wellness benefits such as gym membership and training programs. Participation in events. Invited to wellness week in the fall with vendors at work. Family leisure passes, fun runs. OTHER EXAMPLES Premium savings incentive for family participation in the wellness program. Spouses participate in all wellness actives and use onsite fit factories. Spouse/domestic partner covered by insurance is required to complete annual assessment. Transit-Specific Implementation Running an effective WHPP program for bus operators is especially diffi- cult because they are a mobile workforce and their schedules are out of phase with other employees. Typically operators work alone, on varied schedules, from various locations, with severe time constraints. This can make it difficult to schedule classes and activities, or to engage their collaboration in program development and implementation. You will need to address this barrier in the planning stage of the WHPP program, and continue to assess it over time. Identify convenient access times: When are operators available? They may be more likely to participate in activities offered during work. Swing periods can provide access and some people are happy to use this time BEST PRACTICE The implementation structure is adapted to suit the mobile workforce, multiple base locations, and varied schedules including evening, night, early morning, and split shifts.

84 A popular weight loss program geared toward the work e n v i r o n m e n t was strongly supported in many transit workplaces. But they all reported that participation was typically limited to office staff and downtown locations. Bus operators found it difficult to reap the benefits of the sched- uled meetings, and missed the support from coworkers at mealtimes that makes these programs effective. for exercise and other wellness activities. And although lunch and learns are a good way to provide training, operator lunch starts and end times vary based on run schedules and traffic. In addition, exercise classes at lunch can interfere with nutrition and needed relaxation. Be aware of schedule barriers that might hinder participation and involve the WHPP planning team, trainers, supervisors, schedulers, and others to help resolve the conflicts. Attractions such as food or health fairs with prizes and samples are a good way to build participation, especially if they are scheduled when people gather with some time to spare, such as route picks. Plan activities, events, and classes to accommodate schedules, including events for early and late shifts: Provide classes at times people can participate. This may include having a class each shift, staggering lunch and learns to span the range of lunch times, and holding events at the work locations rather than a central or downtown facility. Successful programs have arranged for vaccinations, doctor visits, and dental care in mobile vans, so transit workers can access these services around their trip schedules. Provide information and training on paid time: Required safety and skills training is usually provided on paid time, but wellness activities may be pushed off to free slots, lunch, or after work. Paid time for health and wellness activities shows the level of commitment of the organization. Identify resources that are shift-specific and even along routes, to encourage wider participation: WHPP resources and activities require adjustment to the physical environment. You can encourage physical activity around the depot by finding places where exercise is safe and inviting, either outside or at facilities that operators can get to easily. Access to healthy food, restrooms, and places to stretch may involve negotiation with local companies along the route. Exercise professionals can develop location-specific exercise routines, including how to stretch or exercise on the road. Your location may have seasonal opportunities or regional restrictions like weather. You can ask local exercise and health promotion groups about who in your area could help you plan safe and healthy location exercises. Create operator-friendly points of contact for training, activities, and reporting: Make your program accessible to the workforce. Do operators have time to check in on computers at the work locations? Do they have access at home? Some are more

85IMPLEMENTING AND INTEGRATING comfortable with hard copy information and reporting, others prefer electronic means. Despite the advantages, technology can be a barrier to effective program implementation. For example, not all transit employees have easy access to computers or use them regularly. At several agencies in the F-17 study, management reported that all workers were accessible by email, while the union representatives felt that many members did not get email. Important information may need to be communicated on paper and orally as well as electronically. Protect workers’ health information: Confidentiality was a major concern of workers and their unions in the F-17 survey. This is partly because the commercial driver’s license procedure means that an operator’s job depends on maintaining a high level of health and compliance compared to workers in other industries. Posting, explaining, and observing confidentiality regulations can help. Confidentiality can be improved in the design of health and wellness activities by using offsite testing for HRAs, and providing private areas for consulting with health coaches or nurses. Effective Communications A comprehensive communication plan is vital to the success of the WHPP program. This plan ensures that program and activity information is disseminated to all levels within the organization clearly and efficient- ly. An effective communication plan will increase transit workers’ knowl- edge and awareness of health protection and promotion issues, prompt individual action to improve health, show the benefits of the program, increase support for the program, strengthen organizational relation- ships, provide feedback to the WHPP program team, and increase employee participation. Keep the whole organization informed: Publicize WHPP program activities, events, and opportunities. This could include memos, newsletters, email, bulletin boards (digital or stationary), mailings, brochures, or word of mouth, depending on the stakeholder. Sharing this beyond your target participants can enhance support and respect for the program. Assess the impact of communication modes you use: Check that your communication methods are reaching throughout the organization. The nature of operator work means that some methods of communica- tion—email blasts, for example—may not reach them all. Identify gaps and make sure there are alternative methods, such as paycheck inserts and Union newsletters and bulletin boards. THE HEALTH ENVIRON- MENT EXTENDS ALONG THE ROUTE An agency contracts with businesses along bus routes to allow operators to use the restrooms along the route. Operators are taught to use exercise bands with a set of exercises that can be done on the road, as well as pretrip stretches. One employer reports building recovery time into the schedules and promotes a stretching series suited to bus operators and micro breaks during shifts. A health promotion consultant in New York City evaluated local parks for exercise poten- tial, developed a DVD, and leads weekly walking and exercise groups. Although this was a city-wide project, similar professionals could be contract- ed by the transit agency for their specific needs. BEST PRACTICE Set up a strategic, comprehensive, and integrated communications plan with multiple communications pieces and delivery channels that are tailored to the transit population.

86 EXAMPLES OF ELECTRONIC OUTREACH One agency runs its point- based incentive program to encourage healthy behavior, learning, and fitness activity via a web-based portal. In an online wellness program tracker, each participant provides data about five broad categories: physical fitness, weight management, stress management, tobacco cessation, and related wellness areas. One agency made it part of their five-year strategic plan to report employee environment key performance indices to the board labor committee quarterly, including measures of employee turnover, grievance rates, absenteeism, and employee injury rates. Reports on the progress and impact of the worksite wellness program including the estimated ROI are reviewed by the Direc- tor of Finance on an annual basis. Recognize the value and limitations of electronic communications: Find out if communications can be understood by all different cultures, ethnicities, and languages within the organization. You might want to do outreach through social networking sites such as Twitter and Facebook, although care must be taken to ensure confidentiality in these public channels. Communication should make it clear how employees can receive additional information or help. Don’t neglect to update the electronic sources, as these may become tired or even incorrect. Provide online education and reporting systems that are accessible out of work: Transit operators cannot always get to a computer during work time. Any online systems should be available for access 24/7, and from home. Employees may not be comfortable providing personal information at work. Enlist the help of the IT department to update and keep the online system current and secure. Facilitate safe and confidential use of computer stations: If the organization can provide access at work, make sure that privacy is respected. To take advantage of downtime for health purposes, some agencies have computer cubicles or banks. These can also allow access to personnel information and benefits interfaces. Privacy and confidence in the interface are especially important when health information is entered at the workplace. Engage recipients with written materials: Don’t underestimate the value of written communication, even in today’s technological climate. Design written information at the right reading level and make it inter- esting. Make sure information is also distributed in the languages the workforce speaks at home. Keep leadership informed about program progress and impact: To develop and maintain support, provide leadership with reports on program activities that are being implemented, upcoming activities, participation numbers, and budget use and needs. Make your case for success, barriers, or needed resources. Include stories and details of positive impact on health and operations to demonstrate the value that the program is bringing to the organization. Establish two-way communication: Design a way for employees to provide their input and suggestions about the WHPP program (suggestion boxes, comment forms, pre- and post-satisfaction surveys, etc.). Ensure that employees’ suggestions are acknowledged and responded to, and give appropriate feedback.

87IMPLEMENTING AND INTEGRATING Training Supports the Program Education and training underpin most WHPP activity and are key to program success. In addition to health information workshops, WHPP should be integrated into the organization’s other training practices, such as new hire orientation, safety classes, and benefits open enrollment periods. Training should be updated when the WHPP program changes. Additional training should be designed and provided to staff and commit- tee members who are supporting and implementing the program. Plan initial training to cover the program orientation, access, and concepts as the WHPP program is rolled out: Address the goals and objectives of the program in agency training and meetings. People in all levels of the organization should be aware of the program goals, program activities, and how to participate. Those responsible for facili- tating participation or tracking incentives, such as supervisors or union representatives, should be trained about their roles, and updated on changes to the program activities and program structure so that they can provide accurate information and best support the program. Develop and carry out topical training events relevant to operators and supported by other program activities: Workshops, lunchtime events, and after-hours training are among the most common WHPP activities. This training will be most effective if it answers existing questions and needs. Although generic wellness training modules are widely available and convenient, they should form only part of your health content training. And even generic training can be improved if it is adapted for the workforce’s interest and needs. For example, a discussion about sun block and skin cancer could also cover the need for some transit workers to get additional vitamin D because they spend so little time in the sun. Schedule training at times and places accessible to operators: Create training schedules that will allow maximum attendance. Schedule them when people have time and are gathering naturally, for example, during schedule picks or safety stand-down meetings. This may mean scheduling multiple training sessions around work shifts and schedules. Plan training frequently enough to maintain the program but not to become burdensome. Make refresher training available to maintain involvement and address questions: Survey participants after events to gauge satisfaction with program activities, content, and relevance and use this feedback to refresh the program activities as needed. BEST PRACTICE Training is designed to promote the program goals, not just deliver information, and is integrated into other agency training. AGENCY TRAINING CONNECTS WORK AND HEALTH One agency enhanced the safety training curriculum to emphasize health and wellness elements particularly related to shift work, work fatigue, and operator-customer conflict minimization. A midwestern agency trains new operators on the policy for using the restroom along the routes when necessary, the locations of restrooms that can be used, and updates all operators when the locations change.

88 BEST PRACTICE The organization utilizes equitable, nondiscriminatory incentives that encourage active involvement and a healthy workplace culture. Equitable Incentives Incentives for health promotion activity, reported by 70% of transit workplaces respondents, include cash prizes, health-related merchan- dise, health club memberships, reduction in health insurance premiums or copays, and recognition or time off. Figure 4.3 shows that among the F-17 survey responders, individual prizes were most common, and that very few agencies awarded time-off incentives or, surprisingly, reduced insurance premiums. HRA and counseling incentives seem to work differently with different groups of people—in research studies, men seem to respond better to cash incentives and women to non-cash rewards, for example (Terry et al., 2013). So it is important to look at who wants to participate, why they might not, and whether financial incentives, recognition, or other non-cash benefits suit the workforce. 45 44% 40% 40 35 31% 30 27% 25 20 18% 15 10 9% 5 4% 0 Individual Prizes Cash/ Gift Cards Group Rewards None Other (recognition, raffles, healthy food, inexpensive giveaways) Insurance Costs Time Off FIGURE 4.3 INCENTIVE USE REPORTED BY F-17 SURVEY RESPONDENTS WITH WHPP PROGRAMS

89IMPLEMENTING AND INTEGRATING The near-term goal is to increase participation in an effective program. An incentive structure that looks punitive or unfair can limit participation. Under the Affordable Care Act, regulations support participatory programs that are available without regard to an individual’s health status (Health and Human Services, 2013). Programs that reward specified levels of achievement must be reasonably designed, be uniformly available to all similarly situated individuals, and accommodate recommendations made at any time by an individual’s physician based on medical appropriateness. The Occupational Safety and Health Administration (OSHA) discourages health and safety incentive systems that reward low injury or illness rates because these may effectively punish workers who report problems. Incentive programs that offer rewards for active participation in the safety and health system, for example by identifying hazards or participating in injury or near-miss investigations, produce more robust and proactive safety programs, and comply with record-keeping rules (OSHA Memorandum, 2012). One approach is to reward participation, not health status or other factors relating to health condi- tions. Another is to provide positive support for activities that are already required, such as commercial driver’s license qualification. Aim incentives at desirable and feasible targets: Although the program may have a range of targets, the incentive structure should focus on a reasonable subset that can achieve individual and population health goals. Match those targets with appropriate incentives, relevant to the workforce, to support your program initiatives. Engage employees in discussions and suggestions about appropriate targets, activities, and incentives for the program. Direct reward systems (cash for achieving a health goal, participation points for prizes) probably work best when they let the participant select the activities they find appealing or important. Reward positive steps rather than punishing the current health status or health problems: Avoid making the program mandatory or creating an incentive structure that penalizes less than satisfactory participation. This can decrease participation and create resistance. Positive reinforcement sustains behavior, encouraging people to contin- ue doing the right thing on their own. With negative reinforcement people may only do the behavior when it is absolutely necessary to avoid reprimand. For example, at one F-17 survey agency, the out-of pocket health care expense was lowered if plan members completed an individual action plan and tracked their progress online. Because family members were also required to participate for the premium reduction, and because they did not trust how the data could be used against them, most operators remained in the lowest tier of the benefit A wellness program uses an online wellness tracker to enroll in the health and wellness program and to track its wellness incentive points. Points are earned for bundles of activities specified throughout the year, including scheduled workshops. Operations employees (police, maintenance, opera- tors) found it hard to get to workshops, which were typically held at lunchtime. To accommodate their complex schedules, operators and others could substitute online information and quizzes that covered the same material.

90 At one agency, the vendor agreed to lower the insurance premium when employee partici- pation goals are achieved for activities such as gym member- ship, aerobics classes, cardio workout, nutri- tionist visits, and smoking cessation support groups. As a result, the health premium for all employees has been reduced by 2% for the upcoming year. Weight Loss Uniform- Set Replacement language in one union contract provides employees who have lost a minimum of 40 pounds with a complete new uniform set. range, paying the highest premiums possible, and workers and their representatives see the WHPP program as punitive. Analyze the incentives for the effect of schedule, family demands, and other potential inequities, and take work challenges for bus operators into account: Test the potential incentives to see if they are appropriate. Ask operators if the incentive program would help them succeed in the program. Consider and accommodate concerns such as work schedules, confidentiality, and access to computers at work and home. Negotiate incentives for group premium cost reductions and other insurance-related incentives: Health care providers or insurance plans are interested in reducing their costs, and can be persuaded to lower individual contributions or the overall cost of the benefit plan. Some will adjust costs based on an experience rating, others will want to encourage HRA or participation for those with existing conditions. It is important, as discussed earlier, to review this with labor representatives to determine the best option for the working environment. The parties need to work together to define the size of the discount, the required activity to qualify, the process for qualifying, and other accommodations to be established. Award ideas for best practice not just individual progress: Don’t limit incentives to individual activities. Develop team challenge incentives. Support and reward people who develop new activities or otherwise enhance the program. Some agencies extend their vision to community wellness, and encourage group social service activities. Consider alternative reward structures: Don’t limit incentives to financial rewards. Be creative and develop incentives that will work for all levels of the organization and for all different work schedules. Get the attention of those who are most at risk. Develop incentives that will reward and encourage participation from family members as well as employees. Summary Implementation and intervention strategies for the WHPP program should involve all levels of the organization and reach across multiple realms: the overall physical environment, the organizational environ- ment, and the individual level. Employees will profit from opportunities to participate in workplace health initiatives as well as health-related programs outside of the organization. Health benefits will also result

91IMPLEMENTING AND INTEGRATING from policies to promote occupational safety and health and other factors that protect and enhance employee health. The strategies must include appropriate training and an effective communication plan to share information among all levels of the organization. Successful implementation of the program should lead to a positive return on investment for the WHPP program. TOOLS + RESOURCES Effective components Task Force on Community Preventive Services: Worksite Health Promotions Task Force Recommendations & Findings summarizes the research findings. www.thecommunityguide. org/worksite/index.html The FMCSA reviews evidence for how health affects driving safety: Reports—How Medical Conditions Impact Driving: www.fmcsa. dot.gov/rules-regulations/topics/mep/mep-reports.htm Use a variety of approaches Lamontagne, F (2002) Case Study: City of Regina’s Transfit Program. This is a case study detailing the health initiatives implemented in the Regina Transit health and wellness program. www.clbc.ca/files/CaseStudies/transfit.pdf ODSAlaska. Article on 101 Low Cost Ideas for Worksite Wellness. www.deltadentalak.com/docs/wellness/low_cost_ activites.pdf +3 Network. This is a free website that logs healthy activities for personal rewards, allows employees to enter personal competitions and send money to charitable organizations. https://www.plus3network.com/ White, M. (2010) Workplace Wellness Challenges—Fun, Effective, and Free! Corporate Wellness Magazine. This is an article that lists some workplace wellness challenge activities that employees can participate in at your organization. www. corporatewellnessmagazine.com/article/workplace-wellness- challenges.html Effective communications SWELL: WelCOA website for connecting with others involved in workplace health protection and promotion (membership required). SWELL.WELCOA.org Communication plans. www.cdc.gov/workplacehealthpro- motion/planning/communications.html Equitable incentives Department of Labor (2013). 29 CFR Part 2590 Final Rule: Incentives for Nondiscriminatory Wellness Programs in Group Health Plan, www.ofr.gov/OFRUpload/OFRDa- ta/2013-12916_PI.pdf The Wellness Council of America. Designing Wellness Incen- tives. Part 1. Absolute Advantage: The Workplace Wellness Magazine. (2005). www.welcoa.org/freeresources/index. php?category=8 Wellness Council of America. Designing Wellness Incentives. Part 2. Absolute Advantage: The Workplace Wellness Magazine. (2005). www.welcoa.org/freeresources/index. php?category=8 Chapter Background Health and Human Services (2013). “Obama administration releases final rules on employment-based wellness programs,” Press Release 5/29/2013 www.hhs.gov/news/ press/2013pres/05/20130529a.html Landsbergis, P. (2013). Personal communication. McLellan, D., E. Harden, et al. (2012). SafeWell Practice Guidelines: An Integrated Approach to Worker Health, Version 2. Boston, Harvard School of Public Health Center for Work, Health and Wellbeing. OSHA Memorandum. (2012). “Employer Safety Incentive and Disincentive Policies and Practices.” Retrieved May 28, 2013, from https://www.osha.gov/as/opa/whistleblowerme- mo.html Terry, P. E., J. Grossmeier, et al. (2013). "Analyzing best practices in employee health management: how age, sex, and program components relate to employee engagement and health outcomes." J Occup Environ Med 55(4): 378- 392. THCU. (2004). Well-Regarded Initiatives for Workplace Health & Wellness Promotion. Toronto, Centre for Health Promotion, University of Toronto.

93EVALUATING Chapter Evaluating: Return on Investment and Ongoing Improvement CHAPTER MAP• EVALUATION FRAMEWORK The organization establishes a comprehensive workplace health protection and promotion program evaluation plan. • Collecting baseline measures. • Involve stakeholders in evaluation. INTEGRATED DATA MANAGEMENT Data collection, management, and analysis are coordinated throughout the organization. • Aim for a single data system or one that allows different data sources to be linked. • Define available data and how it can be grouped. • Use data warehousing to coordinate existing databases throughout the organization with common measures. • Review data, problems, and solutions across departments. • Promote vendor data integration. PROCESS MEASURES The organization tracks costs, participation, goals met, and barriers and then uses data to improve the program. • Record quantitative and descriptive data. • Use process evaluation to make time-sensitive adjustments. IMPACT AND OUTCOME MEASURES The program documents changes in impact measures and outcome measures. • Include both short-term and long-term measures. • Document changes in impact measures such as knowledge, attitudes, behaviors, or skills in a target population. • Document changes in outcome measures, such as health status, employee morale, work environment, health care costs, absenteeism, presenteeism, injuries, and disability.

94 T CHAPTER MAP (continued) COST-BENEFIT AND RETURN ON INVESTMENT Cost savings are quantified to show how the program supports the bottom line. • Collect program financial data continuously. • Quantify the economic benefits from improvements in outcome measures. • Be realistic and simple. • Recognize the potentially extended time period for achieving a positive ROI. • Estimate the effect of the WHPP program. DATA-DRIVEN ONGOING IMPROVEMENT The organization communicates the impact of the program. • Package your evaluation data. • Communicate progress and success. • Present aggregated evaluation results to all levels of management and employees. ransit agencies need to carefully assess their WHPP inter- ventions to determine their impact and value. Evaluation tells you what works and what doesn’t, suggests what you should change, and gives you evidence to share with stakeholders. Many of the WHPP program managers and coordinators responding to the F-17 survey reported problems with systematic track- ing of program progress, impact, and outcomes. They often lack access to important information and easy-to-use and reliable tools to analyze their programs’ costs and benefits. Union leaders had even less access to information. Ideally, evaluation plans should be developed as part of the initial program planning process and integrated with routine program opera- tions. Evaluation, return on investment (ROI), and ongoing improvement activities are designed to track program delivery and participation, analyze program impact and results, and determine whether goals and objectives are being met. Evaluation identifies what has been successful and what may need improvement, and provides critical information for future decision making. How much the agency invests in WHPP programs can depend on the perceived value. Value is supported by measures of program quality (was it carried out well?), cost-effectiveness (did the benefits exceed the costs, and by how much?), and impact (did the program accom-

95 Capital Metropolitan Transportation Authority: An Example of Program Evaluation and Return on Investment In the early 2000s, Capital Metropolitan Transportation Authority (Capital Metro) was confronted with record high health care costs, especially among operators, and greatly increased absenteeism. In 2003, Capitol Metro partnered with the Austin/Travis County Health and Human Services Department to initiate a comprehensive health and wellness plan for the transit employees to promote healthier lifestyles, increase employee morale, and contain rising health care costs and absenteeism rates. During 2012, approximately 250 out of the 668 Capital Metro bus operators actively participated in the program. Initiatives of the program included: • Opening and operating two onsite 24-hour fitness centers with free personal training and health assessments, and nominal membership fees. • Cash incentives of up to $250 annually for achieving quantifiable health milestones, such as blood pressure reduction, weight loss, smoking cessation, and others. • Improved access to healthy food in the employee café and coupons for purchases of healthy food options. • Education and outreach events, such as cooking demonstrations, wellness fairs, onsite Weight Watchers meetings, and smoking cessation programs. Capital Metro is among one of the few transit agencies that reported conducting a compre- hensive ongoing cost-benefit analysis of the worksite wellness programs. A study published in 2009 found that Capital Metro’s employee health care costs were reduced dramatically as a result of this program. Capital Metro’s health care costs continued to increase each year between 2003 and 2006, but at smaller rates each succeeding year. The increases were below the national average. In 2007, when participation in the WHPP program grew dramatically, Capital Metro saw a four percent decrease in total health care costs. Similarly, rates of absenteeism among bus drivers remained stable at approximately 10 percent from 2001 through 2005. The rate declined to 8.2 percent in 2006 and 7.6 percent in 2007, for a savings of $450,000. These savings represent a return on investment of $2.43 for each dollar invested in the program. Agency documents show that the return on investment reached $3.95 and $2.88 in 2009 and 2010. EVALUATING

96 plish something important?). These dimensions interact: A program could be well executed and have an impact but be judged as not worth the cost, perhaps because the impact area was not very impor- tant to key decision makers. While planning and executing WHPP program evaluation, it is important to assess both what you did (process) and what the impact was (outcome). Useful assessment looks at short-term and long-term measures. Executives or the Board may be most interested in counting the costs and financial benefits of WHPP activities, and calculating or estimating the ROI. Others, including program managers, union leaders, and participants, may want to know how things went, how the program changed the work environment, and other more qualitative results. This chapter looks at simple tools to help the WHPP program team identify effective program approaches. WHPP program impact, along with costs and benefits, can be assessed over time to calculate annual and multi- year ROIs. The Planning, Evaluation, and ROI Template accompanying the Practitioner’s Guide provides worksheets for tracking process and outcome measures, including ongoing goals, objectives and activities tracking, health impact, and program cost tracking. It is a set of spreadsheets that guides you through setting measurable program goals. Data you record is used to automatically calculate values to show how well the WHPP program is doing. The spreadsheets produce charts and tables you can transfer to your reports. The Template is available for download along with the Practitioner’s Guide. Figure 5.1 lists examples of indicators of WHPP program success associ- ated with major program goals. These can be measured at the individual level, by job title, within a location or depot, or across the organization. The measures will be explained in further detail later in the chapter.

97 FIGURE 5.1. SAMPLE PROGRAM GOALS AND MEASURES Program Goals Type of Measures Detailed Measures Measures Increase fitness/ health Process Program Reach # eligible, # participating, # successful, # maintaining Implementation measures (# courses, meetings, targets hit) Impact Behavioral change Diet Physical activity Outcome Health measures Body mass index (BMI) CDL medical disqualifications Health claims Improve work conditions and environment Outcome Health environment Exercise facilities Food access Health culture—commitment, education Leave policies Outcome Organizational Schedules Employee involvement Morale Work-family policies: Calling children Dependent care Restroom access Outcome Occupational Vehicle & passenger safety On-the-job injuries Workers compensation claims Assault policy Locations Housekeeping and walking/working surfaces Chemicals Ergonomics Improve operations Outcome Internal operations Absenteeism/lost time Productivity/presenteeism Turnover Outcome Service provision On-time performance Customer satisfaction Reduce costs Outcome/ Benefits Health care premiums and claims costs Absenteeism costs Presenteeism costs Turnover costs Accidents and injury costs Workers’ comp costs EVALUATING

98 BEST PRACTICE The organization establishes a comprehensive workplace health protection and promotion program evaluation plan. Evaluation Framework Program evaluation is a complex, multilevel challenge. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) approach can simplify the process (King et al., 2010). RE-AIM provides a framework for consistent reporting of program impact and results, looking at five important dimensions. It was developed to assess health intervention research, and has been used to plan programs and improve success in worksite health promotion and disease prevention programs. The model defines process evaluation in terms of: Reach: participation size and range; Effectiveness: the impact of the intervention on targeted health outcomes, costs, and quality of life; Adoption: how widely the program elements are delivered; Implementation: how consistently and skillfully program elements are delivered; and Maintenance: how behavior change is maintained long term and the program is sustained over time. A link to instruments for applying the RE-AIM model can be found in the Tools and Resources section at the end of this chapter. There are self- assessment quizzes, calculations for reporting on the reach, adoption and impact of the practice, measures and checklists to help in planning and evaluation, and suggestions for visual displays for communicating evaluation results. Collecting baseline measures: It is important to measure where you start from to assess what changes have occurred. By designing the evaluation plan before implementation begins, you can establish a start- ing place and frame of reference for the WHPP program. Baseline measures can be developed from data collected during the initial assessment activities described in Chapter 1. Baseline measures show where the organization currently is on a given health problem (for example, operators with pre-diabetes), behavior (the percent of employees who use tobacco), knowledge or attitude (the percent of employees who are aware of recommended physical activity guidelines), or condition (the number of bus routes with adequate toilet access). They establish the benchmarks and targets to assess program performance against.

99EVALUATING Baseline measures can also be used to describe the current level of program activities and allow measurement of the program’s progress over time, such as the number of new physical activity classes offered to employees, the frequency of worksite health and safety inspections, or the establishment of a new health benefit. Involve stakeholders in evaluation: A comprehensive evaluation initia- tive involves many actors. Key stakeholders for evaluation of a transit WHPP program are found in three major groups: • Those involved in WHPP program operations: management, program staff, union representatives, organizational partners, and funders. • Those served or affected by the program: targeted employees, eligi- ble family members, and other affected community members. • Those who are intended users of the evaluation findings: people in a position to make decisions about the program, such as senior management, union leaders, partners, funding agencies, or taxpayers. Stakeholders can help an evaluation before, during, and after the results are collected and reported on. Stakeholders are essential in making sure that the right evaluation questions are identified and that evaluation results will be used to make a difference. Stakeholders are much more likely to support the evaluation and act on the results and recommenda- tions if they are involved in the evaluation process. Without stakeholder support, your evaluation may be ignored, criticized, resisted, or even sabotaged. Stakeholders should be involved widely in the evaluation. For example, WHPP committee members can form an evaluation team and develop questions, collect data, and analyze results. Establish ways to assess what participants are interested in when it comes to evaluation, and develop means of keeping them informed of the evaluation progress and of integrating their ideas into evaluation activities. Again, stakeholders, including participants, are more likely to support the evaluation and act on results and recommendations if they are involved in the evaluation process. Engage your program’s critics in the evaluation as well. Critics can strengthen the evaluation process by identifying weaknesses in your program strategies and evaluation information that could be attacked or discredited. This will help you understand the critics’ rationales and

100 engage potential agents of change who may start by opposing the program. At the same time, use caution when engaging with critics: there may be conflicting interests or motives that can undermine your program, unrelated to the program itself. BEST PRACTICE Data collection, management, and analysis are coordinated throughout the organization. Integrated Data Management It is important to establish systems to collect data in consistent ways over time, and that allow data to be used where it is needed. F-17 survey respondents often complained that they did not have access to information that would help plan, implement, or evaluate their programs, because it was held by some other department and not shared. An integrated data management system coordinates data collection, management, and analysis throughout the organization. Such a system can be challenging to organize and implement, and may be more appropriate for organizations that are well resourced and have a long- term commitment to using the integrated approach to worker health. However, it can simplify the evaluation system and ensure data integrity and consistency. It can also contribute to the design and evaluation of programs and policies, and may help to identify current strengths and resources, as well as gaps and limitations of the organization. Coordinat- ed data collection can help with monitoring progress and inform the need for mid-course corrections. The goal of such a system, as described by the National Institute of Medicine (IOM), is “to drive collection of universal and reliable data that will satisfy common program goals and ensure that information obtained is meaningful to all participants.” (IOM, 2005, p. 54). Aim for a single data system or one that allows different data sources to be linked: Transit agencies should consider integrating health data systems across programs and among vendors. This will clarify how the various contributors to and elements of worker and worksite health and safety interact. Such a system can reduce the silo structure that impedes WHPP implementation. It will allow you to identify at-risk groups or work areas, highlight lower-risk populations, and help you understand and predict the impact of your program activities. The implementation of an integrated system requires significant management commitment and support. Define available data and how it can be grouped: You may be able to categorize by division or by title, including changes over time. To set up your data collection system you need to decide what information you can and want to collect and how often. This can be driven by organiza-

101EVALUATING tional priorities. As part of the approach, consider collecting data on the work environment, organizational policies, and individual health risks into a coordinated system. Data entry should allow for reporting both at a given moment and over time. You may be able to categorize by division, location title, gender, age, or other categories. Use data warehousing to coordinate existing databases throughout the organization with common measures: One step toward achieving an integrated system is through data warehousing— coordinating existing databases throughout the organization with common measures for reporting and analysis. In data warehousing, data and software are standardized across the organization. Measures to protect data security and confidentiality need to be assured in the process. Elements of an integrated database might include: • Medical and pharmacy expenses; • Quality-of-life indicators; • Environmental policies and factors; • Risk factors for disease, including health behaviors such as smoking; • Productivity and operational indicators; and • Program participation. Review data, problems, and solutions across departments: Even if the organization is not ready to integrate data fully, the principle of cross-departmental reviewing of data and addressing problems can be applied. Sit down with other departments and talk about the information each has about health, and how it relates to other sources of data. Data may be collected separately by department, and then discussed and addressed by representatives from multiple departments. Many transit agencies already do this for safety, reviewing employee, passenger, and vehicle safety and security concerns in regular meetings that include operations, safety, and other divisions. Promote vendor data integration: Vendors such as health care or insurance providers and HRA consultants can be important partners in planning and evaluating the WHPP program. The outside vendor may already collect and analyze the data that you need, but it is up to the transit agency personnel to ask for data that will help the WHPP program, including the type of information and format of the report.

102 Number of employees with targeted health issues by division, job title, and other groups Per case and total treatment cost for a specific health issue Trends in health problems or health care use Groups of employee at particular risk—by age, title Health insurance premiums compared to similar organizations or groups—for example, statewide Health insurance premium changes over time, and compared to others Target cost areas that could be addressed to reduce premiums Actions to be taken to reduce premiums As an active partner in an agency’s WHPP program, one large health plan provided sophisticated and flexi- ble data reports. A nearby agency, with the same provider, had not negotiated a similar arrangement and was not aware it was possible. Since its inception, the large WHPP program has used aggregate health status data from the carriers. This is compared periodically both to negotiate rates and to plan program targets. Reports include prevalence of chronic health conditions and utilization data compared to past years and to the whole health plan population. continued You can ask to see a sample report from a new vendor, or from your health insurer. In integrating vendor data, consider the following: • Are the measures used and presented by the vendor aligned with organizational goals? • Will the report compare the organization’s results with national, state, or industry figures? • Can results be compared by title, division, or other grouping? • Can a cohort of employees be tracked so that results show the impact of programs on employees over time? • When and how will the reports be presented? Will there be a chance for review and editing before the final is delivered? • Does the vendor have a process for maintaining confidentiality by eliminating identifying information in the aggregate report? Figure 5.2 lists the kinds of information that the health plan could gener- ate from an existing database or by additional data collection. FIGURE 5.2 WHAT DATA CAN THE VENDOR PROVIDE?

103EVALUATING Process Measures Ongoing evaluation supports continuous improvement by helping you see how well you are implementing your activities even before they have had a measurable impact. Processes to measures include the steps and activities taken in implementing a program and the outputs generated, such as the number and type of educational materials for a stress management class that are developed and given to employees. Assess- ing process indicators keeps program implementation on track and lets you see if you have met the quality and other standards you aimed for. If a project or activity does not achieve its intended outcomes, this step will help determine whether the program took the wrong approach or if it was simply was not implemented correctly. Process evaluation also tracks important measures such as the costs of operating a program, the number of employees reached, the most successful program locations, or how the program’s design and activities compare to others. Track common process measures including: • What you did in establishing WHPP programs, policies, benefits, or environmental support (number of meetings, staff time, deadlines met). • Number of events scheduled and carried out. • Employee awareness of and satisfaction with programs, services, and providers. • Participation in and use of programs and services. • WHPP committee meetings and activities. • Meeting and revision of program goals and measurable objectives. • Program costs. Record quantitative and descriptive data: The process evaluation relies on a mix of qualitative and quantitative metrics. For example, program participation data can be combined with employee satisfaction survey results to obtain a full picture of how successful the program activity is in attracting employees, retaining their participation, and providing value to them. Figures 5.3 and 5.4 show sample task and participation/reach tracking tools using the Planning, Evaluation, and ROI Template. In the second figure many of the results are calculated automatically by the spreadsheet. BEST PRACTICE The organization tracks costs, participation, goals met, and barriers, then uses data to improve the program. continued The program also receives health markers data from a specialized health indicators compa- ny, as a series of tables reporting on health fair screenings data. Howev- er, it became clear that this information dupli- cated more extensive information already available from the health plan.

104 FIGURE 5.3 SAMPLE TASK TRACKING TOOL Target Date Tasks Description Lead Support Completion Completed Status Operator workstation assessment and training Workstation assessment and training of operators with MSDs or other concerns by trained ergonomist OSH Coordinator Operations 3/31/2013 3/15/2013 Completed Prepare for walking clubs Identify safe, attractive walking area at each base Base Champions Committee 3/31/2013 3/13/2013 Completed Family pass program centers Contract outside health center for family pass Wellness Manager 2/1/2013 4/1/2013 Completed Family pass program Register families HR Coordinator Shop Stewards 4/1/2013 Ongoing Base exercise workshops Provide hoops, bands, and weights for on-base activity Trainer Purchasing 9/15/2013 Ongoing FIGURE 5.4 SAMPLE PARTICIPATION AND REACH TRACKING TOOL % of # of % of Eligible Partici- Partici- Employ- Eligible # of pants pants ees Cost Employ- Partici- Reach Reaching Reaching Reaching Total per Par- Activity ees pants % Goal Goal Goal Goal Costs ticipant Operator Workstation Assessment 1350 150 11.1% Complete full assessment and training 130 86.7% 9.6% $9000 $60 Walking Club 1350 210 15.6% Walking five miles per week 100 47.6% 7.4% $5000 $24 Base Exercise Workshops 1350 350 25.9% Attend at least one workshop 150 42.9% 11.1% $5000 $14 Family Pass 1350 250 18.5% Sign up 250 100.0% 18.5% $9000 $36

105EVALUATING Use process evaluation to make time-sensitive adjustments: Target the identified bumps and barriers that may limit your program effectiveness to improve your activities selection, scheduling, communications, and other areas, Convene the WHPP committee or even the top-level planning group to review the analyses, interpret the findings, and discuss what actions to recommend. A summary of the assessments should be prepared and shared before this meeting. While the strengths, weaknesses, and recommendations may be apparent to the WHPP program leads, these items will benefit from richer discussion with representatives from human resources, occupational health and safety, operations, and other departments. Just keep in mind that when you use process evaluation results to introduce or remove activi- ties, change incentives, or measure different things, you may need to adjust the baseline level you refer to in the outcome analysis described below. Figure 5.5 shows key sections of a template one agency uses for planning and monitoring each health promotion initiative. Detailed data from the participation logs, trackers, and employee surveys are plugged into the template to track process outcomes and the ultimate impact of the program. FIGURE 5.5 KEY SECTIONS OF A PROGRAM MONITORING TEMPLATE: AGENCY EXAMPLE Program Phase Areas Tracked Program Planning Program Demographics Program Justification Program Description Program Procedures Program Goals Management Objectives Team Responsibilities and Timeline Promotion Methods Program Implementation Participation Numbers and Rates Costs/Incentives Cost Analysis Program Evaluation Executive Summary (after implementation) Biometric Results Program/Survey Results Staff Evaluation

106 Evaluation and tracking activities in the F-17 case study sites • Capital Metro: The program tracks an extensive list of measures to gauge program outcomes against yearly goals, beginning with program participation and penetration rates. To calculate gym participation, badge reports are provided by security and logged into a customized spreadsheet. Each month, the wellness center logs gym participation, personal training sessions, biometric assessments, fitness class participants, and one- on-one fitness consultations. For each challenge, such as weight loss, progress of individual participants or teams is kept in a spreadsheet that calculates the percentage change at the end of the program. The dietician provides monthly reports on class participation and individual consultation sessions. For vendors, reports are provided to wellness coordinators after the event takes place. All unique participants are entered into a customized spreadsheet showing which activity they participated in the main sections of the monthly summary of the wellness center activities: • Program Highlights. • Membership. • Membership Penetration. • Active Participation. • Enrollments/Appointments. • Visits by Time Allotments for the Month (time of day and days of the week). • Group Exercise Activities. • Upcoming Activities. In addition to the fitness center logs, a rolling wellness program tracker tracks each individual participant in five broad categories of wellness activities, namely physical fitness, weight management, stress management, tobac- co cessation, and miscellaneous wellness. The wellness staff also conducts an annual employee survey on their satisfaction with the fitness center staff, equipment and offerings, as well as ways to improve the wellness program. Employee response in the past few years has been overwhelmingly positive. The monthly management report and survey results are then used to adjust programming to fit the needs and desires of employees. • OCTA’s Shoes and Wheels: Participation is recorded for all events. Employees use a computer interface to record activities in 15 60-minute increments for the Shoes and Wheels point system. This, along with sign-in sheets from lunchtime events, allows the wellness administrator to monitor participation. The fitness trainer records and reports monthly on all fitness equipment use, assessments, consults, and other coaching. This data is reported in number of visits rather than number of unique users so the total participation is an estimate. • DART’s Online Wellness Tracker: The DART wellness program structure is based on a point system. Employ- ees use an online wellness tracker to enroll in the health and wellness program and to track their wellness points. Program participants receive wellness points for completing health risk assessments, wellness workshops, fitness challenges, the wellness program kick-off, and the health expo. They can receive points for putting away a percentage of their income into the DART 401K plan and for attending continuing education classes. • UTU-LCMTA: Process evaluation is done through program participation rates, participant feedback, and qualitative input from Ambassadors, Champions, and others involved in program implementation. The program identifies and describes success stories to illustrate the program impact to support its quantitative analysis.

107EVALUATING Impact and Outcome Measures Important as it is to be sure you are doing what you planned, and to make mid-course corrections as needed, what your organization cares about most is, “What difference did it make?” Impact measures are the areas you target for change because they can lead to a healthier person or environment, such as knowledge, attitudes, behaviors, skills, or policies. Outcome measures are the end results, such as health status, the work environment, absenteeism, productivity, presenteeism, and health care costs. Include both short-term and long-term measures: Maintaining and improving worksite and worker health can be a complex effort and it takes a few years to see an impact on most health measures. However, the organization may be prepared to support the program even if it does not show concrete positive outcomes within a shorter timeframe. Providing a balanced combination of short-term and long-term results is an effective strategy to justify your program budget and sustain management support, and to encourage further employee engage- ment. Program planning staff or work groups should pay particular attention to this while identifying the WHPP needs, defining program goals and objectives, and planning program offerings and evaluation in the early stages of the program. Examples of short- and intermediate- term milestones include changes in employee health behaviors and risk profiles, and cleaner and safer worksites. Longer-term changes, such as reduced disqualifications for high blood pressure, or fewer compensa- tion claims, should follow. Document changes in impact measures such as knowledge, attitudes, behaviors, or skills in a target population: Impact evaluation focuses on the observable effects of a program that can lead to measurable health outcomes. Impact variables include health knowledge, attitudes, skills, and behavior. In determining the appropriate impact measures, look at cause and effect. Just as you did when setting your targets, think about whether the changes that occurred can be reasonably attributed to the program that was implemented. To confirm that effects are maintained, impact evaluation can be repeated over the months following the intervention. Figure 5.6 lists the characteristics of the four categories of impact metrics. BEST PRACTICE The program documents changes in impact measures and in outcome measures.

108 FIGURE 5.6 TYPES OF IMPACT MEASURES Metric Definition Changeability Example of Change Knowledge Acquired facts and information Easy Understanding decibel levels and hearing loss Attitudes How someone feels about a topic Moderate Support seatbelt use Skills Ability to carry out a specific action Difficult Learn to use a pedometer Behaviors Actions someone takes part in Difficult Eating five fruits or vegetables most days Vigorous exercise 30 minutes 3-4 days per week Impact metrics can be tracked using methods such as: • Pre- and post-event tests or surveys—used to measure changes in attitude, knowledge, and current eating, physical activity, and mental health status from an initial assessment to completion of a program or campaign. Could be group or individual changes. • Quizzes—measure retained level of knowledge at any time. • Physical activity and diet log sheets—data provided by participants. • Vending machine choices—you can arrange with vendors to track selections and sales. • Cafeteria menu options selected. • Number of safety, health, or housekeeping issues reported or resolved. You can also calculate the proportion of issues reported to issues resolved. This is a good approach because reporting often increases following effective outreach, making it look like things are getting worse. Document changes in outcome measures such as health status, employee morale, work environment, health care costs, absenteeism, presenteeism, injuries, and disability: Outcome evaluation focuses on a goal or product of your WHPP program, generally measured in the longer term through health status changes or biological health indicators such as cholesterol levels or diseases treated, work environment and occupational injury changes, and financial outcomes.

109EVALUATING These outcomes, like the common target areas of WHPP programs, can fall into three major improvement categories: health, work conditions and environment, and operations and productivity. Associated cost savings can be identified within each area. WHPP programs that improve employee health by reducing, preventing, or controlling disease can affect operational efficiency and worker productivity, which can in turn can lead to higher customer satisfaction and better overall image of the transit agency. The benefits from the WHPP program implementation can be measured in many ways: 1. Indicators of Health Improvement • Optimal health status (such as percent of employees reporting good or excellent health before and after a health promotion program or intervention). • Levels of disease, injury, or disability (such as number of workers newly diagnosed with diabetes before and after an intervention or number of employees who experience a fall at work before and after a falls prevention intervention). • Prevalence of risk factors (such as percent of employees who are overweight/obese before and after a weight management program). • Changes in the number and type of health insurance claims over time (such as hospitalizations, outpatient visits, or pharmacy claims). • Changes in health care utilization (such as use of preventive health services such as cancer screening). • Quality of care indicators (such as percent of employees with high blood pressure that is being controlled through medication). 2. Indicators of Work Organization and Environment Improvement • Health-promoting environment (exercise facilities, food access). • Health-enhancing organizational policy and procedures (scheduling, employee involvement, work-home conflicts, restroom use). • Occupational safety and health outcomes and policy improvements (overall safety and health compliance, housekeeping, on-the-job injuries tracking, vehicle and passenger safety, operator assault policies, ergonomics assessment).

110 Figure 5.7 shows an example of using the Planning, Evaluation, and ROI Template to track injuries. FIGURE 5.7 EXAMPLE OF OCCUPATIONAL INJURIES TRACKING Change Injuries in Inju- # Injuries per per 1,000 # ries per Number Employ- 1,000 Number of # Employ- Differ- 1,000 Type of of Injuries ees - Employees - Injuries – Employees ees - ence Employ- % Injury Before Before Before After After After in Injuries ees Change Neck Strains 5 1350 3.70 4 1359 2.94 -2 -0.76 -20.5% Slips and Falls 8 1350 5.93 7 1359 5.15 -3 -0.78 -13.1% Hip Strain 5 1350 3.70 3 1359 2.21 -3 -1.50 -40.4% Back Strain 10 1350 7.41 8 1359 5.89 -4 -1.52 -20.5% Knee Injury 4 1350 2.96 2 1359 1.47 -3 -1.49 -50.3% Total 32 1350 23.70 24 1359 17.66 -14 -6.04 -25.5% 3. Indicators of Operations and Productivity Improvement • Absenteeism—the amount of time employees are paid but not at work. Absenteeism can be caused by stress, work-related injury, illness, family needs, and other personal needs. • Availability—the flip side of absenteeism. Not having enough operators every day means service has to be cut or someone else has to fill in at overtime. Service quality and passenger commitment to public transit may also be affected if schedules are changed. • Presenteeism—the impact of employees who are at work but not optimally productive because of poor health, sleep disturbance, distractions, or other limits such as lack of training. Presenteeism can be more of a problem where an agency’s contractual sick leave policy provides unpaid waiting days before paid sick leave begins. In some agencies even legitimate absence is part of the progressive discipline system. Both of these practices encourage ill operators to come to work rather than lose a day’s pay or notch another occurrence under

111EVALUATING the attendance policy. WHPP programs that boost operator health and include policies to encourage responsible sick leave not only help agencies achieve the desired performance, but also relieve the pressure on operators to choose between coming to work sick and accumulating absent days. Presenteeism can be measured by extrap- olating estimates of productivity loss in the past few weeks using, for example, the Work Limitations Questionnaire Loss Score. See Tools and Resources below and the Planning, Evaluation, and ROI Template for details. • Turnover—the percentage of employees who leave each year. Medical disqualification can be a major headache for transit agencies. Operators may fail CDL physical exams due to uncontrolled hypertension, sleep apnea, or stress-related mental health problems. Targeted activities, supportive policies, and training can reduce the number of involuntary turnovers caused by medical disqualifications or by ill-health. Exit interviews are one way to find out if health has contributed to loss of employees. • Operations efficiency—on-time service, customer comments, reportable or investigated incidents. Use the Outcomes Worksheet from the Planning, Evaluation, and ROI Template to document and track the things that change as a result of your WHPP program, as illustrated in Figure 5.8. In the template you can also estimate how much of any change you think was the result of the WHPP program. This estimation was included in the spreadsheet because many contributors recognized that their activities may not have been wholly responsible for observed changes. It is not required in using the template, and you can estimate that your program was entirely responsible for the changes measured.

112 FIGURE 5.8 HEALTH-RELATED TURNOVER Num- # Number # Employ- Loss ber of # Employ- Loss Differ- % Im- of Exits - ees - Be- Rate – Exits - ees – Rate - ence in Change in prove- Exit Reason Before fore Before After After After Exits Loss Rate ment Work Stress 5 1350 0.4% 3 1359.0 0.2% -2 -0.1% 40.4% Medical Disqualification 7 1350 0.5% 3 1359 0.2% -4 -0.3% 57.4% Work Schedule 4 1350 0.3% 4 1359 0.3% 0 0.0% 0.7% Other Health Issues 3 1350 0.2% 2 1359 0.1% -1 -0.1% 33.8% Total 19 1350 1.4% 12 1359 0.9% -7 -0.5% 37.3% 100 80 57% 60 40 40% 34% 37% 20 0 Work Stress Medical Disqualification 1% Work Schedule Other Health Issues Total

113EVALUATING Figure 5.9 provides examples of data sources for the impact and outcome metrics of transit WHPP programs. FIGURE 5.9 EXAMPLES OF WHPP METRIC SOURCES Category Sources Health Status or Behavioral Changes Smoking: class graduates, nicotine replacement therapy claims, and tobacco- free cash incentive figures Exercise: gym participation, challenge participation, 10K steps programs Biometrics Aggregate Health Risk Assessment (HRA) reports Screenings at depots quarterly, reports provided by vendor CDL qualifications data provided by HR BMI measured in challenges Medical Claim Condition-specific data from health plan, annually Overall costs from broker or other pool source, quarterly Health Culture Observation of worksite physical and organizational environments Workplace Injuries, Accidents, or Conditions OSHA 300 logs, monthly, from risk management Summary annual reports by division Monthly notes from safety committee meetings reviewed by wellness team Workers’ Compensation Claims From insurer, by condition, with advice or required improvements Absenteeism/Time Lost Human resources monthly reports, including: Sick Leave Family Medical Leave Act (FMLA) Short-term Disability, Long-term Disability Occupational Injuries/Illnesses Personal Leave Presenteeism Employee survey (e.g., Work Limitations Questionnaire, Loss Questionnaire) Customer Complaints Turnover Employee separation records by reason, e.g., health, involuntary termination Self-report reasons for separation—exit interviews Analysis of retention trends by operations and HR—annually by department, length of service, and reason Medical Disqualification Informal listing or knowledge of CDL or Employee Health Service decisions Annual review of disability findings

114 BEST PRACTICE Cost savings are quantified to show how the WHPP program supports the bottom line. Cost-Benefit and Return on Investment For many businesses, the key indicator of WHPP program success is costs to benefit ratio or return on investment (ROI). Comprehensive programs are more likely to yield better impacts on health outcomes and health care costs than smaller programs or isolated activities, but they cost more to establish and maintain. The pursuit of ROI is a balanc- ing act requiring both enough investment in the right programs and frugal use of available funds. This section describes methods used to record and analyze the financial impact of the WHPP program activities. Collect program financial data continuously: Program cost data should be tracked throughout the program delivery, as part of the process evaluation. Aggregated costs can then be carried over into the cost-benefit analysis and ROI calculations. The balance sheet should include financial and in-kind contributions from partners and participants, as well as staff time, materials purchased, and other costs. Quantify the economic benefits from improved outcomes: The results tracked in the outcomes evaluation need to be recorded in monetary terms to determine the cost-effectiveness and ROI of the program. That could mean estimating the dollar benefits of retention, reduced sick time, and productivity, among others. The risk management team or human resources could help you here. Cost measures may include: • Health care premium and claims costs. • Absenteeism costs. • Presenteeism costs. • Turnover costs. • Accidents and injury costs. • Workers’ compensation costs. Tracking of cost reductions is covered extensively in the “Financial Benefits” tab of the Planning, Evaluation, and ROI Template. Be realistic and simple: It is important that the evaluation and ROI analysis process be kept efficient, financially viable, and meaningful, both because WHPP program staff in most agencies are typically stretched between the WHPP and other responsibilities and because management wants to see the bottom line and the executive summary. It is with this in mind that the Planning, Evaluation, and ROI Template

115EVALUATING supporting this Practitioner’s Guide is simplified and streamlined. Although the template allows you to enter a wide range of variables, you should focus on evaluating the items that are most pertinent and that are reflected in your goals and objectives. For example, agencies that are actively targeting rising health care costs and absenteeism may focus on the program outcomes in those two areas, rather than the full list of outcome measures. Recognize the potentially extended time period for achieving a positive ROI: Enough time must be permitted to pass before significant impacts can be expected. Some programs, such as back injury preven- tion and medical self-care, have shown ROIs within a short time frame. In contrast, for programs targeting risk factors and behaviors such as weight management, the payoff can take some years. Look carefully at your activities design and schedule, participation and adherence levels, and total programming costs to gauge a realistic time frame for achiev- ing a true intervention-driven ROI. Estimate the effect of the WHPP program: Although research projects try to control the influence of other programs or factors, it is not possible to isolate the effects of the WHPP program relative to other changes in complex, real-world environments. Without investing a large amount of resources in this task, transit WHPP practitioners can estimate how much the WHPP program contributed to the dollar savings or benefits identified in the outcomes evaluation by soliciting opinions from internal subject-matter experts, stakeholders, and program participants. High-, medium-, and low-range estimates of impacts and benefits can be entered, providing you with a range of ROI rates. Figure 5.10 shows how the calculations look in the Planning, Evaluation, and ROI Template, and Figures 5.11 and 5.12 show the charts that the template can generate. Some costs associated with improving the health culture and work environment may show up in other budgets. For example, scheduling in extra time for restroom breaks, health training, or exercise will not be paid out of the WHPP program budget. The ROI Template allows you to consider these costs as well if you have this data.

116 FIGURE 5.10 SAMPLE COST-BENEFIT AND ROI SUMMARY Year 1 Year 2 Year 3 Year 4 Year 5 Cumulative Total Program Benefits —Overall $350,773 $415,909 $434,000 $490,000 $510,000 $2,200,682 Total Program Benefits— Due to WHPP Program $272,380 $330,357 $332,000 $430,000 $442,000 $1,806,737 Total Program Costs $210,000 $239,000 $220,000 $240,000 $220,000 $1,129,000 Net Program Benefits— Overall $140,773 $176,909 $214,000 $250,000 $290,000 $1,071,682 Net Program Benefits— Due to WHPP Program $62,380 $91,357 $112,000 $190,000 $222,000 $677,737 ROI Year 1 Year 2 Year 3 Year 4 Year 5 Cumulative Annual ROI Achieved— Benefits Overall 67.03% 74.02% 97.27% 104.17% 131.82% 94.92% Annual ROI Achieved— Benefits Due to WHPP Program 29.70% 38.22% 50.91% 79.17% 100.91% 60.03% Annual ROI Goal (Optional) 50.00% 70.00% 90.00% 100.00% 120.00% N/A Goal Achieved? —Benefits Overall Exceeded Exceeded Exceeded Exceeded Exceeded N/A Payback Period— Benefits Overall 0.60 years 0.57 years 0.51 years 0.49 years 0.43 years 0.51 years Payback Period— Benefits Due to WHPP Program 0.77 years 0.72 years 0.66 years 0.56 years 0.50 years 0.62 years Discount Factor 2.00% Net Present Value— Cumulative Benefits Overall $1,003,332 Net Present Value— Cumulative Benefits Due to WHPP Program $631,109

117EVALUATING $2,500,000 $2,000,000 $1,500,000 $1,000,000 $500,000 0 Year 1 Year 2 Year 3 Year 4 Year 5 Cumulative Benefits Overall Benefits Due to WHPP Program Program Costs FIGURE 5.11 ANNUAL AND CUMULATIVE PROGRAM COSTS VS. BENEFITS 140% 120% 100% 80% 60% 40% 20% 0% Year 1 Year 2 Year 3 Year 4 Year 5 Cumulative Annual ROI Achieved— Benefits Overall FIGURE 5.12 ANNUAL ROI ACHIEVED Annual ROI Achieved—Benefits Due to WHPP Program

118 BEST PRACTICE The organization communicates the impact of the program. Data-Driven Ongoing Improvement Your ROI calculations ideally will show that it is worth running your program and even expanding it. At the same time, the data you collect and analyze can also point to barriers, opportunities, and other process issues that can affect programs and people. Measurements for this type of data should be simple, easy to implement, and reported frequently. Package your evaluation data: First and foremost, understand your stakeholders and figure out the range of variables (“scope”) that stake- holders want to look at, as well as the level of detail (“specificity”) they would like to see. In other words, who will receive the evaluation? What individuals and departmental representatives will be the primary recipi- ents—human resources personnel? The benefits director? The occupa- tional health specialist? Safety and risk management personnel? Senior management? Certain stakeholders will prefer a high level approach while others may prefer to see the details, such as completed evaluation forms distributed following the program or the transcript for the focus groups you completed. Determine how you can present the data within the organization’s expected reporting formats. Lastly, understand the venue in which the evaluation results will be presented. Communicate progress and success: Program staff should provide timely feedback and follow-up to participants. Individual participants’ weekly, monthly, and yearly participation logs and progress made in health measures can be presented. Online trackers can largely automate this process, although it should not completely replace personal communications. When positive changes are observed in participation, health behaviors, status, or working conditions, celebrate successes with the responsible people and more broadly. Present aggregated evaluation results to all levels of management and employees: It is important to share aggregated evaluation data with participants, staff, the leadership committee, and other management and union stakeholders. As mentioned earlier, this may mean different types of communications for different audiences. Managers may be more interested in returns on investment, while workers may be more interested in changes in benefits, health, and well-being.

119EVALUATING Summary Calculating costs and showing a strong return on investment is not easy. Some of the very impressive results shown in the literature go far beyond the typical ROI found in most business practice. Even a more conservative return will not only save your organization money but also shore up your operations and staffing needs. More importantly, improving working conditions, health behaviors, and health outcomes will increase viability and sustain growth in transit agencies and make life better for the transit workers that run them. TOOLS + RESOURCES Planning for Evaluation RE-AIM model tools and resources www.re-aim.hnfe.vt.edu/ resources_and_tools/index.html. Data Collection and Databases An Organizational Framework for Integrated Data Manage- ment. Institute of Medicine (IOM) describes how an organiza- tional framework for integrated data management can help in identifying useful data collection purposes and strategies. In Integrating Employee Health: A Model Program for NASA. Washington, DC: National Academies Press, 2005. Especially see Table 6-1, p. 154. http://www.iom.edu/reports/2005/integrating-employee-health- a-model-program-for-nasa.aspx The National Business Coalition on Health also addresses integrated data systems at: http://www.nbch.org/Founda- tional-Business-Diagnostics-Introduction Impact and Outcomes Measures Penetration, Implementation, Participation, and Effectiveness (PIPE) Impact Metric. This tool provides a score to measure the impact of a workplace health promotion program. Pronk NP. Designing and Evaluating HP Programs. Dis Manage Health Outcomes. 2003; 11(3):149-157. NIOSH: How to Evaluate Safety and Health Changes in the Workplace: Does it Work? This simple guide provides recom- mendations for evaluation, descriptions of actual worksite evaluations, and a couple of tools that worksites might use. Measuring Presenteeism: Work Limitations Questionnaire. The most common approach to measuring presenteeism is to ask employees how much their health hinders their perfor- mance while at work. Among the available instruments, research has shown that the Work Limitations Questionnaire has relatively strong validity and reliability, and has been used in a variety of workplace settings with a variety of health risks and conditions. The questionnaire is available from Debra Lerner, The Health Institute, Tufts-New England Medical Center, Boston MA, USA. WLQ@tufts-nemc.org. A New Tool to Measure the Relationship between Health- Related Quality of Life and Workforce Productivity. This dissertation provides sample items from the Work Limitations Questionnaire, along with other survey instruments for measuring health-related absenteeism and presenteeism and their impact on work productivity. http://hdl.handle.net/1853/24642 Online ROI Calculators. The following list of online ROI calculators can be used to plan and choose target areas, forecast potential program costs and benefits, and estimate program ROIs. Many target the payoff from a specified health change.

120 Cost-Benefit and ROI SAMPLE WHPP COST-BENEFIT AND ROI CALCULATORS Tool Description Source Link Health and Work Performance Questionnaire (HPQ) An internationally supported tool for investigating health care costs and business decisions, indirect costs of untreated and under-treated employee health problems, and ROI of employee health benefits and programs. It includes practical subscales for presenteeism/ absenteeism, and other concerns. World Health Organization and Harvard Medical School www.hcp.med. harvard.edu/hpq WellSteps ROI Calculator Simple online ROI tool that offers three modes of calculation—health care costs, absenteeism, and presenteeism. Inputs: annual costs, trends, percent employees at risk, target percent, program intensity, and percent at risk. Outputs: savings from decreased percentage of employees who are either smokers or obese. WellSteps www.wellsteps.com/ roi/resources_tools_ roi_cal_health.php Depression Cost Calculator Known as the Productivity Impact Model, this calculator uses detailed algorithms based on established clinical research and applies them to any workforce to determine the incidence of depression within an organization. The calculator then predicts the expected number of days each year employees will be absent or suffer low productivity due to his/her depression, and the associated costs. Finally, the tool projects the net savings that will accrue with treatment of those employees suffering from depression. The National Partnership for Workplace Mental Health www. depressioncalculator. com/Welcome.asp Smoking Cessation ROI Calculator Web-based ROI calculator that estimates the impact of smoking cessation interventions for 1–5 years. Contains preloaded data that represent the disease, health care use, and plan eligibility for a cohort of smokers, and how cessation programs alter these experiences. Inputs can be modified to reflect the key smoking and environmental factors of target population. Center for Health Research (Kaiser Permanente Northwest) and America’s Health Insurance Plans www.businesscaseroi. org/roi/default.aspx

121EVALUATING Tool Description Source Link Alcohol Cost Calculator Online cost calculator that shows how common alcohol problems are in each sector, how many work days are lost due to alcohol problems, the extent of alcohol-related hospital and emergency room visits of employees and their families, and the costs of missed work days and health care of employees and their families. Center for Integrated Behavioral Health Policy, The George Washington University Medical Center www. alcoholcostcalculator. org/alcohol/ Physical Inactivity Cost Calculator Online calculator that provides an estimate of the financial cost of physically inactive people to a particular community, city, state, or business. A total estimate is provided as well as individual costs for medical care, workers’ compensation, and workers’ lost productivity. Also provides companion resources and information for reallocating resources and plan for healthier workplaces and communities that are more supportive of physical activity. Fifty Plus Lifelong Fitness, and the National Coalition for Promoting Physical Activity www.ecu.edu/ picostcalc/ Substance Use Disorder Calculator Online calculator that estimates the prevalence of alcohol, illicit drug, and prescription pain medication abuse or dependence in your population. Center for Integrated Behavioral Health Policy www. alcoholcostcalculator. org/sub/ Obesity Cost Calculator Downloadable calculator that estimates the costs of obesity based on characteristics of your company. These include costs for medical expenditures and the dollar value of increased absenteeism resulting from obesity. Costs are estimated separately for four groups based on BMI. LEANWorks—Center for Disease Control and Prevention www.cdc.gov/ leanworks/ costcalculator/index. html

122 Chapter Background Adams, T. (2008). The ROI calculator. WELCOA’s Absolute Advantage Magazine, 7(4), 28-33. Aldana, S. (2009). The top 5 strategies to enhance the ROI of worksite wellness programs. WELCOA’S Special Report. Chapman, L. (2005). Meta-evaluation of worksite health promotion economic return studies: 2005 update. American Journal of Health Promotion, 19, 1–11. Chenoweth, D., Hunnicut, D. (2011). Worksite wellness evalu- ation. WELCOA’s News & Views: An expert interview with David Chenoweth. Davis L. et al. (2009) A comprehensive worksite wellness program in Austin, Texas: partnership between Steps to a Healthier Austin and Capital Metropolitan Transportation Authority. Preventive Chronic Disease, 6(2) www.cdc.gov/pcd/ issues/2009/apr/08_0206.htm accessed November 11, 2011. Glasgow, R. E., et al. (2006). Evaluating the impact of health promotion programs: Using the RE-AIM framework to form summary measures for decision making involving complex issues. Health Education Research, 21(5), 688–694. Grossmeier, J., Terry, P., Cipriotti, A., Burtaine, J. (2010). Best Practices in Evaluating Worksite Health Promotion Programs. The Art of Health Promotion, January/February 2010, 1-10. Hunnicut, D. (2007). By the numbers. WELCOA’s Absolute Advantage Magazine, 6(4), 10-17. Hunnicut, D. (2007). Communicating your evaluation results. WELCOA’s Absolute Advantage Magazine, 6(10), 20-23. Hunnicut, D. (2007). Fundamentals of evaluation. WELCOA’s Absolute Advantage Magazine, 6(10), 13-19. Kentucky Cabinet for Health and Family Services and the Kentucky Chamber of Commerce. (May 2009). Investing in a healthy bottom line: guide for worksite wellness. Retrieved from kychamber.com/sites/default/files/worksitewellness.pdf King, D. K., R. E. Glasgow, et al. (2010). “Reaiming RE-AIM: using the model to plan, implement, and evaluate the effects of environmental change approaches to enhancing popula- tion health.” Am J Public Health 100(11): 2076-2084. McKenzie, J.F., Neiger, B.L. and Thackeray, R. (2009). Planning, Implementing, and Evaluating Health Promotion Programs: A Primer (5th Ed.). San Francisco, CA: Pearson Benjamin Cummings. Mitchell, R., and P. Bates. Measuring Health-Related Produc- tivity Loss. Popul Health Manag. 2011 April; 14(2): 93–98. www.ncbi.nlm.nih.gov/pmc/articles/PMC3128441/ Moffat, G.K., A. H Ashton, and D.R. Blackburn. (2001). TCRP Synthesis 40: A Challenged Employment System: Hiring, Training, Performance Evaluation, and Retention of Bus Operators, A Synthesis of Transit Practice. TRB, National Research Council, Washington, D.C. http://www.trb.org/main/blurbs/160920.aspx Valente, T. (2002). Evaluating Health Promotion Programs. Oxford University Press, 2002, 11-17.

123CARRYING ON T Chapter Carrying On: Maintaining Effectiveness with Growth CHAPTER MAP• MAINTAINING Workplace Health Protection and Promotion is essential to the organization, not an extra. • Justify organizational support. • Contribute to the organization. • Plan to survive internal changes in focus. • Keep the committee fresh and retain experience. GROWING The WHPP program adapts. • Stay up-to-date with changing needs and resources. • Engage with transit health issues. • Develop targeted programs. • Improve on what is available. • Expand the WHPP program perspective. A REALISTIC PERSPECTIVE The WHPP program prepares for difficulties. • Looking for problems means you find them. • You can’t solve everything. he NIOSH Total Worker Health™ model recommends: “Be willing to start small and scale up.” As the Workplace Health Protection and Promotion (WHPP) program grows, it is important to both maintain momentum and adapt to current needs. Some of the things that made the WHPP program successful can be retained but others might no longer be appropri- ate. The program planning and implementation flow chart (Figure 6.1) is a useful reminder of the loop of assessment, planning, action, and evalua- tion that identifies areas that change as time passes and the program matures. Evaluation leads back to program planning, annually or as new issues develop. Although you will not have to start the entire process over again from the beginning, as the organization changes you may need to reestablish commitment and keep build- ing your team.

124 Transit Workplace Health Protection and Promotion Roadmap Preparing the Organization and Making the Commitment • Culture of health and safety • Organizational needs assessment • Organizational resources • Meeting needs with resources Setting Targets in Transit Health Protection and Promotion • Setting priorities • A comprehensive health risk focus • Effective components • Transit-specific programming Building the Team • Taking the lead • Putting the team together • Management support • Labor support • Committee • Champions and ambassadors • Vendor integration Implementing and Integrating an Effective Transit Program • An inclusive range • Transit-specific implementation • Effective communications • Training supports the program • Equitable incentives Evaluation, Return on Investment, and Ongoing Improvement • Evaluation framework • Integrated data management • Process measures • Impact and outcome measures • Cost-benefits and return on investment • Data-driven ongoing improvement Maintaining Effectiveness with Growth • Maintaining • Growing • A realistic perspective FIGURE 6.1 WORKPLACE HEALTH PROTECTION AND PROMOTION PROCESS BEST PRACTICE Workplace Health Protection and Promotion is essential to the organization, not an extra. Maintaining Justify organizational support: As described in Chapter 1, on setting up the program, and especially in Chapter 5, covering evaluation and return on investment, you will need to keep making your case to the organization. Regularly scheduled report sessions require the program team to assess and describe the program progress. They also require stakeholders to pay attention to the program, to recognize past commit- ments, and to understand the program’s role in the organization.

125CARRYING ON United Transportation Union— Los Angeles County Metropolitan Transportation Authority: Maintaining Excellence with Growth The UTU-LACMTA program in Los Angeles, described in Chapter 2, exemplifies how an agency can start with a pilot project in two locations and over time develop it into a comprehensive program that serves almost all job titles in one of the largest transit agencies in the country. Extensive union and management commitment, a skilled and respected lead, vendor support, and careful planning and evaluation have all contributed. The program lead and the extensive committee are eager to integrate additional health protection and promotion concerns but important initiatives are planned and rolled out carefully, and the program is conservative in estimating the impact. Contribute to the organization: The WHPP program also supports the organization. As you grow, it is important to establish how the WHPP program can have an impact on policy and operations. When developing components that overlap with other departments such as safety, human resources, and operations, make sure to provide support, policy language, and positive influence to help those departments integrate WHPP in their planning and strategy. Keep top level commitment: Plan for succession. Top transit agency leadership may change every few years, and union leadership may change during election years. This means you can lose a champion or foundational support. Stay ahead of this by encouraging written plans and policies that clearly define the organizational support for the WHPP as well as job descriptions or defined responsibilities for staff and other WHPP team members. Plan to survive internal changes in focus: As working conditions, economics, individual participants, and other factors change, the WHPP initiatives risk being seen as dispensable. For example, health problems may seem less important when there is a larger pool of younger appli- cants for operator jobs. In times of conflict, labor-management commit-

126 COLLECTIVE BARGAINING LANGUAGE EXAMPLE Letter of Understanding re Wellness Program The parties discussed the benefit of an enhanced wellness program (including the potential to reduce employee injury and sickness) during the current round of bargaining. The parties agree in principle to, through the OH&S Committee, instituting a wellness program with the following elements: Participation by employees is voluntary but encouraged; A program similar to that offered by [Health Centre] The Wellness Committee will be continued during the duration of this Collective Agreement. Composition of the Committee will be three appointees of the Union and three appointees of the employer. The Wellness Committee will report to the OH&S Committee. The Wellness Committee will oversee and monitor progress of the program including changes noted above. tees may not be well supported by one side or the other. The problem is that initiating a program is difficult and costly, so allowing it to hiber- nate wastes past work and makes restarting less likely. Do not depend on individual skills alone: A program that relies heavily on a very effective lead person may not survive when that person moves on. Those effective leaders should work hard to share their skills, teaching others how to be effective also. Keep the committee fresh and retain experience: Like the US Senate, the committee will be improved by a combination of experience and innovation. Encourage the ongoing recruitment of new members. And make sure that incumbents can continue to grow and contribute. A few examples of policies that maintain WHPP as a priority are listed in Figure 6.2. FIGURE 6.2 MAINTAINING WHPP IN THE ORGANIZATION CULTURE AND POLICIES Strategic plan elements refer to WHPP WHPP committee charter Including WHPP responsibilities in job descriptions Policies on committee structure and participation Policies in other departments that refer to or define specific WHPP functions Contract language or memorandums of understanding that define the program and the roles BEST PRACTICE The WHPP program adapts. Growing Stay up-to-date with changing needs and resources: Figure 6.1 shows how evaluation and assessment lead back to needs assessment and planning. The impact of your program could mean that some activities are no longer needed, or conversely that they should be continued. Engage with emerging transit health issues: Health issues such as obesity, nutrition, or occupational exposures are continually researched and sometime reframed. The guidance and regulatory environment is changing too. Just a few examples: CDL medical requirements and

127CARRYING ON recommendations are likely to be revised over the next few years. The new Federal Transportation Administration oversight of transit agency safety management systems and training are expected to have an impact. States are passing bills addressing workplace assault. The WHPP program staff, committee, champions, and participants will all profit from keeping up with these changes. Develop targeted programs: Transit WHPP programs have to address events that are not common across other industries, or even in all transit workplaces or titles. Your organization can develop tailored approaches to the issues of concern. Try to engage with industry partners on issues such as: • Post-Traumatic Stress Disorder (PTSD) that may be the result of assault, passenger accidents, or past experience such as military service • Emergency response • Family conflict, grief, and other problems that can affect performance and be aggravated by the demands of work Improve on what is available: Integrating health protection and promotion in transit will require you to add concepts to otherwise useful standards and tools designed for in offices and other workplaces. For example, the workplace assessment tool designed for the Total Worker Health™ program has physical demands and ergonomics questions, but they only refer to heavy lifting and repetitive motion. To use such tools, you can add bus operator musculoskeletal demands such as bending, sitting, awkward forceful motions, impact of potholes, and vehicle accidents. The same is true for work organization tools and interven- tions. You do not have to reinvent the wheel but you might need to make some changes. Expand the WHPP program perspective: Wherever your program started you can grow to the next level as you develop your program, organizational health culture, skills, and payoff. Organizations that have focused on disease management and individual risk factors (the tradi- tional health promotion model) can expand by targeting health and well-being through developing policies and a work culture that encour- age and reward healthy exercise and food choice. If you have been successfully promoting health challenges, group activities, and the health environment, you have probably seen the areas where changes in the work conditions and policies will improve workplace health protection and promotion. Increasing WHPP program involvement throughout the

128 organization and evaluating results will lead you to set new priorities with stakeholders. A comprehensive WHPP program can expand by covering more titles and supporting a wider range of organization priorities. For example, tying in to new worker or incumbent skills development or community service projects engages the organizational and community policy level that is described in the SafeWell Integrated Management System for Worker Health and the World Health Organization Healthy Workplace Framework. BEST PRACTICE The WHPP program prepares for difficulties. A Realistic Perspective Health protection and promotion is challenging. Getting people to change behavior is difficult, as is getting organizations to adapt to new processes. Here are just two concerns, in addition to those covered throughout the Practitioner’s Guide. Looking for problems means you find them: The health situation can temporarily look worse when you start your program. Screenings, workplace inspections, symptoms surveys, and even education make it more likely that you will find problems. Some WHPP activities, such as mobile dental vans, are designed to increase health service users. As a result, costs and other demands on the system can increase. It doesn’t mean the program caused the problem, and these surges should balance out over time with improved health outcomes. You will want to warn you organization about this. You can’t solve everything: Some problems are very hard to head off, such as existing but undiagnosed cancer. And some WHPP areas are not addressed well yet. For example, the cognitive and attention demands of a modern bus dashboard can contribute to distraction, stress, or accidents. At the same time, the information carried is impor- tant to safe operations. Realistic goals setting, prioritizing, and ongoing communication with stakeholders and participants are critical to success and growth.

129CARRYING ON Summary “Develop a “Human-Centered Culture.” “Start small and scale up.” “Eliminate recognized occupational hazards.” “Make sure the program lasts.” These elements of a Total Worker Health™ culture are tall charges for any organization. Public transit faces some of the highest rates of chronic disease of any workforce in the US, along with a schedule-driven system, expanding demand, and shrinking funding. Anyone working in transit must acknowledge that it is a business, a public service, and a job. The resulting conflicts among operations demands, budgets, worker health needs, and other factors make WHPP difficult. This Practitioner’s Guide is designed to help you organize, implement, and sustain a practical and effective workplace health protection and promotion program, tailored to your needs, that can grow and adapt. The Guide was developed through a tremendous group effort. Transit agency employees and union representatives around the country, including WHPP staff and other champions, provided the information and ideas covered in this Practitioner’s Guide. Groups of enthusiastic and dedicated people from management and labor discussed the findings. This conversation continues in American Public Transit Associa- tion (APTA) meetings, health education and research conferences, NIOSH’s Total Worker Health™ program, employee benefits meetings, and union halls. You can add to the skills and body of knowledge concerning transit worker health protection and promotion by sharing your experience. The F-17 research team would like to know how the Practitioner’s Guide is being used, what innovations are developed, and what barriers are encountered. Please provide follow-up information and findings in a brief survey at tinyurl.com/TransitWHPP as you continue to improve health, safety, and wellness for bus operators and other transit workers, their families, and the communities we all live in.

Appendix A NIOSHTotal Worker Health™ Elements 130

A National Institute for Occupational Safety and Health Initiative October 2008 Page 1 of 4 Essential Elements of Effective Workplace Programs and Policies for Improving Worker Health and Wellbeing Introduction The Essential Elements of Effective Workplace Programs and Policies for Improving Worker Health and Wellbeing is a resource document developed by the National Institute for Occupational Safety and Health (NIOSH) with substantial input from experts and interested individuals. This document, a key part of the NIOSH WorkLife Initiative, is intended as a guide for employers and employer- employee partnerships wishing to establish effective workplace programs that sustain and improve worker health. document identifies twenty components of a comprehensive work-based health protectionThe Essential Elements and health promotion program and includes both guiding principles and practical direction for organizations seeking to develop effective workplace programs. The WorkLife Initiative is intended to identify and support comprehensive approaches to reduce workplace environment--both physical and organizational--while also addressing the personal health risks of individuals, are hazards and promote worker health and well being. The premise of this Initiative, based on scientific research and practical experience in the field, is that comprehensive practices and policies that take into account the work more effective in preventing disease and promoting health and safety than each approach taken separately. The twenty components of the Essential Elements, presented below, are divided into four areas: Organizational Culture and Leadership; Program Design; Program Implementation and Resources; and Program Evaluation. The document is a framework that will be enhanced by links to resource materials intended to assist in the design and implementation of workplace programs and offer specific examples of best and promising practices. Organizational Culture and Leadership 1. Develop a “Human Centered Culture.” Effective programs thrive in organizations with policies and programs that promote respect throughout the organization and encourage active worker participation, input, and involvement. A Human Centered Culture is built on trust, not fear Commitment to worker health and safety, reflected in words and actions, is . 2. Demonstrate leadership. critical. The connection of workforce health and safety to the core products, services and values of the company should be acknowledged by leaders and communicated widely. In some notable examples, corporate Boards of Directors have recognized the value of workforce health and wellbeing by incorporating it into an organization’s business plan and making it a key operating principle for which organization leaders are held accountable. 3. Engage mid-level management. Supervisors and managers at all levels should be involved in promoting health-supportive programs. They are the direct links between the workers and upper management and will determine if the program succeeds or fails. Department of Health and Human Services Centers for Disease Control and Prevention National Institute for Occupational Safety and Health

October 2008 Page 2 of 4 Mid level supervisors are the key to integrating, motivating and communicating with employees. Program Design 4. Establish clear principles. Effective programs have clear principles to focus priorities, guide program design, and direct resource allocation. Prevention of disease and injury supports worker health and well being. 5. Integrate relevant systems. Program design involves an initial inventory and evaluation of existing programs and policies relevant to health and well-being and a determination of their potential connections. In general, better integrated systems perform more effectively. Programs should reflect a comprehensive view of health: behavioral health/mental health/physical health are all part of total health. No single vendor or provider offers programs that fully address all of these dimensions of health. Integrate separately managed programs into a comprehensive health-focused system and coordinate them with an overall health and safety management system. Integration of diverse data systems can be particularly important and challenging. 6. Eliminate recognized occupational hazards. Changes in the work environment (such as reduction in recognized hazards in the workplace is foundational to toxic exposures or improvement in work station design and flexibility) benefit all workers. Eliminating WorkLife principles. 7. Be consistent. Workers’ willingness to engage in worksite health-directed programs may depend on perceptions of whether the work environment is truly health supportive. Individual interventions can be linked to specific work experience. Change the physical and organizational work environment to align with health goals. For example, blue collar workers who smoke are more likely to quit and stay quit after a worksite tobacco cessation program if workplace dusts, fumes, and vapors are controlled and workplace smoking policies are in place. 8. Promote employee participation. Ensure that employees are not just recipients of services but are engaged actively to identify relevant health and safety issues and contribute to program design and implementation. Barriers are often best overcome through involving the participants in coming up with solutions. Participation in the development, implementation, and evaluation of programs is usually the most effective strategy for changing culture, behavior, and systems. 9. Tailor programs to the specific workplace and the diverse needs of workers. Workplaces vary in size, sector, product, design, location, health and safety experience, resources, and worker characteristics such as age, training, physical and mental abilities, resiliency, education, cultural background, and health practices. Successful programs recognize this diversity and are designed to meet the needs of both individuals and the enterprise. Effective programs are responsive and attractive to a diverse workforce. One size does not fit all—flexibility is necessary. Incentives and rewards, such as financial rewards, time off, and10. Consider incentives and rewards. recognition, for individual program participation may encourage engagement, although poorly designed incentives may create a sense of “winners” and “losers” and have unintended adverse consequences. Vendors’ contracts should have incentives and rewards aligned with accomplishment of program objectives. 11. Find and use the right tools. Measure risk from the work environment and baseline health in order to track progress. For example, a Health Risk Appraisal instrument that assesses both individual and work-environment health risk factors can help establish baseline workforce health information, direct environmental and individual interventions, and measure progress over time. Optimal assessment of a program’s effectiveness is achieved through the use of relevant, validated measurement instruments. Department of Health and Human Services Centers for Disease Control and Prevention National Institute for Occupational Safety and Health

October 2008 Page 3 of 4 12. Adjust the program as needed. between work and health are complex. New workplace programs and policies modify complex systems. Successful programs reflect an understanding that the interrelationships Uncertainty is inevitable; consequences of change may be unforeseen. Interventions in one part of a complex system are likely to have predictable and unpredictable effects elsewhere. Programs must be evaluated to detect unanticipated effects and adjusted based on analysis of experience. 13. Make sur Ensure confidentiality. e the program lasts. Design programs with a long-term outlook to assure sustainability. Short- term approaches have short-term value. Programs aligned with the core product/values of the enterprise conditions. endure. There should be sufficient flexibility to assure responsiveness to changing workforce and market 14. Be sure that the program meets regulatory requirements (e.g., HIPAA, State Law, ADA) and that the communication to employees is clear on this issue. If workers believe their information is not kept confidential, the program is less likely to succeed. Program Implementation and Resources 15. Be willing to start small and scale up. Although the overall program design should be comprehensive, For example, tar starting with modest targets is often beneficial if they are recognized as first steps in a broader program. get reduction in injury rates or absence. Consider phased implementation of these elements if adoption at one time is not feasible. Use (and evaluate) pilot efforts before scaling up. Be willing to abandon pilot projects that fail. 16. Provide adequate resources. Identify and engage appropriately trained and motivated staff. If you use program design achieve the results you seek. Direct and focus resources strategically, reflecting the principles embodied in voluntary and government agencies. Allocate sufficient resources, including staff, space, and time, to vendors, make sure they are qualified. Take advantage of credible local and national resources from and implementation. 17. Communicate strategically. Effective communication is essential for success. Everyone (workers, their families, supervisors, etc.) with a stake in worker health should know what you are doing and why. The messages and means of delivery should be tailored and targeted to the group or individual and consistently term communication strategy reflect the values and direction of the programs. Communicate early and often, but also have a long- . Provide periodic updates to the organizational leadership and workforce. Maintain program visibility at the highest level of the organization through data-driven reports that allow for a linkage to program resource allocations. 18. Build accountability into program implementation. to improve programs and outcomes and should cascade through an organization starting at the highest levels of leadership. Reward success. Accountability reflects leadership commitment Program Evaluation 19. Measure and analyze. Develop objectives and a selective menu of relevant measurements, recognizing that the total value of a program, particularly one designed to abate chronic diseases, may not be determinable in the short run. Integrate data systems across programs and among vendors. Integrated systems simplify the evaluation system and enable both tracking of results and continual program improvement. 20. Learn from experience. Adjust or modify programs based on established milestones and on results you have measured and analyzed. Department of Health and Human Services Centers for Disease Control and Prevention National Institute for Occupational Safety and Health

October 2008 Page 4 of 4 Acknowledgments We appreciate the contributions of the following individuals who participated in the 2007 workshop leading to the development of this document: David Benjamin Amick, PhD, Scientific Director, Institute for Work & Health (Canada) Anderson, PhD, Vice President, Program Strategy and Development, StayWell Ron Goetzel, PhD, Vice President, Consulting and Applied Research, Thomson Healthcare Nico Pronk, PhD, Vice President, Health and Disease Management and Executive Director, Health Behavior Group, HealthPartners Bonnie Rogers, DrPh, Director, North Carolina, Occupational Safety and Health Education Center and Director, Occupational Health Nursing Program, University of North Carolina at Chapel Hill Martin Sepulveda, MD, Vice President, Global Occupational Health Services Health Benefits, IBM Seth Serxner, PhD, Principal, Mercer Health and Benefits Michael Silverstein, MD, MPH, Clinical Professor, Department of Environmental and Occupational Health Sciences, School of Public Health and Community Medicine, University of Washington Glorian Sorensen, PhD, MPH, Director, Center for Community-based Research, Dana-Farber Cancer Institute and Professor, Department of Society, Human Development, and Health, Harvard School of Public Health Laura Welch, MD, Medical Director, Center for Construction Research and Training Department of Health and Human Services Centers for Disease Control and Prevention National Institute for Occupational Safety and Health This document is in the public domain and may be freely copied or reprinted Disclaimer Mention of any company or product does not constitute endorsement by the National Institute for Occupational Safety and Health (NIOSH). In addition, citations to Web sites external to NIOSH do not constitute NIOSH endorsement of the sponsoring organizations or their programs or products. Furthermore, NIOSH is not responsible for the content of these Web sites. All web addresses referenced in this document were accessible as of the publication date. Ordering Information To receive niosh documents or more information about occupational safety and health topics, please contact NIOSH: Telephone: 1-800-cdc-info (1-800-232-4636) /TTY: 1-888-232-6348 email: cdcinfo@cdc.gov or visit the NIOSH Web site at www.cdc.gov/niosh For a monthly update on news at NIOSH, subscribe to NIOSH eNews by visiting www.cdc.gov/niosh/eNews. DHHS (NIOSH) Publication No. 2010-140

Appendix B Sleep Disturbance and Sleep Apnea for Transit Drivers 135

Sleep Disturbance and Sleep Apnea for Transit Drivers Sleep problems lead to fatigue, irritability, and errors. Sleep debt can cause you to fall asleep briefly when you should be awake, even when driving. Moderate to severe sleep apnea is a disqualifying condition for the commercial driver’s license (CDL). It is not the only cause of sleep disturbance. How sleep disturbance affects transit drivers Sleep apnea, sleepiness at work, and fatigue- related accidents are a concern for bus drivers around the world. Sleep disturbance affects health, and can interact with diabetes and other disease.1 One in 12 Scottish bus operators studied reported falling asleep at the wheel at least once a month.2 Many reported having had an accident (7%) or a near-miss accident (18%) due to sleepiness while working. Sleep apnea in particular is common in all types of drivers: Almost 29% of 1,400 US CDL holders reported sleep apnea.3 It was mild in 18%, moderate in 6%, and severe in 5%. In some research the rates for bus operators are close to other commercial drivers and other working men.4 Causes and contributors to sleep disturbance Shift work: Evenings, nights, very early work, and long shifts make it hard to sleep enough and still interact with family and participate in regular activities. Many transit drivers try to stay up, get up early, or adjust their sleep habits to meet personal obligations. This can lead to sleep debt and fatigue. Even 10 hours between shifts may not leave enough time for meals, 8 hours of sleep, and commuting. Stress: Transit drivers take home the stress they experience from schedule demands, passenger interaction, and other work concerns. Relaxing or going to sleep quickly can be difficult. Some drivers stay up late to recover from the stress of work. Trying to sleep using alcohol or over-the- counter aids makes restful sleep less likely. Sleep apnea: Apnea means without breath— this disorder blocks breathing when you sleep, so you wake up briefly throughout the night. Contributors to sleep apnea include overweight, the structure of the skull or airways, and age. Men are more likely to have sleep apnea and it runs in families. Nasal congestion from allergies, colds, or sinus infections, medications, smoking, or alcohol can make it worse. What can employers do to address sleep disturbance? 5 Encourage Regular Rest: Establish at least 10 consecutive hours per day of protected time off-duty in order for drivers to get 7-8 hours of sleep. Plan one or two full days of rest to follow five consecutive 8-hour shifts or four 10-hour shifts. Consider two rest days after three 12- hour shifts. Ensure Adequate Rest Breaks: Frequent brief rest breaks (e.g., every 1-2 hours) during demanding work are more effective against fatigue than a few longer breaks. Allow longer breaks for meals. Provide Rest and Exercise Areas: Provide both quiet rooms and exercise resources to help operators stay rested and fit. Incident Analysis: Examine near misses and incidents to determine the role, if any, of fatigue as a root cause or contributing cause. Identify and address the work organization elements. Training: Provide training to make sure that all employees—schedulers, supervisors, human resources, as well as operations staff—understand the impact that shiftwork and other conditions have on sleep. Support Diagnosis and Treatment of Sleep Apnea: Some transit agencies cover the full cost of treatment for health problems related to CDL qualification, and a few cover the lost time.

What can transit vehicle operators do about sleep disturbance? Establish the best possible sleep schedule: You need time to sleep enough between work shifts. That should include 10 hours, or at least 8 hours in addition to both commutes, relaxing, eating, and the other things you have to do. Try not to change your schedule a lot on days off. Keep away from light sources in the hours before bedtime: Computers, TVs, and other electronic devices emit a lot of light and make your body think it is time to be awake. If you work nights, avoiding a lot of sunlight on the way home can help you get to sleep easier. Change what you consume: Avoid heavy foods and alcohol before sleeping. This can be hard when you get off a late shift—people expect to eat a full dinner at the end of the day. And alcohol seems like it will help you relax. The problem is that both will disturb your sleep. Coffee may keep you going into a late shift, but if you have trouble getting to sleep try to avoid caffeine and other stimulants—you will have to find out for yourself how long before sleep you need to cut off. Use exercise to get fit and to relax: People who exercise regularly report the best sleep.4 You may have heard that exercising is not recom- mended in the few hours before sleep, but most research shows that your exercise schedule doesn’t matter as long you are comfortable and relaxed at bedtime.6 Leave work at work: Try to establish a good transition so that you don’t carry stress home. Get comfortable: Your sleep space should be dark, comfortable, quiet, and cool so you can fall asleep quickly and stay asleep. Take naps if needed: Even a brief 15 to 20 minute nap can improve alertness. You can make up some sleep debt with naps 1 hour or longer. However, napping too long may make it harder to get to sleep when you plan to. Be well: Get help in identifying and treating sleep apnea. Get help with your health7 Suspect obstructive sleep apnea (OSA) if you snore, are very sleepy during the day, or you stop breathing briefly when sleeping. Signs you should see your doctor: Even with enough sleep, you consistently take more than 30 minutes to fall asleep, you consistent- ly wake several times or for long periods, you take frequent naps, you often feel sleepy, especially at inappropriate times Get evaluated – this usually means a consult with a sleep specialist followed by an overnight sleep study at-home or in a sleep center. Get treated: Treatment can include behavioral training, an active sleep device such as a CPAP, an oral device, weight loss, or surgery. Resources FMCSA Spotlight on Sleep Apnea (www.fmcsa.dot.gov/ safety-security/sleep-apnea/sleep-apnea.aspx) NIOSH Sleep and Work Blog (blogs.cdc.gov/niosh-science- blog/2012/03/sleep-and-work/) Gertler, J., Popkin, S., Nelson, D., and O’Neil, K. TCRP Report 81: Toolbox for Transit Operator Fatigue. TRB, National Research Council, Washington, D.C., 2002. pubs.trb.org/onlinepubs/tcrp/tcrp_rpt_81.pdf NIH Your Guide to Healthy Sleep www.nhlbi.nih.gov/health/public/sleep/healthy_sleep.pdf Additional Transit Health Protection and Promotion materials at http://www.trb.org/TCRP/TCRP.aspx and Transportcenter.org Technical References 1 Martins, R. C., Andersen, M. L., and Tufik, S. (2008) . The reciprocal interaction between sleep and type 2 diabetes mellitus: facts and perspectives. Braz J Med Biol Res, 41(3), 180-187. 2 Vennelle, M., H. M. Engleman, et al. (2010). “Sleepiness and sleep- related accidents in commercial bus drivers.” Sleep Breath 14(1): 39-42. 3 Pack, A., D. Dinges, et al. (2002). A Study of Prevalence of Sleep Apnea Among Commercial Truck Drivers Tech Brief, Federal Motor Carrier Safety Administration. 4 Xie, W, Chakrabarty S, Levine R, Johnson R, Talmage JB. Factors associated with obstructive sleep apnea among commercial motor vehicle drivers. Journal of Occupational and Environmental Medicine 2011;53:169-73. 5 Adapted from NIOSH blogs.cdc.gov/niosh-science-blog/2012/03/ sleep-and-work/ 6 www.sleepfoundation.org/alert/national-sleep-foundation-poll- finds-exercise-key-good-sleep. 7 Adapted from NIH Your Guide to Healthy Sleep http://www.nhlbi.nih.gov/health/public/sleep/healthy_sleep.pdf.

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TRB’s Transit Cooperative Research Program (TCRP) Report 169: Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention addresses some of the health and safety issues common throughout the transit industry, and describes approaches that transit organizations in the United States and Canada have taken to address health problems faced by transit employees.

The report is supplemented by a presentation, Making the Case for Transit Workplace Health Protection and Promotion, and an Excel worksheet, Transit Operator Workplace Health Protection and Promotion Planning, Evaluation, and ROI Template, that may assist transit agencies with implementing and carrying out transit-specific programs to protect the health of bus operators and other employees.

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